Search

BACKGROUND Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation. METHODS A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively. RESULTS Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points. CONCLUSIONS The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention.

Background Schwannomas, benign tumors arising from neurolemmocytes, are the most common type of peripheral nerve tumors. Extracranial schwannomas are most often found in the parapharyngeal space, commonly involving the vagus nerve to cervical sympathetic trunk. Vagal schwannomas present several unique clinical and therapeutic challenges. Methods A comprehensive literature review was conducted on 197 articles reporting 235 cases of cervical vagal schwannomas. Presenting symptoms, treatment approach, and postoperative outcomes were recorded and analyzed. Results Vagal schwannomas commonly present as asymptomatic neck masses. When they become symptomatic, surgical resection is the standard of care. Gross total resection is associated with higher postoperative morbidity compared to subtotal resection. Initial reports using intraoperative nerve monitoring have shown improved nerve preservation. Recurrence rates are low. Conclusion The combination of intermittent nerve mapping with novel continuous vagal nerve monitoring techniques may reduce postoperative morbidity and could represent the future standard of care for vagal schwannoma treatment.

Abbreviations: SCP = survivorship care program; TCC = Thyroid Care Collaborative

We present the case of a 38-year-old Caucasian female who underwent a total thyroidectomy for papillary thyroid carcinoma. We identified a large anomalous superior thyroid artery (STA) that emerged as a second branch of the external carotid artery and entered the thyroid isthmus superficial to the right sternothyroid muscle. In this case report, we discuss the embryology of the thyroid gland as well as the possible embryological basis for this unusual course of the STA. In doing so, we aim to improve recognition of the potential vascular variations in the thyroid gland, in turn aiding surgeons in the prevention of unnecessary complications and providing insight into the embryologic development of this organ.

Objective A subset of patients who undergo major palatomaxillary reconstruction do not initially achieve their intended oncologic and/or reconstructive goals and require additional surgery. We aim to detail the unique management considerations in this patient population. Methods We performed a retrospective review of patients who underwent palatomaxillary reconstruction by the senior author (m.l.u.) between 1998 and 2016. Results Twenty-one patients required multiple reconstructions. The median time to second reconstruction was 17 months. The most common reason for a second reconstruction was for recurrent disease (10 of 21), followed by functional/aesthetic reasons (7 of 21) and osteoradionecrosis (4 of 21). Four patients went on to have a third reconstruction, and two underwent a fourth. A total of 27 reconstructions were performed, consisting of 20 soft tissue free flaps, four vascularized bone free flaps, and three locoregional flaps. Conclusion This patient cohort represents unique oncologic and reconstructive challenges. With long-term follow-up, multiple reconstructions may be required to optimize oncologic and functional/aesthetic outcomes. This is the first series of its kind that details the reasons for, as well as the outcomes of, patients who required multiple reconstructive procedures following initial palatomaxillary reconstruction. Level of evidence 2B Laryngoscope, 130:2349-2353, 2020.

Background Aggressive histologic worst pattern of invasion (WPOI) in surrounding soft tissue has been shown to be predictive of higher local recurrence and poorer survival in oral cavity squamous cell carcinoma (OCSCC) patients. This study investigates whether aggressive WPOI can predict the mandibular invasion phenotype. Methods Patients consecutively diagnosed with OCSCC undergoing a mandibulectomy (marginal or segmental) between 2013 and 2018 were reviewed. Senior physicians re-reviewed radiologic scans and pathologic slides of 44 cases. Results Aggressive WPOI (WPOI-4, 5) is significantly associated with infiltrative bone invasion. Non-aggressive WPOI (WPOI-1, 2, 3) is significantly associated with the absence of bone invasion. Conclusions WPOI has become a useful tool that further characterizes the biologic behavior of OCSCC. Potentially, planned surgery may escalate from a marginal to segmental mandibulectomy based on aggressive WPOI for patients with radiographically uncertain cortical status. Further studies are needed to validate the relationship between OCSCC WPOI and mandible status.

Background Osteoradionecrosis (ORN) is a well-known complication following irradiation of head and neck malignancies. ORN commonly occurs in the mandible but is rarely reported in the hyoid bone. Case presentation A 76-year-old female with a history of oropharyngeal squamous cell carcinoma presented with pharyngocutaneous fistula 14 years after primary chemoradiation. Imaging showed necrosis of the hyoid bone. She underwent excision of the hyoid to rule out malignancy. Pathology was negative for carcinoma, but did show extensive fragmentation and bony necrosis consistent with ORN. The patient's clinical course, surgical treatment, and management considerations are discussed here. Conclusions Hyoid ORN should remain in the differential during diagnostic workup of previously irradiated head and neck cancer patients. The presentation of a pharyngocutaneous fistula should prompt workup to rule out malignancy before assigning a diagnosis of ORN.

Background Septic arthritis of the sternoclavicular joint is a rare infection associated with significant morbidity and mortality. Several risk factors for septic arthritis have been reported in the literature ranging from immunodeficiency to intravenous drug use. Case presentation A 63-year-old male previously treated for synchronous squamous cell carcinomas of the epiglottis and floor of mouth presented with tenderness and swelling of the sternoclavicular joint two months after tracheostomy decannulation. Computed tomography and bone scans confirmed the diagnosis of septic arthritis of the sternoclavicular joint. The patient's clinical course, surgical treatment, and management considerations are discussed here. Conclusion Septic arthritis of the SCJ is a rare but serious infection. Once diagnosed, septic arthritis of the SCJ should be promptly treated to prevent further morbidity and mortality.

Background: Paragangliomas are rare neuroendocrine tumors which develop at the site of extra-adrenal paraganglia of the autonomic nervous system, originating in the neural crest. Case presentation: We report the extremely rare finding of 4 concurrent paragangliomas arising bilaterally and simultaneously involving the carotid bodies and superior cervical ganglia of the sympathetic trunk in a 53-year-old man. These tumors were large enough to cause unilateral sympathetic chain dysfunction resulting in Horner's syndrome, in addition to oropharyngeal compression causing obstructive sleep apnea. The patient's clinical course, surgical treatment, and management considerations are discussed here. Conclusion: The morbidity associated with Horner's syndrome is relatively low; therefore, resection of these tumors is less controversial. However, the surgical access to large masses in the parapharyngeal space is more difficult and, in some cases, requires mandibulotomy to ensure that critical neurovascular structures are preserved during the resection. Keywords: Paraganglioma, Parapharyngeal space, Cervical sympathetic chain, Carotid body tumor, Horner's syndrome

Intensive care unit is one of the stressful environments for its staff, especially physicians and nurses. This study was objective to determine anxiety in physicians and nurses working in intensive care units in Yasuj,s hospitals in Iran. This research is an intervention study conducted in Yerevan city in 2009. The number of participants in this study is 150 which are randomly selected. In this study 120 nurses and 30 specialists participated as the working in the intensive care unit of Yasuj,s hospitals in Iran. In the study, a 10-question demographic questionnaire, 20-question situational anxiety, 20-question personality anxiety Berger is used. After codification, the questionnaires Results indicate that average score for the situational anxiety of the nurses has been 46.96, average score for the situational anxiety of physicians has been 39.40 and that average score for the personality anxiety of the nurses has been 40.96, average score for the personality anxiety of physicians has been 36.73. This study provides valuable insight into the actual and perceived stressful experiences of critical care nurses, thus contributing to the ongoing effort to reduce burnout in this population.

Summary: Clinical yeast isolates were taken from 37 patients with presumptive skin candidiasis in Kuwait. In vitro sensitivity tests using amphotericin B, nystatin, miconazole nitrate, 5-fluorocytosine and chlorhexidine were carried out. Amphotericin B was found to be the most effective and 5-fluorocytosine the least. Zusammenfassung: Von 37 Patienten wurden wegen vermuteter Candida-Mykose Hefen isoliert. In-vitro-Resistenztestungen wurden mit Amphotericin B, Nystatin, Miconazolnitrat, 5-Fluorocytosin und Chlorhexidin ausgefuhrt. Bei dieser Testung wurde Amphotericin B als die wirksamste und 5-Fluorocytosin als die am wenigsten wirksame Substanz ermittelt.

Background. In early postpartum haemorrhage (PPH), a low concentration of fibrinogen is associated with excessive subsequent bleeding and blood transfusion. We hypothesized that pre-emptive treatment with fibrinogen concentrate reduces the need for red blood cell (RBC) transfusion in patients with PPH. Methods. In this investigator-initiated, multicentre, double-blinded, parallel randomized controlled trial, we assigned subjects with severe PPH to a single dose of fibrinogen concentrate or placebo (saline). A dose of 2 g or equivalent was given to all subjects independent of body weight and the fibrinogen concentration at inclusion. The primary outcome was RBC transfusion up to 6 weeks postpartum. Secondary outcomes were total blood loss, total amount of blood transfused, occurrence of rebleeding, haemoglobin ,58 g litre 21 , RBC transfusion within 4 h, 24 h, and 7 days, and as a composite outcome of ‘severe PPH’, defined as a decrease in haemoglobin of .40 g litre 21 , transfusion of at least 4 units of RBCs, haemostatic intervention (angiographic embolization, surgical arterial ligation, or hysterectomy), or maternal death. Results. Of the 249 randomized subjects, 123 of 124 in the fibrinogen group and 121 of 125 in the placebo group were included in the intention-to-treat analysis. At inclusion the subjects had severe PPH, with a mean blood loss of 1459 (SD 476) ml and a mean fibrinogen concentration of 4.5 (SD 1.2) g litre 21 . The intervention group received a mean dose of 26 mg kg 21 fibrinogen concentrate, thereby significantly increasing fibrinogen concentration compared with placebo by 0.40 g litre 21 (95% confidence interval, 0.15 –0.65; P¼0.002). Postpartum blood transfusion occurred in 25 (20%) of the fibrinogen group and 26 (22%) of the placebo group (relative risk, 0.95; 95% confidence interval, 0.58 –1.54; P¼0.88). We found no difference in any predefined secondary outcomes, per-protocol analyses, or adjusted analyses. No thromboembolic events were detected. Conclusions. We found no evidence for the use of 2 g fibrinogen concentrate as pre-emptive treatment for severe PPH in patients with normofibrinogenaemia. Clinical trial registration. ClinicalTrials.gov: http://clinicaltrials.gov/show/NCT01359878. Published protocol: http://www.trialsjournal.com/content/pdf/1745-6215-13-110.pdf.

Liquid paraffin or mineral oil is a transparent, colourless, odourless, or almost odourless, oily liquid composed of saturated hydrocarbons obtained from petroleum.1 Petroleum was used as a medicine at least 400 years before Christ.2 The earliest internal use of refined petroleum appears to date back to 1872, when Robert A. Chesebrough was granted a patent for the manufacture of “a new and useful product from petroleum”.2 The use of liquid paraffin gained popularity, after Sir W. Arbuthnot Lane, Chief Surgeon of Guy's Hospital in 1913, recommended its use as a treatment for intestinal stasis and chronic constipation.3 The popularity of liquid paraffin as a treatment for constipation and encopresis stems primarily from its tolerability and ease of titration. Although conversion of mineral oil to hydroxy fatty acids induces an osmotic effect,4 liquid paraffin appears to work primarily as a stool lubricant.5 Therefore, liquid paraffin is not associated with abdominal cramps, diarrhoea, flatulence, electrolyte disturbances, or the emergence of tolerance with long term usage, side effects commonly associated with osmotic or stimulant laxatives.6 These features make liquid paraffin particularly attractive for use in chronic constipation and encopresis of childhood, where large doses and prolonged administration commonly are necessary during the disimpaction and maintenance phases of treatment, respectively.6 However, although liquid paraffin is widely accepted and recommended as a fundamental component of regimens for the management of constipation in North America and Australia,6 7 it is little used in the United Kingdom.8 9 This trans-Atlantic dichotomy in liquid paraffin usage has been underscored by the American Academy of Pediatrics (AAP) endorsement of practice guidelines developed by the North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) for the management of constipation in infants and children.6 NASPGN clearly identify liquid paraffin (mineral …

Background: Hepatocellular Carcinoma is the third most common cause of cancer related death worldwide, often diagnosed by measuring serum AFP; a poor performance stand-alone biomarker. With the aim of improving on this, our study focuses on plasma proteins identified by Mass Spectrometry in order to investigate and validate differences seen in the respective proteomes of controls and subjects with LC and HCC. Methods: Mass Spectrometry analysis using liquid chromatography electro spray ionization quadrupole time-of-flight was conducted on 339 subjects using a pooled expression profiling approach. ELISA assays were performed on four significantly differentially expressed proteins to validate their expression profiles in subjects from the Gambia and a pilot group from Nigeria. Results from this were collated for statistical multiplexing using logistic regression analysis. Results: Twenty-six proteins were identified as differentially expressed between the three subject groups. Direct measurements of four; hemopexin, alpha-1-antitrypsin, apolipoprotein A1 and complement component 3 confirmed their change in abundance in LC and HCC versus control patients. These trends were independently replicated in the pilot validation subjects from Nigeria. The statistical multiplexing of these proteins demonstrated performance comparable to or greater than ALT in identifying liver cirrhosis or carcinogenesis. This exercise also proposed preliminary cut offs with achievable sensitivity, specificity and AUC statistics greater than reported AFP averages. Conclusions: The validated changes of expression in these proteins have the potential for development into highperformance tests usable in the diagnosis and or monitoring of HCC and LC patients. The identification of sustained expression trends strengthens the suggestion of these four proteins as worthy candidates for further investigation in the context of liver disease. The statistical combinations also provide a novel inroad of analyses able to propose definitive cutoffs and combinations for evaluation of performance.

Background The prevalence of toxoplasma gondii (T.g) infection in blood donors has been poorly studied. The aim of this study was to assess the prevalence of acute and chronic toxoplasmosis in blood products. Methods A total of 223 blood products (101 fresh frozen plasma (FFP) and 122 packed cells (PC)) in Imam Reza hospital blood bank, Tehran, Iran were tested for specific T.g antibodies (IgG and IgM) by ELISA method. Positive IgG anti-T.g samples were further tested for IgM anti-T.g. A positive IgG test with the negative and positive IgM test was interpreted as a chronic and acute toxoplasmosis respectively. Results Of 223 samples 38.6% and 0.45% were positive for IgG anti-T.g and IgM anti-T.g levels respectively. Therefore, one and 85 samples were involved acute and chronic toxoplasmosis respectively. Twenty-six of fresh frozen plasma samples were positive for IgG anti-T.g and one of them was positive for IgM anti-T.g. Sixty packed cell samples were positive for IgG anti-T.g. Conclusions Our study showed that there were chronic and acute toxoplasmosis in blood products and the prevalence of toxoplasmosis especially chronic form was high. Therefore screening of blood for T.g antibodies may be considered.

Metastases from solid tumors to lymph nodes do not portend as poor a prognosis as metastases to other sites. The authors wished to determine whether specific subpopulations of cells metastasized to lymph nodes and whether they have different properties than cells metastatic to visceral sites. Repetitive selection for "spontaneous" metastases of a B16 melanoma to either lung or lymph node increased the incidence of lymph node metastases. Cells derived from pulmonary and lymph node metastases were assayed for their ability to adhere to cryostat sections of lung and lymph node and respond to target organ-conditioned media in serum-free conditions. Both cell types were four times more adherent to lymph node than lung, and consistently attached to the hilar and subcapsular sinuses. Attachment of cells derived from pulmonary metastases to either tissue was threefold greater than that of cells derived from nodal metastases. Lung-conditioned media stimulated proliferation of both cell types, and transiently induced differentiated morphology in cells derived from lymph node metastases, but not in cells from pulmonary metastases. Neither effect was found in lymph-node-conditioned medium. These results suggest that cells metastasize to lymph nodes preferentially not because of a specific predilection for lymph node, but because it is an easy site to colonize. Adhesive interactions in the lymph node rather than trophic ones appear to account for this effect. Cells metastatic to lymph node may be less "malignant" than cells metastatic to visceral sites because less has been required for them to succeed as a metastatic focus.

Background Poisoning is a major cause of morbidity and mortality in children and adolescents. Pharmaceutical and household products are responsible for the majority of cases. Aim To analyse poisoning cases presenting to a paediatric hospital. Methods A retrospective study of all poisoning cases presenting to the Accident and Emergency (A&E) department of one hospital over a nine-month period. Children from birth to 15 years of age were included. The cases were categorised into accidental or intentional with or without suicidal intention. Demographic features included age, gender, toxin, location of poisoning, need for admission and mortality. Results A total of 148 cases were recorded, 47% were male, 31% were hospitalised and there was no mortality. Of ingestions, 74% were between 1 and 4 years of age and 86% were accidental. Of the intentional, 33% were suicidal, all 12 years or older. Conclusions Few unintentional ingestions in the paediatric group result in serious toxicity. Mortality is rare. There is increasing intentional poisoning and alcohol abuse in adolescents. Poison prevention should be part of all well child visits. Agencies catering for children should carry educational leaflets for parents on how to ‘poison proof’ a child’s environment, as the majority of incidents occur at home.

OBJECTIVES: Focally enhanced gastritis (FEG) has been suggested as a specific diagnostic marker for patients with Crohn’s disease. However, the utility of FEG for distinguishing Crohn’s disease from ulcerative colitis is uncertain in adults, and the occurrence of this lesion in children has not been defined. The aim of this study was to evaluate the occurrence of FEG and other gastric histological abnormalities in children with inflammatory bowel disease (IBD) and to examine the utility of FEG in discriminating between ulcerative colitis and Crohn’s disease. METHODS: This is a retrospective, case-controlled study of upper GI histopathological findings in children with IBD. Gastric histopathology was defined and graded according to the Updated Sydney System. RESULTS: FEG was present in 28 of 43 (65.1%) children with Crohn’s disease and five of 24 (20.8%) children with ulcerative colitis, compared to three of 132 (2.3%) children without IBD or one of 39 (2.6%) children with Helicobacter pylori infection. There were no differences between those with and without FEG with regard to upper GI symptoms or previous anti-inflammatory drug ingestion (5-aminosalicylic acid compounds or steroids). All patients with H. pylori infection had chronic antral gastritis, but only one child with H. pylori had FEG. In addition, mild to moderate chronic gastritis was present in 15 of 43 (34.9%) children with Crohn’s disease and in 12 of 24 (50%) patients with ulcerative colitis. CONCLUSIONS: The presence of FEG suggests underlying IBD. Although FEG is particularly common in children with Crohn’s disease, it does not reliably differentiate between Crohn’s disease and ulcerative colitis. (Am J Gastroenterol 2002;97:1415–1420. © 2002 by Am. Coll. of Gastroenterology)

Background: Eating, drinking and swallowing (EDS) disorders can have serious consequences for children which include dehydration, malnutrition, failure to thrive, aspiration pneumonia, choking and possibly death. Paediatric feeding disorders have been reported in up to 25% of children. This number increases to 80% in developmentally delayed children. Therefore disordered feeding should involve assessment by a multidisciplinary team. The problem is seldom limited to the child alone and non-organic factors must also be addressed. Aims: To audit the first 18 months of practice in a new regional EDS clinic from July 2007-December 2008. Methods: Retrospective chart review of clinic reports was carried out. All patients had formal assessment of EDS by a speech and language (SALT) and occupational therapist (OT), a medical review by a doctor and dietetics consult at each clinic visit. Results: 28 patients received full assessment. Average age of 1st consult was 4.16 years. 27/28 patients had an underling diagnosis, the most common being; genetic disorder(n=7), autism(n=3), cerebral palsy(n=3), Ex-prem(n=3), developmental delay of unknown aetiology(n=3). Diverse reasons for referral included(often > 1); issues with coordination of swallow(n=14), perceived behavioural issues(n=6), chronic reflux(n=5), PEG feeding(n=4), aspiration(n=4). 22/28 patients had an abnormal EDS assessment. The two most common interventions initiated were a sensory feeding programme(n=15) or food desensitisation programme(n=4) by SALT/OT. Conclusion: Our EDS clinic has provided further therapeutic intervention for children already with complex medical needs. In conjunction with medical therapy, behavioural and oromotor strategies can be applied successfully even in feeding disorders with an underlying organic cause.

The brain is being evaluated as a de novo source of cytokines. Because recent evidence indicates that interleukin-6 (IL-6) may influence blood-brain barrier function and vascular permeability, we have sought to determine whether mechanical injury can directly induce in situ cerebral IL-6 production. Adult human astrocyte cultures were subjected to mechanical injury by the in vitro method of fluid percussion barotrauma, developed in our laboratory. Serial supernatant samples were collected for 8 h and evaluated for IL-6 activity using a proliferation assay employing the dependent B cell hybridoma cell line, B9. At optimum injury, the IL-6 level became significantly (P

The adverse affects of high blood levels of lead are well established. There is now data emerging which looks at lower blood levels of lead associated with poor cognition and other developmental concerns. The authors undertook a literature review to examine the causal effect of low lead level and impaired cognitive function. The plausibility of including lead screening as part of developmental delay workup in Ireland is also explored. This review concludes that there is an adverse relationship between increasing level of lead and cognition. Children with developmental delay would be at an increased risk to the cognitive impairment associated with low levels of lead. Given that there are preventative and therapeutic options to minimise the effects of lead, we argue that this group of children should be routinely screened for lead. Currently there is lack of prevalence data in Ireland. The authors are working in conjunction with British Paediatric Surveillance Unit Project to undertake active surveillance of lead poisoning in Ireland.

The ability to metastasize requires that tumor cells be able to degrade matrix. Nontoxic compounds that inhibit matrix digestion might be useful as anti-metastatic agents. We have investigated whether phenytoin, a drug commonly used in clinical practice that inhibits the production of collagenase by some cells, inhibits metastases in a standard animal model of metastasis: In vitro, phenytoin inhibited the proliferative response of B16 F10 melanoma cells to serum-containing media (75% inhibition at 25 micrograms/ml) but had no effect on their ability to degrade a type I collagen gel (1-100 micrograms/ml). Treatment of these cells with phenytoin prior to inoculation in vivo did not inhibit tumor growth, implantation in a surgical wound, or incidence of spontaneous metastases from a primary tumor growing in the foot. Pretreatment of mice with phenytoin (15, 40, and 75 mg/kg/day) diminished pulmonary metastases following tail vein injection in a minimal but dose dependent fashion; mean number of pulmonary colonies 4.6 +/- 3.1 (75/mg/kg/day) vs. 10.2 +/- 9.9 (control). However, tumor growth, implantation, and spontaneous metastases were not inhibited by pretreating the mice with the same doses of phenytoin. It is concluded that phenytoin has an insignificant inhibitory effect on tumor growth and metastasis.