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Aim: The classic laryngeal mask airway (cLMATM) can be used in place of an endotracheal tube (ETT) as the ventilatory device during percutaneous dilational tracheostomy (PDT). We aimed to investigate the possible loss of efficacy of cLMATM after tracheal intubation., Methods: Severity of laryngeal lesions and efficacy of cLMATM were determined in two groups of thirty patients each who were switched from ETT ventilation to cLMA ventilation for PDT after a short (<4 days) or a long (>12 days) tracheal intubation., Results: cLMATM allowed us to carry out PDT in all patients. Short tracheal intubations resulted in mild lesions of the larynx and mild gas leaks during cLMATM ventilation. Longer intubations caused moderate-to-severe (P<0.05) lesions of the larynx and larger gas leaks. A single complication occurred in one patient post-procedurally and in no patient at 6-month follow-up., Conclusion: Efficacy of cLMATM was maintained after short tracheal intubation and decreased after long intubation.

Objectives/hypothesis: To document the long-term advantages and disadvantages of cartilage grafts used to correct traumatic saddle nose deformity. Additionally, to demonstrate functional improvement and cosmetic satisfaction with the use of this graft., Study Design: Retrospective chart review and prospective follow-up telephone survey of 20 patients after dorsal augmentation of saddle nose deformity secondary to trauma., Methods: This is a single-surgeon, single-institution investigation within an academic tertiary care medical center. All patients presented for correction of saddle nose deformity after trauma, and cartilage grafts were used for augmentation of the dorsum. Minimum postoperative follow-up period of 1 year was required. A modified and expanded Nasal Obstructive Symptoms Evaluation survey, which included questions pertaining to the appearance of their nose, was used to assess both functional and cosmetic changes after surgery., Results: Only 1 of the 20 patients was dissatisfied with the overall outcome. Three (15%) were extremely satisfied, 12 (60%) were very satisfied, three (15%) were somewhat satisfied, and one (5%) was indifferent. In terms of function, four (20%) experienced excellent relief in nasal obstruction, five (25%) moderate relief, four (20%) mild relief, and seven (35%) noted no difference. Regarding cosmesis, two (10%) noted excellent improvement, three (15%) moderate improvement, nine (45%) mild improvement, and five (25%) noted no significant change. One (5%) patient reported worsening due to tip edema. Mean follow-up time was 6.8 years., Conclusions: Autogenous cartilage grafts are useful in the correction of mild to moderate traumatic saddle nose deformity. The graft is readily available, preserves long-term structural stability, and achieves functional and cosmetic satisfaction in most patients.

Many women with cerebrospinal shunts are now reaching the childbearing age and may face risks from shunt malfunction during pregnancy. We report on a case of a 35-year-old primigravida at 36 weeks of gestation who was admitted to our hospital because of headache and cognitive and visual disturbances. At 13 years of age the patient had had a ventriculoperitoneal shunt for hydrocephalus related to an aqueduct stenosis. A computerized tomography scan of the brain showed moderate ventricular dilatation likely resulting from a malfunctioning shunt. On the second day after admission her level of consciousness and neurologic condition suddenly worsened and a second brain scan showed further enlargement of the ventricular system. After multidisciplinary consultation, it was decided to proceed with urgent sequential shunt revision and cesarean delivery. Anesthetic considerations included the risk of difficult airway, rising intracranial pressure and conflicting demands between neurological and obstetrical procedures (such as deep versus low-dose anesthesia). General anesthesia was provided with an oxygen/air mixture (50/50%), i.v. fentanyl (5 microg/kg total dose) and i.v. propofol infusion (4-6 mg kg(-1) h(-1)). Surgical procedures were carried out without complications and both mother and infant were doing well at a 6-month follow-up. An interdisciplinary approach allowed two urgent sequential operations to be performed with a unique anesthetic regimen and excellent maternal and fetal outcome.

Objective: Report the experience of the Karmanos Cancer Institute with sinonasal mucosal melanoma (SNMM) in patients diagnosed between 1995 and 2007., Results: Eighteen patients, ages 31 to 85 (mean, 67), whose most common presenting symptoms included epistaxis and facial pressure. Most common anatomic locations were the maxillary sinus and nasal cavity. Seventy-two percent presented with tumors extending to the skull base, frontal sinus, orbit, or cranium. Tumor size ranged from 0.3 cm to 5.3 cm. Most common surgical procedure was medial maxillectomy (12 patients). Eight patients received chemotherapy, ten received radiotherapy and six received both. One third of patients received interferon-alpha. Median recurrence-free survival (RFS) was 14.4 months, with a 1-year RFS rate of 55%. Median overall survival (OS) was 19.3 months with a 1-year OS rate of 60% and a 2-year OS rate of 42%. The 5-year OS rate was 34%., Conclusion: SNMM remains a disease that has eluded breakthroughs in treatment. Patients are typically treated with wide local resection; however unique to our institution was the frequent use of interferon and chemoradiation. Further research in adjuvant therapies will be necessary to improve outcomes.

We report a case of an obese patient who presented with laryngeal edema and difficult ventilation after failed attempts to intubate. A Laryngeal Mask Airway Supreme (LMA Supreme) reestablished the ventilation and allowed bronchoscope- guided intubation of the trachea. The case suggests that the LMA Supreme may be useful in patients with a difficult airway.

A 79-year-old woman presented with hypoxemic acute respiratory failure secondary to pneumonia and was started on continuous noninvasive positive pressure ventilation (NPPV) by helmet. Patient improved over first two days of NPPV, but worsened suddenly on the third day because of development of a pneumothorax. Pneumothorax may have been caused by barotrauma from desynchronization between patient and ventilator.

Background: Chemotherapeutic stop-flow perfusion is a new investigational treatment for locally advanced cancers that is usually performed under general anesthesia (GA), and, less frequently, under spinal anesthesia (SA). We designed this clinical trial to compare the clinical profiles of GA and SA for stop-flow perfusion., Methods: Anesthesia and recovery times, scores on visual analog scales for postoperative pain, and postoperative nausea and vomiting, and admission to the postanesthesia care unit were measured in 40 cancer patients who randomly received either GA with propofol, nitrous oxide/sevoflurane, and fentanyl, or SA with bupivacaine hydrochloride for lower limb or pelvic stop-flow perfusion., Results: GA and SA did not differ in times to achieve home readiness or patient satisfaction. Compared with GA, SA significantly (P < 0.05) reduced anesthesia times (34 vs 16 min), postoperative visual analog scale scores for pain (5 vs 0) and nausea (8 vs 2), and the number of admissions to the postanesthesia care unit (9 vs 0)., Conclusions: For stop-flow perfusion, GA and SA are both effective, but SA provides faster recovery, superior analgesia, and less postoperative nausea and vomiting in the immediate postoperative period.

In the dry Swiss Rhone Valley, Scots pine forests have experienced increased mortality in recent years. It has commonly been assumed that drought events and bark beetles fostered the decline, however, whether bark beetle outbreaks increased in recent years and whether they can be linked to drought stress or increasing temperature has never been studied. In our study, we correlated time series of drought indices from long-term climate stations, 11-year mortality trends from a long-term research plot, and mortality probabilities modeled from tree rings (as an indicator of tree vitality) with documented occurrences of various bark beetle species and a buprestid beetle, using regional Forest Service reports from 1902 to 2003 and advisory cases of the Swiss Forest Protection Service (SFPS) from 1984 to 2005. We compared the historical findings with measured beetle emergence from a 4-year tree felling and breeding chamber experiment. The documented beetle-related pine mortality cases increased dramatically in the 1990s, both in the forest reports and the advisory cases. The incidents of beetle-related pine mortality correlated positively with spring and summer temperature, and with the tree-ring based mortality index, but not with the drought index. The number of advisory cases, on the other hand, correlated slightly with summer drought index and temperature, but very highly with tree-ring-based mortality index. The tree-ring-based mortality index and observed tree mortality increased in years following drought. This was confirmed by the beetle emergences from felled trees. Following dry summers, more than twice as many trees were colonized by beetles than following wet summers. We conclude that increased temperatures in the Swiss Rhone Valley have likely weakened Scots pines and favored phloeophagous beetle population growth. Beetles contributed to the increased pine mortality following summer drought. Among the factors not addressed in this study, changed forest use may have also contributed to increased beetle populations and Scots pine mortality, whereas air pollution seems to be of lesser importance.

Objective: To compare the percent mucosal surface area of adenoids removed from children with chronic rhinosinusitis (CRS) and those with obstructive sleep apnea (OSA) infected with biofilms., Design: Comparative micro-anatomic investigation of adenoid mucosa using scanning electron microscopy from patients with CRS and OSA., Subjects: 4 females and 12 males ranging from 3 months to 10 years of age., Results: Adenoids removed from patients with CRS had dense mature biofilms covering the mucosal surface. More specifically, adenoids removed from patients with CRS had an average of 94.9% of their mucosal surface covered with mature biofilms vs. an average of 1.9% coverage on the adenoids removed from patients with OSA. These differences were statistically significant at the p<0.001 level., Conclusions: It is well established that adenoidectomy is useful in the treatment of CRS resistant to antibiotics. Adenoids removed from patients with CRS had almost their entire mucosal surface covered with biofilms vs. scant coverage for patients with OSA (p<0.001). Decreased metabolic activity, decreased growth rate, and transmission of resistance genes all contribute to the antibiotic resistant nature of the biofilms. These metabolically sessile communities shed planktonic microorganisms on an intermittent basis. Therefore biofilms in the nasopharynx of children with CRS may act as a chronic reservoir for bacterial pathogens resistant to standard antibiotics. Also, the mechanical debridement of the nasopharyngeal biofilms may explain the observed clinical benefit associated with adenoidectomy in this subset of pediatric patients.

Aim: Loco-regional antiblastic perfusion with circulatory block (stop-flow perfusion, SFP) is a procedure designed to treat solid tumors of the limb and pelvis in an advanced stage, like melanoma, sarcoma of the soft tissues and colon-rectal cancer. The aim of this study was to evaluate if subarachnoid anesthesia could represent a safe and suitable anesthetic technique for this procedure., Methods: Thirty SFP procedures were performed in the angiographic room, 15 for the treatment of lower-limb neoplasias and 15 for pelvic neoplasias. The patients (ASA I-III) had a mean age of 59.1 years (range: 19-81 years). The patients were given different dosages of bupivacaine (range: 10-20 mg) in hyperbaric solution at the concentration of 0.5% and 1% by lumbar subarachnoid injection at different levels (from T12-L1 to L3-L4). Standard monitoring was set up (ECG, pulse-oximetry, and non-invasive artery pressure). The use of any anesthetic and analgesic drug, eventually used in the intra- or postoperative period, was recorded., Results: The lumbar puncture was approached at L1-L2 and L2-L3 levels in 80% of the cases. Doses of bupivacaine between 12 mg and 14 mg were administered in 2/3 of the cases. Bupivacaine was formulated in hyperbaric solution and administered at a concentration of 0.5% (8 patients) or 1% (22 patients). Complica-tions related to the anesthetic technique were absent. Intraoperative pain control was almost complete with one exception, when the procedure lasted unusually long. Pain control was satisfying immediately after the procedure as well: only in 3 cases were non-opiod analgesics administered within the first 6 h., Conclusions: Spinal subarachnoid anesthesia has proven to be an effective, safe, and easy-to-manage technique for carrying out SFP procedure in a non-conventional environment such as an angiographic room. It was free of serious side effects and well tolerated even in patients in poor general conditions.

Objective: To assess the effect of tetrathiomolybdate on cytokine expression, angiogenesis, and tumor growth rate in human squamous cell carcinoma (SCC)., Design: Three human SCC cell lines were used in this study for both in vitro and in vivo investigations. Conditioned media from untreated and tetrathiomolybdate-treated cell lines were compared with regard to cytokine levels, endothelial cell chemotaxis, endothelial cell tubule formation, and migration and the ability to induce angiogenesis in a rat aortic ring array. In vivo UM-SCC-38 was seeded onto tissue-engineered scaffolds and surgically implanted into the flanks of immunodeficient mice. Tumor growth rates and the level of angiogenesis were compared after 2 weeks of therapy., Setting: A tertiary care facility., Results: In this study, we demonstrate that tetrathiomolybdate significantly decreases the secretion of interleukin 6 and basic fibroblast growth factor by head and neck SCC (HNSCC) cell lines in vitro. Furthermore, we demonstrate that tetrathiomolybdate significantly decreases the secretion of interleukin 6 and basic fibroblast growth factor by HNSCC cell lines in vitro. Furthermore, tetrathiomolybdate treatment of HNSCC cell lines results in significantly decreased endothelial cell chemotaxis, tubule formation, and neovascularization in a rat aortic ring assay. This in vitro evidence of decreased angiogenesis by tetrathiomolybdate is confirmed in vivo by using a severe combined immunodeficiency disorder mouse model in which tetrathiomolybdate therapy is shown to prevent human blood vessel formation. Finally, human HNSCC implanted into immunodeficient mice grow to a much larger size in untreated mice compared with those treated with 0.7 mL/kg per day of oral tetrathiomolybdate., Conclusions: These findings illustrate the ability of tetrathiomolybdate to down-regulate proinflammatory and proangiogenic cytokines in HNSCC. These observations are potentially exciting from a clinical perspective because a global decrease in these cytokines may decrease tumor aggressiveness and reverse the resistance to chemotherapy and radiation therapy seen in this tumor type.

Different friable Hevea callus lines from the same genotype can display different embryogenic and regenerative potentials. These lines can not be distinguished on the basis of macroscopic criteria. A histological and molecular study was undertaken to characterize the differences existing between five callus lines with different potentials. The genes differentially expressed during induction were analyzed using the differential display (DD-RT) technique. Twenty-eight cDNAs were found to be differentially expressed during induction in the embryogenic regenerating line (ER). Embryogenic nodules were formed earlier in the ER lines than in the embryogenic non-regenerating lines and were completely absent in the non-embryogenic line. Of these 28 cDNAs, five could be used to distinguish between calli prior to induction, thereby enabling an early diagnosis of friable Hevea callus embryogenic potential.

Technetium-99m pertechnetate scintigraphy was performed in the involved extremities of six patients with severe frostbite of the hands (six cases) and feet (one case). There was good correlation between the scintigraphic findings and the extent of deep tissue ultimately requiring surgical resection. Technetium-99m pertechnetate imaging distinguishes viable from dead tissue in frostbite in a simple, noninvasive manner, and findings are easy to interpret. A persistent perfusion defect is seen in nonviable tissue.

Major and selected minor elements were determined in seven whole rock fragments, five portions of pulverized lunar rock, and the lunar soil. Three different rock types were represented: vesicular, fine-grained basaltic rocks; medium to coarse-grained, vuggy gabbroic rocks; and breccia. The ranges (in percent) for the major constituents of the lunar samples are: SiO(2), 38 to 42; Al(2)O(3), 8 to 14; total iron as FeO, 15 to 20; MgO, 6 to 8; CaO, 10 to 12; Na(2)O, 0.5 to 1; K(2)0, 0.05 to 0.4; TiO(2), 8 to 13; MnO, 0.2 to 0.3; and Cr(2)O(3), 0.2 to 0.4. The high reducing capacity of the samples strongly suggests the presence of Ti(III).