Size of septectomy does not affect distribution of nasal irrigation after endoscopic modified Lothrop procedure

Background

The endoscopic modified Lothrop procedure (EMLP) is commonly performed in recalcitrant frontal sinusitis, in part to achieve better penetration of medicated irrigations postoperatively. Although EMLP requires a septectomy for exposure, it is unknown whether septectomy size affects delivery of irrigations. In this study we evaluated the role of septectomy in delivery of irrigations to the EMLP cavity.

Methods

EMLP was performed on fresh human cadavers with sequentially increasing septectomy (minimal septectomy: drilling across septum to combine frontal sinuses; standard septectomy: 1.5 cm anterior to middle turbinate and inferiorly to the midlevel of the turbinate; large septectomy: extension to nasal floor). Irrigation with fluorescein‐labeled water was performed with a 240‐mL irrigation bottle in the vertex position and recorded with a 30° endoscope fixed in a 4‐mm trephine in the paramedian EMLP cavity. Two blinded reviewers scored irrigation distribution recordings (0 = nasal cavity only; 1 = frontal recess; 2 = medial distribution; 3 = lateral distribution; 4 = entire sinus lavage). Distribution scores were assessed with Wilcoxon rank sum analysis.

Results

Six specimens (mean age, 75.2 ± 2.4; 50% female) were assessed. Interobserver scores were highly concordant (Kendall's W = 0.86, p < 0.01), internally validating the experiment. Distribution scores did not vary significantly when comparing minimal septectomy with standard or large septectomy (Z = 0.55, p = 0.58, Z = 0.37, p = 0.71).

Conclusion

Increasing septectomy does not improve irrigation delivery in patients undergoing EMLP. These results suggest that a limited septectomy for access to the bilateral frontal sinuses is all that is required for effective drug delivery postoperatively. This strategy may reduce morbidity associated with larger septectomies.

     

Cardiac resynchronization therapy: “Nonresponders” and “hyperresponders”

BACKGROUND: Cardiac resynchronization therapy (CRT) is a recognized treatment modality for patients with dilated cardiomyopathy (DCM), left bundle branch block, and severe cardiac failure. However, 30% of patients are "nonresponders." Intriguingly, the opposite case has not been reported until recently: Do some patients treated with CRT have a "complete" recovery and thus can be considered "hyperresponders"? OBJECTIVE: The purpose of this study was to investigate patients treated with CRT who have a "complete" functional recovery, with normalization of left ventricular function after therapy. METHODS: Eighty-four consecutive patients with DCM, sinus rhythm, and left bundle branch block in New York Heart Association functional class III and IV who were implanted with a CRT device were prospectively followed. Patients were considered to be "hyperresponders" if they concurrently fulfilled two criteria: functional recovery and left ventricular ejection fraction > or = 50%. RESULTS: Among the 84 patients with DCM, 11 (13%) were "hyperresponders" within 6 to 24 months after CRT (left ventricular ejection fraction increased from 25% +/- 8% to 60% +/- 6.5%, P = .001). Comparison of baseline parameters between "hyperresponders" and the remaining patients showed that only etiology of the DCM was statistically discriminative. All "hyperresponders" belonged to the group of patients with nonischemic DCM (18% vs 0%, P = .05). CONCLUSION: In a subset of patients successfully implanted with a CRT device, "complete" functional recovery associated with normalization of LV function was observed, giving rise to the concept of "hyperresponders." This finding is observed exclusively in the subgroup of patients with nonischemic DCM and suggests that left bundle branch block may be the causal factor of DCM in this subgroup of patients.     

Nitric oxide‐releasing microparticles as a potent antimicrobial therapeutic against chronic rhinosinusitis bacterial isolates

Background

Bacteria, particularly in the biofilm state, may be implicated in the pathogenesis of chronic rhinosinusitis (CRS) and enhance antibiotic resistance. Nitric oxide (NO) is a gaseous immunomodulator with antimicrobial activity and a short half‐life, complicating achievement of therapeutic concentrations. We hypothesized that a novel microparticle‐based delivery platform, which allows for adjustable release of NO, could exhibit potent antibacterial effects.

Methods

Porous organosilica microparticles (SNO‐MP) containing nitrosylated thiol groups were formulated. Dissociation of the nitrosothiol groups generates NO at body temperature. The susceptibility of bacterial isolates from CRS patients to SNO‐MP was evaluated through a colony forming unit (CFU) assay. Serial dilutions of SNO‐MP in triplicate were incubated with isolates in suspension for 6 hours followed by plating on tryptic soy agar and overnight incubation followed by CFU quantification. Statistical analysis was performed with SPSS using one‐way analysis of variance with Bonferroni correction.

Results

SNO‐MP displayed antibacterial activity against gram‐positive (methicillin‐resistant and ‐sensitive Staphylococcus aureus) and gram‐negative (Pseudomonas aeruginosa, Enterobacter aerogenes, and Proteus mirabilis) isolates. SNO‐MP induced dose‐dependent reductions in CFU across all strains. Compared with controls and blank nanoparticles, SNO‐MP (10 mg/mL) induced a 99.99%‐100% reduction in CFU across all isolates, equivalent to a 5–9 log kill (p < 0.005). There was no statistically significant difference in CFU concentration between controls and blank microparticles.

Conclusion

SNO‐MP demonstrates potent bactericidal effect against antibiotic‐resistant CRS bacterial strains.

     

Beware the “red herring”

A young patient with relapsed diffuse large B‐cell lymphoma presented with new onset respiratory symptoms and hypereosinophilia in the early stage post high‐dose therapy/autologous stem cell rescue. Here, we present a step‐wise practical approach to this unexpected laboratory finding for a not uncommon infective complication in the immunosuppressed patient.     

“Pills and Pulses”: Hybrid Therapy for Atrial Fibrillation

Hybrid Therapy for Atrial Fibrillation. Nonpharmacologic techniques are being increasingly applied to the treatment of atrial fibrillation (AF). None of these techniques (other than maze surgery) begins to approach 100% efficacy for long‐term elimination of arrhythmia. This review examines the evidence for “hybrid” therapy, using combinations of drug and nonpharmacologic treatments. The immediate success rate of electrical cardioversion can be increased with amiodarone or ibutilide, and a number of drugs reduce the risk of AF recurrence. Preventing or reversing electrical atrial remodeling is an attractive strategy for maintenance of sinus rhythm. However, the available evidence (relating to the use of verapamil) is limited and conflicting. Ablation of the cavotricuspid isthmus is effective when antiarrhythmic drugs given for AF give rise to typical flutter. Isthmus and other right atrial linear lesions are poor as a sole therapy for AF, but better when drugs are added. Better still is the combination of left atrial linear lesions with drugs. In patients with AF recurrence following focal ablation/pulmonary vein isolation procedures, drugs are an alternative to extensive linear ablation. Some studies indicate that pacing to prevent AF may be effective, but rarely without continued antiarrhythmic drug therapy. This may represent a specific effect or simply improved drug tolerance. Drugs also might assist pacemaker therapy by increasing the proportion of atrial arrhythmias that are highly organized and thus amenable to antitachycardia pacing. This and other forms of hybrid therapy will remain the subject of conjecture in the absence of controlled clinical trials, which are urgently needed.