Sonographic Assessment of the Epiglottis

OBJECTIVES: The ideal diagnostic test for the diagnosis of epiglottitis would be simple, rapid, noninvasive, and highly accurate, performed at the bedside, and would not use ionizing radiation. The purpose of this study was to assess the utility of ultrasound to image the epiglottis and to determine the range of normal epiglottis diameter for men and women. METHODS: This was a prospective study of a convenience sample of 100 subjects between the ages of 18 and 50 years who had no known acute or chronic laryngeal diseases or surgeries. The anterior neck of each subject was scanned in both the long and short axis with a 5-10 MHz linear transducer. Sonographically, the epiglottis appeared as a curvilinear, hypoechoic structure with an echogenic pre-epiglottic space. The sonographic appearance of the epiglottis and the pre-epiglottic space were recorded and anteroposterior measurements of the epiglottis just distal to the hyoid bone were made. Comparisons between men and women were performed with use of a Student's t-test. Pearson's correlation analysis was performed to evaluate the relationship between subject height and epiglottic size. RESULTS: The epiglottis was visualized in all 100 subjects including 62 women and 38 men. The average patient age was 35.2 +/- 8.1 years. The epiglottic thickness was 2.39 +/- 0.15 mm. This was greater in men (2.49 +/- 0.13 mm) than in women (2.34 +/- 0.13 mm) (p < 0.001). There was moderate correlation between height and epiglottic thickness (R = 0.48). However, when this was analyzed separately for men and women, there was no significant correlation between epiglottic thickness and height. CONCLUSIONS: Bedside ultrasonography is easy to perform and can accurately evaluate the epiglottis. Further analysis should include patients with known epiglottic disease to assess the utility of this technique to detect pathologic enlargement.     

显微支撑喉镜下二氧化碳激光与高频电刀切除会厌囊肿的临床效果比较

目的比较显微支撑喉镜下二氧化碳CO_2激光和传统高频电刀切除会厌囊肿的临床疗效。方法选取44例会厌囊肿患者,随机分为观察组与对照组各22例,所有患者均在全麻支撑喉显微镜下进行手术。观察组采用CO_2激光,对照组采用高频电刀进行手术。比较两者术中、术后临床适用性。结果 CO_2激光与传统高频电刀相比手术时间明显缩短,术后疼痛评分明显低,且差异有统计学意义。CO_2激光手术精准程度高,可完整切除囊肿,对周围组织的损伤程度明显轻于高频电刀。两者在术后复发情况上无差异,均无1例复发。结论显微支撑喉镜下CO_2激光治疗会厌囊肿具有切割精准、囊壁不易破损、操作方便和副损伤小等优点。     

Movement of the epiglottis during deglutition

The movements of epiglottis during swallowing of barium were studied by high-speed cineradiography in 150 volunteers who had no dysphagia. In 137 individuals the epiglottis tilted down in a twostep fashion during deglutition. The first movement from an upright to transverse position was accomplished by elevation of the larynx and approximation of the hyoid bone and thyroid cartilage. This first movement is evidently a passive one and induced by the muscles that lift the hyoid bone. The second movement of the epiglottis, from transverse to an inverted position, occurs later in swallowing and seems related to contraction of the thyroepiglottic muscle. The second epiglottic movement was absent in 7 individuals, and 6 others demonstrated obliquity of their epiglottis (30–90) when studied in AP projection.     

原发性肾上腺淋巴瘤的诊断与临床处理

原发性肾上腺淋巴瘤(primary adrenal lymphoma,PAL)临床表现不典型,多数患者存在局部疼痛或全身发热、消瘦症状,在双侧受累患者中肾上腺皮质功能不全很常见,但仅少数患者进行全面系统的检查。正电子发射断层扫描/计算机体层成像是定性定位诊断这类肾上腺肿瘤的有效手段,磁共振成像用来区别肾上腺淋巴瘤与皮质癌尚有待更多研究证实。对于PAL的治疗尚需进一步研究,以对此类患者制定最佳的诊疗方案。目前,尚不清楚利妥昔单克隆抗体联合CHOP方案(环磷酰胺+阿霉素+长春新碱+强的松)治疗高危侵袭性PAL患者是否可提高患者完全反应率。病变早期,尤其是在肾上腺皮质功能不全出现之前诊断PAL,有助于减少患者的发病率和死亡率。     

原发性肾上腺淋巴瘤的诊断与临床处理

原发性肾上腺淋巴瘤(primary adrenal lymphoma, PAL)临床表现不典型, 多数患者存在局部疼痛或全身发热、消瘦症状, 在双侧受累患者中肾上腺皮质功能不全很常见, 但仅少数患者进行全面系统的检查。正电子发射断层扫描/计算机体层成像是定性定位诊断这类肾上腺肿瘤的有效手段, 磁共振成像用来区别肾上腺淋巴瘤与皮质癌尚有待更多研究证实。对于PAL的治疗尚需进一步研究, 以对此类患者制定最佳的诊疗方案。目前, 尚不清楚利妥昔单克隆抗体联合CHOP方案(环磷酰胺+阿霉素+长春新碱+强的松)治疗高危侵袭性PAL患者是否可提高患者完全反应率。病变早期, 尤其是在肾上腺皮质功能不全出现之前诊断PAL, 有助于减少患者的发病率和死亡率。     

喉切除对叠式气-食管通路发音重建防治误咽的研究

目的晚期喉癌行全喉切除发音重建及防误咽一直是头颈肿瘤外科攻关难题,研究气-食管通路发声重建防治误咽的新方法,评价对叠式气-食管通路发声口重建及檐状会厌成形术防治误咽的疗效。方法将纵形切开的气-食管漏行衣襟样对叠缝合;保留带蒂环状软骨瓣并修成会厌形状;在重建气-食管通路发声口上方将会厌形状骨片植入食道前壁粘膜下,使曲面向下凸入食管腔形成檐状会厌”。结果33例喉鳞癌术后3,7或12d拔除鼻饲管,经6～11d常规进食适应后均无误咽。随访2～5年,28例无发声口漏,2例癌复发肺、骨转移死亡,3例失访。结论对叠式气-食管通路发声口及“檐状会厌”有效地防治误咽。     

Adrenal insufficiency due to metastatic lung carcinoma and shown by abdominal CT scan

Our patient's symptoms of adrenal insufficiency were the first evidence of recurrence of the primary tumor. The diagnosis of hypoadrenalism was established by the standard ACTH stimulation test. The elevated ACTH level provided corroborating evidence that this was primary adrenal insufficiency rather than secondary to hypothalamic-pituitary dysfunction. The CT scan of the abdomen then revealed bilateral adrenal gland enlargement as well as a less dense area in the spleen, both suggestive of metastatic disease. The CT scan has proven to be of value in diagnosing tumor involvement of the adrenal glands. The patient's response to hormonal replacement was both rapid and gratifying, and he was able to leave the hospital to resume his usual activities. The possibility of adrenal insufficiency should be considered in any patient with a history of carcinoma who has malaise, weakness, and weight loss. Adrenal insufficiency is a treatable condition, and treatment of it provides symptomatic relief that may increase the quality of life. As patients with cancer survive longer, this complication may be observed more frequently.     

The hypothalamic orexinergic system: pain and primary headaches

The primary headaches are a group of distinct individually characterized attack forms, which although varying in presentation, share some common anatomical basis responsible for the pain component of the attack. The hypothalamus is known to modulate a multitude of functions and has been shown to be involved in the pathophysiology of a variety of primary headaches including cluster headache and chronic migraine. It seems likely that it may be involved in other primary headache disorders due to their episodic nature and may underlie many of their diverse symptoms. We discuss the hypothalamic involvement in the modulation of trigeminovascular processing and examine the involvement of the hypothalamic orexinergic system as a key regulator of this function.     

Adrenal insufficiency in the acquired immunodeficiency syndrome

Patients with the acquired immunodeficiency syndrome (AIDS) often have signs and symptoms suggestive of adrenal insufficiency. Reports in the literature suggest that adrenal insufficiency may be relatively common in patients with AIDS based on the finding of destructive adrenal lesions in a large number of the patients studied. In no series, however, has standard testing for adrenal reserve been done in an unselected population of patients with AIDS. We found a normal response to a standard, short adrenocorticotropic hormone test in 11 consecutive patients with AIDS (P less than .0005). Thus, although adrenal involvement by various destructive lesions may be common in patients with AIDS, clinically significant adrenal insufficiency does not appear to be common.     

A randomized trial of behavioral physical therapy interventions for acute and sub-acute low back pain (NCT00373867)

Psychological factors consistent with fear-avoidance models are associated with the development of chronic low back pain (LBP). As a result, graded activity (GA) and graded exposure (GX) have been suggested as behavioral treatment options. This clinical trial compared the effectiveness of treatment-based classification (TBC) physical therapy alone to TBC augmented with GA or GX for patients with acute and sub-acute LBP. Our primary hypothesis was that GX would be most effective for those with elevated pain-related fear. In total, 108 patients enrolled in this clinical trial and were randomly assigned to receive TBC, GA, or GX. Outcomes were assessed by a blinded evaluator at 4 weeks and by mail at 6 months. The primary outcomes for this trial were disability and pain intensity, and the secondary outcomes were fear-avoidance beliefs, pain catastrophizing, and physical impairment. There were no differences in 4-week and 6-month outcomes for reduction of disability, pain intensity, pain catastrophizing, and physical impairment. GX and TBC were associated with larger reductions in fear-avoidance beliefs at 6 months only. Six-month reduction in disability was associated with reduction in pain intensity, while 6-month reduction in pain intensity was associated with reductions in fear-avoidance beliefs and pain catastrophizing. This trial suggests that supplementing TBC with GA or GX was not effective for improving important outcomes related to the development of chronic LBP.     

自体造血干细胞移植治疗原发中枢神经系统淋巴瘤

原发中枢神经系统淋巴瘤(PCNSL)由于发生率较低,不少医生对整体治疗流程中自体造血干细胞移植(ASCT)的作用还不甚了解。大剂量甲氨蝶呤(HD-MTX)为基础的诱导治疗使得PCNSL的早期控制率明显提高,但不少患者缓解深度不够,国际上大型临床研究提示完全缓解(CR)率多低于50%;缓解维持时间短,多在1年内复发。ASCT作为巩固治疗措施应用于初治或复发难治PCNSL使得CR率明显提高,长期无病生存率(PFS)显著提高;初治PCNSL患者长期PFS可达70%,复发难治PCNSL患者长期PFS可达50%。目前的临床实践证实,PCNSL多见于老年人,器官功能状态良好的老年PCNSL患者仍然可以耐受ASCT,并明显获益于ASCT。PCNSL的ASCT预处理方案以含大剂量塞替派的方案为佳,年轻、身体转态较好、前期诱导治疗未获得CR的患者,以预处理强度更强的TBC方案为佳;年龄偏大的患者可以选择TT-BCNU或减量的TBC预处理方案。     

Coexistence of multiple and widespread cardiovascular complications in a patient with Marfan syndrome

Inherited connective tissue diseases such as Marfan syndrome are frequently associated with cardiovascular manifestations. Aortic involvement with dilation and dissection is the most common finding and the major cause of death in Marfan syndrome patients. We report the echocardiographic study of a 53‐year‐old male patient with uncommon coexistence of cardiovascular abnormalities typical of connective tissue disease at first clinical presentation in acute clinical setting: dissection of the descending aorta associated with severe mitral regurgitation due to leaflet flail and massive aortic insufficiency due to ascending aortic enlargement, leading to left ventricular dilation and dysfunction. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2013     

Transplantation pulmonaire : suites postopératoires précoces et réadmissions en réanimation

Lung transplantation is nowadays a suitable procedure for end-stage respiratory insufficiency. In France, a threefold increase of single-and double-lung transplantation has been observed since 2003. Postoperative course may be uneventful, with a short length of stay in the intensive care unit (ICU). However, some complications may occur with an attributable mortality of 10 to 20 %, including primary graft dysfunction due to ischemia-reperfusion phenomenon, bacterial pneumonia, and cellular rejection. A multidisciplinary approach is mandatory. Later, some patients may require readmission to the ICU, mainly due to infectious pulmonary complications. Prognosis is related to the presence of bronchiolitis obliterans syndrome and to the severity of the respiratory illness on admission.     

Clinical and genetic analysis of a Korean patient with late-onset X-linked adrenal hypoplasia congenita and hypogonadotropic hypogonadism: identification of a novel mutation in the NR0B1 gene

Adrenal hypoplasia congenita (AHC) is caused by mutations in the NR0B1 gene on chromosome Xp21.3-p21.2. It manifests as X-linked primary adrenal failure in early infancy or childhood and as hypogonadotropic hypogonadism (HHG) at puberty. Although studies of AHC patients and mutations in the NR0B1 gene have been reported throughout the world, there has previously been only one other case report from Korea. We encountered a 23-year old Korean male with delayed-onset AHC/HHG who had been previously diagnosed with adrenal insufficiency of unknown aetiology at age 13 years. Delayed puberty and incomplete HHG were observed. Direct sequencing of the NR0B1 gene revealed the patient to have a novel insertion mutation (c.959_960insT; Leu321ProfsX68). Although AHC is believed to be rare, it should be considered in a differential diagnosis of patients showing late-onset primary adrenal insufficiency.     

Primary Conjunctival Herpetic Geographic Ulcer in an Immunocompetent Patient

Herpes simplex virus ocular infections have been recognized as a major cause of corneal blindness in the developed world. The major signs of a primary infection are limited to the lids, conjunctiva, and cornea. Presence of a conjunctival dendrite without corneal involvement has been reported. Although conjunctival ulceration has been associated with recurrent attacks, it has not been documented as a manifestation of primary herpetic infection. We report a case of primary herpetic infection with geographic conjunctival ulcer with multiple corneal dendrites.     

Histamine metabolism in patients with chronic gastritis

Examination of 104 patients has demonstrated that in marked exacerbation of chronic gastritis, surface involvement of the gastric mucosa largely localized to the fundal part, high acid-peptic activity and short-term duration of the disease, absolute hyperhistaminemia are noted. Subsiding gastritis exacerbation, the presence of glands atrophy, primary involvement of the mucous membrane in the antral part of the stomach, secretory insufficiency, as well as the disease of many years are accompanied of absolute hypohistaminemia manifesting in a low blood histamine content, the activity of histaminase and histaminopexia being unchanged or elevated.     

Pleural effusion in a patient with allergic bronchopulmonary aspergillosis

The involvement of pleura in patients with allergic bronchopulmonary aspergillosis (ABPA) is uncommon. In most reported cases the involvement of the pleura is presumed to be due to ABPA per se, due to the observed response to corticosteroids. We report a case of histopathologically proven tubercular pleural effusion in a patient with ABPA at the time of initial diagnosis. This case highlights the importance of intensive evaluation of an exudative pleural effusion in settings where pleural effusion due to the primary underlying disease is uncommon or rare.     

Hypokalemic adrenal crisis in a patient with AIDS

Electrolyte disorders have been reported frequently in patients with AIDS. Adrenal insufficiency has been associated with hyponatremia in this group of patients. We have presented the case of a patient with AIDS whose early course was complicated by hyponatremia, hypoglycemia, and hyperkalemia. Shortly thereafter, hypokalemia developed due to gastrointestinal potassium losses from diarrhea. Although cosyntropin stimulation testing later confirmed the diagnosis of adrenal insufficiency, it was not considered because of coexistent hypokalemia. Diarrhea in patients with AIDS and diminished adrenal reserve may invalidate hypokalemia as an exclusion criterion for the diagnosis of adrenal crisis.     

Primary adrenal insufficiency

Primary adrenal insufficiency is a potentially life‐threatening condition. We report a case of a 49‐year‐old female patient who presented to the hospital for evaluation of dizziness, nausea, and vomiting. Darkening of the palmar creases and tongue was noted. The adrenocorticotropic hormone stimulation test confirmed the diagnosis of adrenal insufficiency.

The combination of darkening of the palmar creases, dark tongue, and hyponatremia merits high suspicion and appropriate diagnostic workup for primary adrenal insufficiency due to Addison''s disease.     

Patients with vascular ulcers and cardiovascular risk factors. Case reports

We present the case of a patient with severe obesity, type 2 diabetes mellitus, hypertension, and chronic venous insufficiency, as well as several vascular ulcers in the right extremity with complex clinical course. The importance of the treatment and follow-up of these vascular ulcers in primary care is essential to achieve healing or improvement. Because primary care centers can provide easy access and daily evaluation -if required-, the clinical course of vascular ulcers can be more favorable in this setting than in the hospital setting, where appointments are less frequent. In our case, the patient required several changes of treatment; at all times, the importance of controlling all the cardiovascular risk factors was explained to the patient. The involvement of the patient and his family in the disease, as well as follow-up in the primary care center, were essential to obtaining improvement.