Clinical outcomes for the elderly patient receiving a tracheotomy

BACKGROUND: Tracheotomies are routinely performed for severely ill and elderly patients with respiratory failure. This intervention is questioned, given the poor survival rate in this group. Outcomes analysis is performed after tracheotomy. METHODS: This is a retrospective study of 78 elderly patients, who received tracheotomies for respiratory failure. Pretracheotomy data (age, length of oral intubation, and DNR status) were collected. Outcomes analyzed during the same admission as the tracheotomy included death versus discharge, ventilator dependence, vocal function, route of feeding, decannulation, and ICU discharge disposition. RESULTS: The mean age was 77.6 +/- 11 years (median, 79 years) and patients were intubated for 16.7 +/- 9 days. Forty-two percent (n = 33) obtained DNR orders after tracheotomy, and 8% (n = 6) before tracheotomy. Seventy-one percent of patients (n = 55) had gastrostomy tubes placed. Fifty-six percent of patients (n = 44) died after tracheotomy; median time from tracheotomy to death was 31 days. After tracheotomy, 53 % (n = 41) remained at least partially ventilator dependent, 18 % (n = 14) regained consistent vocal function, and 13 % (n = 10) were decannulated. For those who died, 27 % (n = 12) died without leaving the ICU. CONCLUSION: These data demonstrate that a large proportion of elderly, severely ill patients with respiratory failure suffer poor outcomes after tracheotomy. More stringent criteria are necessary for performing the tracheotomy in this patient population.     

A questionnaire survey concerning the most favourable treatment for Graves' disease in children and adolescents

Graves' disease (GD) is the most common cause of juvenile thyrotoxicosis in children and adolescents (1, 2). Three treatment modalities are now available for the treatment of Graves' thyrotoxicosis in childhood: antithyroid drugs (ATD), surgery and radioactive iodine (RAI). However, none of these treatments has been shown to be ideal or clearly superior to the others. Physicians in different countries have different approaches concerning the optimal treatment of juvenile GD.In a European questionnaire study (3), which was conducted by the European Thyroid Association in 1993 and in which 99 individuals or groups from 22 countries participated, it was found that 22 out of 99 physicians from nine countries would consider RAI treatment as the treatment of choice for children with recurrent thyrotoxicosis after surgery, or with recurrent thyrotoxicosis 2 years after ATD. However, RAI is preferred by only a small percentage of physicians for this group of patients in Europe. Hardly any of the respondents chose RAI for the patients with a toxic adenoma or a multinodular toxic goiter (3). On the other hand, in view of the difficulties with medical therapy in children and adolescents, including poor compliance, a high rate of relapse, drug toxicity and continued thyroid enlargement, some eminent American physicians emphasize the safety, simplicity and economic advantages of (131)I ablation which should be considered more commonly in children (4, 5).We had the opportunity to conduct a similar study during a pediatric thyroidology symposium, which was organized by Professors Buyugkebiz and Laron in Izmir (Smyrna) Turkey from 30 October to 1 November 2003. During the congress a questionnaire with the following four questions was circulated among the 120 participants from eight countries who were mainly paediatric endocrinologists. Most of them were from Turkey and the rest, except for one who came from the USA, were Europeans. Sixty-one out of the 120 physicians responded.     

Differences between males and females in the seasonality of birth and month of clinical onset of disease in children with type 1 diabetes mellitus in Ireland

The aim was to study the monthly rhythm of birth and clinical onset in 303 children with type 1 diabetes mellitus (DM1) aged 0-15 years (156 males, 147 females) born between 1980 and 1996 in Ireland and compare to 951,717 infants born in the general population during the same period. Analysis was performed using the cosine fit for rhythm and t-test between the seasons of the year. Whereas the males showed a rhythmic pattern of month of birth, peaking in the summer (p < 0.05), similar to that in the general population, the females showed no seasonal differences in either month of birth or month of onset. A mirror image pattern, nadir in spring and summer (p < 0.01), was observed in month of clinical onset, also only in males. If we assume a viral infectious etiology of DMI, females seem to be less susceptible than males to the environmental infectious influences.     

High prevalence of müllerian anomalies diagnosed by ultrasound in women with polycystic ovaries

OBJECTIVE: To determine, with a case-control study, if polycystic ovaries are associated with a higher rate of uterine müllerian anomalies. STUDY DESIGN: A total of 214 women were included. Transvaginal ultrasonography of the ovaries and the uterus was performed in all. The women were divided into 2 groups, a group with polycystic ovaries (n = 120) and another with normal ones (n = 94). RESULTS: Women with polycystic ovaries had a higher rate of uterine müllerian anomalies. In the polycystic ovary group, 53 (44.2%) had uterine müllerian anomalies; 17 (18.1%) were found in the normal ovary group (P < .0001). CONCLUSION: There is an association between polycystic ovaries and high rate of uterine müllerian anomalies.     

The use of otic powder in the treatment of acute external otitis

BACKGROUND: Acute external otitis (AEO) is a painful condition that results as a secondary infection of macerated skin and subcutaneous tissues of the external auditory canal. The most commonly causative microorganisms are Pseudomonas aeruginosa and Staphylococcus aureus. Classic management strategies include moisture prevention, cleansing of the canal and administration of topical antimicrobial agents in drop form, such as aminoglycosides and quinolones, at times in combination with steroid solutions. The objective of this study was to evaluate and compare the efficacy of topical otic powder, tobramycin drops and ciprofloxacin drops in patients suffering from AEO. MATERIALS AND MEASURES: A randomized prospective trial was performed to determine the efficacy of Auricularum powder (dexamethasone 10 mg, oxytetracycline HCl 90,000 U, polymyxin B Sulfate 100,000 U, nystatin 1,000,000 U; Trima, Serolam Laboratories, Germany) compared with ciprofloxacin (Ciloxan, Alcon Laboratories, Fort Worth, TX) and tobramycin (Tobrex, Alcon Laboratories) drops for the treatment of AEO. One hundred twenty patients who presented with signs and symptoms of AEO were enrolled. Inclusion criteria were: AEO diagnosed by an otolaryngologist, patient age 18 years, no prior treatment with other drops or systemic antibiotics, no sensitivity to any of the drugs used or their contents, and no perforation of the tympanic membrane. All patients were instructed to avoid moisture and wetness of the ear during the course of their treatment. After we received informed consent, a swab culture was taken, and the patient was randomly assigned topical treatment for 14 days. RESULTS: Eighty-six percent of those treated with Auricularum powder were cured at day 3-4 after initial treatment. Seventy-seven percent of those treated with ciprofloxacin drops, and fifty-six percent of those treated with tobramycin were cured at that time. All 120 patients were cured by day 14. CONCLUSION: The results show that topical treatment with Auricularum powder is an effective and rapid method for the treatment of AEO. Ciloxan also was effective in the treatment of AEO and relieved symptoms quickly and efficiently in a short period of time. Tobrex was effective in treating AEO, but our results show that relief of symptoms was slower than with the other drugs.     

Treatment of intestinal worms is associated with decreased HIV plasma viral load

BACKGROUND: We have previously suggested that helminthic infections make the host more susceptible to HIV infection and enhance its progression due to the chronic immune activation they cause. OBJECTIVE: To study the effect of antihelminthic treatment on HIV plasma viral load (VL) in HIV- and helminth-infected individuals living in Ethiopia. METHODS: Fifty-six clinically asymptomatic HIV-1-infected individuals, 31 (55%) of whom were also infected with helminths, were studied. All participants received antihelminthic treatment at baseline and at 3 and 6 months. Worm egg excretion, HIV plasma VL, and T-cell subsets were determined at baseline and 6 months after treatment. RESULTS: The mean age, number of CD4 T cells, and gender distribution were similar in the helminth-infected and -noninfected groups. At baseline, HIV plasma VL was strongly correlated to the number of eggs excreted (p <.001) and was higher in individuals infected with more than one helminth (5.28 +/- 0.35 versus 4.30 +/- 1.13 log RNA copies/mL, respectively; p =.16). After treatment of helminths, the 6-month change in HIV plasma VL was significantly different between the successfully treated group and the persistently helminth-positive group (p =.04) CONCLUSIONS: Helminth "load" is correlated to HIV plasma VL, and successful deworming is associated with a significant decrease in HIV plasma VL. The results of the current study, if confirmed in a larger study, may have important implications for slowing disease progression and reducing risks of transmission.     

Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia

Major breakthroughs in catheter, guidewire, and other angiographic equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. Similarly, the interventional radiologist can treat acute intestinal ischemia safely and effectively with selective catheterization and papaverine administration and treat chronic mesenteric ischemia by percutaneous angioplasty and stent placement. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is critical in managing GI bleeding and intestinal ischemia, particularly in patients at high risk or presenting as diagnostic dilemmas.     

Interplay between heredity and environment in the recent explosion of type 1 childhood diabetes mellitus

The fast increase in the incidence of childhood type 1 diabetes mellitus (T1DM) that cannot be explained by changes in the genetic susceptibility, led us to look for environmental causes. To test the hypothesis that the initiation of the autoimmune process of childhood T1DM in genetically susceptible subjects begins in the perinatal period by a viral infection, we studied the seasonal variations in the month of birth of several cohorts of patients compared to the general population. Population groups with high or low T1DM incidence were analyzed separately by t-test and the Cosinor methods. In areas with populations with a high incidence (Israeli Jews, Sicily, Sardinia, Slovenia, Germany) we found that the children (in Sicily also young adults) who subsequently developed T1DM, have a higher incidence of births in the summer months than in other seasons of the year, a mirror image of the seasonality of the clinical onset of disease. This pattern differed significantly from the seasonality of the total live births in the same populations. In populations with a low T1DM incidence, (China, Japan and Cuba) no seasonality of month of birth was found. Similar findings have been reported, from five counties in the U.K. and the Netherlands. It is hypothesized that mothers who become pregnant during the period of yearly viral epidemics transmit to the fetus, either a virus or antiviral antibodies, which determine whether an autoimmune process against the pancreatic beta is initiated or whether the fetus is protected against that process.     

Type 2 diabetes mellitus in childhood--a global perspective

Type 2 diabetes mellitus is a group of diseases of different etiologies but similar symptopathology characterized by insulin resistance (insulin insensitivity) of different degrees. It can be associated with specific genetic mutations, with a series of chromosomal abnormalities, with states of lean body or obesity, the latter showing a worrying increase in incidence. The literature on the above is reviewed and a personal opinion is expressed on the prevention and treatment of the above conditions.