Pharynx and oesophagus evaluation during the swallow using helical computerized tomography.

PURPOSE: Videofluorography (VF) and endoscopy are commonly used for dynamic imaging (DI) of pharyngeal swallowing but do not offer transverse plane (TP) information. The aim of the present study was to evaluate helical computerized tomography (HCT) to measure the DI capability pharyngeal swallowing in the TP. METHODS: The HCT scan technique used was a single-slice cine mode with scan times of 100 ms. All 15 subjects were studied supine during dry swallow, swallowing of barium sulphate jelly and 3, 10, 15 or 20 ml of a 40% barium sulphate solution. Nine subjects repeated the test twice at more than 1 week's interval to determine the test-retest reliability. RESULTS: Swallowing leads to closure of the vocal folds, pharyngeal constriction and narrowing of the piriform sinuses allowing jelly passage between the sinuses. Laryngeal elevation then occurs with the opening of the pharyngoesophageal segment (PES). Swallowing a bolus of 20 ml produced the maximum anteroposterior and transverse diameters as well as the maximum opening area of the PES. The test-retest intraclass correlation coefficients with liquid deglutition ranged from 0.86 to 0.98. CONCLUSIONS: This study shows that HCT enables visualization of TP of PES complementing VF or endoscopic swallowing studies.     

Colony-stimulating factors for chemotherapy-induced febrile neutropenia: a meta-analysis of randomized controlled trials.

PURPOSE: Current treatment for febrile neutropenia (FN) includes hospitalization for evaluation, empiric broad-spectrum antibiotics, and other supportive care. Clinical trials have reported conflicting results when studying whether the colony-stimulating factors (CSFs) improve outcomes in patients with FN. This Cochrane Collaboration review was undertaken to further evaluate the safety and efficacy of the CSFs in patients with FN. METHODS: An exhaustive literature search was undertaken including major electronic databases (CANCERLIT, EMBASE, LILACS, MEDLINE, SCI, and the Cochrane Controlled Trials Register). All randomized controlled trials that compare CSFs plus antibiotics versus antibiotics alone for the treatment of established FN in adults and children were sought. A meta-analysis of the selected studies was performed. RESULTS: More than 8,000 references were screened, with 13 studies meeting eligibility criteria for inclusion. The overall mortality was not influenced significantly by the use of CSF (odds ratio [OR] = 0.68; 95% CI, 0.43 to 1.08; P = .1). A marginally significant result was obtained for the use of CSF in reducing infection-related mortality (OR = 0.51; 95% CI, 0.26 to 1.00; P = .05). Patients treated with CSFs had a shorter length of hospitalization (hazard ratio [HR] = 0.63; 95% CI, 0.49 to 0.82; P = .0006) and a shorter time to neutrophil recovery (HR = 0.32; 95% CI, 0.23 to 0.46; P < .00001). CONCLUSION: The use of the CSFs in patients with established FN caused by cancer chemotherapy reduces the amount of time spent in hospital and the neutrophil recovery period. The possible influence of the CSFs on infection-related mortality requires further investigation.     

Cost-effectiveness and pain medicine

The specialty of pain medicine, as noted by Lippe,“… justifies itself as a unique medical specialty by virtue of a distinct body of knowledge and a well-defined scope of practice. In common with other medical specialties, it is founded on an infrastructure of scientific research, education, and clinical practice [1].“ The traditional methods of education for healthcare providers, such as medical schools, nursing schools, physical therapy schools, and clinical psychology programs, do not prepare their students adequately for the delivery of evaluation and treatment services to patients experiencing pain. Also apparent, as evidenced by the dearth of medical literature, is that the traditional methods of educating pain specialists do not adequately prepare students for an effective approach to the realities of healthcare economics in their respective fields.The result of a lack of significant education in the economics of pain medicine can be financially devastating to a new practitioner who is practicing “good” medicine yet not meeting the financial obligations incipient in the operation of a multidisciplinary pain center or even a solo practice. One important concept in the study of healthcare economics is the issue of cost-effectiveness [2].     

Adrenarche and the evolution of human life history.

Adrenarche, the prepubertal onset of adrenal production of dehydroepiandrosterone sulfate (DHEAS), is a distinctive aspect of the human life course. Yet its evolutionary origins remain unexplained. Production of DHEAS is associated with the development of the zona reticularis, a novel histological layer within the adrenal gland, derived from the fetal adrenal gland, and associated with primates more generally. Evidence that DHEAS is a neurosteroid, together with the fact that increases in DHEAS parallel patterns of cortical maturation from approximately age 6 years to the mid-20s, suggests that DHEAS may play an important role in extended brain maturation among humans. DHEAS has demonstrated effects on mood in humans, and acts at neuron receptor sites. I suggest three ways in which DHEAS may play a role in human brain maturation: 1) increasing activity of the amgydala; 2) increasing activity of the hippocampus; and 3) promoting synaptogenesis within the cortex. I propose that associated changes in fearfulness and anxiety, and memory, could act to increase social interaction with nonfamiliar individuals and shape cognitive development. Comparison with the African apes suggests that the timing of adrenarche in chimpanzees may be similar to that in humans, though the full course of age-related changes in DHEAS and their relationship to reproductive and brain maturation are not clear. The role of DHEAS as a physiological mechanism supporting increased brain development, extended life span, and decreased sexual dimorphism is most compatible with Kaplan et al.'s (2000) theory of the evolution of human life history and intergenerational transfers.