Four-quadrant cricoid cartilage division in laryngotracheal reconstruction.

Four-quadrant division of the cricoid cartilage is a relatively new technique of laryngotracheal reconstruction. Division of the lateral walls of the cricoid cartilage, with or without placement of autogenous cartilage grafts, allows for increased expansion of the subglottic lumen. Between October 1, 1986, and January 1, 1990, 185 laryngotracheal reconstructions were performed at our institution. During that time, 31 four-quadrant division laryngotracheal reconstruction procedures were performed in 29 patients (mean age at surgery, 5 years 5 months). Grade 3 or 4 laryngeal stenosis existed preoperatively in 72% (22/31) of cases. The initial decannulation rate after four-quadrant division laryngotracheal reconstruction was 58% (18/31). Of 11 patients requiring revision surgery after four-quadrant division laryngotracheal reconstruction, four were eventually decannulated, for an overall decannulation rate of 76% (22/29). The indications, technique, results, and potential complications of four-quadrant division of the cricoid cartilage in laryngotracheal reconstruction are discussed.     

Phonation and swallowing considerations in pediatric laryngotracheal reconstruction.

Experience with laryngotracheal reconstruction (LTR) has resulted in and continues to yield modifications and refinements in approach and technique with the goal to restore and maintain total laryngeal function. In addition to airway obstruction, the laryngeal functions of phonation and swallowing also may be affected by the underlying injury as well as by procedures designed to enlarge the airway. This paper discusses various problems encountered with phonation and swallowing in pediatric patients who underwent LTR and postoperative patients who were seen during the year July 1, 1990, through June 30, 1991. Phonation problems became apparent as long-term difficulties that persisted after tracheotomy decannulation. Swallowing was frequently a short-term perioperative problem while a stent was in place following LTR. The approaches and techniques that have been employed to treat, minimize, and prevent these problems are discussed.     

Is sedation safe during dynamic sleep fluoroscopy of children with obstructive sleep apnea?

OBJECTIVE: Airway compromise is considered a relative contraindication for pediatric sedation. This contraindication presents a paradoxical problem when patients require sedation in preparation for imaging performed to evaluate the cause of airway obstruction. We use dynamic sleep fluoroscopy in the evaluation of children who have obstructive sleep apnea. The purpose of this study was to evaluate the success and safety of a structured sedation program for dynamic sleep fluoroscopy. MATERIALS AND METHODS: Eighty consecutive dynamic sleep fluoroscopic studies were evaluated. The type of sedation used, success rate, complications related to the sedation, and characteristics of the children studied were reviewed. Patients were sedated in accordance with our departmental sedation program guidelines. Findings on fluoroscopy were correlated with episodes of oxygen desaturation or noisy breathing. RESULTS: In all 80 cases, dynamic sleep fluoroscopy was successfully performed. Seventy-two studies were performed, with sedation supervised by the radiologist. Four patients fell asleep without sedation. In four patients, sedation was performed by an anesthesiologist (preprocedural decision). Sixty-four children (80%) had complex medical problems, and 39 (49%) had a history of previous airway surgery. All studies were considered successful. Specific diagnoses were identified in 66 children (83%). No children suffered complications or required tracheal intubation. CONCLUSION: Children with airway compromise who are being evaluated for obstructive sleep apnea can be successfully and safely sedated for dynamic sleep fluoroscopy when a structured sedation program is used.     

Nested case-control study of cervical mucosal lesions, ectopy, and incident HIV infection among women in Cape Town, South Africa

OBJECTIVE: The objective of this study was to test whether cervical mucosal lesions and ectopy increase women's susceptibility to HIV infection. STUDY DESIGN: HIV-seronegative women ages 35 to 65 years (n = 5773) enrolled into a cervical cancer screening trial were followed for up to 36 months. All HIV seroconverters (n = 86) in the cohort were compared with randomly selected controls (n = 324) who did not seroconvert. Magnified photographs of the cervix taken during speculum examination at enrollment were evaluated for cervical mucosal lesions and ectopy using standard criteria. RESULTS: The presence of mucosal lesions (observed among 19% of controls) was associated with increased risk of HIV seroconversion (adjusted odds ratio [AOR] = 1.93; 95% confidence interval [CI] = 1.07-3.48). Ectopy extending over >20% of the cervix was also associated with HIV seroconversion (AOR = 2.18; 95% CI = 1.01-4.69). CONCLUSIONS: Visible lesions of cervical mucosa and cervical ectopy may be markers of increased susceptibility to HIV infection among women. Protection of the mucosa of the cervix may provide an important approach for new HIV prevention technologies.     

Design and evaluation of a drama-based intervention to promote voluntary counseling and HIV testing in a South African community

BACKGROUND: Voluntary counseling and testing (VCT) services are a major component of HIV prevention and treatment efforts. We developed a drama-based intervention to promote VCT services in a peri-urban community in South Africa. METHODS: Young adults from the community received training in HIV/AIDS and drama, and developed sketches to address perceived barriers to VCT. Over 12 months, 80 performances were held in busy community settings. The intervention was evaluated through changes in VCT uptake at the local clinic compared with comparable communities nearby. RESULTS: After the start of the intervention in August 2003, a 172% increase in the uptake of VCT services was observed in the intervention community. This was significantly greater than demand for VCT in either of the control communities during the same period (P < 0.0001). CONCLUSION: A structured, community-based education program based on drama can lead to substantial increases in the demand for VCT services in resource-limited settings.     

Access of behavioral health patients to prescribing professionals

OBJECTIVE: Advanced practice nurses (APNs), including clinical nurse specialists and nurse practitioners, now have prescribing privileges in all states. This study examined the proportion of Department of Veteran Affairs (VA) mental health patients who were seen by any prescribing professional and specifically the proportion and characteristics of patients who were treated exclusively by APNs. METHOD: Logistic regression models were used to examine data on all patients who received care in VA specialty mental health clinics in 2002 (n=767,920). We first identified patient characteristics independently associated with prescriber contact and, secondly, among those with prescriber contact, exclusive contact with an APN. We also compared characteristics of patients seen exclusively by an APN with those who saw both a physician and an APN. RESULTS: The strongest predictors of both whether a veteran saw a prescriber (66.6%) and whether that prescriber was exclusively an APN (6.7%) were indicators of severity. Specifically, more severe diagnoses, such as schizophrenia or bipolar disorder, receipt of VA disability payments and greater service use increased the odds that a veteran would have had a prescriber contact, decreased the odds that they would see an APN exclusively and, among those who saw an APN, increased the odds that they would also see a physician. CONCLUSIONS: Patients who see physician prescribers have more severe mental health problems than those who see APNs. Our results indicate that APNs and physicians treat distinguishable patient populations, suggesting that APNs may not be substitutes for physicians.     

Severe holocarboxylase synthetase deficiency with incomplete biotin responsiveness resulting in antenatal insult in samoan neonates

We describe 7 Polynesian babies with a unique severe form of holocarboxylase synthetase deficiency characterized by antenatal growth retardation, subependymal cysts, only partial response to biotin, and a poor outcome.     

Reducing knee and anterior cruciate ligament injuries among female athletes: a systematic review of neuromuscular training interventions

There is evidence that neuromuscular training not only decreases the potential biomechanical risk factors for ACL injury, but also decreases knee and, specifically, ACL injury incidence in female athletes. Five of the six interventions in this systematic review demonstrated significant effects on overall knee or ACL injury rates. It appears that plyometric power, biomechanics and technique, strength, balance, and core stability training can induce neuromuscular changes and potential injury prevention effects in female athletes. However, it is unknown which of these components is most effective or whether the effects are combinatorial. Future research should assess the relative efficacy of these interventions alone and in combination to achieve the optimal effect in the most efficient manner possible. Selective combination of neuromuscular training components may provide additive effects, further reducing the risk of ACL injuries in female athletes. Additional research directions include the assessment of relative injury risk using mass neuromuscular screening, the development of more specific injury prevention protocols targeted toward high-risk athletes, and the determination of when these interventions should be implemented. It may be that prepubertal or early pubertal female athletes may have the potential to achieve optimal biomechanical changes and the greatest chance of injury-free sports participation throughout their careers.     

Neuromuscular training improves single-limb stability in young female athletes

STUDY DESIGN: Controlled single-group pretest/posttest design. OBJECTIVE: The purpose of this study was to determine if a 6-week neuromuscular training program designed to decrease the incidence of anterior cruciate ligament (ACL) injuries would improve single-limb postural stability in young female athletes. We hypothesized neuromuscular training would result in an improvement in postural stability, with the greatest improvement taking place in the medial-lateral direction. BACKGROUND: Balance training has become a common component of programs designed to prevent ACL injury. Rehabilitation programs can improve postural stability following ACL injury and reconstruction; however, there is limited information available which quantifies improvement of postural stability following neuromuscular training designed to prevent ACL injuries in a healthy population. METHODS AND MEASURES: Forty-one healthy female high school athletes (mean age, 15.3 years; age range, 13-17 years) participated in this study. Single-limb postural stability for both lower extremities was assessed with a Biodex Stability System. The neuromuscular training program consisted of three 90-minute training sessions per week for 6 weeks. Following the completion of the training program, each subject was re-evaluated to determine change in total, anterior-posterior, and medial-lateral single-limb stability. Two-way analysis of variance models were used to determine differences between pretraining and posttraining and between limbs. RESULTS: The subjects showed a significant improvement in single-limb total stability (P = .004) and anterior-posterior stability (P = .001), but not medial-lateral stability (P = .650) for both the right and left lower extremity following training. In addition, the subjects demonstrated significantly better total postural stability on the right side as compared to the left (P = .026). CONCLUSIONS: A 6-week neuromuscular training program designed to decrease the incidence of ACL injuries improves objective measures of total and anterior-posterior single-limb postural stability in high school female athletes.