Vocal fold fixation due to proximal stenosis progression complicating idiopathic subglottic stenosis

European Archives of Oto-Rhino-Laryngology - This study examined the incidence and risk factors for vocal fold fixation due to proximal progression of idiopathic subglottic stenosis (ISS) over the...     

Prospective Comparison of Geriatric Assessment and Provider’s Assessment of Older Adults With Metastatic Breast Cancer in the Community

BackgroundGeriatric assessment (GA) is recommended for evaluating fitness of an older adult with cancer. Our objective was to prospectively evaluate the gaps that exist in the assessment of older adults with metastatic breast cancer (OA-MBC) in community practices (CP).MethodsSelf-administered GA was compared to provider’s assessment (PA) of patients living with MBC aged ≥65 years treated in CP Providers were blinded to the GA results until PA was completed. McNemar’s test was used to detect differences between PA and GA.ResultsOne hundred patients were enrolled across 9 CP (median age 73.9). Geriatric assessment detected a total of 356 abnormalities in 96 patients; of which, 223 required interventions. African American and widowed/single patients were more likely to have abnormalities identified by GA. On average, across 100 patients, PA did not detect 25.5% of GA-detected abnormalities, mostly in functional status, social support, nutrition, and cognition. These differences were less pronounced among providers with more clinical experience. Patients with abnormal Timed Up and Go tests more likely had additional abnormalities in other domains, and more abnormalities that were not identified by PA. Providers were “surprised” by GA results in 33% of cases, mainly with cognitive or social support findings, and reported plans for management change for 39% of patients based on GA findings.ConclusionsIncluding a GA in the care of OA-MBC in CP is beneficial for the detection of multiple abnormalities not detected by routine PA.     

The Asplund-Davies vertical scar breast reduction technique preserves the sub-areolar skin thickness in the long term: a matched comparative study with the inverted T technique.

BACKGROUND AND AIM: The inverted T technique, a popular method of breast reduction, relies on stretching the skin over glandular breast tissue to create the breast shape. The Asplund-Davies vertical scar method of breast reduction by contrast uses glanduloplasty to create the desired breast shape, achieving tension-free skin closure. Indeed the skin at the end of the vertical scar technique is wrinkled. It is known from tissue expansion literature that when skin is placed under tension the dermis becomes thinner. In this pilot cross-sectional study we compared breast skin thickness between two matched groups of patients undergoing breast reduction either with the inverted T or the vertical scar techniques, to determine whether the method of breast reduction impacts on breast skin thickness in the long term. MATERIALS AND METHOD: With a high frequency ultrasound machine the breast skin thickness of 24 breasts, 12 in each group, was measured by an independent consultant radiologist. Patients were matched in terms of age, time since operation, Fitzpatrick skin type, preoperative cup size and the amount of tissue resected. RESULTS: The breast skin in the inverted T group was significantly thinner than the vertical scar group (P<0.001). The inverted T group also had thinner skin in comparison to its control point (P<0.05). The vertical scar group had comparable skin thickness compared to its control point (P>0.05). CONCLUSION: This pilot study suggests that tension-free closure of skin with the vertical scar technique maintains breast skin thickness. Maintenance of breast skin thickness in this group may in turn contribute to the long term preservation of breast shape and form.     

An anatomical comparison of Blair and facelift incisions for parotid surgery

Background: The rhytidectomy approach for parotidectomy allows the incision to be hidden, and post‐operative scarring minimised. Furthermore, separate elevation of the Superficial Musculo‐Aponeurotic System (SMAS) reduces the incidence of Frey's syndrome, and provides vascularized soft tissue for contour reconstruction. The technique has gained popularity particularly with plastic surgeons, but concerns persist that with this approach, particularly with lesions located anteriorly, access to the gland may be inadequate, and facial nerve identification may be compromised. Materials and Methods: We undertook an anatomical study to quantitatively compare the surgical access achieved using the facelift approach with the conventional Blair incision, by comparing the distances between the parotid edge and the retracted flaps. Results: Despite reduced tissue elasticity due to formaldehyde fixation, it proved possible to demonstrate all regions of the parotid gland to the operating surgeon with either approach. There were no significant differences in the distance between the parotid edge and the retracted skin flaps (P > 0.1; paired t‐test). Conclusions: The facelift approach provides at least equal access to all regions of the parotid gland when compared to a Blair's incision. It is a superior approach aesthetically and its more widespread use in parotid surgery is advocated.     

Endonasal endoscopic approach to the petrous apex: an image-guided quantitative anatomical study.

BACKGROUND: The petrous apex is a relatively inaccessible region, deeply situated within the skull base. Removal of lesions from this area, traditionally accomplished via lateral approaches, can cause significant morbidity. We undertook an anatomical study to investigate the surgical anatomy of the petrous apex through an endonasal endoscopic approach, which has been sporadically described in the literature, to investigate its feasibility and to characterise clear and consistent surgical landmarks for access. METHODS: Cadaveric dissections were performed on five heads. Pre-dissection computed tomography scans were used, with the BrainLab navigation system, to verify entry into the petrous apex. Surgical landmarks were characterised in relation to fixed sphenoid sinus structures, and surgical access before and after drilling the sphenoid sinus rostrum was quantitatively compared. RESULTS: The landmark for entry into the petrous apex was the intersection of a vertical line halfway between the medial surface of the internal carotid artery and the midline, with a horizontal line one-third of the way up from the postero-inferior floor of the sphenoid sinus. The dimensions of the postero-superior sphenoid sinus were characterised by the inter-carotid distance, pituitary-to-sphenoid-floor distance and the width of the sphenoid sinus floor, which were 15 +/- 3 mm, 16 +/- 3 mm and 26 +/- 1.6 mm respectively. The surface area of surgical access was 193 +/- 28 mm(2), increasing to 316 +/- 39 mm(2) after drilling of the sphenoid rostrum (P < 0.001; paired t-test). CONCLUSIONS: Endoscopic approach to the petrous apex is anatomically feasible, and, aided by image navigation, could extend the scope of endonasal surgery to access highly-selected lesions in the middle cranial fossa.     

Dose-related effect of sevoflurane sedation on higher control of eye movements and decision making

Background. Saccadic latency may provide an objective methodto assess sedative doses of anaesthetic on cortical oculomotormechanisms and decision making. Methods. We tested the effects of random doses of 0, 0.1, 0.2and 0.3 MAC sevoflurane in six subjects, in a double-blind studyusing two measures of behavioural impairment: saccadic latencyand stop signal reaction time (SSRT) in a countermanding task. Results. Saccadic latency and SSRT both increased with increasingdoses of sevoflurane. In both measures, reciprocal reactiontime was linearly related to dose in each subject: all but twoof the twelve regression coefficients were statistically significant(P<0.05). In one subject, SSRT was significantly more sensitivethan simple latency (P<0.05); for the others there was nosignificant difference. Conclusion. Measurements of this kind could potentially provideestimates of cortical effects of sevoflurane sedation, and givea clinically useful measure of cognitive fitness. Br J Anaesth 2003; 91: 175–83     

Management of transfusion-related acute lung injury with extracorporeal cardiopulmonary support in a four-year-old child

We report a case of successful management of transfusion-relatedacute lung injury (TRALI) with prolonged cardiopulmonary bypasssupport in a 4-yr-old patient undergoing elective cardiac surgery.TRALI was diagnosed clinically and immunologically by detectionof reactive antibodies in a unit of fresh frozen plasma thathad been administered to the patient. The aetiology and managementof TRALI are briefly discussed and possible implications ofthis case for the management of TRALI are highlighted. Br J Anaesth 2003; 91: 292–4     

Computer assisted analysis of 2-DG autoradiographs

A computerized image processing system is described that assists the neurobiologists in analyzing data from 2-DG autoradiography by providing for: (1) Rapid fine-scale digitization of gray levels using a TV camera (2) The recognition of and verification of subtle differences in optical density with the aid of color windows (3) The superimposition of the autoradiographic image upon the histological image, so that the activity seen in the autoradiograph can be accurately assigned to anatomically defined structures (4) The production of numerical data suitable for statistical analysis and line drawings suitable for black on white publication (5) The relating of local gray level to a norm for the image as a whole, so as to remove the variability introduced by variations in section thickness, in the amount of 2-DG seen by the brain during incorporation, in level of anaesthesia, etc. If the localized darkening in autoradiographic images is being used as an index of localized functional activity rather than as a measure of metabolism, normalization obviates the need to obtain arterial blood samples. These routines permit anatomically accurate numerical analysis of autoradiographs without any constraints on the experimental situation.     

Total spinal anaesthesia in association with insertion of a paravertebral catheter

An association between intercostal nerve block and the developmentof a total spinal is rare. Usually, subarachnoid injection isconsidered to have followed intraneural placement or inadvertententrance into a dural cuff extending beyond an intervertebralforamen. We report a patient that followed injection of localanaesthetic into a paravertebral catheter sited at surgery inthe thoracic paravertebral space of a patient undergoing thoracotomy.This was a life-threatening event that occurred on two occasionsbefore the definitive diagnosis was made. It is considered likelythat the paravertebral catheter entered an intervertebral foramenand the tip perforated the dura. Br J Anaesth 2001; 86: 280–2