Feasibility and safety of airway bypass stent placement and influence of topical mitomycin C on stent patency

OBJECTIVE: Airway bypass via transbronchial fenestration has been shown to improve forced expiratory volume and flow in explanted human emphysematous lungs. The aim of this study was to evaluate the feasibility and safety of in vivo airway bypass stent placement by using a canine model and to assess the influence of topical mitomycin C on the prolongation of stent patency. METHODS: With dogs under general anesthesia, suitable segmental and subsegmental bronchial wall sites were selected by direct visualization with a flexible bronchoscope. Peribronchial blood vessel injury was avoided by using a Doppler probe. Transbronchial fenestration was formed with a 22-gauge transbronchial needle, and the passage was then dilated with a 2.5-mm angioplasty balloon. A balloon expandable stainless-steel stent (3 mm long x 3 mm wide) with a sleeve of silicone rubber covering was placed within the fenestration. Animals were bronchoscoped weekly to assess stent patency. Seventy stents were placed in 12 dogs. Thirty-five served as controls, and the other 35 received transbronchoscopic topical application of mitomycin C once weekly to evaluate the effect on the maintenance of stent patency. Mitomycin C stents were divided into 4 groups according to the number of treatments: group A, 1 treatment only; group B, 4 weeks; group C, 7 weeks; and group D, 9 weeks. Each once-weekly mitomycin C application consisted of 0.2 mL at a concentration of 1 mg/mL, delivered through a small polyethylene catheter. RESULTS: Four instances of minor and brief bleeding occurred during stent placement and resolved without incident. One pneumothorax occurred and was treated by chest tube placement, without any adverse sequelae. There was no mortality associated with stent placement. No delayed hemorrhage or pneumothorax occurred. All control stents were occluded at the 1-week follow-up. The median durations of stent patency for group A (n = 8), group B (n = 9), group C (n = 10), and group D (n = 8) were 3, 8, 13, and greater than 20 weeks, respectively. CONCLUSIONS: Airway bypass stent placement can be performed safely. In an animal model, most stents became occluded within 1 week, but topical mitomycin application resulted in significant prolongation of patency.     

Cervical spine assessment in the unconscious trauma patient: a major trauma service's experience with passive flexion-extension radiography

BACKGROUND: There is no consensus on the most appropriate method of cervical spine assessment in unconscious trauma patients. Passive flexion-extension imaging is one option for further investigating unconscious patients whose plain cervical radiographs are normal. This study examines the usefulness of this passive imaging in investigating for occult cervical injury. METHODS: All unconscious patients admitted to The Alfred Trauma Intensive Care Unit over 1 year (January 1-December 31, 1998), who could not be clinically assessed within 48 hours in regard to their cervical spine, were identified. Results of passive flexion-extension radiography were compared with final injury status and clinical outcome as determined by retrospective review of the imaging reports, radiographic films, and case notes. RESULTS: One hundred twenty-three patients with normal three-view plain radiographs proceeded to passive functional investigation. These were false-negative in four of the seven patients with cervical spine injuries at presentation. No patients suffered any adverse neurologic events from their delayed diagnoses or from the flexion-extension procedure. CONCLUSION: Passive flexion-extension imaging has inadequate sensitivity for detecting occult cervical spine injuries. Although no patients suffered adverse neurologic complications, the potential for devastating consequences from missed cervical injury has resulted in the removal of passive flexion-extension imaging from the screening protocol.     

Utility of restricted neck movement as a diagnostic criterion in case definition for neck disorders

OBJECTIVES: This study explored the utility of restricted neck movement in epidemiologic case definition for neck disorders. METHODS: Data on neck pain, sensory symptoms in the arm, psychosocial and physical risk factors for neck disorders, and the range of active neck movements were obtained through a self-administered questionnaire, interview, and physical examination for a community-based sample of 2145 adults aged 25-64 years. The prevalence of neck pain and sensory symptoms was examined according to the extent of neck movements. Logistic regression was used to assess the relation of risk factors to neck disorders, defined by various combinations of pain and restricted movement, and the associations were compared. RESULTS: The ranges of different categories of neck movement were correlated within persons, and their sum ("total neck movement") was unimodally distributed across persons. The prevalence of neck pain and sensory symptoms was elevated when total neck movement was below the 30th centile, and particularly below the 10th centile. Associations between neck pain and low vitality and poor support at work were stronger when there was also restricted neck movement, but the extent of neck movement did not materially modify the relation of neck pain to physical risk factors. CONCLUSIONS: The restriction of total neck movement may serve as a marker of severity in community-based studies of neck disorders, but no indication was found that it distinguishes a subset of cases with a distinct etiology.     

Failed intubation in obstetrics: has the incidence changed recently?

Editor—Over the years, airway problems have dominatedanaesthesia related maternal mortality. Failed intubation inparturients is more common than the general surgical populationwith incidences in the obstetric population being as high as1 in 250.^{1 2} We report our local experience. As a part     

An Internet Study of Cybersex Participants

Cybersex is a subcategory of online sexual activities (OSA) and is defined as when two or more people are engaging in sexual talk while online for the purposes of sexual pleasure and may or may not include masturbation. Cybersex is a growing phenomenon with a significant impact on participants but very little research has been done on this subject to date. This study is the first to attempt to delineate characteristics of those who engage in cybersex. Data were collected through an online questionnaire in Swedish, administered through the Swedish web portal Passagen.se. Out of the total sample (N = 1828), almost a third, both men and women, reported to have engaged in cybersex. A logistic regression analysis showed that age, sex, and sexual orientation were important demographic variables to consider when investigating cybersex. A comparison of interval data showed those engaging in cybersex to have a higher likelihood of spending more time online for OSA and having more offline sex partners than those not engaging in cybersex.This revised article was published online in June 2005 with the book reviews as separate articles     

Use of evidence in decision models: an appraisal of health technology assessments in the UK since 1997

OBJECTIVES: To review the sources and quality of evidence used in the development of economic decision models in health technology assessments (HTAs). METHODS: All economic decision models developed as part of the NHS Research and Development HTA Programme between 1997 and 2003 were reviewed. Quality of evidence was assessed using a hierarchy of data sources developed for economic analyses. RESULTS: Decision models are parameterized using diverse sources of evidence (e.g. randomized controlled trials, observational studies, expert opinion). Evidence on the main clinical effect was mostly identified and quality assessed as part of the companion systematic review/meta-analysis of the HTA and therefore reported in a transparent and reproducible way. For the other model inputs (i.e. adverse events, baseline clinical data, resource use and utilities), the search strategies for identifying relevant evidence were rarely made explicit and in a number of reports the sources of specific evidence were unclear due to poor reporting. CONCLUSIONS: A more formal and replicable approach to identification and assessment of quality of model inputs is required to reduce the 'black box' nature of decision models, and lead to less scepticism regarding model outputs.     

Localization of immunoreactivity for deleted in colorectal cancer (DCC), the receptor for the guidance factor netrin-1, in ventral tier dopamine projection pathways in adult rodents

DCC (deleted in colorectal cancer)-the receptor of the netrin-1 neuronal guidance factor-is expressed and is active in the central nervous system (CNS) during development, but is down-regulated during maturation. The substantia nigra contains the highest level of netrin-1 mRNA in the adult rodent brain, and corresponding mRNA for DCC has also been detected in this region but has not been localized to any particular neuron type. In this study, an antibody raised against DCC was used to determine if the protein was expressed by adult dopamine neurons, and identify their distribution and projections. Significant DCC-immunoreactivity was detected in midbrain, where it was localized to ventrally displaced A9 dopamine neurons in the substantia nigra, and ventromedial A10 dopamine neurons predominantly situated in and around the interfascicular nucleus. Strong immunoreactivity was not detected in dopamine neurons found elsewhere, or in non-dopamine-containing neurons in the midbrain. Terminal fields selectively labeled with DCC antibody corresponded to known nigrostriatal projections to the dorsolateral striatal patches and dorsomedial shell of the accumbens, and were also detected in prefrontal cortex, septum, lateral habenular and ventral pallidum. The unique distribution of DCC-immunoreactivity in adult ventral midbrain dopamine neurons suggests that netrin-1/DCC signaling could function in plasticity and remodeling previously identified in dopamine projection pathways. In particular, a recent report that DCC is regulated through the ubiquitin-proteosome system via Siah/Sina proteins, is consistent with a potential involvement in genetic and sporadic forms of Parkinson's disease.