A novel endoscopically placed stent to relieve glottic obstruction from bilateral vocal fold paralysis

Objective

Congenital bilateral vocal fold paralysis (BVP) is a rare but serious condition often requiring a tracheostomy to temporize the airway. In cases of idiopathic BVP, studies suggest waiting twelve months prior to laryngeal surgery because of a high rate of spontaneous recovery. Therefore a less invasive and reversible intervention would be optimal. A prospective study in a piglet model was undertaken to evaluate the efficacy of a novel spring-loaded stenting device designed to maintain laryngeal patency in an in vivo animal model of BVP.

Methods

Eight Yorkshire piglets had BVP induced by surgical division of the recurrent laryngeal nerves. Stents were endoscopically deployed between the arytenoid vocal processes. Animals were recovered and monitored for stridor, dietary intake, and weight gain. Animals were sacrificed after five days. Airway resistance using a calibrated manometer was measured at four time-points: baseline, BVP induction, stent insertion, and pre-sacrifice.

Results

Six of eight animals survived greater than five days with an average weight gain of 1.9 kg (p = 0.003). Relative inspiratory resistance increased from baseline after inducing BVP (1.00 vs. 1.468, p = 0.0315) and decreased to baseline levels with stent insertion (1.468 vs. 1.092, p = 0.0238). Expiratory resistance was not significantly influenced by stage of measurement (p = 0.236). Of the two animals not surviving the protocol, one had an unrelated anesthesia complication and the other a malpositioned stent.

Conclusion

The novel stent was successful in relieving the inspiratory resistance associated with BVP, without compromising swallowing and daily function. This may hold promise in temporarily securing the pediatric airway in the setting of BVP.     

Khite: a non-Western technique for temporary hair removal

Background Khite (also known as fatlah in Egypt) is a manual technique of temporary vellus hair removal that is widely performed In the Middle East. Methods The technique of khite is reviewed as illustrated. Results Khite is an effective method of removing unwanted vellus hairs. Conclusions Dermatologists in all parts of the world should be familiar with khite, because the ease of international travel may bring patients to their attention who have khite-association complications such as erythema, folliculitis, and secondary pigmentary changes.     

A systematic review of therapeutic hypothermia for adult patients following traumatic brain injury

Introduction

Research into therapeutic hypothermia following traumatic brain injury has been characterised by small trials of poor methodological quality, producing variable results. The Cochrane review, published in 2009, now requires updating. The aim of this systematic review is to assess the effectiveness of the application of therapeutic hypothermia to reduce death and disability when administered to adult patients who have been admitted to hospital following traumatic brain injury.

Methods

Two authors extracted data from each trial. Unless stated in the trial report, relative risks and 95% confidence intervals (CIs) were calculated for each trial. We considered P < 0 · 05 to be statistically significant. We combined data from all trials to estimate the pooled risk ratio (RR) with 95% confidence intervals for death, unfavourable outcome, and pneumonia. All statistical analyses were performed using RevMan 5.1 (Cochrane IMS, Oxford, UK) and Stata (Intercooled Version 12.0, StataCorp LP). Pooled RRs were calculated using the Mantel-Haenszel estimator. The random effects model of DerSimonian and Laird was used to estimate variances for the Mantel-Haenszel and inverse variance estimators.

Results

Twenty studies are included in the review, while 18 provided mortality data. When the results of 18 trials that evaluated mortality as one of the outcomes were statistically aggregated, therapeutic hypothermia was associated with a significant reduction in mortality and a significant reduction in poor outcome. There was a lack of statistical evidence for an association between use of therapeutic hypothermia and increased onset of new pneumonia.

Conclusions

In contrast to previous reviews, this systematic review found some evidence to suggest that therapeutic hypothermia may be of benefit in the treatment of traumatic brain injury. The majority of trials were of low quality, with unclear allocation concealment. Low quality trials may overestimate the effectiveness of hypothermia treatment versus standard care. There remains a need for more, high quality, randomised control trials of therapeutic hypothermia after traumatic brain injury.PROSPERO Systematic Review Registration Number 2012: CRD42012002449.     

The experiences of risk managers in providing emotional support for health care workers after adverse events

Risk managers often meet with health care workers who are emotionally traumatized following adverse events. We surveyed members of the American Society for Health care Risk Management (ASHRM) about their training, experience, competence, and comfort with providing emotional support to health care workers. Although risk managers reported feeling comfortable and competent in providing support, nearly all respondents prefer to receive additional training. Risk managers who were comfortable listening to and supporting health care workers were more likely to report prior training. Health care organizations implementing second victim support programs should not rely solely on risk managers to provide support, rather engage and train interested risk managers and provide them with opportunities to practice.     

Diabetes mellitus and the risk of cancer

Although diabetes has been known to increase the risk of cancer for over a century, it was not until recently when this area gained momentum and generated a lot of interest. That is in- part because of the rising global diabetes epidemic and the wide spread use of insulin analogues, metformin and other anti-diabetic agents, providing hypothesis generating data on the cancer risk in the diabetic population. Type 2 diabetes is associated with increased risk of breast, colon, pancreatic and other types of cancer, while type 1 diabetes is associated with increase in stomach, pancreatic, endometrial and cervical cancer. Mechanisms postulated for increased cancer risk in diabetes include hyperglycemia, hyperinsulinemia with stimulation of IGF-1 axis, obesity that serves as a common soil hypothesis for both cancer and diabetes as well as other factors such as increased cytokine production. More recently some antidiabetic agents have been thought to increase cancer risk such as insulin glargine, while metformin appears to lower cancer risk. In this review, we present the evidence for the link between diabetes and cancer highlighting the general mechanisms proposed for such a link as well as specific hypotheses for individual cancer. We will also discuss the role of insulin, metformin and other antidiabetic agents in cancer risk.     

Role of prothrombotic polymorphisms in successful or unsuccessful aging

The study of the genetic profile of centenarians aims to identify the genes and allelic variants which may influence a greater life expectancy and that can be considered as predisposing factors associated to the aging diseases, such as Alzheimer. Centenarians, that represent a cohort of selected survivors, show an hypercoagulability state characterised by striking signs of high coagulation enzyme activity, as directly assessed by the tested higher plasma level of some important factors involved in the haemostasis balance. Anyway, these individuals seem to have a reduced susceptibility to dementia, as well as to cardiovascular events. In this study we analyze the frequencies of Leiden Factor V polymorphism (G1691A), and G20210A of prothrombin (FII) in three cohorts of subjects: patients with Alzheimer’s disease (unsuccessful aging), nonagenarians (successful aging) and young healthy controls, to assess whether allelic variants associated to the modification of haemostatic system function, may play a role in the protection or susceptibility to Alzheimer disease, as well as to reach a successful aging. No significant differences were observed in the frequencies of the three groups studied. These results indicate that the presence or absence of the gene variants examined did not influence the achievement of advanced age and are not risk factors for Alzheimer’s disease. The state of hypercoagulability and the possession of these risk alleles appear to be compatible with the achievement of longevity and are not implied as risk factors in Alzheimer disease development.     

Percutaneous device closure of congenital and iatrogenic ventricular septal defects in adult patients

Objectives : We report our 10‐year experience with percutaneous closure of adult congenital and acquired (non‐post‐infarct) ventricular septal defects (VSDs) using different types of Amplatzer occluder devices. Background : Adult congenital and acquired VSDs may produce significant morbidity and mortality. Furthermore, such VSDs pose a significant surgical challenge. Methods : Between February 2000 and August 2009, data were retrospectively reviewed from 28 patients who underwent 29 procedures for percutaneous device closure of hemodynamically significant VSDs. Seventeen had unrepaired congenital VSDs, 10 had post‐operative VSDs (5 with residual patch‐margin defects, 4 post‐aortic valve replacement, 1 post‐myomectomy), and one had an acquired traumatic VSD. Indications for closure included : symptoms related to significant shunt (dyspnea on exertion); unexplained deterioration of LV function, and/or LV dilation; recurrent endocarditis, and pulmonary hypertension. Outcome parameters were procedural success, procedure‐related complications, evidence of residual shunt by echocardiography, and improvement in the signs/symptoms for which the procedure was performed. The mean follow‐up interval was 68 months. Results : Of the 28 patients studied, a single VSD was present in 26 patients, while one patient had two defects, and one patient had one defect on the LV side with three openings at the RV side. The median size of the defects by echocardiography was 6 mm. A device was successfully implanted in 28 of 29 (97%) procedures and 28 of 28 (100%) patients. Procedure‐related complications occurred in two cases : one involving an access site hematoma not requiring transfusion as well as nonsustained ventricular tachycardia that resolved spontaneously and the other involving acute mitral regurgitation due to inadvertent trapping of the anterior mitral valve leaflet between the left ventricular disk and the septum that was resolved by recapturing of the disk. There was immediate complete closure in 20 patients (71%). In six cases there was trivial residual shunt and in two patients the residual shunt was mild. At the latest follow‐up, four of the eight with a residual shunt had no shunt and in the remaining four the residual shunt was trivial. Among symptomatic patients 18 (64%), there was marked improvement in symptoms and for those patients 17 (61%) for whom the procedure was performed to address left ventricular enlargement, there was reduction or stabilization in LV size on serial echoes. Conclusions : Percutaneous closure of VSDs in the adult patient appears to be safe and effective. © 2010 Wiley‐Liss, Inc.