Macroglossia: a case study

A young child with macroglossia of unknown cause was seen for treatment to modify resting tongue posture and improve speech sound production. Evaluation of the treatments indicated positive change in resting tongue posture and a modest change in speech sound production. Treatment for such patients can be complex and must consider orthodontic and/or surgical interventions, because an enlarged tongue can influence growth, development, and physiology of the oropharyngeal complex. The speech-language pathologist must be prepared to deal with the complex of problems demonstrated by patients with macroglossia during growth and development. LEARNING OUTCOMES: (1) As a result of this activity, the participant will be able to describe the sequelae of macroglossia. (2) As a result of this activity, the participant will be able to identify appropriate treatment options for children with macroglossia.     

Effectiveness of naltrexone in a community treatment program

OBJECTIVE: In several large, well-designed, randomized, double-blind studies, the opiate antagonist naltrexone demonstrated efficacy in the treatment of alcohol dependence. Specifically, when combined with certain psychosocial therapies, naltrexone reduces the number of drinking days, heavy drinking, and time to relapse to alcohol use in alcohol-dependent individuals. Whether this efficacy can be generalized to individuals who have alcohol use disorders and present for treatment at front-line community treatment programs has not been well established. METHODS: A total of 145 patients who presented for treatment at a rural community substance abuse treatment center were randomized to receive naltrexone 50 mg daily plus usual program treatment (n = 54), placebo plus usual treatment (n = 43), or usual treatment alone (n = 48) for 12 week. A total of 133 participants had at least one follow-up visit. Primary outcome measures included percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days (four or more for women and six or more for men), and time to first heavy drinking day. Secondary measures included changes in serum biological markers (alkaline phosphatase, alanine transaminase, aspartate transaminase, and gamma-glutamyltransferase), craving, and psychosocial functioning. RESULTS: In the intention-to-treat analysis, there were no between-group differences for any of the primary drinking outcomes at 12 weeks. In post hoc exploratory analyses, the entire sample of participants was divided into two new groups: (1) people who drank during the 2 weeks before the start of medication (entry drinkers) and (2) people who did not drink during this interval (entry abstainers). Entry abstainers were at an advantage at study entry in that they were significantly more likely to have an inpatient hospitalization immediately before entry into outpatient treatment. Mixed-model analysis of variance revealed a main effect for entry group at the 12-week treatment endpoint on the primary outcome measures of percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days, and time to first heavy drinking day. Participants in any of the randomized groups who were entry abstainers had significantly better improvement on all of the primary outcome measures. The abstainer groups that were randomized to placebo and usual treatment had significantly better outcomes than the entry drinkers in those perspective groups. However, for the naltrexone-treated group, entry drinkers and entry abstainers had similar improvement in drinking-related outcomes. CONCLUSIONS: These data suggest that naltrexone may offer particular benefit to patients who continue to drink during the early stages of the trial as compared with those who have achieved abstinence before treatment entry.     

Use of percutaneous drainage to treat hepatic abscess after radiofrequency ablation of metastatic pancreatic adenocarcinoma

Radiofrequency ablation (RFA) is well described in the treatment of primary hepatic malignancies and colorectal carcinoma hepatic metastases. A known complication of RFA is the development of hepatic abscess. The management of hepatic abscesses subsequent to RFA for metastatic disease is not well described. A 49-year-old female with pancreatic adenocarcinoma underwent pancreaticoduodenectomy followed by adjuvant chemoradiation. Following 6 months' treatment, a new liver metastasis was identified. It remained stable for 6 months during additional chemotherapy and thereafter was treated with RFA. Three weeks after RFA, the patient presented with malaise and leukocytosis, and a CT scan demonstrated a large hepatic abscess at the site of the RFA. She remained febrile despite needle aspiration and intravenous antibiotics. A percutaneous drain was placed and the symptoms resolved. Contrast injection of the drain 4 weeks later demonstrated resolution of the abscess cavity but communication with the biliary tree. The drain was removed and the tract embolized with Gel-foam to prevent complications of biliary-cutaneous fistula. She remains well without evidence of abscess or disease recurrence. Thus, RFA can be used in treatment of limited isolated hepatic metastases from previously treated pancreatic adenocarcinoma. However, the incidence of hepatic abscess is increased due to bilioenteric anastomosis; extended antibiotic prophylaxis should be considered.     

Muscle-type specific intramyocellular and hepatic lipid metabolism during starvation in wistar rats

The physiological dynamics of intramyocellular lipids (IMCLs) in different muscle types and of hepatocellular lipids (HepCLs) are still uncertain. The dynamics of IMCLs in the soleus, tibialis anterior, and extensor digitorum longus (EDL) muscles and HepCL during fed, 12- to 72-h starved, and refed conditions were measured in vivo by (1)H-magnetic resonance spectroscopy (MRS) in Wistar rats. Despite significant elevations of free fatty acids (FFAs) during starvation, HepCLs and IMCLs in soleus remained constant. In tibialis anterior and EDL, however, IMCLs increased significantly by 170 and 450% after 72 h of starvation, respectively. After refeeding, elevated IMCLs dropped immediately in both muscles. Total muscle long-chain acyl-CoAs (LCACoAs) remained constant during the study period. Hepatic palmitoleoyl-CoA (C16:1) decreased significantly during starvation while total hepatic LCACoAs increased significantly. Consistent with constant values for FFAs, HepCLs, IMCLs, and muscle LCACoAs from 12-72 h of starvation, insulin sensitivity did not change. We conclude that during starvation-induced adipocytic lipolysis, oxidative muscles dispose elevated FFAs by oxidation, while nonoxidative ones neutralize FFAs by reesterification. Both mechanisms might prevent impairment of insulin signaling by maintaining low levels of LCACoAs. Hepatic palmitoleoyl-CoA might have a special role in lipid metabolism due to its unique dynamic profile during starvation.     

Rat estrous cycle influences the sexual diergism of HPA axis stimulation by nicotine

We previously reported that female rats had significantly greater hypothalamic-pituitary-adrenal (HPA) axis responses to cholinergic stimulation by nicotine (NIC) than did male rats. Females in defined estrous cycle stages, however, were not studied because of sample size limitations. We further explored this finding by determining HPA axis responses to two doses of NIC in female rats (N = 101) during different estrous cycle stages, and in males (N = 69). NIC doses were: 0.3 mg/kg, which provided the greatest female-male difference in the earlier study, and 0.5 mg/kg, which stimulated the HPA axis similarly in the two sexes. Plasma AVP, ACTH, and corticosterone were measured. Proestrous and estrous females had higher ACTH responses to NIC (0.3 mg/kg) compared to metestrous and diestrous females, and compared to males. ACTH responses to NIC (0.5 mg/kg) were similar, regardless of estrous cycle stage or sex. Males had higher AVP responses to both NIC doses compared to females in all estrous cycle stages. Corticosterone responses followed the ACTH responses, except that females in all estrous stages started from a higher corticosterone baseline compared to males. These results are similar to our earlier findings across the estrous cycle with non-specific cholinergic stimulation by physostigmine and suggest that the nicotinic system contributes to the differential HPA axis responses to cholinergic challenge across the estrous cycle.     

Improving health with tobacco dollars from the MSA: the Arkansas experience

Analyses of expenditures from the historic tobacco Master Settlement Agreement (MSA) demonstrate the difficulties in achieving support for long-term disease prevention and health promotion initiatives. We report as a policy case study the successful development, political execution, and program deployment of new state health programs funded by Arkansas' MSA funds. Arkansas' success demonstrates the need for political leadership, the development and insertion of empirical health information into the policy deliberations, in-depth knowledge of the political process, and a broad-based coalition committed to improving health.     

The role of fetal breathing motions compared with gasping motions in pulmonary airway uptake of intra-amniotic iron dextran

OBJECTIVE: We hypothesized that normal fetal breathing, not acute asphyxial gasping, results in the movement of iron dextran from the amniotic cavity into the fetal lungs. In addition, the amount of iron dextran moving into the fetal lungs is cumulative with time. STUDY DESIGN: Twelve pregnant New Zealand White rabbits at 25 days of gestation were sedated and underwent ultrasound-guided injections of iron dextran into the amniotic cavities of the rabbit fetuses in both horns of each pregnant doe. Oxygen saturation was maintained at >90% in the pregnant does. The 12 does were then equally assigned to four groups on the basis of the duration of fetal exposure to the dextran (0, 8, 16, and 24 hours). At the end of each time point, one half of the fetuses received an intracardiac injection of potassium chloride to induce gasping just before necropsy. Gasping was confirmed by ultrasound scanning. At necropsy, the fetal lungs were evaluated grossly and underwent histomorphometry for iron distribution and quantification in the fetal airways. RESULTS: In the animals that received iron dextran, there was no significant difference in iron accumulation at any time point between those animals that did and did not receive potassium chloride, which suggests that acute gasping does not increase the accumulation of amniotic fluid substances in the lungs. The amount of iron in the fetal airways increased significantly with progressive length of exposure. CONCLUSION: We conclude that normal fetal breathing, not acute asphyxial gasping, resulted in the movement of intra-amniotic iron dextran into the fetal lungs and that the amount of substances that move into the fetal lungs accumulated with time.     

Remodelling of uteroplacental arteries is decreased in high altitude placentae

Uterine blood flow and birth weight are reduced and the risk of pre-eclampsia is increased in high-altitude pregnancies. Since IUGR and pre-eclampsia are associated with reduced invasion and remodelling of maternal spiral arteries we asked whether the terminal ends of uteroplacental arteries located at the maternal-foetal decidual interface evidenced less remodelling in 19 high (3100 m) compared with 13 moderate (1600 m) altitude placentae from normal pregnancies. Previous work has demonstrated marked villous angiogenesis in high altitude placentae. We asked whether such changes are compensatory for reduced modelling and/or whether they contribute to increased birth weight. Placentae were randomly sampled and examined with immunohistochemistry to evaluate vessel remodelling and foetal capillary density. The decidual ends of uteroplacental arteries were 8-fold more likely to be remodelled at 1600 vs. 3100 m (OR=8.1; CI 2.4, 27.0,P< 0.001). There were more than twice as many uteroplacental arteries observed in the high vs. moderate altitude placentae (OR=2.1; CI: 1.3, 3.5, P=0.006). Foetal capillary density was greater at 3100 vs. 1600 m (P< 0.001), but did not relate to remodelling nor to birth weight. In this in vivo model for chronic hypoxia, remodelling is reduced, and villous angiogenesis is not fully compensatory for reduced PO(2).     

Minimal ventilation to prevent bronchopulmonary dysplasia in extremely-low-birth-weight infants

OBJECTIVE: To determine whether minimal ventilation decreases death or bronchopulmonary dysplasia (BPD).Study design: Infants with birth weight 501 g to 1000 g and mechanically ventilated before 12 hours were randomly assigned to minimal ventilation (partial pressure of carbon dioxide [PCO(2)] target >52 mm Hg) or routine ventilation (PCO(2) target <48 mm Hg) and a tapered dexamethasone course or saline placebo for 10 days, using a 2 x 2 factorial design. The primary outcome was death or BPD at 36 weeks' postmenstrual age. RESULTS: After enrollment of 220 patients, the trial was halted because of unanticipated nonrespiratory adverse events related to dexamethasone therapy. The relative risk for death or BPD at 36 weeks in the minimal versus routine ventilation groups was 0.93 (95% CI, 0.77-1.12; P =.43). Ventilator support at 36 weeks was 1% in the minimal versus 16% in the routine group (P <.01). Major morbidities and long-term outcome were comparable in both treatment groups. CONCLUSIONS: With the sample size studied, minimal ventilation did not reduce the incidence of death or BPD. The reduced ventilator support at 36 weeks in the minimal ventilation group warrants further study of this intervention.