Type I thyroplasty for acute unilateral vocal fold paralysis following intrathoracic surgery

Patients who undergo intrathoracic operative procedures for malignancy may require sacrifice of a recurrent laryngeal nerve. Postoperative vocal fold paralysis may lead to diminished cough with secretion retention, aspiration, and life-endangering pneumonia. This study retrospectively reviews our institution's experience of 23 patients who underwent type I thyroplasty within the 2-week (acute) period after thoracic surgery. Primary lung cancer (n = 16) was the most common disease. Upper lobectomy (n = 9) and pneumonectomy (n = 7) were the most frequent surgical procedures. Silicone medialization alone (n = 11) or with arytenoid adduction (n = 12) was performed. There were no significant postoperative complications. Improvements in hoarseness (86%), dyspnea (72%), dysphagia (50%), and aspiration (79%) were noted. Pulmonary status improved after vocal fold medialization, as reflected by decreased need for therapeutic bronchoscopy in the majority of patients in the postoperative period. Type I thyroplasty for vocal fold paralysis in the acute phase following thoracic surgery is well tolerated and is associated with improved patient outcome with no postoperative deaths in this high-risk patient population.     

Distribution,progression and chemical composition of cortical amyloid-β deposits in aged rhesus monkeys: similarities to the human

A comprehensive investigation of the incidence, distribution, progression and chemical composition of Abeta deposits in the brains of two young (5 years) and seven aged (25-30 years) rhesus monkeys was conducted to determine the similarity of this phenomenon to that in the human. The brains of the young rhesus were devoid of Abeta deposits. In contrast, Abeta deposits were observed within the cerebral cortex of all aged animals. In animals with mild Abeta burden, deposits were observed primarily in association cortical zones. In animals with moderate Abeta burden, many paralimbic cortical zones also contained Abeta deposits. Finally, in an animal with a heavy burden of Abeta, core limbic cortical zones were also involved. The primary sensory and motor cortices were relatively free of Abeta deposits. A higher proportion of plaques contained Abeta40 as compared with Abeta42. Abeta deposits contained a number of other constituents. Cholinesterases were present in nearly 50% of plaques and displayed the exact same biochemical characteristics as those in the human. Nearly 20% of Abeta deposits also contained apolipoprotein E and a smaller proportion contained heparin sulfate proteoglycans and alpha1-anti-chymotrypsin. The latter three chemicals were present in many compact plaques. These results indicate that the distribution, progression and chemical composition of plaques in the aged rhesus monkey display many similarities to those observed in the aged human and Alzheimer's disease. Therefore, despite some differences from the human, the aged rhesus may be a good model for studies of the pathological effects of Abeta in the primate brain.     

The effects of advanced age on the incidence of supraventricular arrhythmias after pneumonectomy in dogs

Because advanced age is the strongest independent risk factor for the development of supraventricular arrhythmias after lung resection, we compared the incidence and premorbid events of supraventricular arrhythmias after pneumonectomy in young and elderly dogs with the aim of better understanding potential age-related arrhythmogenic mechanisms. Right pneumonectomy was performed in 15 male mongrel dogs ("old" > or =8 yr [n = 8], "young" <4 yr [n = 7]) and the electrocardiogram continuously recorded by an implantable telemetry system for 1 wk before euthanizing. After surgery, 7 of 8 older animals (88%) developed a total of 23 episodes of sustained (>30 s) paroxysmal supraventricular tachycardia (SVT), compared with 0 of 7 (0%) young dogs, P = 0.0014. Analysis of heart rate over the 60 min preceding the onset of SVT revealed a progressive increase in sinus rhythm beginning 15 min before the arrhythmia. Comparison of the heart rate and rhythm obtained in younger animals from the corresponding postoperative hour demonstrated that although older animals developed more atrial (P = 0.03) and ventricular premature contractions (P = 0.056) and episodes of nonsustained ventricular tachycardia (P = 0.01), heart rate was similar for both groups until the increase in elderly dogs preceding the onset of SVT. Histologic examination of the atria showed interstitial fibrosis in old but not young animals. In addition, 4 of 8 (50%) elderly animals exhibited an inflammatory response within the atria consistent with acute myo- and epicarditis. We conclude that elderly dogs have an increased supraventricular arrhythmogenic potential within the first week after pneumonectomy than younger animals, perhaps because of increased atrial fibrosis and inflammation. Heart rate analysis before SVT onset suggests that adrenergic predominance was a probable responsible trigger. IMPLICATIONS: In this canine pneumonectomy model, advanced age was associated with an increased incidence of supraventricular arrhythmias, perhaps because of increased atrial fibrosis and inflammation.     

Clinical pattern and pathologic stage but not histologic features predict outcome for bronchioloalveolar carcinoma

BACKGROUND: The histologic criteria defining bronchioloalveolar carcinoma (BAC) were recently revised, but it is unclear whether these criteria predict clinical behavior. This study determined the outcome of resected BAC in relationship to clinical and radiologic disease pattern, and pathologic features. METHODS: Between 1989 and 2000, 100 consecutive surgically treated patients with adenocarcinomas exhibiting various degrees of BAC features were retrospectively studied. Histology was reviewed; tumors were classified as pure BAC, BAC with focal invasion, and adenocarcinoma with BAC features. Clinical and radiologic pattern were classified as unifocal, multifocal, or pneumonic. Demographic data, tumor stage, and outcome were recorded. Survival was analyzed by the Kaplan-Meier method, and prognostic factors were determined by the log-rank test. RESULTS: Patient median age was 65, and 74% of the patients were female. Pure BAC, BAC with focal invasion, and adenocarcinoma with BAC features occurred in 47, 21, and 32 patients, respectively. Unifocal disease occurred in 64 patients, multifocal in 29, and pneumonic in 7. Seventy-one patients had stage I/II tumors, 22 had stage III/IV, and 7 patients had Stage X tumors. Overall 5-year survival was 74%. There was no significant difference in survival among the three histologic subtypes. The pneumonic pattern had significantly worse survival compared with unifocal and multifocal patterns. Pathologic stage predicted survival, with 5-year survivals for I/II and III/IV of 83.7% and 59.6%, respectively. CONCLUSIONS: Clinical pattern and pathologic stage, but not the degree of invasion on histologic examination predict survival. Multifocal disease is associated with excellent long-term survival after resection. The favorable survival of stage III/IV BAC indicates that the current staging system does not fully describe this disease in patients undergoing resection because of its distinct tumor behavior.     

Cost effectiveness of combined spa–exercise therapy in ankylosing spondylitis: A randomized controlled trial

Objective

To evaluate the cost effectiveness and cost utility of a 3‐week course of combined spa therapy and exercise therapy in addition to standard treatment consisting of antiinflammatory drugs and weekly group physical therapy in ankylosing spondylitis (AS) patients.

Methods

A total of 120 Dutch outpatients with AS were randomly allocated into 3 groups of 40 patients each. Group 1 was treated in a spa resort in Bad Hofgastein, Austria; group 2 in a spa resort in Arcen, The Netherlands. The control group stayed at home and continued their usual activities and standard treatment during the intervention weeks. After the intervention, all patients followed weekly group physical therapy. The total study period was 40 weeks. Effectiveness of the intervention was assessed by functional ability using the Bath Ankylosing Spondylitis Function Index (BASFI). Utilities were measured with the EuroQoL (EQ‐5D_utility). A time‐integrated summary score defined the clinical effects (BASFI‐area under the curve [AUC]) and utilities (EQ‐5D_utility‐AUC) over time. Both direct (health care and non‐health care) and indirect costs were included. Resource utilization and absence from work were registered weekly by the patients in a diary. All costs were calculated from a societal perspective.

Results

A total of 111 patients completed the diary. The between‐group difference for the BASFI‐AUC was 1.0 (95% confidence interval [95% CI] 0.4–1.6; P = 0.001) for group 1 versus controls, and 0.6 (95% CI 0.1–1.1; P = 0.020) for group 2 versus controls. The between‐group difference for EQ‐5D_utility‐AUC was 0.17 (95% CI 0.09–0.25; P < 0.001) for group 1 versus controls, and 0.08 (95% CI 0.00–0.15; P = 0.04) for group 2 versus controls. The mean total costs per patient (including costs for spa therapy) in Euros (€) during the study period were €3,023 for group 1, €3,240 for group 2, and €1,754 for the control group. The incremental cost‐effectiveness ratio per unit effect gained in functional ability (0–10 scale) was €1,269 (95% CI 497–3,316) for group 1, and €2,477 (95% CI 601–12,098) for group 2. The costs per quality‐adjusted life year gained were €7,465 (95% CI 3,294–14,686) for group 1, and €18,575 (95% CI 3,678–114,257) for group 2.

Conclusion

Combined spa–exercise therapy besides standard treatment with drugs and weekly group physical therapy is more effective and shows favorable cost‐effectiveness and cost‐utility ratios compared with standard treatment alone in patients with AS.

     

Empowering employees with chronic diseases; development of an intervention aimed at job retention and design of a randomised controlled trial

Background  

Persons with a chronic disease are less often employed than healthy persons. If employed, many of them experience problems at work. Therefore, we developed a training programme aimed at job retention. The objective of this paper is to describe this intervention and to present the design of a study to evaluate its effectiveness.