Carcinoma of the laryngeal saccule: a novel biopsy technique to make a difficult diagnosis

Tumours of the laryngeal ventricle and saccule are rare and difficult to diagnose endoscopically. We present a case in which the tumour remained confined within the saccule, and describe how the problem of obtaining a positive biopsy was overcome.     

Acute respiratory distress syndrome among trauma patients: trends in ICU mortality, risk factors, complications and resource utilization

OBJECTIVE: To evaluate trends in mortality and related factors among trauma patients who developed acute respiratory distress syndrome (ARDS). STUDY: Observational study based on data prospectively gathered in computerized trauma registry. SETTING: Trauma intensive care unit (ICU) of 48 beds in level I trauma center. PATIENTS: All trauma patients with ARDS admitted during 1985-87 (486, group 1 [G1]) and 1993-95 (552, group 2[G2]). METHODS: ARDS was defined by American-European Consensus Conference criteria and the need for 48 h or more on mechanical ventilation with FIO2 greater than 0.50 and PEEP of more than 5 cmH2O. Demographics, severity score, injury-admission delay time, first 24-h transfusion and septic and organ system failure complications were independent variables. ICU mortality was the dependent variable. ICU length of stay (LOS) and life support techniques were considered. Respiratory and renal support strategies were different in the two time periods. RESULTS: Mortality decreased over the period (G1: 29.2% vs G2: 21.4%, p < 0.04), in patients aged both over and under 65 years. Multivariate analysis showed mortality was related to age, severity and time period (G1 1.68-fold that in G2) and that the greater G1 mortality was related to more renal failure and hematologic failure/dysfunction. ICU LOS decreased from 31.7+/-26.7 days (G1) to 27.3+/-22 days (G2) (p < 0.003). CONCLUSIONS: Mortality among trauma patients with ARDS declined over the 8 years studied and was associated with less organ failure. This reduction was probably the result of new approaches to mechanical ventilation, renal failure replacement and vasoactive drug therapy.     

Interhospital transport of the adult mechanically ventilated patient

Interhospital transport of the adult mechanically ventilated patient may be necessary for those who require specialized care. An experienced medical team can safely transport even the most critically ill patients if the care is optimized before departure. Patients with severe respiratory failure may have to remain on an ICU ventilator throughout the transport period, depending on the specific transport ventilator. Near-terminal ARDS can be treated with ECLS, and these patients also may be safely transported to a regional center.     

Associations between a polymorphism in the gene encoding glycoprotein IIIa and myocardial infarction or coronary artery disease

OBJECTIVES: The purpose of this study was to determine whether a common variant (PIA2) of the membrane glycoprotein (GP) IIIa gene is associated with myocardial infarction (MI) or coronary artery disease (CAD). BACKGROUND: Platelet GP IIb/IIIa is believed to play a central role in MI, binding fibrinogen, cross-linking platelets and initiating thrombus formation. Genetically determined differences in binding properties of GP IIb/IIIa might result in changes in platelet activation or aggregation and affect the risk of MI or CAD. METHODS: To determine associations (odds ratios [OR] > or =1.5 to 2.0) of genotype with MI or CAD, blood was drawn from 791 patients (pt) undergoing angiography. A 266 base pair fragment of the GP IIIa gene was amplified by the polymerase chain reaction and digested with the MspI restriction enzyme. Genotypes were identified after electrophoresis of digestion products in 1.5% agarose gel. RESULTS: Of the 791 pt, 225 had acute (n = 143) or previous MI, and 276 did not have MI or unstable angina. The PI(A2) allele was carried by 33.8% of MI pt versus 26.9% of no-MI control subjects, OR = 1.39 (95% CI, 0.95 to 2.04, p = 0.09). Angiographically, 549 pt had severe (>60% coronary stenosis) CAD, and 170 had normal coronary arteries (<10% stenosis). The PI(A2) allele was found in 31.0% of CAD pt versus 28.2% of no-CAD control subjects, OR = 1.14 (CI, 0.78 to 1.67, p = 0.50). When adjusted for six standard risk factors, ORs were 1.47 (CI, 0.98 to 2.20, p = 0.062) for MI and 1.20 (CI, 0.80 to 1.81, p = 0.38) for CAD. CONCLUSIONS: The PI(A2) variant of the gene encoding GP IIIa is modestly associated (OR approximately 1.5) with nonfatal MI but shows little if any association with CAD per se.     

Lung injury induced by sepsis: lessons learned from large animal models and future directions for treatment

Acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) remain common complications of sepsis. Unfortunately, development of effective pharmacologic and ventilatory treatment strategies for sepsis-induced ALI/ARDS has not made significant progress over the past several decades. One of the major reasons for this conundrum involves the animal models used as platforms for testing new treatment strategies. High-fidelity, clinically translational, large animal models are essential for developing treatments that will ultimately be successful in human clinical trials. Additionally, treatment strategies purely based on pharmacologic intervention are largely destined for failure as the redundancies in the systemic inflammatory response largely negate the effectiveness of a single-action drug. Conversely, a treatment strategy based on the appropriate use of mechanical ventilation affects lung physiology on a breath-to-breath basis and has the potential to treat, and even prevent, the ALI/ARDS associated with sepsis.