Cough and paradoxical vocal fold motion

OBJECTIVES: The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause. STUDY DESIGN AND SETTING: We conducted a review of the literature. METHODS: We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion. RESULTS: The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patient's reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists. CONCLUSION: Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients.     

Reconstruction of a transmetatarsal amputation stump using a salvaged peroneal artery fasciocutaneous flap from the opposite leg: A case report

During lower extremity amputation, the objective is to provide a functional residual limb that permits maximum patient mobility and independence. Preservation of length of the fore part of the foot using salvageable tissue from the amputated part in young patients prevents equines deformity and revision of amputation to a higher level. This can be achieved using tissue available from the amputated part. The spare part concept in reconstructive surgery should be integrated into the trauma algorithm to avoid additional donor site morbidity. Reported here is a young adult patient with crush injuries to both feet, which resulted in amputations. A fasciocutaneous flap raised from one extremity was used to facilitate transmetatarsal amputation stump length preservation of the other extremity.     

Hybrid Anterior Cruciate Ligament Reconstruction: Introduction of a New Technique for Anatomic Anterior Cruciate Ligament Reconstruction

Recently, anatomic or double-bundle reconstruction of the anterior cruciate ligament (ACL) has been presented in an effort to more accurately restore the native anatomy. These techniques create 2 tunnels in both the femur and tibia to reproduce the bundles of the ACL. However, the increased number of tunnels, particularly on the femoral side, has raised some concerns among authors and surgeons. We describe a technique to reconstruct the 2 distinct bundles of the ACL by using a single femoral tunnel and 2 tibial tunnels, the “hybrid” ACL reconstruction. The femoral tunnel is drilled through an anteromedial arthroscopy portal, which allows placement in a more anatomic position. Fixation in the femur is achieved with a novel device that separates a soft-tissue graft into 2 independently functioning bundles. Once fixed in the femur, the anteromedial and posterolateral bundles of the graft are passed through respective tunnels at the anatomic footprint on the tibia. These bundles are independently tensioned, which creates a reconconstruction that is similar to the native ACL. The technique presented provides surgeons with an alternative to other double-bundle techniques involving 4 tunnels.     

The Clinical Data Repository: A Challenge to Medical Student Education

The implementation of comprehensive clinical data repositories carries implications for the medical informatics curriculum for pre-MD medical students. There is the risk that electronic health records will detract from students’ acquisition of basic skills in inquiry and information management. It is possible, however, to create an application within the data repositories that will provide students with opportunities to practice their skills as they follow the evaluation and management of patients.     

Prevalence of posttraumatic stress disorder in wounded Vietnam veterans

Of 156 wounded Vietnam veterans evaluated for posttraumatic stress disorder (PTSD) by a questionnaire and a diagnostic interview in selected cases, 40% had a definite or probable lifetime diagnosis of PTSD. Of the 27 interviewed patients with lifetime PTSD, 81% currently met the PTSD criteria.     

Tularemia. A pathogen in nature and a biological weapon.

Tularemia as a potential biological weapon is of great concern because F. tularensis is a hardy organism that can be spread with a small inoculum. In addition, tularemia can be contracted through nature, predominately in rural areas. This disease can be spread by a wide variety of animals and can range from skin lesions to multi-organ involvement. The severity varies with amount of inocula, the virulence of the bacterium, and the port of entry. Exposure to aerosolized forms of F. tularensis, the major concern with bioterroism, can rapidly lead to respiratory failure and death. Untreated, other forms of tularemia can spread through the blood stream to other organs, leading to sepsis and death. Early recognition and treatment is tantamount to treatment and prevention of morbidity and mortality. Occupational health nurses are on the front line and must be assertive in identifying risk factors associated with exposure. Furthermore, education of the general population about exposure through nature can potentially decrease the incidence of tularemia. Occupational health nurses, as one of the largest health specialties in the workplace, may be the first contact for the exposed individual. Tularemia is treatable with knowledge of prevention, astute assessment, prompt identification, and treatment. Combined, they are powerful nursing tools in achieving optimal outcomes.