Anesthesia for pediatric airway endoscopy

Anesthesia for endoscopic assessment and treatment of airway problems in infants and children requires a systematic and thoughtful approach. The anesthesiologist and otolaryngologist should have a sound knowledge of the causes of airway obstruction. The anesthesiologist must be aware of the instrumentation likely to be used and the endoscopist must be well informed about the principles of anesthesia. The choice of technique depends upon the needs for each patient, but in most cases, the safest and most controlled method is a gaseous induction with assisted spontaneous respiration and continued maintenance by the inhalational method, supplemented by topically applied local anesthesia.

Obstructive suprastomal granulation tissue following percutaneous tracheostomy

Percutaneous dilatational tracheostomy is frequently performed as an alternative to traditional surgical open tracheostomy with many reported benefits. Despite its relative safety and widespread acceptance, complications can be associated with the procedure itself or long-term. We present four cases where there was difficulty with decannulation because of exuberant obstructive granulation tissue. In each case, the percutaneous tracheostomy involved the cricoid cartilage.

Recurrent laryngeal nerve injury caused by a laryngeal mask airway

Although there have been few reports of serious complications with the laryngeal mask airway, we record a case of permanent unilateral vocal cord paralysis following the use of a laryngeal mask airway and review the literature describing injuries, not only to the recurrent laryngeal nerves but also to the hypoglossal and lingual nerves.

[Legionellosis in Israel--a view of the situation]

Infection with Legionella remains an important cause of disease and death. We analyzed our laboratory data from 1993 through 1997, augmented by our 20 years of experience. The incidence of Legionella as a cause of pneumonia varied in our study from 5%-9%, with a slight increase during the winter. Isolation of these microorganisms from different water sources was higher during the summer and ranged from 7%-70%. Special laboratory tests are necessary to diagnose the disease and monitor these bacteria in water samples. The serologic method--indirect immunofluorescent assay--for 41 serogroups of Legionella was the main diagnostic method used. Legionella sg. 1 was the most frequent cause of the disease, with an incidence of 52% in 1993, decreasing to 15% in 1997. An increase in the incidence of seropositivity to "other Legionellae" is characteristic for our country. No correlation was found between the incidence of isolation of a specific strain and exposure. However, it is well known that the disease is overtreated but underdiagnosed, which requires reversal. Larger studies of Legionella colonization in water supplies and in air are needed in order to establish the risk of infection. Water sources are presently under-studied, as are respiratory devices in hospitals, or they are not studied at all in Israel, such as in mist machines in supermarkets, in dental clinics, and in ships and airplanes.

Psychosocial stressors among sheltered homeless children: relationship to behavior problems and depressive symptoms

Level of exposure to severe psychosocial stressors was assessed among homeless children in emergency family shelters in an urban locale. The relationship between such exposure and child mental health problems was then investigated, along with the effects of adult family social support. Implications of the findings are discussed.

Thirty-five-millimeter photography using the Kantor-Berci video laryngoscope

The Kantor-Berci model II laryngoscopes employ a centrally located rigid telescope. Although the primary application is for video laryngoscopy, the system can also be used for 35-mm photography during microlaryngeal operations. The fixed, unchangeable field of view and the great depth of focus make this system ideal for photographic documentation during endolaryngeal surgery without interruption of the procedure.

Acute rheumatic fever in southern Saudi Arabia

Forty six attacks of acute rheumatic fever (ARF) in forty patients were diagnosed between November 1987 and August 1995. Thirty four were initial attacks and 12 were recurrences. Arthritis was the commonest feature, 84.8%. Carditis occurred in 65.2% of the group, 67.6% of the initial attacks and 58.3% of the recurrences; however, the frequency of moderate/severe carditis was higher in recurrences, 25% versus 11.8%. Of those with carditis, mitral regurgitation occurred in 93.3%, aortic regurgitation in 16.7% and significant tricuspid regurgitation in 6.7%. Mitral stenosis was not encountered. No mortality occurred during ARF. Chorea, erythema marginatum and subcutaneous nodules were infrequent. These data are similar with those from a previous study which demonstrated the mild nature of ARF in Saudi Arabia, but showed higher frequency of carditis and suggested the frequency of carditis was not significantly higher during recurrences as compared to frequency of moderate/severe carditis.

Indirect laryngeal photography using rigid telescopes

A technique for indirect laryngeal color photography for the office or clinic using rigid rod-lens angled telescopes is outlined. The photographic equipment can be used for documentation at both direct and indirect laryngoscopy except that the latter requires purpose-designed 70 degrees or 90 degrees telescopes. The method, which requires practice and patience, and the equipment are described in detail, and the difficulties and frustrations that are encountered are discussed.

Idiopathic subglottic stenosis: diagnosis and endoscopic laser treatment

The records of 15 patients with idiopathic subglottic stenosis treated at Royal North Shore Hospital, Sydney, between 1980 and 1994 were reviewed. All were female and had similar characteristic clinical and histopathologic features. Endoscopic laser vaporization was the primary treatment in 12 patients and was successful in maintaining the airway of 8 of these 12; this outcome indicates that the disease can be managed, at least initially, by endoscopic laser treatment in most cases.

Airway management in acute infectious croup syndromes

The article presents the author's experience with airway management of 500 children with acute infectious croup and epiglottitis over a 7-year period in a teaching hospital setup. A policy of early elective protective intubation under controlled condition for children with severe croup and epiglottitis, in a multidisciplinary intensive care setting resulted in a satisfactory outcome. Recent developments in the field are discussed; these include non-invasive monitoring, medical treatment options for viral croup with parenteral high dose dexamethasone and nebulized adrenaline, newer broad-spectrum antimicrobials for drug-resistant bacterial infectious and an effective vaccine against Hemophilus influenzae type b. These hold the promise of reducing morbidity and mortality from acute infectious croup syndromes even in situations with limited surgical and monitoring facilities.

Renal agenesis and ureteropelvic junction obstruction in an infant with Turner syndrome

An infant who had Turner syndrome with left renal agenesis and right hydronephrosis due to functional ureteropelvic junction obstruction is reported. The importance of routine imaging for early identification of potentially serious renal anomalies in patients being evaluated for short stature and possible Turner syndrome is emphasized.

Sheltered homeless children: their eligibility and unmet need for special education evaluations

OBJECTIVES

This study described the proportion of sheltered homeless children in Los Angeles, Calif, who were eligible for special education evaluations because of a probable behavioral disorder, learning disability, or mental retardation, and to explore their level of unmet need for special education services.

METHODS

This was a cross-sectional study of 118 parents and 169 children aged 6 through 12 years living in 18 emergency homeless family shelters in Los Angeles County, California. Parents and children were interviewed with standardized mental health and academic skill measures in English and Spanish.

RESULTS

Almost half (45%) of the children met criteria for a special education evaluation, yet less than one quarter (22%) had ever received special education testing or placement. The main point of contact for children with behavioral disorders and learning problems was the general health care sector.

CONCLUSIONS

School-aged sheltered homeless children have a high level of unmet need for special education evaluations, the first step toward accessing special education programs. Interventions for homeless children should include integration of services across special education, general health care, and housing service sectors.

Hypoplasia of the epiglottis: case report and review

We report an infant born with a hypoplastic epiglottis and present the first in vivo photograph of the condition. Absence or hypoplasia of the epiglottis is a rare anomaly. Previously reported cases either died shortly after birth due to multiple congenital anomalies or details of the outcome were lacking. The clinical effects of hypoplastic epiglottis are discussed.

Effects of gender on listeners' judgments of speech intelligibility

Effects of gender on listeners' judgments of intelligibility were investigated. Subjects (15 women; 15 men) provided magnitude-estimation scaling responses and over-all impression of the intelligibility of a male and female speaker's comparable versions of audiotaped speech samples varying systematically in terms of the number of phonemes produced correctly. There was no significant difference between male and female subjects' magnitude-estimation scaling responses; however, their over-all impressions of the intelligibility of the speakers tended to differ. Women indicated that the male speaker was more understandable, and men indicated that the female speaker was more understandable. Magnitude-estimation scaling may provide an objective means for evaluating a speaker's intelligibility. It appears to transcend gender-biases associated with judgments of speech intelligibility.

Death following elective tracheostomy decannulation in chronic neonatal lung disease

Widespread air leak as a fatal complication of elective tracheostomy decannulation in a child aged 20 months with chronic neonatal lung disease (CNLD) is reported. We discuss likely mechanisms for the development of air leak following tracheostomy tube removal in young children with obstructive airways disease and suggest that this procedure be performed in an intensive care or high dependency unit.

Gastric outlet obstruction caused by prepyloric web in a case of Down's syndrome

The authors describe an infant with Down's syndrome who had a prepyloric web complicated by severe gastric outlet obstruction. The delay in diagnosis was responsible for malnutrition and the early postoperative complications of hypothermia and hypoglycemia. Awareness of the association of gastrointestinal abnormalities with Down's syndrome will enable appropriate evaluation for early diagnosis of this surgically correctable malformation.

Mental health problems among homeless mothers: relationship to service use and child mental health problems

BACKGROUND

The purpose of this study was to describe the prevalence of psychological distress and probable lifetime mental disorders among homeless mothers, their use of services, and the relationship between maternal and child mental health problems.

METHOD

The study involved a cross-sectional assessment of 110 mothers and 157 children living in homeless shelters in Los Angeles County.

RESULTS

The majority (72%) of sheltered homeless mothers reported high current psychological distress or symptoms of a probable lifetime major mental illness or substance abuse. However, few mothers (15%) in need of services received mental health care, and the main point of contact for those with a mental health problem was the general medical sector. Mothers with a probable mental disorder were also significantly more likely to have children with either depression or behavior problems.

CONCLUSIONS

Homeless mothers have a high level of unmet need for mental health services. The relationship between maternal and child problems underscores the need for homeless family interventions that promote access to psychiatric care for both generations.

Objective life circumstances and life satisfaction: results from the course of homelessness study

Relations between objective life circumstances and life satisfaction were examined using structural equation modeling of two waves of data obtained from homeless and mentally ill homeless participants (N = 298) in the Course of Homelessness Study (COH). Cross-sectional analyses revealed that objective indexes of life quality were primarily associated with domain-specific, rather than general, life satisfaction. Results could not be attributed to the covariation of life satisfaction with other indexes of subjective well-being (i.e., psychological symptoms and perceived self-mastery). In addition, significant direct ("causal") cross-lagged effects were found linking initial objective housing status with subsequent income and subsequent satisfaction with housing. By contrast, neither life satisfaction nor any other index of subjective well-being exerted a direct impact on subsequent life quality as assessed by objective indexes. Finally, we found no support for previous claims that perceived self-mastery mediates the impact of objective life circumstances on subsequent life satisfaction. Findings are discussed with reference to the utility of a hierarchical model of life satisfaction that incorporates domain-specific, as well as global, satisfaction.

Subglottic ductal cysts in the preterm infant: association with laryngeal intubation trauma

Acquired subglottic ductal cysts following prolonged intubation in preterm infants have been reported with increasing frequency during the past two decades. This paper reviews the subglottic ductal cysts diagnosed in 15 pediatric patients between 1989 and 1993--the largest such review. Eighty percent were observed in preterm low-birth weight infants following prolonged intubation, and all but 3 of the patients had major intubation trauma of the larynx--an association not previously reported. The cysts were usually multiple and arose in the posterolateral subglottis. Most were small and did not cause significant airway obstruction, but associated intubation changes were sufficiently severe to necessitate tracheotomy in 10 patients. The cysts observed in our study did not enlarge and in 4 patients were observed to spontaneously resolve or shrink in size--trends not previously reported. Subglottic ductal cysts noted in preterm infants after prolonged intubation most commonly occur in association with laryngeal intubation trauma and are likely a component of intubation trauma. Although these cysts may resolve without therapy, careful follow-up and treatment of potentially obstructing subglottic ductal cysts is recommended.

Effects of Medicare's prospective payment system on service use by depressed elderly inpatients

OBJECTIVE

To determine the effects of Medicare's prospective payment system (PPS) on hospital care, changes in length of stay and intensity of clinical services received by 2,746 depressed elderly patients in 297 acute care general medical hospitals were studied.

METHODS

A pre-post design was used, and differences in sickness at admission were controlled for. Data on length of stay and use of specific clinical services were obtained from the medical record using a medical record abstraction form. Care provided on units exempt from PPS was compared with care provided in nonexempt units.

RESULTS

After implementation of PPS, the average length of stay fell by up to three days within the different types of acute care settings studied, but this decline was partially offset by proportionately more admissions to psychiatric units, which had longer lengths of stay. Intensity of clinical services increased after PPS implementation, especially in nonexempt psychiatric units.

CONCLUSION

Despite financial incentives for hospitals to reduce clinical services under PPS, its implementation was not associated with a marked decline in length of stay, when averaged across all treatment settings, and was associated with an increase in the intensity of many clinical services used by depressed elderly patients in general hospitals.

Heterotopic bone formation affecting the hip joint is preventable in high risk patients by post-operative radiation

Between 1984 and 1993, 40 high risk patients (45 hips) received postoperative irradiation as prophylaxis against heterotopic ossification (HO). Radiotherapy was commenced within 5 days of the surgery in 43 of 45 hips. The development of HO was assessed by comparison of radiographic films prior to irradiation and at least 2 months after treatment (median interval 12 months). Progression of HO was observed in only two of 45 hips (4.3%) and of clinical significance in one (2.2%). Treatment was well tolerated with no acute complications or loosening of prosthetic components attributable to irradiation. During the study period, the treatment programme changed from 20 Gy in 10 fractions to 6-8 Gy in a single fraction, without loss of treatment efficacy. As well as improving resource utilization, single fraction techniques allow fewer patient transfers thereby reducing patient discomfort and risk of hip dislocation. This procedure is uncomplicated and should be considered more widely in the management of this disabling non-malignant condition.