Who judges medical practice?

Lawsuits due to patient perception of inappropriate medical actions are a growing reality in medical practice, which entails widespread concern in the medical community. Lawsuits often entail additional circumstances beyond the primary concern of preventing or sanctioning acts of medical negligence. CETREMI proposes various recommendations aimed at legal and medical professionals to improve this circumstance and avoid harming the doctor-patient relationship.

Incidence and management of gusher in cochlear implantation

Objective

To present a report on the incidence and management protocol of cerebrospinal fluid gusher in cochlear implantation in the national institute of respiratory diseases.

Method

We conducted a clinical, longitudinal, retrospective investigation of all the medical charts from implanted patients between October 1999 and December 2016 in the national institute of respiratory diseases to evaluate the incidence of gusher, management protocol and evolution after surgery. Statistical analysis was conducted using Fishers test to find out if there was a relationship between the number of inner ear malformations and gusher severity and between the surgical access to the inner ear (cochleostomy or round window) and gusher severity.

Results

276 patients were evaluated, 12 (4.3%) presented gusher during cochlear implantation. Seven had minimal gusher that stopped completely with a fascia seal, three had moderate gusher that required fascia and cartilage and two had severe gusher that required middle ear packing and obliteration of the eustachian tube. There was no statistically significant relationship between the number of inner ear malformations or the surgical access to the inner ear with gusher severity.

Conclusions

A thorough evaluation of the imaging study should always be conducted, it should include specific measurements and an individualized management in accordance with gusher severity should always be performed.

Surgical Treatment of Labyrinthine Fistula Caused by Cholesteatoma

In a 144-month period, 27 cases of labyrinthine fistula (LF) were seen, and 360 mastoid operations were performed; the LF prevalence was 7.5%. Primary symptoms were hypoacusis, otorrhea, vertigo, tinnitus, and otalgia. All patients underwent preoperative CT scans and preoperative audiometry. LF diagnosis was made before surgery for 93% of patients on the basis of symptoms, signs, and imaging studies. With respect to surgical technique, the canal-wall-down procedure was performed in 92%, and the canal-wall-up procedure was performed in 8%. In 88% of patients the fistula was located in the horizontal semicircular canal. In 96% of patients the cholesteatoma matrix was removed, and the fistula was sealed; in 4% of patients the matrix was left. With a follow-up of 13 years, vertigo disappeared in 96% of patients, and hearing remained unchanged in 70% of patients. Further complications of chronic otitis media existed in approximately half of the patients with LF. Open surgery with removal of the cholesteatoma matrix and sealing of the fistula with temporalis fascia in a canal-wall-down manner is a safe procedure that can make vertigo disappear and helps to preserve cochlear function.

Functionality of CD4+ and CD8+ T cells from tonsillar tissue

For many years, tonsillectomy has been used routinely in children to treat chronic or recurrent acute tonsillitis. Palatine tonsils are secondary lymphoid organs and the major barrier protecting the digestive and respiratory tracts from potential invasive microorganisms. They have been used as sources of lymphoid tissue; however, despite the hundreds of papers published on tonsillectomy, no studies addressing the functionality of the CD4(+) and CD8(+) T cells from chronically infected tonsils have yet been published. The aim of this study was to analyse the functionality of the CD4(+) and CD8(+) T cells with respect to tonsillar tissue. We used an affordable approach to measure the frequency of antigen-specific CD4(+) T cells, the direct ex-vivo cytotoxicity of CD8(+) T cells, memory T cell phenotype, cytokine profile and DC phenotype. Our results demonstrate that CD4(+) and CD8(+) T cells from tonsillar tissue are totally functional, as shown by their ability to produce cytokines, to degranulate and to differentiate into effector-memory T cells.

Intralesional cidofovir in severe juvenile respiratory papillomatosis

Recurrent respiratory papillomatosis causes significant morbidity among affected children and usually requires frequent surgeries. We present a prospective case series including nine children at a Mexican tertiary referral center. All enrolled patients had severe disease that had required at least four surgical procedures, with a median of 6. Two children had tracheobronchial involvement, one had lung parenchymal disease, and one had a tracheostomy performed during his first surgery.

OBJECTIVE

To assess the efficacy of intralesional cidofovir in lowering the surgery rate.

STUDY DESIGN

Prospective case series.

SETTING

Tertiary referral center in Mexico City.

METHODS

Nine Mexican children with severe disease were enrolled. Intralesional cidofovir was applied after surgical debulking at a concentration of 5 mg/mL with a four to six week interval.

RESULTS

Six of the nine patients had a notable decrease in the rate of surgeries, with three patients remaining disease-free with follow up ranging from 1.8 to 3.3 years. No patient demonstrated laboratory abnormalities. Two patients showed moderate and mild dysplasia on papilloma biopsy distinguished by a lack of epithelial maturation with no mitoses or cellular atypia. Two patients died several months after the last injection.

CONCLUSIONS

Intralesional cidofovir appears to be effective in the treatment of recurrent respiratory papillomatosis, although further studies are required to determine its safety.

[Middle ear packing with collagen-polyvinylpyrrolidone sponge. Experimental study in guinea pigs]

INTRODUCTION

Packing material is mandatory in middle ear (ME) surgery in order to avoid inflammation, adhesions and fibrotic healing. Collagen polivynil-pirrolidone (CPVP) is a healing modulator, which reduces inflammation and fibrosis. Hence we can hypothesize that packing of the ME with CPVP sponge will lead a good ME healing.

OBJECTIVE

The aim of this study was to evaluate the otoscopic and microscopic changes induced on the healthy mucosa of the ME and Tympanic membrane (TM) after packing with CPVP sponge in guinea pigs.

MATERIAL AND METHODS

Twelve guinea pigs were operated on of right myringotomy. The ME was packed with: Group I (n = 6): Absorbable gelatin sponge (AGS) in SS; Group II (n = 6): CPVP soaked in SS. TM and ME integrity was evaluated otoscopically, as well as residual packing material. Euthanasia was performed on the 4th post-operative week. ME mucosa histologic examination was done.

RESULTS

Group I in all the cases showed residual packing material (p < 0.007 Student's test p < 0.001 ANOVA). Histologically both groups presented inflammation with polymorphonuclears, in addition group I showed severe lymphocytosis (p < 0.003 Student's, test p < 0.001, ANOVA).

CONCLUSION

The CPVP sponge when it is used as material of packing in the OM of guinea pigs produces less chronic inflammatory changes, but more studies with the injured mucosa are required to validate their utility in the otologic surgery.

Endoscopic assessment of adenoid size is an indicator of tissue virologic response to highly active antiretroviral therapy

OBJECTIVE

To compare human immunodeficiency virus viral load (HIVVL) in plasma versus the adenoid HIVVL during highly active antiretroviral therapy (HAART).

DESIGN

Adenoid biopsies were taken basally and after 3 and 6 months of treatment. Also, the adenoid diameter by simple endoscopy was measured, and its correlation with adenoid HIVVL was calculated.

SETTING AND PATIENTS

A public tertiary care human immunodeficiency virus (HIV) hospital research centre. Twenty-seven antiretroviral-naive HIV-infected patients, with a mean age of 34.7 years, were included in the study.

MAIN OUTCOME MEASURE

Correlation between adenoid diameter and plasma and tissue HIVVL.

RESULTS

At 3 months, although plasma HIVVL reduced by almost 5 log to a level below 1 log, adenoid HIVVL only decreased 2.36 log, remaining well over 4 log. At 6 months, plasma HIVVL further decreased to 0.205 log, but adenoid HIVVL remained at 2.424 log. Adenoid diameter also decreased over time, with means at 8.52, 5.61, and 4 mm, respectively. It significantly correlated with plasma and adenoid viral load, but the correlation was higher with the biopsies.

CONCLUSION

HIVVL in adenoid tissue is more resilient to HAART than plasma VL and may need more than 6 months to reach asymptomatic levels. Nevertheless, simple endoscopic measurement of the adenoid diameter is a good indicator of viral load decrease in this tissue.

Residual hearing preservation after cochlear implantation: Comparison between straight and perimodiolar implants

Objective

Investigate whether perimodiolar cochlear implants provide a better preservation of residual hearing than straight implants.

Study Design and Setting

Longitudinal, observational, and comparative study in tertiary center in Mexico City. Forty-eight patients who underwent cochlear implant surgery were included and were divided into two groups depending on whether they received a straight or a perimodiolar implant. The residual hearing of the operated ear was measured audiometrically before and after surgery. Variables analyzed were pure-tone average threshold at 125, 250, and 500 Hz and residual hearing at frequencies from 125 to 8000 Hz. Residual hearing was considered as preserved when audiometric changes were less than 10 dB HL in each variable.

Results

No statistically significant difference was found in the preservation of residual hearing between the two groups or between individual devices ( P > 0.05 in all variables).

Conclusion

Straight and perimodiolar cochlear implants seem to preserve residual hearing at similar rates across frequencies.

Surgical treatment of labyrinthine fistula caused by cholesteatoma

In a 144-month period, 27 cases of labyrinthine fistula (LF) were seen, and 360 mastoid operations were performed; the LF prevalence was 7.5%. Primary symptoms were hypoacusis, otorrhea, vertigo, tinnitus, and otalgia. All patients underwent preoperative CT scans and preoperative audiometry. LF diagnosis was made before surgery for 93% of patients on the basis of symptoms, signs, and imaging studies. With respect to surgical technique, the canal-wall-down procedure was performed in 92%, and the canal-wall-up procedure was performed in 8%. In 88% of patients the fistula was located in the horizontal semicircular canal. In 96% of patients the cholesteatoma matrix was removed, and the fistula was sealed; in 4% of patients the matrix was left. With a follow-up of 13 years, vertigo disappeared in 96% of patients, and hearing remained unchanged in 70% of patients. Further complications of chronic otitis media existed in approximately half of the patients with LF. Open surgery with removal of the cholesteatoma matrix and sealing of the fistula with temporalis fascia in a canal-wall-down manner is a safe procedure that can make vertigo disappear and helps to preserve cochlear function.

Scleroma of the lower respiratory tract: case report and review of literature

The case of a 46-year-old man who presented with acute respiratory distress due to a tracheal mass is reported. The patient underwent endoscopic resection of the mass and the histopathology revealed scleroma. No other sites of involvement by scleroma were found. This case is reported because laryngotracheal involvement by scleroma as the only manifestation of this disease is extremely rare.