How reliable is assessment of true vocal cord-arytenoid unit mobility in patients affected by laryngeal cancer? a multi-institutional study on 366 patients from the ARYFIX collaborative group

PURPOSE

In clinical practice the assessment of the "vocal cord-arytenoid unit" (VCAU) mobility is crucial in the staging, prognosis, and choice of treatment of laryngeal squamous cell carcinoma (LSCC). The aim of the present study was to measure repeatability and reliability of clinical assessment of VCAU mobility and radiologic analysis of posterior laryngeal extension.

METHODS

In this multi-institutional retrospective study, patients with LSCC-induced impairment of VCAU mobility who received curative treatment were included; pre-treatment endoscopy and contrast-enhanced imaging were collected and evaluated by raters. According to their evaluations, concordance, number of assigned categories, and inter- and intra-rater agreement were calculated.

RESULTS

Twenty-two otorhinolaryngologists evaluated 366 videolaryngoscopies (total evaluations: 2170) and 6 radiologists evaluated 237 imaging studies (total evaluations: 477). The concordance of clinical rating was excellent in only 22.7% of cases. Overall, inter- and intra-rater agreement was weak. Supraglottic cancers and transoral endoscopy were associated with the lowest inter-observer reliability values. Radiologic inter-rater agreement was low and did not vary with imaging technique. Intra-rater reliability of radiologic evaluation was optimal.

CONCLUSIONS

The current methods to assess VCAU mobility and posterior extension of LSCC are flawed by weak inter-observer agreement and reliability. Radiologic evaluation was characterized by very high intra-rater agreement, but weak inter-observer reliability. The relevance of VCAU mobility assessment in laryngeal oncology should be re-weighted. Patients affected by LSCC requiring imaging should be referred to dedicated radiologists with experience in head and neck oncology.

Exploring Muscle Synergies for Performance Enhancement and Learning in Myoelectric Control Maps

This work proposes two myoelectric control maps based on a DoF-wise synergy algorithm, inspired by human motor control studies. One map, called intuitive, matches control outputs with body movement directions. The second one, named non-intuitive, takes advantage of different synergies contribution to each DoF, without specific correlation to body movement directions. The effectiveness and learning process for the two maps is evaluated through performance metrics in ten able-bodied individuals. The analysis was conducted using a 2-DoFs center-reach-out task and a survey. Results showed equivalent performance and perception for both mappings. However, learning is only visible in subjects that performed better in non-intuitive mapping, that required some familiarization to then exploit its features. Most of the myoelectric control designs use intuitive mappings. Nevertheless, non-intuitive mapping could provide more design flexibility, which can be especially interesting for patients with motor disabilities.

Validation of modular endoscopic medial maxillectomies for inverted papilloma of the maxillary sinus

BACKGROUND

Treatment of inverted papilloma of the maxillary sinus (IPMS) has a lower success rate compared to other IPs. As such, its correct management generally needs trans-nasal endoscopic medial maxillectomy (EMMs) for adequate resection. The aim of this manuscript is to describe outcomes and major prognostic factors of a cohort of patients with IPMS who were treated with EMM.

METHODOLOGY

In this multicentric study, patients affected with IPMS and treated with EMMs were included. The site of origin of the IPMS were studied as well as the type of EMM performed. The histological features (IP vs dysplasia), type of mucosal resection (total vs. pedicle oriented), and post-operative complications were analyzed.

RESULTS

310 patients were included (212 primary and 98 recurrent cases). After a mean follow-up of 45.4 months, 15 patients experienced recurrence (4.8%) due to the application of EMMs tailored to the surgical insertion point. Dysplasia was significantly associated with a higher risk of recurrence. The rates of early and late complications were 11.6% and 11.9%, respectively.

CONCLUSIONS

IPMS resection via tailored EMM is associated with excellent disease control, thus excluding the systematic use of extended EMMs, which can however be justified in case of dysplastic IPMS given its significant impact on recurrence.

WGA-LP: a pipeline for whole genome assembly of contaminated reads

SUMMARY

Whole genome assembly (WGA) of bacterial genomes with short reads is a quite common task as DNA sequencing has become cheaper with the advances of its technology. The process of assembling a genome has no absolute golden standard and it requires to perform a sequence of steps each of which can involve combinations of many different tools. However, the quality of the final assembly is always strongly related to the quality of the input data. With this in mind we built WGA-LP, a package that connects state-of-the-art programs for microbial analysis and novel scripts to check and improve the quality of both samples and resulting assemblies. WGA-LP, with its conservative decontamination approach, has shown to be capable of creating high quality assemblies even in the case of contaminated reads.

AVAILABILITY AND IMPLEMENTATION

WGA-LP is available on GitHub (https://github.com/redsnic/WGA-LP) and Docker Hub (https://hub.docker.com/r/redsnic/wgalp). The web app for node visualization is hosted by shinyapps.io (https://redsnic.shinyapps.io/ContigCoverageVisualizer/).

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Predictors of recurrence after surgical treatment of idiopathic progressive subglottic stenosis

Idiopathic progressive subglottic stenosis is a rare cause of tracheal narrowing. Partial cricotracheal resection and anastomosis can cure idiopathic stenosis, even if some patients may require multiple interventions and experience voice and swallowing deterioration. We investigated risk factors for retreatment and assessed the impact of crico-tracheal resection on functional parameters. We conducted a retrospective multicentric study on 44 female patients (mean age 52.6 ± 13.1 years) affected by idiopathic stenosis and treated by crico-tracheal resection between 2002 and 2016. Functional outcomes after crico-tracheal resection were assessed by the airway-dyspnoea-voice-swallowing score (range 1-5, with “1” expressing normal and “5” completely altered function). Previous treatments, grade of stenosis, site, airway comorbidities, age and resection length were tested as predictors of postoperative complications and number of additional treatments, using bivariate and multivariate analysis. The overall decannulation rate was 97.3%. The dyspnoea score improved (mean variation 1.4 ± 1.0; p < 0.001), while voice and swallowing were negatively affected (mean variation 1.6 ± 0.9 and 0.5 ± 0.7, respectively; p < 0.001). Airway comorbidities were associated with a higher rate of complications (p < 0.05). Retreatments were more frequent in patients with postoperative complications (p < 0.05). The length of resection correlated with the number of subsequent treatments (R = 0.52; p < 0.01). At multivariate analysis, post-operative complications were predicted by comorbidities and disease stage (p < 0.05); number of retreatments was linked to the length of resection (p < 0.05) as well as with the application of mitomycin C (p < 0.001). Crico-tracheal resection for idiopathic progressive subglottic stenosis offers good functional results in terms of airway patency. These data suggest that a higher complication rate can be expected in patients affected by comorbidities. Moreover, more extensive surgical resection seems to be associated with the occurrence and number of subsequent retreatments. On the contrary, the local application of an anti-proliferative drug does not seem to be of use in preventing recurrences.

Tongue carcinoma in young adults: a review of the literature

SUMMARY

A recent reduction in the number of smoke-related tumours has been observed thanks to the diffusion of anti-tobacco campaigns carried out in the majority of developed countries. Nevertheless, as demonstrated by recent global epidemiologic studies, squamous cell carcinoma of the mobile tongue appears to be progressively increasing in incidence, particularly among young adults and especially in females. The driving mechanism responsible for such changes is still to be precisely defined. Several genetic studies have compared the mutational pattern of tongue squamous cell carcinoma in young adults to that of more elderly patients, without identifying significant differences that may help in better characterising this subgroup of subjects. Tongue squamous cell carcinomas in young adults have been historically considered as particularly aggressive clinical entities, with a high risk of loco-regional relapse, survival rates inferior to those of the general head and neck cancer group and need for a more aggressive therapy. However, considering the most recent studies, prognostic results in this patient group are heterogeneous and it is not possible to confirm this tendency. Thus, it is not justified to embrace different therapeutic approaches according to patient age. Eventually, an additional element to consider when examining young subjects affected by tongue cancer is the possibility of genetic predisposition. Alterations affecting pathways involved in DNA repair, surveillance of genetic stability or regulation of cellular growth may determine an increased likelihood of developing head and neck cancers.

ERP and Adaptive Autoregressive identification with spectral power decomposition to study rapid auditory processing in infants

The ability to process rapidly-occurring auditory stimuli plays an important role in the mechanisms of language acquisition. For this reason, the research community has begun to investigate infant auditory processing, particularly using the Event Related Potentials (ERP) technique. In this paper we approach this issue by means of time domain and time-frequency domain analysis. For the latter, we propose the use of Adaptive Autoregressive (AAR) identification with spectral power decomposition. Results show EEG delta-theta oscillation enhancement related to the processing of acoustic frequency and duration changes, suggesting that, as expected, power modulation encodes rapid auditory processing (RAP) in infants and that the time-frequency analysis method proposed is able to identify this modulation.

Adaptive synergies for the design and control of the Pisa/IIT SoftHand

In this paper we introduce the Pisa/IIT SoftHand, a novel robot hand prototype designed with the purpose of being robust and easy to control as an industrial gripper, while exhibiting high grasping versatility and an aspect similar to that of the human hand. In the paper we briefly review the main theoretical tools used to enable such simplification, i.e. the neuroscience-based notion of soft synergies. A discussion of several possible actuation schemes shows that a straightforward implementation of the soft synergy idea in an effective design is not trivial. The approach proposed in this paper, called adaptive synergy, rests on ideas coming from underactuated hand design. A synthesis method to realize a desired set of soft synergies through the principled design of adaptive synergy is discussed. This approach leads to the design of hands accommodating in principle an arbitrary number of soft synergies, as demonstrated in grasping and manipulation simulations and experiments with a prototype. As a particular instance of application of the synthesis method of adaptive synergies, the Pisa/IIT SoftHand is described in detail. The hand has 19 joints, but only uses 1 actuator to activate its adaptive synergy. Of particular relevance in its design is the very soft and safe, yet powerful and extremely robust structure, obtained through the use of innovative articulations and ligaments replacing conventional joint design. The design and implementation of the prototype hand are shown and its effectiveness demonstrated through grasping experiments, reported also in multimedia extension.

A new device for the care of Congenital Central Hypoventilation Syndrome patients during sleep

Congenital Central Hypoventilation Syndrome (CCHS) is a genetic disease that causes an autonomous nervous system dysregulation. Patients are unable to have a correct ventilation, especially during sleep, facing risk of death. Therefore, most of them are mechanically ventilated during night and their blood oxygenation is monitored, while a supervisor keeps watch over them. If low oxygen levels are detected by the pulse-oximeter, an alarm fires; the supervisor deals with the situation and, if there is neither a technical problem nor a false alarm, wakes the subject, as CCHS patients usually recover from hypoxia when roused from sleep. During a single night multiple alarms may occur, causing fractioned sleep for the subject and a lasting state of anxiety for supervisors.

Differential enamel and osteogenic gene expression profiles in odontogenic tumors

Odontogenic tumors occur within the jaw bones and may be derived from odontogenic epithelium or ectomesenchyme or contain active components of both tissue types. We investigated the gene expression profile of enamel matrix proteins (EMPs), genes related to osteogenesis, and the mineralization process in odontogenic tumor cell populations focusing on an ameloblastoma (AB-1), a keratocystic odontogenic tumor (KCOT-1), and a calcifying epithelial odontogenic tumor (CEOT-1). All cell populations were shown to be epithelial in origin by CK14 expression. All tested EMPs were expressed by all odontogenic tumor cell types, with higher transcript levels seen in the AB-1 population especially for AMEL, AMBN, and ODAM. CEOT-1 cell populations showed a greater content of ALP-positive cells as well as higher ALP mRNA levels. Using qRT-PCR, we found a higher expression of 8 genes in the CEOT-1 compared to the AB-1 and KCOT-1. In this study we demonstrated the establishment of AB-1, KCOT-1 and CEOT-1 cell populations. The unique gene expression profiles of AB-1, KCOT-1, and CEOT-1 cells and their interactions with the surrounding microenvironment may support their unique tumor development, progression, and survival.

Endoscopic treatment of Zenker's diverticulum by carbon dioxide laser

The management of Zenker's diverticulum remains controversial, as both external and endoscopic procedures are potentially associated with post-operative complications and risks. The endoscopic approach is based on cricopharyngeal myotomy or myectomy by laser, cautery or stapling. A retrospective chart review has been made from December 1994 to April 2009 of all patients with Zenker's diverticulum treated by endoscopic cricopharyngeal myectomy using CO(2) laser at the Department of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia, Italy. Of the 28 patients (19 males, 9 females; mean age, 64 years; range, 46-95) scheduled for the trans-oral procedure, 27 (96%) were endoscopically treated. Diagnosis was based on the patient's history, flexible fiberoptic examination of the larynx, hypopharynx, and oesophagus, and videofluoroscopy with barium. Exclusion criteria included severe medical co-morbidities, impossibility to endoscopically expose the diverticulum, and small (< 2 cm) or large (> 6 cm) diverticula. The endoscopic procedure was performed using a CO(2) laser to section the cricopharyngeal muscle and remove the posterior part in order to obtain partial myectomy. Major complications occurred in 2 (7%) patients. No cases of recurrent nerve paralysis, pharyngo-cutaneous fistula, neck emphysema, post-operative bleeding, mediastinitis or aspiration pneumonia were observed in the present series. A swallow survey was obtained by telephone: 85% of patients reported improved swallowing (without symptoms in 11 and with moderate dysphagia in 7). Based on the present series, endoscopic CO(2) laser cricopharyngeal myectomy for Zenker's diverticulum can be considered an effective and safe procedure, with reduced hospitalization time and complication rate.

Quality of life in patients treated for cancer of the oral cavity requiring reconstruction: a prospective study

Surgical treatment for cancer of the oral cavity can result in dramatic aesthetic and functional sequelae partially avoidable by reconstructive techniques. Many studies concerning quality of life have been carried out in order to retrospectively assess outcomes after such major oncological procedures. Aim of this study was to evaluate, in a prospective fashion, the quality of life as a primary endpoint in patients treated for cancers involving the oral cavity and requiring reconstruction. The study design consisted of a prospective evaluation of pre- and post-operative quality of life at 3, 6, and 12 months to assess variations during follow-up using two different questionnaires: the University of Washington Quality of Life and the Head and Neck Performance Status Scale. Between May 1999 and October 2004, 92 patients with oral cancer requiring reconstruction were treated. All were included in the study, but only 35 (38%) concluded the evaluation protocol at one year after surgery without evidence of disease. The mean pre- and post-operative (3, 6, and 12 months) scores of the questionnaires and the scores of specific University of Washington Quality of Life categories (disfigurement, chewing, swallowing, comprehension of speech) were evaluated. The impact on residual quality of life of different factors such as gender, extension of tongue and mandibular defects, type of reconstruction, and radiotherapy was statistically quantified with a Wilcoxon non-parametric test and logistic regression for multivariate analysis. Comparison of mean pre- and post-operative scores between the University of Washington Quality of Life and Head and Neck Performance Status Scale, showed a similar trend during the study period with a significant decrease at 3 months after surgery and subsequent gradual improvement at 6 and 12 months. The majority of patients (77%) preserved normal or near normal functions at 12 months after surgery. The chewing domain worsened considerably (p <0.05), with poorer outcome in patients undergoing segmental mandibulectomy (p <0.05). By multivariate analysis, mandibular resection maintained its statistical significance in the chewing domain (p = 0.038). Moreover, the type of reconstruction was an independent factor (p = 0.038) that influenced the University of Washington Quality of Life total score, with better functional results after free flap reconstruction. Despite the dismal prognosis of patients affected by advanced oral cavity cancer, reconstructive techniques play a crucial role in maintenance of satisfactory quality of life.

Narrow-band imaging: a new tool for evaluation of head and neck squamous cell carcinomas. Review of the literature

Head and neck squamous cell carcinoma of the upper aerodigestive tract is well known for its frequently late presentation and diagnosis at an advanced stage. In addition, it is well recognized that it may arise in multiple sites, either synchronously or metachronously. Thus it should be imperative to endoscopically screen the upper aerodigestive tract of patients at risk for head and neck squamous cell carcinoma with a new diagnostic tool, especially due to the fact that early lesions are very difficult to detect even by multiple passes with a standard endoscopy, if they are < or = 1 cm in diameter. Lugol chromoendoscopy, which is mainly used in the oesophagus, is not suitable for the head and neck region due to severe mucosal irritation. Herein, narrow-band imaging is described, a diagnostic tool already proved as a useful screening method in other endoscopic fields, and its application in the early detection of head and neck squamous cell carcinoma is reviewed, as reported by previous studies in the otolaryngologic literature. Narrow-band imaging relies on the principle of depth of penetration of light, with the narrow-band blue light having a short wavelength (415 nm) penetrating into the mucosa and highlighting the superficial vasculature. Furthermore, the blue filter is designed to correspond to the peak absorption spectrum of haemoglobin to enhance the image of capillary vessels on surface mucosa. Thus, superficial mucosal lesions that would be missed by regular white light endoscopy, are identified, in view of their neoangiogenetic pattern of vasculature, using the blue light of the narrow-band imaging. Narrow-band imaging has been used extensively in the lower aerodigestive system, yet there are only 2 reports of applications in the region of the head and neck, specifically the oropharynx and the hypopharynx. However, these are not the only sites that can benefit from narrow-band imaging. Herewith, the uses and importance are highlighted of narrow-band imaging as a future diagnostic tool in otolaryngology, in the pre-, intra- and post-operative settings.

[Management of lymph node metastases in well-differentiated and medullary thyroid cancer: retrospective study on 52 cases]

OBJECTIVE

To define the surgical principles of neck dissections as applied to the head and neck squamous cell carcinomas, extending their rationale to treatment of lymph nodes metastases from thyroid carcinomas.

MATERIALS AND METHODS

Between January 1994 and June 2002, 52 patients affected by well-differentiated thyroid cancers (1 follicular, 9 medullary, and 42 papillary cancers) underwent uni- or bilateral neck dissections at our Department, for a total of 73 neck dissections. Patients were subdivided into 2 groups: 37 simultaneously treated on the thyroid and the neck (Group A), and 15 operated elsewhere on the thyroid and for a neck recurrence and/or persistence at our Department (Group B).

RESULTS

48 patients underwent a regular follow-up (range: 3-86 months, mean: 38). Among patients alive with disease, 5 in Group A and 4 in Group B had a local-regional recurrence. In particular, 2 patients for each group (2 medullary and 2 papillary cancers) had a regional recurrence on the N site, at the level of one or more lymph nodes "in field" as regards the neck dissection previously performed. Moreover, in all these patients a local recurrence on the T site has been observed.

DISCUSSION

Lymph nodes metastases have a minor prognostic impact in well-differentiated thyroid cancers in respect of the rest of head and neck cancers. Nonetheless, when performing a curative or elective neck dissection, the gold standard surgical principles must be the same. As a matter of fact, a 20% incidence of lymph nodes metastases at the V level, often not specifically addressed in neck dissections for thyroid cancers, it is noteworthy. Aim of such an aggressive surgical approach of the neck is to obtain a low incidence of "in field" regional recurrences, which become no more amenable of a subsequent surgical salvage.

CONCLUSION

Surgical techniques as lymphadenectomy or "pick-berry procedure" must be abandoned because they do not respect the basic anatomic, physiopathologic, and oncologic principles of neck dissections along cervical fasciae and spaces.

[Identification of the patient with sepsis]

Sepsis may be defined as a clinical syndrome caused by an organism's response to infection. The complex alterations triggered by the infection include inflammation and systemic coagulopathy in the absence of effective fibrinolysis. Possible manifestations vary in entity and severity, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiorgan dysfunction syndrome (MODS). The nurse can play a fundamental role in the timely recognition of SIRS and in the early identification of the onset of signs of organ damage. In this way, an additional aid to establishing diagnosis can be provided and targeted treatment instituted. Following a brief presentation of the pathophysiology and epidemiology of sepsis, the manifestations and attendant risks are described, the most appropriate monitoring methods and the main nursing tasks in treating sepsis are discussed. We present the results of our experience in identifying patients with sepsis through the application of selection criteria adopted from clinical studies on the use of activated protein C.

Tracheocoele in a Duchenne muscular dystrophy patient. Case report

Tracheocoele, a congenital or acquired lesion, is rarely detected radiologically and even more rarely diagnosed clinically. This tracheal lesion is characterised by the presence of a single cystic lesion filled with air or a mixture of liquid and air, of extremely variable size, occurring in almost all cases, in a locus minoris resistentiae situated in the right posterolateral portion of the trachea. The rare case is described of a voluminous tracheocoele located in the left paratracheal region, extending from the cricoid to sternal notch, manifesting clinically, 3 months prior to evaluation in our hospital in a 27-year-old male suffering from Duchenne muscular dystrophy since the age of 5 years. For 10 years, the patient had been treated with intermittent positive pressure ventilation via nasal mask, due to progressive deterioration of respiratory function. Diagnosis of tracheocoele, initially made at computed axial tomography scan, was confirmed by flexible laryngotracheoscopy under local anaesthesia. Due to severe comorbidity associated with the clinical picture described, the absence of a significant set of symptoms, and the problems concerning anaesthesiological management of the patient, palliative treatment was the only choice. This consisted in cervical compression bandaging during assisted nasal ventilation. Close follow-up was performed in order to monitor any progression of the lesion or onset of related complications. This is the second case of tracheocoele originating in the left paratracheal region reported in the literature, and the first associated with Duchenne muscular dystrophy and prolonged use of a positive pressure respirator. The aetiopathogenic mechanisms that may have determined the formation of this rare lesion are then taken into consideration.

Atypical carcinoid tumour of the larynx treated with CO2 laser excision: case report

A case of atypical laryngeal carcinoid tumour of the right aryepiglottic fold is described in a 56-year-old female. The patient presented a 4-year history of dysphagia, occasional dyspnoea and pain originating in the right tonsillar fossa and radiating to the ear. A sessile, submucosal neoplasm of about 1 cm in diameter and apparently benign appearance was detected endoscopically in the supraglottic region. An excisional biopsy was collected by CO2 laser during direct microlaryngoscopy from which a diagnosis of atypical carcinoid tumour of the larynx was made, and later confirmed by histochemical and immunohistochemical staining. Post-operative course was uneventful, with return to a normal diet per os on the first post-operative day. Histopathological evaluation of the excised specimen revealed the presence of a neoplasm in proximity of the surgical margins, which were not, however, directly involved by the tumour. The close endoscopic follow-up was, nonetheless, implemented in order to promptly detect any evidence of relapse of the disease. After 18 months, a lesion, suspected of being a recurrence, was found, in the site of the original tumour. CO2 laser excision was again carried out, this time allowing for wider margins on the surgical resection. The post-operative diagnosis confirmed the clinical hypothesis of recurrence of atypical carcinoid tumour. The patient is presently alive and free from disease 7 years after the second endoscopic procedure. The difficult aspects of clinical and histopathological diagnoses, the surgical treatment as well as endoscopic and instrumental follow-up of this rare condition are discussed.

[Laryngeal carcinoma associated with congenital tracheobronchomegaly (Mounier-Kuhn syndrome): a case report]

Congenital tracheobronchomegaly or Mounier-Kuhn Syndrome is a rare disorder of controversial etiology. It is characterized by an abnormal enlargement of the trachea and primary bronchi, because of atrophy or absence of their elastic fibers and smooth muscles. Such alterations lead to the collapse of the respiratory tract during forced exhalation, making expectoration by coughing of little use. Subjects with this disorder are, therefore, predisposed to the development of phlogistic bronchopulmonary pathologies such as bronchitis, emphysema, bronchiectasis and pulmonary fibrosis. The present work reports the case of a 65-year-old man suffering from asymptomatic congenital tracheobronchomegaly which was unknown until preoperative testing was performed (standard chest x-ray, tracheobronchoscopy) following a diagnosis of squamous cell carcinoma of the larynx. The patient underwent total laryngectomy and bilateral neck dissection without any intra- and postoperative complication. This is the first case reported in the literature of an association between laryngeal carcinoma and Mounier-Kuhn Syndrome, although a cause-effect relationship between the two pathologies cannot be advanced at this time. This paper also reports how the patient was managed in terms of anesthesiology and surgical technique, both conditioned by the marked tendency for anteroposterior tracheal wall collapse and its high reactivity to mechanical insults.

Oncological results of endoscopic resections of Tis and T1 glottic carcinomas by carbon dioxide laser

A cohort of 88 patients with glottic cancer (13 Tis, 75 T1) who underwent endoscopic CO2 laser excision between January 1995 and June 1997 was prospectively studied. The mean follow-up was 43 months (range, 30 to 60 months). The depth and extent of the excision (graded according to the European Laryngological Society Classification, which includes 5 types of resection) were based on the results of a preoperative and intraoperative diagnostic test battery. Five patients died of other diseases, and none of glottic cancer. Of the 12 patients who developed a local recurrence, 5 underwent a second endoscopic procedure, 5 a total laryngectomy, and 1 a supracricoid laryngectomy, and 1 was treated with radiotherapy. The 5-year local control rate with endoscopic surgery alone, according to the Kaplan-Meier method, was 91%. None of the variables (8 related to the tumor and 2 to the treatment) tested in a univariate analysis by the log-rank test was found to have a significant impact on disease-free survival rates. The present study confirmed that endoscopic partial cordectomy for Tis and T1 glottic cancers can be regarded as a valid alternative to radiotherapy in terms of oncological results.

[Pulsating tinnitus associated with high homolateral jugular bulb and aplasia of the contralateral transverse and sigmoid sinuses]

Pulsating tinnitus is uncommon in the general population. This clinical manifestation can be associated with severe intracranial pathologies and is particularly characterized by a rhythm and synchronism reflecting the heart beat. This work presents a clinical case of pulsating, subjective tinnitus associated with a high homolateral jugular bulb and marked hypoplasia of the contralateral transverse and sigmoid sinuses and the clinical-radiological examinations that made diagnosis possible (particular reference going to CT, MRI and angio-MRI). The intracranial venous drainage pattern varies and is nearly always asymmetrical. The jugular bulb is defined as "high" when its upper edge extends nearly to the level of the tympanic anulus, a condition found in 6-20% of the general population. In many cases it is found by chance as often this condition is asymptomatic. However, the pathological picture associated with pulsating tinnitus is highly complex and requires a detailed diagnostic process which some Authors have arranged in specific "flow charts". Imaging methods are essential and must be identified according to the clinical-audiological findings. The radiologist can avail himself of CT, MRI (in association with angio-MRI), Doppler ultrasound of the supraortic and transcranial branches, and digital imaging subtraction angiography. The therapeutic approach to the patient manifesting a "high" jugular bulb is surgical and makes use of such procedures as: ligature of the internal jugular vein, extracranial transposition of the bulb and, in cases of dehiscence of the limiting bone, hypotympanum repair using an autologous or homologous graft of cartilage or bone. Whichever the case, an accurate cost-benefit evaluation must be made, particularly in regard to the risks of endocranial hypertension from the reduced venous drainage, a condition which is significantly increased when concomitant abnormalities of the dural sinuses are present. In the present case, this risk was quite high because of the particular venous morphology described and the patient refused surgery. Currently the patient is under clinical-radiological observation.

Schwannoma of the nasal septum: a case report with review of the literature

Schwannomas are neurogenic neoplasms rarely found in the sinonasal tract, where localization to the nasal septum is exceedingly rare (only 11 cases have been described in the western literature). We report the case of a 29-year-old white male with a schwannoma completely filling the left nasal fossa and arising from the bony part of the septum. A computer tomography (CT) scan and a biopsy suggestive of benign schwannoma were obtained before the lesion was removed by a degloving approach. The preoperative diagnosis of nasal septum schwannoma was confirmed. The patient is asymptomatic and without endoscopic evidence of recurrence 7 years after surgery. A review of the literature with particular emphasis on the clinical presentation, histological features, differential diagnosis and therapeutic options for such a rare lesion is included.

[Functional results after type I thyroplasty with the Montgomery's prosthesis]

Between January 1999 and October 2000, 16 patients with glottic insufficiency of varying etiologies underwent Montgomery type I thyroplasty at the E.N.T. Department of the University of Brescia, Italy. In 2 cases revision surgery was required for the onset of delayed complication (cutaneous and endolaryngeal exposure of the prosthesis). All subjects underwent a battery of clinical-instrumental tests pre- and postoperatively as well as 2, 6 and 12 months after surgery. These tests included videolaryngostroboscopy, subjective perception analysis using the GRBAS scale proposed by Hirano on vowels, statements and songs, and, using the Multi-Dimensional Voice Program (MDVP), acoustic measurement of the following parameters: jitter (J), shimmer (S), noise to harmonic ratio (NHR) and maximum phonation time (MPT). The patients also filled out a self-evaluation questionnaire to judge the postoperative voice and this was used to calculate the "voice handicap index" (VHI). In order to make the study sample as homogeneous as possible, detailed pre- and postoperative functional data were studied only for the 11 patients with glottic insufficiency subsequent to monolateral vagal or recurrent paralysis. Analysis of these data revealed that, in these patients, postoperative perceptive and subjective evaluation was similar to that found in normal subjects. Videolaryngostroboscopy showed that the glottis closed completely in most cases and objective acoustic analysis parameters were significantly improved after surgery. Despite the small sample, our functional results confirm the validity of the cord medialization technique through an external approach in laryngeal hemiplegia. In cases of glottic insufficiency of various etiologies (trauma, scarring subsequent to external and/or endoscopic surgery and radiotherapy), more accurate selection of the patients is required to reduce the incidence of complications and to improve vocal results.

[Laryngeal-tracheal resection in the treatment of thyroid malignancies: description of a case and review of literature]

Well-differentiated thyroid carcinomas infiltrate into the respiratory tract in between 0.9 and 7% of the cases. Laryngeal-tracheal involvement--most often discovered intra-operatively--can substantially modify the surgical approach. It should be evaluated pre-operatively through laryngo-tracheoscopy with a flexible fibroscope and, in some selected cases, using CT or NMR. Thyroidectomy, associated with laryngeal-tracheal resection and termino-terminal anastomosis, ensures good oncological results without any negative effect on the incidence of post-operative complications. The present work reports the case of a 64-year-old patient who, for 5 months, had presented a swelling of increasing consistency in the left hemithyroid, fixed on the deep planes. Echography showed a 5 cm mass in the left lobe and thyroid isthmus, without suspected lymphadenopathy for metastasis. Fine needle cytology was compatible with papillary carcinoma. CT using a contrast medium revealed an infiltration into the left antero-lateral wall of the I and II tracheal ring, with submucosal extension with no significant signs of stenosis of the airway. Esophagogastroscopy was normal while tracheobroncoscopy confirmed the radiological picture and made it possible to perform a tracheal biopsy which proved positive for papillary carcinoma. The patient underwent total thyroidectomy associated with anterior compartment lymphadenectomy and crico-tracheal resection of the cricoid arch and the first 5 tracheal rings. When surgery was completed, the patient was extubated without complications. Post-operative recovery was uneventful and the patient was discharged on the 9th day after surgery. Histopathological examination confirmed the pre-operative diagnosis and made it possible to stage the lesion as pT4N1bM0 because of the presence of one prelaryngeal lymph node metastasis and another one at the right paratracheal space. Complementary I131 therapy was scheduled along with periodic laryngo-tracheoscopic controls. 16 months after surgery the anastomotic line is perfectly healed and the patient is clinically disease free. A review of the literature on the surgical treatment of well-differentiated malignant thyroid neoplasms with respiratory tract involvement through resection and laryngo-tracheal anastomosis has made it possible to trace the indications, limits and results of this type of therapeutic approach.

(alphaMe)Nva: stereoselective syntheses and preferred conformations of selected model peptides

Using different stereoselective chemical and chemoenzymatic approaches we synthesized the chiral, Calpha-methylated alpha-amino acid L-(alphaMe)Nva with a short, linear side-chain. A set of terminally protected model peptides to the pentamer level containing either (alphaMe)Nva or Nva in combination with Ala and/or Aib was prepared using solution methods and characterized fully. Two (alphaMe)Nva peptides were also synthesized using side-chain hydrogenation of the corresponding Calpha-methyl, Calpha-allylglycine (Mag) peptides. A detailed solution and crystal-state conformational analysis based on FT-IR absorption, 1H NMR and X-ray diffraction techniques allowed us to define that: (i) (alphaMe)Nva is an effective beta-turn and 3(10)-helix former; and (ii) the relationship between (alphaMe)Nva chirality and the screw sense of the turn/helix formed is that typical of protein amino acids, i.e. L-(alphaMe)Nva induces the preferential formation of right-handed folded structures. In more general terms, this study reinforced previous conclusions that peptides based on alpha-amino acids with a Calpha-methyl substituent and a Calpha-linear alkyl substituent are characterized by a strong tendency to fold into turn and helical structures.

Granular cell tumor of the hypopharynx treated by endoscopic CO(2) laser excision: report of two cases

BACKGROUND

Granular cell tumor (GCT), or Abrikossoff's tumor, is an unusual lesion probably arising from Schwann cells. It is frequently found in the head and neck region, where the tongue is the most commonly affected site. Involvement of the hypopharynx is exceedingly rare because, to the best of our knowledge, only four cases have been reported in the literature.

METHODS

We describe hypopharyngeal GCT in two women aged 29 and 52 years, respectively.

RESULTS

In the first patient, preoperative diagnostic examination, including endoscopy, CT, and MRI scan, was suggestive of a benign lesion arising from the posterior wall of the hypopharynx. In the second patient, a previous biopsy of the postcricoid area performed elsewhere suggested a diagnosis of well-differentiated squamous cell carcinoma, and CT scan staged the lesion as T1 N0. In both cases, treatment included surgical excision under microlaryngoscopy with CO(2) laser. The histopathologic study of the specimens, supported by immunohistochemical techniques, determined the lesions to be a GCT. The postoperative course was uneventful, and the patients were discharged 12 and 2 days after surgery, respectively. Both patients were asymptomatic without evidence of recurrence when last seen 2 years and 4 months after surgery, respectively.

CONCLUSIONS

GCT should be included in the differential diagnosis of submucosal hypopharyngeal lesions. Endoscopy and radiologic imaging do not display any typical finding suggestive of the diagnosis, which can be based only on histologic findings. Resection of the tumor, when technically feasible, should be performed under microlaryngoscopy with the CO(2) laser, which makes it possible to work in a bloodless field with minimal thermal damage and reduction of scarring and postoperative edema.

[Pleomorphic adenoma: a case treated by laryngotracheal resection and reconstruction]

Benign Pleomorphic Adenoma (PA) is a tumor rarely found in tracheal and laryngotracheal sites. A review of the literature published since 1922 has revealed only 30 certain cases of which 3 presented simultaneous involvement of both larynx and trachea. The present work describes the thirty-first case (the fourth with a laryngotracheal localization), diagnosed in a white, 40-year-old male who had been complaining of acute dyspnea for the last three years. Initially these symptoms had been interpreted as asthmatic crises. During one of these episodes, the patient underwent emergency tracheotomy and a laryngotracheoscopy revealed a rounded cricotracheal lesion with smooth surface and approximately 4 cm in cranio-caudal diameter. The mass occupied 90% of the air space and originated from the posterolateral right portion of the cricoid, and from the first 3 tracheal rings. CT and esophagoscopy ruled out its transmural invasion into the esophagus. Under rigid bronchoscopy, assisted NdYAG laser debulking was performed for biopsy purposes. The histological diagnosis was benign AP. For this reason a Grillo cricotracheal resection was performed with exeresis of the cricoid arch, mucosa of the cricoid plate and the first 4 tracheal rings. Reconstruction of the respiratory tract was achieved through termino-terminal cricothyrotracheal anastomosis. The initial diagnosis was confirmed and the resection edges were without evidence of neoplasm. Post-operative recovery proceeded without complications and the patient was discharged 7 days after surgery. Endoscopic and radiological follow-up after 30 months is still negative for any neoplastic recurrences. The laryngo-tracheal lumen is within the norm and cord motility has been preserved. The authors then describe the clinical, anatomopathological and radiological elements which prove useful in evaluating tracheal neoplasms and they underline the problems of differential diagnosis between benign AP and adenoid-cystic carcinoma. In addition, the various therapeutic options are discussed with special attention being focused on surgery through external approaches. Given the location of the AP described, the Grillo procedure-most commonly used in cases of inflammatory cricotracheal stenoses-proved well suited to the loco-regional control of the neoplasm. Stringent respect for some parts of this surgical technique make it possible to reduce post-operative complications to a minimum.

Ticks infesting domestic animals in Italy: current acarological studies carried out in Sardinia and Basilicata regions

The note reviews published and unpublished data on acaralogical studies carried out by different parasitologists' groups in Sardinia and Basilicata regions. In Sardinia 72 collecting sites were investigated and a total of 4,086 ticks were collected from hosts (cattle, sheep, goats and pigs) and from soil. So far 2,413 ticks belonging to six genera have been identified: Rhipicephalus (67.2%), Haemaphysalis (24.1%), Hyalomma (2.7%), Boophilus (0.7%), Dermacentor (4.9%), Ixodes (0.3%). Host-associated ticks were collected from 50 out of 200 selected farms in Basilicata. About 4,000 tick specimens were collected and 1,794 ticks have been identified (of which 1,215 were adults, 6 larvae and 573 nymphs). The following genera were identified: Ixodes (20%), Rhipicephalus (27%), Hyalomma (31%), Haemaphysalis (18%), Dermacentor (6%). The seasonal distribution of the species identified in the two regions studies is discussed from a geographical and climatic point of view.

Total synthesis and membrane modifying properties of the lipopeptaibol trikoningin KB II and its analogues with acyl chains of different length at the N- and C-termini

Trikoningin KB II, a ten-amino acid residue lipopeptaibol blocked at the N-terminus by the n-octanoyl group and at the C-terminus by the 1,2-amino alcohol L-leucinol, and extracted from the fungus Trichoderma koningii, exhibits membrane-modifying properties. We have synthesized by solution-phase methods trikoningin KB II and several analogues with acyl chains of different length at the N- and C-termini. Permeability measurements showed that an appropriate length of the linear acyl chain is a more important characteristic for the onset of significant membrane-modifying activity than its position in the peptide chain.

CD4+ T cells orchestrate both amplification and deletion of CD8+ T cells

This review focuses on the role of CD4+ T cells in regulating immune responses, orchestrating both the amplification and deletion of immune cells, particularly CD8+ T cells. These two functions, which represent only an apparent contradiction, appear to be two faces of the same process of regulation. In fact, because the immune response, once activated, needs to be carefully controlled or switched off when the antigenic stimulus is eliminated, the immune system has developed several strategies either to regulate clonal amplification or to avoid useless expansion of activated cells. In particular, we have reported many data demonstrating that CD4+ T cells may be indicated as the regulatory element in the activation as well as the deletion of CD8+ T cells. New data are also reported on the ability of anergic CD4+ T cells to suppress CD8+ T-cell activation through induction of apoptosis, and on the need for CD8+ T cells for antigen recognition in inducing cell death in CD4+ T cells. Moreover, the central role of CD4+ T cells in the maintenance of peripheral tolerance has been widely described.

Cutting edge: CD4+ T cells kill CD8+ T cells via Fas/Fas ligand-mediated apoptosis

To explore the possibility that CD4+ T cells, described to mediate the elimination of themselves or B lymphocytes, could also mediate the elimination of CD8+ T cells, we analyzed apoptotic phenomena in cocultures of CD4+ and CD8+ autologous T cell lines. The data show that CD8+ T cells were lysed by activated CD4+ helper T cells by a Fas/FasL-mediated mechanism. CD4+ T cells were not lysed by activated CD8+ T cells, although Fas and FasL were equally expressed and anti-Fas Abs induced apoptosis in both CD4+ and CD8+ T cell populations. The results allowed us to speculate that CD4+ T cells not only help CD8+ T lymphocytes to mature into effector killer cells and to sustain this function but can also limit their growth.

Cutting edge: CD4+ T cells kill CD8+ T cells via Fas/Fas ligand-mediated apoptosis

To explore the possibility that CD4+ T cells, described to mediate the elimination of themselves or B lymphocytes, could also mediate the elimination of CD8+ T cells, we analyzed apoptotic phenomena in cocultures of CD4+ and CD8+ autologous T cell lines. The data show that CD8+ T cells were lysed by activated CD4+ helper T cells by a Fas/FasL-mediated mechanism. CD4+ T cells were not lysed by activated CD8+ T cells, although Fas and FasL were equally expressed and anti-Fas Abs induced apoptosis in both CD4+ and CD8+ T cell populations. The results allowed us to speculate that CD4+ T cells not only help CD8+ T lymphocytes to mature into effector killer cells and to sustain this function but can also limit their growth.

Ligation of either CD2 or CD28 rescues CD4+ T cells from HIV-gp120-induced apoptosis

Temporal or quantitative imbalance in signals delivered to T cells via T cell antigen receptor (TCR), the CD4 co-receptor, and accessory molecules can lead to anergy, apoptosis, or both. This has been observed following ligation of CD4 by HIV gp120 prior to TCR occupancy. The ability of molecules such as CD2 and CD28, interacting with their ligands LFA-3 and B7, to provide signals that protect T cells from the induction of anergy, has been reported. Here, we demonstrate that ligation of CD2 and CD28 in conjunction with TCR occupancy rescue T cells that have been programmed for apoptotic death by prior CD4 ligation to gp120. This appears to be the result of augmented interleukin-2 and interleukin-4 release by the T cells following these molecular interactions. In conclusion, our results suggest that an impairment of antigen-presenting accessory cell functions could favor gp120-mediated apoptosis in HIV-uninfected cells.

Functional communication training with and without extinction and punishment

Functional communication training has been reported to be a promising treatment for severe behavior problems. In this study, functional communication training alone and combined with extinction and/or punishment was evaluated for 4 clients with severe retardation, behavior problems, and communication deficits. The participants were inpatients on a hospital unit for treatment of severe behavior disorders. They received individualized interventions based on functional assessment that included reinforcement of a communication response with the same function as their destructive behavior. Results showed that for some patients, functional communication training was not sufficient to produce clinically significant reductions in destructive behavior, and the combination of training plus punishment produced the largest and most consistent reductions.

Cardiac transplant recipients with preoperative pulmonary hypertension. Evolution of pulmonary hemodynamics and surgical options

Among 48 consecutive patients with pretransplant pulmonary vascular resistance (PVR) greater than 4 Wood units, 38 patients underwent orthotopic heart replacement (OHT), and the remaining 10 received a graft in a heterotopic position (HHT). The OHT recipients were smaller (63 vs. 73 kg, p less than 0.05) and received a larger donor heart (donor-recipient, 109% vs. 79%, p less than 0.001) with a shorter graft ischemic time (108 vs. 139 minutes, p less than 0.05) than HHT recipients, reflecting patient selection and surgical complexity. Comparison between the hospital survivors and nonsurvivors identified the selection of HHT and graft ischemic time in excess of 150 minutes as potent risk factors. Immediately after transplantation, pulmonary artery (PA) pressures dropped to almost one half of preoperative values regardless of the mode of transplantation. Within the next 24 hours, however, the OHT group required lower doses of inotropes, had lower left atrial pressure (12 vs. 16 mm Hg, p less than 0.05), and were more frequently extubated (58% vs. 10%, p less than 0.01). Catheterization at 10 days revealed a doubled cardiac index and a dramatic reduction in PVR for both groups. The higher the preoperative PVR value, the more substantial the reduction observed, resulting in normalization of PVR for all survivors. The incidence of early graft failure was similar between the groups, but HHT recipients frequently developed pulmonary complications and infection, resulting in a 30% hospital survival in contrast to 71% in OHT recipients (p less than 0.05). The results suggest that transplant candidates with pulmonary hypertension might better be treated by OHT with an oversized, on-site, viable donor heart than by HHT.

Heterotopic heart transplantation: current status in 1988

Among the 480 patients who underwent heart transplantation in our institution (since 1968), 40 patients received an allograft in the heterotopic position. The recipients were evaluated by using hemodynamics and Doppler echocardiography before and after surgery. Ten to 30 days after surgery, preoperative pulmonary artery pressure, pulmonary artery wedge pressure, and pulmonary vascular resistance (PVR) decreased significantly (p less than 0.005). Cardiac output increased significantly (p less than 0.0001). Postoperative Doppler echocardiography showed that heterotopic hearts had an excellent ejection fraction (mean 73% +/- 11%). No improvement occurred in the left ventricular function of the native heart. Among the factors affecting short-term prognosis of heterotopic heart transplantation (HHT) recipients. PVR seems to be the most important determinant of survival. HHT does not seem to improve the prognosis of patients with elevated PVR. HHT, however, is still indicated in large patients and in emergency situations in which an available donor heart appears unable to support the recipient's circulation if used in the orthotopic position.