Longitudinal changes in swallowing function after surgery and proactive swallowing therapy for oral cancer

BACKGROUND

This study aimed to describe and explore the longitudinal changes in swallowing function among patients with oral cancer who underwent surgery and proactive swallowing therapy from baseline to 1-year postoperation.

METHODS

We retrospectively studied 118 patients over a 4.5-year duration. Swallowing functional assessment including 10-item Eating Assessment Tool (EAT-10), Functional Oral Intake Scale (FOIS), M. D. Anderson Dysphagia Inventory, and Modified Barium Swallow Impairment Profile (MBSImP™) was performed at baseline, 1-month, 6-month, and 1-year postoperatively.

RESULTS

All swallowing parameters worsened 1-month postoperation. EAT-10, FOIS, and MBSImP™ oral and pharyngeal impairment scores improved significantly compared with 1-month postoperation at 6 months. Other swallowing parameters, except for weight, did not differ significantly from baseline at 6 months. The rate of tube-feeding dependency was 11.5% and 5.6% at 1 and 6 months postoperation, respectively.

CONCLUSIONS

Periodic swallowing functional assessments help delineate the longitudinal changes in swallowing functional outcomes.

Autologous Fat Plus Platelet-Rich Plasma versus Autologous Fat Alone on Sulcus Vocalis

Sulcus vocalis is a frequent cause of glottic insufficiency that leads to incomplete vocal fold closure during phonation. Type II sulcus vocalis is defined as a partial defect of the lamina propria (LP). Treatment with fillers, such as fat or hyaluronic acid (HA), in the vocal folds is widely used, but the duration of effect is variable. Platelet-rich plasma (PRP) can enhance the survival of autologous fat in fat grafting, and also is used to treat sulcus vocalis. This study aimed to compare the effectiveness of autologous fat graft versus fat graft plus PRP to treat type II sulcus vocalis. Thirty-four patients with a voice handicap index (VHI) ≥ 11 were randomized to two groups, which received LP injections of fat graft (n = 17) or fat graft plus PRP (n = 17). At 1 month and 6 months after injection, the VHI decreased significantly in both groups. The fat plus PRP group had better Jitter, Shimmer, and noise to harmonic ratio (NHR) in 1 month and 6 months after surgery. The fat plus PRP group resulted in lower VHI scores one month after surgery, and stroboscopy revealed sustained smaller gaps after six months. These results indicate that a combination of fat graft plus PRP is safe and effective for treating sulcus vocalis type II and associated vocal atrophy.

Combined Transoral Robotic Tongue Base Surgery and Palate Surgery in Obstructive Sleep Apnea Syndrome: Modified Uvulopalatopharyngoplasty versus Barbed Reposition Pharyngoplasty

Background: Successful surgery outcomes are limited to moderate to severe obstructive sleep apnea (OSA) syndrome. Multilevel collapse at retropalatal and retroglossal areas is often found during the drug-induced sleep endoscopy (DISE). Therefore, multilevel surgery is considered for these patients. The aim of our study was to survey surgical outcomes by modified uvulopalatoplasty (UPPP) plus transoral robotic surgery tongue base reduction (TORSTBR) versus barbed repositioning pharyngoplasty (BRP) plus TORSTBR. Methods: The retrospective cohort study was performed at a tertiary referral center. We collected moderate to severe OSA patients who were not tolerant to positive pressure assistant PAP from September 2016 to September 2019; pre-operative–operative Muller tests all showed retropalatal and retroglossal collapse; pre-operative Friedman Tongue Position (FTP) > III, with the tonsils grade at grade II minimum, with simultaneous velum (V > 1) and tongue base (T > 1), collapsed by drug-induced sleep endoscopy (DISE) under the VOTE grading system. The UPPP plus TORSTBR (n = 31) and BRP plus TORSTBR (n = 31) techniques were offered. We compare the outcomes using an Epworth sleepiness scale (ESS) questionnaire, and measure the patients’ apnea–hypopnea index (AHI), lowest O₂ saturation, cumulative time spent below 90% (CT90), and arousal index (AI) by polysomnography six months after surgery; we also measure their length of hospital stay and complications between these two groups. Results: Comparing BRP plus TORSTBR with UPPP plus TORSTBR, the surgical success rate is 67.74% and 38.71%, respectively. The significantly higher surgical success rate in the BRP plus TORSTBR group was noted. The surgical time is shorter in the BRP plus TORSTBR group. The complication rate is not significant in pain, bleeding, dysgeusia, dysphagia, globus sensation, and prolonged suture stay, even though the BRP plus TORSTBR rendered a higher percentage of globus sensation during swallowing and a more prevalent requirement of suture removal one month after surgery. The length of hospital stay is not significantly different between the two groups. Conclusion: In conclusion, BRP plus TORSTBR is a considerable therapy for moderate to severe OSA patients with DISE showing a multi-level collapse in velum and tongue base area. The BRP technique might offer a better anterior–posterior suspension vector for palate level obstruction.

Increased Incidence of Tinnitus Following a Hyperthyroidism Diagnosis: A Population-Based Longitudinal Study

BACKGROUND

An association between thyroid disease and tinnitus has been described previously but further longitudinal, population-based studies are limited.

OBJECTIVE

To investigate the incidence of tinnitus in patients with hyperthyroidism in a national sample, and to identify risk level and associated factors for tinnitus in hyperthyroidism patients.

DESIGN

Retrospective cohort study. Patient data were collected from the Longitudinal Health Insurance Database (LHID 2000), which includes national claims data of patient expenditures for admissions or ambulatory care from 1996 to 2011.

SETTING

Taiwan hospitals and clinics providing healthcare nationwide.

PARTICIPANTS

Patients aged 20 years and older with newly diagnosed hyperthyroidism (ICD-9-CM code 242) between 2000-2010 were selected as the study cohort. Hyperthyroidism patient cohort were identified from the LHID2000. Those with tinnitus history (ICD-9-CM code 388.3) before the index date (first hyperthyroidism diagnosis), younger than 20 years, and with incomplete demographic data were excluded. The non-hyperthyroidism cohort included patients with no history of hyperthyroidism and no documented tinnitus.

MAIN OUTCOMES AND MEASURES

Incidence of tinnitus was the primary outcome. Baseline demographic factors and comorbidities possibly associated with tinnitus, including age, sex, and comorbidities of hearing loss, vertigo, insomnia and anxiety, were retrieved from the LHID 2000. Patients were followed until end of 2011.

RESULTS

During the study period, 780 (4.9%) hyperthyroidism patients and 2007 (3.2%) non-hyperthyroidism controls developed tinnitus. Incidence rate of tinnitus in the hyperthyroidism cohort was significantly higher in hyperthyroidism cohort (7.86 vs. 5.05 per 1000 person-years) than that in non-hyperthyroidism cohort. A higher proportion of patients with hyperthyroidism had comorbid insomnia (45.1% vs. 30.9%) and anxiety (14.0% vs. 5.73%) than those without hyperthyroidism. After adjusting for age, gender and comorbidities (vertigo, insomnia, anxiety, hearing loss), hyperthyroidism patients had 1.38-fold higher risk of tinnitus (95% CI = 1.27-1.50) than those without hyperthyroidism.

CONCLUSIONS

This large population-based study suggests patients with diagnosed hyperthyroidism was more prone to develop tinnitus. Our findings suggest evaluation for comorbid vertigo, insomnia, anxiety and/or hearing loss may identify patients who are at high risk of developing tinnitus in patients with hyperthyroidism.

Low-grade albuminuria is associated with hearing loss in non-diabetic US males: A cross-sectional analysis of 1999-2004 national health and nutrition examination survey

High levels of albuminuria have been demonstrated to associate with hearing loss in non-diabetic people, while the clinical impact of low-grade albuminuria has attracted less attention. This cross-sectional population-based study aimed to examine whether hearing loss in non-diabetic United States (US) adults is independently associated with low-grade albuminuria or reduced estimated glomeruli filtration rate (eGFR).A total of 2518 participants aged 20 to 69 years were selected from the US National Health and Nutritional Examination Survey database. Participants with diabetes or high-grade albuminuria were excluded. Hearing loss was assessed using low-frequency pure-tone average (LFPTA) thresholds (0.5, 1.0, 2.0 kHz) and high-frequency pure-tone average (HFPTA) thresholds (3.0, 4.0, 6.0, 8.0 kHz). Logistic and linear regression analyses were used to evaluate associations between renal function indicators and hearing loss.The median age of included participants was 37.4 years, and 55% of them were female. Multivariate analysis revealed that participants with urinary albumin-to-creatinine ratio (UACR) in the highest tertile had a significantly higher risk of hearing loss (OR, 1.79; 95% CI, 1.01-3.19) and higher HFPTA thresholds (β: 2.23; SE: 0.77). Participants with eGFR <60 mL/min/1.73 m had higher LFPTA thresholds (β: 4.31; SE: 1.79). After stratification by sex, a significant risk remained only for males in the highest UACR tertile, with 2.18 times the risk of hearing loss (95% CI, 1.06-4.48).Non-diabetic US males with low-grade albuminuria are at increased risk of hearing loss, independent of eGFR.

Perceived challenges and priorities in co-morbidity management of older patients with Type 2 diabetes

AIMS

To explore older patients' perceived impact of chronic co-morbid conditions on Type 2 diabetes self-management.

METHODS

We used purposive sampling to select 32 mentally alert community-dwelling adults, aged 60 years or older, diagnosed with Type 2 diabetes and at least one other chronic health condition to participate in focus groups. We summarized the discussions following each focus group and identified codes to describe the overarching themes.

RESULTS

We conducted eight 90-min focus groups, each consisting of two to six patients. Three themes emerged. (i) Diabetes complications as a motivator: managing co-morbid conditions made health an important focal point in the lives of older patients. Most patients acknowledged the positive effect complications had on their diabetes self-management by motivating them to pay greater attention to their diabetes to diminish the progression of these complications. (ii) Prioritizing health conditions: patients reported prioritizing health conditions and selectively attending to the management of those conditions based on perceived severity or importance. Further, many patients perceived some conditions as more serious than others and admitted to prioritizing another health condition over their diabetes. (iii) Emotional impact of co-morbidity management: patients described feeling frustrated, confused, and overwhelmed in response to conflicting treatment recommendations, particularly for diet, physical activity and medication regimens.

CONCLUSIONS

Complications and co-morbidities may have differential impacts on the diabetes self-management of older patients. Addressing the perceived impact of co-morbidity on diabetes self-management may improve patients' outcomes; however, the most effective method of utilizing this information in clinical practice needs to be examined.

Association between genetic polymorphism of tumor necrosis factor-alpha and risk of oral submucous fibrosis, a pre-cancerous condition of oral cancer

Many cytokines have been thought to play important roles in the pathogenesis of oral submucous fibrosis (OSF), an areca nut chewing-specific pre-cancerous condition characterized by the deposition of collagen in oral submucosa. Tumor necrosis factor-alpha (TNF-alpha), situated in the class III region of human leukocyte antigen (HLA), is a mediator with multiple functions, including the regulation of inflammatory reaction and transcriptions of collagen and collagenase. In total, 809 male subjects were recruited for assessment of the association of OSF with a bi-allelic promoter-region (-308) polymorphism on the TNFA gene. The high production allele, TNF2, was significantly lower among OSF subjects (n = 166) than in areca-chewing controls (n = 284). This association was independent of oral cancer status. The multivariate-adjusted odds ratio for the TNFA 11 genotype was 2.6 (95% confidence interval = 1.4-4.9; p = 0.004). The finding may imply a multifunctional etiological factor of TNF-alpha in OSF pathogenesis.

Effect of a lacto-ovo vegetarian diet on fasting small intestinal motility

BACKGROUND

Changes in diet can alter gastric and small intestinal (SI) motility. The effects of a vegetarian diet on fasting SI motility are unknown.

METHODS

Manometric studies were performed in 9 lacto-ovo vegetarians (7 women) and 9 omnivores (7 women) of similar age and body mass index. On each study day, manometry was used to assess SI motility for 5 h, or 3 complete cycles of the interdigestive motor complex (IDMC). Lacto-ovo vegetarians were studied once: omnivores were studied twice, on their usual diet, and after consuming a 14-day lacto-ovo vegetarian diet. Diet diaries were kept for 5 days prior to each manometric study. Data were analysed for dietary composition and for cycle length and duration of each phase (I, II and III) of the IDMC.

RESULTS

Dietary intake did not differ between chronic vegetarians and chronic omnivores apart from a trend to higher fibre intake (29 +/- 3 versus 20 +/- 3 g/day; P = 0.058). Omnivores eating a vegetarian diet showed a trend to decreased alcohol consumption (P = 0.068), but did not increase their fibre intake (20 +/- 3 versus 21 +/- 3 g/day). Neither cycle length nor duration of each IDMC phase differed between chronic vegetarians and chronic omnivores. After 14 days of a vegetarian diet, omnivores had a reduction in cycle length (128 +/- 19 versus 86 +/- 12 min; P = 0.02), with a non-significant reduction of Phase II (99 +/- 20 versus 50 +/- 8 min: P = 0.066).

CONCLUSIONS

A chronic vegetarian diet has no major effect on fasting SI motility; but acute dietary change may alter the cycle length and component phases of the IDMC.

Myopia and contrast sensitivity function

PURPOSE

to measure the contrast sensitivity function of varying degrees of myopia with two types of optical correction (spectacle lens and contact lens).

METHODS

One hundred and five myopic eyes and twenty-eight emmetropic eyes were collected. The myopic group included 105 eyes corrected with spectacle lenses and 71 eyes of them corrected with contact lenses, too; all had corrected vision acuity of 20/20 or better. The myopic eyes were divided into four groups: group 1 (-1D to -3D), low myopia; group 2 (-3.25D to -6D), medium myopia; group 3 (-6.25D to -12D), high myopia; and group 4 (> -12D), severe myopia. Spatial contrast sensitivity was measured using the OPTEC 2000 Contrast Sensitivity System.

RESULTS

In groups 1 and 2, no statistically significant difference was found between myopes and emmetropes. In group 3, statistically significant loss of contrast sensitivity at higher spatial frequencies was found for myopic subjects corrected with spectacle lens, but not for myopes corrected with contact lens. In group 4, myopic subjects corrected with spectacle lenses showed significantly reduced contrast sensitivity function at all spatial frequencies; subjects corrected with contact lenses showed statistical sensitivity losses at 6, 12, 18 cycle/degree spatial frequencies.

CONCLUSIONS

1. We may suppose that low and medium myopes (groups 1 and 2), who showed normal contrast sensitivity functions, had no retinal dysfunction. 2. For high myopes, contact lens correction could reduce optical defocus and improve contrast sensitivity function in high spatial frequencies. 3. As retinal function disturbances occurred in severe myopes, the diminished contrast sensitivity was not fully compensated by contact lens correction. 4. Loss of contrast sensitivity might be interpreted as evidence for early retinal function disruption before retinal pathological events occur in severe myopes.

Cloning and nucleotide sequencing of the S4 genome segment of avian reovirus S1133

The sequence of RNA genome segment S4 of the avian reovirus (ARV) strain S1133 was determined. S4 RNA is 1185 base pairs long and contains one open reading frame encoding a protein of 367 amino acid residues (40.6 kDa), the similar size as the known S4 gene product (sigma NS), with a net charge of -1 at neutral pH. The S4 RNA sequence possesses a pentanucleotide sequence UCAUC at the 3'-terminus of its plus strand like in ARV S1 and S3 segments and ten segments of mammalian reovirus (MRV). The predicted amino acid sequence comparison revealed that the homology is 44.02%, 45.71%, and 42.33% for ARV sigma NS and three serotypes of MRV sigma NS, respectively. The relatively high content of alpha-helix structure in the C-terminal portion of ARV sigma NS suggests that this protein may functionally relate to MRV sigma NS. Northern blot hybridization showed that a 32P-labeled cDNA insert S4-49 from ARV S4 RNA cross-hybridized with the corresponding RNA segments of all seven strains of ARV tested.

The roles of ventilation and perfusion in lung metabolism

The lung, like other viable organs, requires the adequate supply of oxygen and metabolic substrates for its functional and structural integrity. Therefore, we studied the metabolic and ultrastructural consequences in the canine lung following bronchial and/or pulmonary arterial occlusions. The results indicate that the lung can maintain its bioenergetic levels for 5 hours with either the ventilation or perfusion alone. Ultrastructural changes appear to precede metabolic alterations measured. When both the ventilation and perfusion were interrupted, rapid biochemical and structural deteriorations occurred, whereas the combinations of alveolar obliteration and hypoxemia, induced with low F102, produced intermediate damage. The implications of these findings on the pathogenesis and evolution of acute respiratory distress syndrome, on the lung preservation for transplantation, and on the rationale for membrane oxygenator support are discussed.

Epithelial lesions in low flow states: a unifying concept

Several epithelium-lined organs are highly vulnerable in low flow states, and may lead to lesions such as hemorrhagic enteritis, stress ulcer, renal tubular necrosis, acalculous cholecystitis and "shock lung". A hypothesis is presented which postulated that the redistribution of the subepithelial microcirculatory blood flow and the subsequent damage to the epithelial barrier are the crucial processes in their pathogenesis. Presently available evidence in support of this thesis is summarized.

Spontaneous aortocaval fistula secondary to ruptured abdominal aortic aneurysm

Two patients with the rare condition of spontaneous aortocaval fistula secondary to ruptured abdominal aortic aneurysm were treated successfully by surgical closure of the fistula. In view of the existing controversies on certain aspects of the pathophysiology involved, canine experiments were performed to elucidate the pathogenesis of regional venous hypertension and hematuria observed in these patients. The experiments demonstrated that regional venous hypertension is a purely rheologic phenomenon and that hematuria originates from a congested lower urinary tract.

Why do radial artery grafts for aortocoronary bypass fail? A reappraisal

The reasons for the high failure rate of radial artery grafts for aortocoronary bypass (ACB) are appraised. Each of 11 dogs received four types of grafts: femoral arteries were grafted to carotid arteries, and jugular veins were grafted to femoral arteries bilaterally. One of each pair of grafts was wrapped in a plastic sheet in order to interfere with the regeneration of vasa vasorum. The grafts were examined 2 months later. The results suggest that although operative trauma and intraluminal pressure change play important roles, the thick-walled artery appears to depend more on vasa vasorum for its integrity than does the thin-walled vein. A free radical artery graft, with vasa vasorum disrupted at both ends, cannot regenerate readily from the adjacent tissue, as is the case at the ACB position, and is therefore more vulnerable to subintimal hyperplasia and occlusion than either the vein graft or the internal mammary artery graft; both of these grafts are thinner, and the internal mammary artery graft remains undisrupted at one end.

Effects of exogenous cyclic adenosine monophosphate in hemorrhagic shock

Hemorrhageic shock produces potentially damaging alterations in the metabolism of cyclic adenosine 3',5'-monophosphate (cAMP), which is an intracellular second messenger for many hormones. The hypothesis that the administration of exogenous cAMP might have salutary effects on cardiovascular hemodynamics in shock was tested in canine experimetns. Intravenous bolus injection of dibutyryl cAMP (2 mg. per kilogram) produced hyperglycemia, but no changes occurred in heart rate, arerial pressure cardiac output, or in the first derivative of left ventricualr pressure (dp/dt). The findings were similar in conscious and anesthetized (Nembutal) normotensive dogs, in dogs after 3 hours of shock (at blood pressure of 40 mm. Hg) and after the reinfusion of shed blood. The only hemodynamic change noted was a transient hypotensionupon injection of massive doses of dibutyryl-(db-) cAMP or cAMP (greater than 10 mg. per kilogram). The implication of these findings in light of earlier reported hemodynamic effects of cAMP is discussed.

Selective arterialization of coronary veins for diffuse coronary occlusion. An experimental evaluation

The selective arterialization of coronary veins as a surgical therapy for diffuse coronary arteriosclerosis was studied in canine and sheep experiments. The arterialized blood can be delivered promptly to the selected region of the myocardium and an adequate runoff exists for this mode of revascularization, so that myocardial edema and hemorrhage do not occur. The retrograde blood flow through an anastomosis between the internal mammary artery (IMA) and great cardiac vein (GCV) is excellent, with a predominantly diastolic flow pattern. Follow-up studies indicate significant but partial protection of the myocardium against diffuse LAD occlusion. The size of infarcts is decreased. However, the focal or small transmural infarcts observed are usually located near the apex of the heart. The studies with radioactive microspheres (15 plus or minus 5 mu diameter) revealed that the degree of capillary trapping of microspheres is very much less when the microspheres are injected retrograde into the vein than when injected into the artery. This may indicate that significant "shunt" blood flow exists when the coronary vein is arterialized. Thus this study demonstrates both the potential and the limitation of the selective arterialization of coronary veins in revascularizing patients suffering from diffuse coronary arteriosclerosis.

Cyclic AMP response to epinephrine and shock

Hormonal regulation is fundamental to homeostasis, and the response in tissues is mediated by adenosine 3':5' equals cyclic phosphate (cyclic AMP). Since circulating levels of catecholamines are elevated during hemorrhagic shock, experiments were carried out to study the effects of epinephrine and of shock on cyclic AMP levels of plasma and of the intestine, a particularly vulnerable organ in canine hemorrhagic shock. Epinephrine was given to normotensive dogs as a constant infusion (group 1) or as a single pulse (group 2). Sequential blood samples showed a marked increase in circulating cyclic AMP, especially in portal and hepatic venous blood. Little change was noted in the tissues. Hemorrhagic shock (group 3) induced a marked increase in plasma cyclic AMP, with a depletion of mucosal cyclic AMP and adenosine triphosphate (ATP). Pretreatment before shock with alpha-blockade (group 4) abolished the decrease in mucosal cyclic AMP and ATP, and reduced the increase in plasma cyclic AMP.

The roles of intraluminal chyme and vasomotor response in the pathogenesis of non-occlusive intestinal infarcts

The purpose of this study is to clarify the role of intraluminal chyme and the splanchnic vasomotor reaction on the pathogenesis of non-occlusive intestinal infarcts. In 5 mongrel dogs, 3 types of intestinal loops were created. A cervical loop, which is a heterotopic autotransplant of a segment of intestine, contains no chyme and is disconnected from the splanchnic innervation. A Thiry-Vella loop simultaneously constructed in the abdomen is also devoid of intraluminal chyme, but is still innervated. The intestine-in-continuity possesses both splanchnic innervation and intraluminal chyme. Hemorrhagic shock was then induced and the morphological response of the three types of intestine examined. The results indicate that the cervical loop is least damaged, whereas both the Thiry-Vella loop and the intestine-incontinuity are both severely damaged. It is concluded that in the non-occlusive hemorrhagic infarction of the intestinal mucosa, the peculiar splanchnic vasomotor response plays the dominant role. The pathogenesis of non-occlusive intestinal infarcts and its clinical implications are discussed.

Volume deficit versus toxic absorption: a study of canine shock after mesenteric arterial occlusion

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