Correlation of patient reported outcome measures with endoscopic findings in pediatric chronic adenoiditis and chronic rhinosinusitis

BACKGROUND

Studies in adult chronic rhinosinusitis (CRS) showed poor correlation between patient reported outcome measures (PROMs) and objective findings. Our goal is to study the correlation between the sinus and nasal quality of life (SN-5) and the 22-items sinonasal outcome test (SNOT-22) surveys with endoscopy findings in children with chronic adenoiditis (CA) and CRS.

METHODS

Cross-sectional study of all pediatric patients (age 2-18) presenting for CA or CRS was performed. Patients and caregivers were asked to fill the SN-5 and SNOT-22 questionnaires at initial and follow up visits. Demographics and comorbidities were collected. Objective findings included endoscopy Modified Lund-Kennedy (MLK) scores and adenoid tissue size.

RESULTS

124 children were included, with mean age of 9.9 years (SD = 4.8) and 46.8% female. 36.3% had allergic rhinitis, 23.4% had asthma, and 4% had obstructive sleep apnea. Moderate correlation was found between the rhinologic domain of SNOT-22 and MLK scores (r = 0.36, p = 0.001) and between SN5 scores and adenoid size in all patients (r = 0.39, p < 0.001). SNOT-22 scores showed moderate correlation with adenoid size (r = 0.42, p < 0.001) more specifically in CA patients (r = 0.54, p < 0.001). The correlation of SN5 and MLK scores were higher in children with allergic rhinitis or asthma. The correlation between SN5 and adenoid size was lower in children with allergic rhinitis or asthma.

CONCLUSION

There is discrepancy between the subjective measures and the objective findings in children with CA or CRS. The physical exam findings may not reflect the effect of CRS on the quality of life of children.

Dysphagia and pulmonary complications in acute cerebrovascular disease: A retrospective observational study

INTRODUCTION

Dysphagia is a common post-stroke complication, which may result in serious pulmonary sequelae. Early detection of dysphagia and aspiration risk can reduce morbidity, mortality and length of hospitalization.

OBJECTIVES

This study aims to identify association between dysphagia and acute cerebrovascular disease, and evaluate the prevalence and impact of pulmonary complications on readmissions and mortality.

MATERIAL AND METHODS

Retrospective observational study based on 250 clinical records of patients with acute cerebrovascular disease: clinical history, neurological examination, imaging and Gugging Swallowing Screen in the first 48h. Patients were followed for 3 months via medical records to estimate 3-month mortality and readmissions.

RESULTS

Out of 250 clinical records analyzed, 102 (40.8%) were evaluated for dysphagia. The prevalence of dysphagia was 32.4%. The risk was higher in older patients (p<0.001), in severe stroke (p<0.001) and in the hemorrhagic subtype (p=0.008). An association was found with dysarthria and aphasia (p=0.003; p=0.017). Respiratory tract infections occurred in 14.4% of all patients (GUSS group 11.8% versus no GUSS group 16.2%), and in 75% of those with severe dysphagia (p<0.001). Mortality at 3 months was 24.2% in dysphagic patients, especially high in the severe dysphagia group (75%, p<0.001).

CONCLUSIONS

The type of cerebrovascular disease, NIHSS and GCS scores, age, dysarthria, and aphasia were significant associated factors to dysphagia. The prevalence of respiratory tract infections was higher in patients with no GUSS record, and no statistical significance was observed in related readmissions. Mortality at 3 months was superior in the severe dysphagia group.

Flexor Tendon Repair in Zone II Augmented With an Externalized Detensioning Suture: Protected Flexor Tendon Repair

Flexor tendon repair in zone II benefits from early finger motion to prevent stiffness. This article presents a technique that serves to augment a zone II flexor tendon repair with an externalized detensioning suture that can be used following any commonly employed repair method. This simple technique enables early active motion and is suited for patients who are less likely to be compliant after surgery or when the soft-tissue injury to the finger and hand is substantial. Although this technique substantially strengthens the repair, a possible drawback is that the tendon excursion distal to the repair is limited until the externalized suture is removed, which may lead to less motion of the distal interphalangeal than what may have occurred without the detensioning suture.

Effects of a high salt diet on blood pressure dipping and the implications on hypertension

High blood pressure, also known as hypertension, is a major risk factor for cardiovascular disease. Salt intake has been shown to have a significant impact on BP, but the mechanisms by which it influences the blood pressure dipping pattern, and 24-h blood pressure remains controversial. This literature review aims to both summarize the current evidence on high salt diet induced hypertension and discuss the epidemiological aspects including socioeconomic issues in the United States and abroad. Our review indicates that a high salt diet is associated with a blunted nocturnal blood pressure dipping pattern, which is characterized by a reduced decrease in blood pressure during the nighttime hours. The mechanisms by which high salt intake affects blood pressure dipping patterns are not fully understood, but it is suggested that it may be related to changes in the sympathetic nervous system. Further, we looked at the association between major blood pressure and circadian rhythm regulatory centers in the brain, including the paraventricular nucleus (PVN), suprachiasmatic nucleus (SCN) and nucleus tractus solitarius (nTS). We also discuss the underlying social and economic issues in the United States and around the world. In conclusion, the evidence suggests that a high salt diet is associated with a blunted, non-dipping, or reverse dipping blood pressure pattern, which has been shown to increase the risk of cardiovascular disease. Further research is needed to better understand the underlying mechanisms by which high salt intake influences changes within the central nervous system.

The impact of changing the diagnostic algorithm for TB in Manicaland, Zimbabwe

SETTING

Governmental health facilities performing TB diagnostics in Manicaland, Zimbabwe.

OBJECTIVE

To investigate the effect of making Xpert® MTB/RIF the primary TB diagnostic for all patients presenting with presumptive TB on 1) the number of samples investigated for TB, 2) the proportion testing TB-positive, and 3) the proportion of unsuccessful results over time.

DESIGN

This retrospective study used data from GeneX-pert downloads, laboratory registers and quality assurance reports between 1 January 2017 and 31 December 2018.

RESULTS

The total number of Xpert tests performed in Manicaland increased from 3,967 in the first quarter of 2017 to 7,011 in the last quarter of 2018. Mycobacterium tuberculosis DNA was detected in 4.9-8.6% of the samples investigated using Xpert, with a higher yield in 2017 than in 2018. The overall proportion of unsuccessful Xpert assays due to "no results", errors and invalid results was 6.3%, and highly variable across sites.

CONCLUSION

Roll out of more sensitive TB diagnostics does not necessarily result in an increase of microbiologically confirmed TB diagnosis. While the number of samples tested using Xpert increased, the proportion of TB-positive tests decreased. GeneXpert soft- and hardware infrastructure needs to be strengthened to reduce the rate of unsuccessful assays and therefore, costs and staff time.

Role of the impulse oscillometry in the evaluation of tracheal stenosis

INTRODUCTION AND OBJECTIVES

Tracheal stenosis is a rare and challenging disease. Bronchoscopy is the gold standard for diagnosis and assessment but brings inherent risks. Spirometry is commonly used to access obstructions but is not always feasible due to patient related factors. We therefore considered impulse oscillometry (IOS) as a non-invasive method to quantify airway obstruction and its potential use for diagnosis and follow-up of tracheal stenosis.

MATERIALS AND METHODS

Patients with confirmed tracheal stenosis were recruited between January 1st, 2015 and December 31st, 2016. Before bronchoscopy, all subjects underwent IOS and spirometry; for patients submitted to interventional bronchoscopy the same techniques were also performed after the procedure. We assessed the correlation between IOS measurements and airway narrowing as well as between IOS and spirometry values.

RESULTS

Twenty-one patients were included. Tracheal narrowing was inversely correlated with X5% (r -0.442, p 0.045) and positively correlated with FEV1/PEF (r 0.467, p 0.033). The stenosis length was inversely correlated with PEF and PEF% (r -0.729, p=0.001 and r -0.707, p=0.002, respectively). There was a strong correlation between spirometric and IOS values. We did not find any significant differences between pre- and post-intervention IOS values for patients assessed after interventional bronchoscopy.

CONCLUSIONS

Our study showed a weak correlation between X5% and tracheal narrowing making it unclear whether IOS can be used for physiological assessment of patients with tracheal stenosis. Stenosis length correlated with PEF making it a potential predictor of successful surgical approach. The correlation between IOS and spirometric values makes IOS a potential alternative in patients with suspected tracheal stenosis who are not able to perform spirometry. Larger scale studies should clarify the role of IOS in this pathology.

Severe asthma in obese patients: Improvement of lung function after treatment with omalizumab

INTRODUCTION

Asthma and obesity have a considerable impact on public health and their prevalence is increasing. Obesity is a known risk factor for asthma and can make it more difficult to control. Omalizumab is recommended in patients with severe allergic persistent asthma. The aim of this study was to assess the impact of omalizumab treatment in obese asthmatic patients with poorly controlled severe persistent asthma.

METHODOLOGY

A non-interventional, prospective study was conducted, in an outpatient asthma clinic. All patients with severe asthma who started treatment with omalizumab were included and followed over 12 months. The study population was divided into two groups (obese and non-obese) for statistical analysis (descriptive and comparative analysis).

RESULTS

Thirty-two patients (19 obese) were followed. After 12 months of omalizumab treatment, there was a statistically significant improvement in body mass index, number of exacerbations in the previous year, rescue medication, disease control and lung function, in the whole population. At the end of the study obese patients had a significantly better lung function (FEV₁) than non-obese.

DISCUSSION

As described in the literature, there was a significant reduction in the number of exacerbations in the previous year, rescue medication and better disease control, in the whole population. In relation to lung function, about which published data are inconsistent, treatment with omalizumab significantly improved it in obese patients.

CONCLUSION

Our study showed that omalizumab significantly improved asthma control, reduced rescue medication and asthma exacerbations in all the population; and for the first time showed that obese patients achieved significantly improved lung function.

Endobronchial ultrasound-guided transbronchial needle aspiration for nodal staging in non-small cell lung carcinoma

INTRODUCTION

Lung cancer staging has recently evolved to include endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for nodal assessment.

AIM

Evaluate the performance and safety of EBUS-TBNA as a key component of a staging algorithm for non-small cell lung carcinoma (NSCLC) and as a single investigation technique for diagnosis and staging of NSCLC.

METHODS

Patients undergoing EBUS-TBNA for NSCLC staging at our institution between April 1, 2010 and December 31, 2014 were consecutively included with prospective data collection. EBUS-TBNA was performed under general anesthesia through a rigid scope.

RESULTS

A total of 122 patients, 84.4% males, mean age 64.2 years. Histological type: 78 (63.9%) adenocarcinoma, 33 (27.0%) squamous cell carcinoma, 11 (8.9%) undifferentiated/other NSCLC. A total of 435 lymph node stations were punctured. Median number of nodes per patient was 4. EBUS-TBNA nodal staging: 63 (51.6%) N0; 8 (6.5%) N1; 34 (27.9%) N2, and 17 (13.9%) N3. EBUS-TBNA was the primary diagnostic procedure in 27 (22.1%) patients. EBUS-TBNA NSCLC staging had a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rate of 83.3, 100, 100, 86.1, and 91.8%, respectively. No complications were attributable to the procedure.

CONCLUSION

A comprehensive lung cancer staging strategy that includes EBUS-TBNA seems to be safe and effective. Our EBUS-TBNA performance and safety in this particular setting was in line with previously published reports. Additionally, our study showed that, in selected patients, lung cancer diagnosis and staging are achievable with a single endoscopic technique.

Surgical treatment of bronchiectasis: A review of 20 years of experience

BACKGROUND

Bronchiectasis is defined as an abnormal and irreversible dilation and distortion of the bronchi, which has numerous causes. Surgical treatment of this disease is usually reserved for focal disease and when the medical treatment is no longer effective. We report our center experience and outcomes in bronchiectasis surgery during the last 20 years.

METHODS

Between 1994 and 2014, sixty-nine patients underwent surgical resection for bronchiectasis. Patient demographics, presenting symptoms, indications for surgical treatment, type of lung resection, morbidity and mortality, as well as clinical follow-up and outcomes were analyzed.

RESULTS

From the 69 patients included, 31 (44.9%) were male and 38 (55.1%) were female. Surgery was indicated because of unsuccessful medical therapy in 33 patients (47.8%), haemoptysis in 22 patients (31.9%), nondiagnostic lung mass in 9 patients (13.0%) and lung abscess in 5 patients (7.3%). The surgical procedures were lobectomy in 45 (65.2%) patients, pneumonectomy in 10 (14.5%) patients, bilobectomy in 8 (11.6%) patients, lobectomy plus segmentectomy in 3 (4.3%) patients and only segmentectomy in 3 (4.3%) patients. Morbidity rate was 14.5% and there was no perioperative mortality. The follow-up was possible in 60 patients, with an outcome reported as excellent in 44 (73.3%) patients, as improved in 11 (18.3%) and as unchanged in 5 (8.3%).

CONCLUSION

Although the number of patients with bronchiectasis referred for surgical treatment has decreased, pulmonary resection still plays a significant role. Surgical resection of localized bronchiectasis is a safe procedure with proven improvement of quality of life for the majority of patients.

Technology and effect: HIV/AIDS testing in Brazil

Contemporary techno-scientific and medical developments are restructuring social interactions and the very processes by which individual subjectivity is formed. This essay elaborates on the experiential and ethical impact of such transformations from the perspective of people who, in ordinary and unexpected ways, act science and technology out. We carried out ethnographic research in an HIV/AIDS Testing and Counseling Center (CTA) in northeastern Brazil, combining participant observation with epidemiological analyses and clinical survey. We found a high demand for free testing by low-risk clients, largely working and middle class, experiencing anxiety and complaining of AIDS-like symptoms. Most of the clients were sero-negative and many returned for a second and third testing. We understand this to be a new techno-cultural phenomenon and call it imaginary AIDS. Throughout this essay, we describe CTA's routine practices, place these practices in historical, political, economic and cross-cultural perspective, and analyze the subjective data we collected from the clients of our pilot study. We explore how clinical epidemiological expertise and HIV testing technology are integrated into new forms of bio-politics aimed at specific marketable and disease-free populations, and on the affective absorption of bio-technical truth and the engendering of a technoneurosis in this testing center.

[Neuroradiology in the physiopathologic diagnosis of subarachnoid hemorrhage--cerebral aneurysm]

The clinical importance of the cerebral aneurismatic lesion in well known. In Portugal we still do not have reliable statistics regarding the occurrence of the subarachnoid hemorrhage, however we can make a comparison through Kassel's and Drake's studies where they refer that annually 28,000 North-Americans suffer from subarachnoid hemorrhage attributed to the rupture of the cerebral aneurysm. This is a clinical situation that needs to be analyzed, more so because if it is not diagnosed and treated in time, it can cause a high level of morbidity and mortality. From 1984 to 1990, the authors studied 208 clinical cases of in-patients at the Santa Maria Hospital who had been diagnosed as having subarachnoid hemorrhage-cerebral aneurysm. They analyzed 172 cranium-encephalic Tomographies and 190 cerebral Angiographies. They found levels that overlapped the series already published with respect to the location of the lesion, dimensions and age groups involved. They tried to relate the presence aneurysm in the willis arterial circle with the occurrence of locoregional anatomic variants that were detected in 51% of the patients with aneurysm of the anterior communicating artery and in 33% of the cases in the posterior communicating artery. The high occurrence of serious forms of tomodensitrometric presentation should also be emphasized. As a matter of fact, 42.6% of the patients studied were grouped in degree IV of the Fisher Scale. This result translates the effort that is still required towards an early clinical and imaging diagnosis of warning hemorrhage to avoid or prevent a catastrophic hemorrhage recurrence.

[Intravascular therapy of giant cerebral aneurysm]

The endovascular therapy in cerebral aneurysms has met significant technical progress, specially related with new microcatheters and different types of detachable balloons. Reviewing seven cases of giant cerebral aneurysms treated by intra arterial approach, the authors present their results pointing out and discussing the different angiosurgical therapy that can actually be used.