Stomal maturation does not increase the rate of tracheocutaneous fistulas

OBJECTIVES/HYPOTHESIS

To determine the rate of persistent tracheocutaneous fistula (TCF) in pediatric patients managed with stomal maturation at the time of the tracheostomy.

STUDY DESIGN

Retrospective chart analysis of all cases of tracheostomy performed at a tertiary pediatric care center between 2001 and 2011.

METHODS

The use of stomal maturation, number of decannulations, number of persistent TCFs, timing of TCF repair, and the overall mortality were assessed.

RESULTS

A total of 264 patients received tracheostomy between 2001 and 2011. Of the total, 173 (66%) underwent stomal maturation. Of those 173 patients, 89 patients (51% of maturation group) underwent planned decannulation. Forty seven (53%) of the 89 decannulated were found to have a persistent TCF in the stomal maturation group. These were diagnosed an average of 1.3 years (range, 4-43 months) after decannulation. Of the 91 patients (34% of the total) who did not undergo stomal maturation, 44 (48% of nonmaturation group) underwent planned decannulation. Twenty of the 44 patients decannulated (45%) were diagnosed with a residual TCF 8 to 28 months later. Both groups achieved similar rates of decannulation (51% maturation vs. 48% non-maturation [P = .80]) and TCF (27% maturation vs. 22% non-maturation [P = .44]). Overall, mortality rates were (32/173) 18% (matured) versus (26/91) 29% (nonmatured). No mortalities were tracheostomy related. The mean (standard deviation) time from operation to TCF closure among those with TCF was 4.0 (1.9) years.

CONCLUSIONS

Comparable rates of persistent TCF with stomal maturation (27%) and without maturation (22%) were found in this single institution's 10-year experience.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2395-2398, 2016.

The role of gastric pepsin in the inflammatory cascade of pediatric otitis media

IMPORTANCE

Otitis media is characterized as an ongoing inflammation with accumulation of an effusion in the middle ear cleft. The molecular mechanisms underlying the pathogenesis, particularly the inflammatory response, remain largely unknown. We hypothesize that aspiration of gastric contents into the nasopharynx may be responsible for the initiation of the inflammatory process or aggravate a preexisting condition.

OBJECTIVE

To investigate the correlation of gastric pepsin A with inflammatory cytokines, bacterial infection, and clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Prospective study of 129 pediatric patients undergoing myringotomy with tube placement for otitis media at a tertiary care pediatric hospital.

MAIN OUTCOMES AND MEASURES

Ear samples were tested for pepsin A; cytokines interleukin (IL)-6, IL-8, and tumor necrosis factor; and bacterial culture inoculation. Data were analyzed by descriptive statistics and regression analysis to identify risk factors for the presence of pepsin A and to correlate pepsin A levels with cytokine levels, infection status, and clinical outcomes.

RESULTS

Of the 129 patients, 199 ear samples were obtained; 82 samples (41%) and 64 patients (50%) were positive for pepsin A as measured by immunoassay. Pepsin A positivity correlated with age younger than 3.0 years (mean [SD], 2.3 [2.1] years in the positive group vs 3.3 [3.0] years in the negative group) and with all 3 cytokine levels (mean [SD] tumor necrosis factor, 29.5 [45.9] pg/mL in the positive group vs 13.2 [21.6] pg/mL in the negative group; IL-6, 6791.7 [9389.1] pg/mL in the positive group vs 2849.9 [4066.3] pg/mL in the negative group; and IL-8, 6828.2 [8122.3] pg/mL in the positive group vs 2925.1 [3364.5] pg/mL in the negative group [all P < .05]); however, logistic regression analysis showed that only IL-8 (odds ratio, 3.96; 95% CI, 1.3-12.0; P = .02) and age (odds ratio, 3.83; 95% CI, 1.2-12.7; P = .03) were significant independent variables. No statistically significant association was found with other parameters. Multiple linear regressions revealed that the levels of pepsin A were correlated with IL-8 levels (R2 = 0.248; P < .001) and the need for second or third tubes 6 to 12 months after the first (R2 = 0.102; P = .006). The presence of pepsin A in the middle ear was not associated with increased bacterial infection. Interleukin 8 was independent and significantly associated with both pepsin A levels and bacterial infection (R2 = 0.144 and 0.263, respectively; P = .001 for both).

CONCLUSIONS AND RELEVANCE

Extraesophageal reflux as indicated by the presence of pepsin A is closely involved in the middle ear inflammatory process and may worsen the disease in some children; however, a proof of cause and effect between extraesophageal reflux and middle ear inflammation requires further investigation.

A homozygous SLITRK6 nonsense mutation is associated with progressive auditory neuropathy in humans

OBJECTIVES/HYPOTHESIS

SLITRK family proteins control neurite outgrowth and regulate synaptic development. In mice, Slitrk6 plays a role in the survival and innervation of sensory neurons in the inner ear, vestibular apparatus, and retina, and also influences axial eye length. We provide the first detailed description of the auditory phenotype in humans with recessive SLITRK6 deficiency.

STUDY DESIGN

Prospective observational case study.

METHODS

Nine closely related Amish subjects from an endogamous Amish community of Pennsylvania underwent audiologic and vestibular testing. Single nucleotide polymorphism microarrays were used to map the chromosome locus, and Sanger sequencing or high-resolution melt analysis were used to confirm the allelic variant.

RESULTS

All nine subjects were homozygous for a novel nonsense variant of SLITRK6 (c.1240C>T, p.Gln414Ter). Adult patients had high myopia. The 4 oldest SLITRK6 c.1240C>T homozygotes had absent ipsilateral middle ear muscle reflexes (MEMRs). Distortion product otoacoustic emissions (DPOAEs) were absent in all ears tested and the cochlear microphonic (CM) was increased in amplitude and duration in young patients and absent in the two oldest subjects. Auditory brainstem responses (ABRs) were dys-synchronised bilaterally with no reproducible waves I, III, or V at high intensities. Hearing loss and speech reception thresholds deteriorated symmetrically with age, which resulted in severe-to-profound hearing impairment by early adulthood. Vestibular evoked myogenic potentials were normal in three ears and absent in one.

CONCLUSION

Homozygous SLITRK6 c.1240C>T (p.Gln414Ter) nonsense mutations are associated with high myopia, cochlear dysfunction attributed to outer hair cell disease, and progressive auditory neuropathy.

Bailout stent deployment during coil embolization of intracranial aneurysms

BACKGROUND AND PURPOSE

Self-expandable stents are an effective tool for coil embolization of wide-neck intracranial aneurysms. The purpose of this study was to assess the feasibility and results of bailout stent positioning during rescue situations after deployment of > or =1 coil.

MATERIALS AND METHODS

Among 318 aneurysms treated by coil embolization in 267 patients, 16 patients who were treated by bailout stent deployment were retrospectively reviewed. Bailout procedures were performed to relieve potential parent artery compromise caused by the protruded coil loops or to prevent migration of the unstable coil basket. The size/location of the aneurysm, technical feasibility, successful stabilization rate, and procedure-related complications were evaluated.

RESULTS

The locations of the aneurysms were the internal carotid artery (n = 12) and basilar artery (n = 4). The mean aneurysm size was 8.3 mm (range, 3.5-19.4 mm) with hemorrhagic presentation in 3 patients. Relief/prevention of parent artery compromise was achieved by molding the encroached loops back into the sac (n = 11), scaffolding the aneurysmal neck in cases with an unstable coil basket (n = 4), and sidetacking the migrated loop to the parent vessel wall (n = 1). The procedure was technically successful in 87.5% (n = 14). Satisfactory molding or stabilization of the coil was seen in 75% (n = 12). Unsatisfactory molding of the protruded small coil loop was noted in 2 cases of small aneurysms. Acute in-stent thrombosis was successfully managed by thrombolysis (n = 1).

CONCLUSIONS

Bailout self-expandable stent deployment may be a feasible and effective method for relief/prevention of parent artery compromise or coil migration caused by prolapsed or unstable coil loops during embolization of aneurysms.

Thrombus volume comparison between patients with and without hyperattenuated artery sign on CT

BACKGROUND AND PURPOSE

Although the hyperattenuated middle cerebral artery sign is known to be related to acute infarction, the volume of clot associated with it is not known. We investigated whether the presence or absence of hyperattenuated artery sign (HAS) on noncontrast CT (NCCT) can predict the thrombus volume.

MATERIALS AND METHODS

We enrolled 90 consecutive patients with acute infarction who underwent both 5- and 1.25-mm NCCT and CT angiography (CTA). HAS was determined on 5-mm NCCT retrospectively. According to the location of thrombi, the patients were classified into ICA (ICA terminus/ICA and others), M1 (M1/both M1 and M2), and M2 (M2) groups. Thrombus volumes were measured by 1.25-mm NCCT and were compared between patients with and without HAS.

RESULTS

Occlusion of major arteries was seen on CTA in 78 patients. HAS was found in 46 patients (59.0%). The mean thrombus volume was significantly larger in patients with HAS than in those without except for the M2 group (ICA group: [n = 14], 188.7 +/- 122.5 mm(3) versus 39.4 +/- 12.1 mm(3) [P = .022]; M1 group: [n = 42], 128.1 +/- 119.2 versus 56.8 +/- 32.5 [P = .005]; M2 group: [n = 22], 34.7 +/- 32.2 versus 20.0 +/- 20.0 [P = .18]). Thrombus volumes determined by receiver operating characteristic curve analysis were 52.36 mm(3) in the ICA group (sensitivity, 90.9%; specificity, 100%) and 53.96 mm(3) in the M1 group (sensitivity, 88.0%; specificity, 58.8%).

CONCLUSION

Thrombus volumes were significantly larger in patients with HAS than in those without in ICA and M1 occlusions. The detection of HAS may provide an idea concerning rapid and dichotomized estimation of thrombus volume, which may be helpful for treatment decisions in potential candidates for thrombolysis.

Targeting bladder tumor cells in vivo and in the urine by a peptide identified using phage display

10071

Background: Bladder cancer is one of the most common tumors of genitourinary tract. Selective delivery of drugs to tumor tissues is important for effective tumor therapy. Here we identified a peptide targeting bladder tumor cells using phage display. Methods: Phage peptide library containing CX7C (C-cysteine and X-any amino acid residue) was based on T7 415–1b phage vector (Novagen). Tumor xenografts were prepared by subcutaneously injecting BALB/c Nu/nu female nude mice with HT-1376 bladder tumor cells. For a carcinogen-induced tumor model, Fischer 344 female rats were supplied ad libitum with tap water containing 0.05% N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN) for 8 weeks. Results: A phage library containing CX7C random peptides was screened for selective binding to cells from human bladder tumor xenografts. Selected phage clones were individually evaluated for binding to cultured bladder tumor cells and for binding to cells from human tumor tissues of six patients. The peptide displayed by the most promising clone was synthesized and designated as Bld-1. Fluorescein-conjugated Bld-1 peptide showed selective binding to frozen sections of human bladder tumor tissues of three patients. In vivo tumor targeting was examined in a carcinogen-induced rat tumor model (n=20). When the fluorescent peptide was introduced into the bladder lumen, it selectively bound to tumor epithelium. Next, when the fluorescent peptide was intravenously injected into the tail vein, it homed to the bladder tumor, but was not detectable in normal bladder and control organs such as lung. Moreover, the fluorescent peptide bound to cells from urinary specimens of tumor patients (n=10), whereas little binding was observed in cells from healthy individuals (n=3). Conclusions: The Bld-1 peptide may be useful for targeting bladder tumor cells in vivo and in the urine.

No significant financial relationships to disclose.

Mental practice effect on line-tracing accuracy in persons with hemiparetic stroke: a preliminary study

OBJECTIVE

To investigate the effect of mental practice on line-tracing accuracy of persons with hemiparetic stroke.

DESIGN

A single-case, experimental, multiple baseline design.

SETTING

Electromyography laboratory of a rehabilitation medicine department of a university hospital.

PARTICIPANTS

Three persons with right hemiparesis from stroke.

INTERVENTION

Mental practice for line-tracing training.

MAIN OUTCOMES MEASURES

Two tracing tasks were used to evaluate the effect of mental practice: (1) tracing a 5.9-inch long horizontal line (task 1); and (2) tracing a 6-inch long curved line (task 2) as a generalization probe. Participants were first trained to master the cognitive rehearsal skill by checking the reduction level of tension in their upper trapezius while listening to a relaxation cassette tape. Second, participants were trained to trace task 1 immediately after listening to a cognitive rehearsal tape that contained the command to trace over a horizontal line as accurately as possible. Then, without the cognitive rehearsal process, participants traced over a curved line as a generalization probe. The dependent variable, called the line length error, was the total distance that the traced line deviated from the printed lines (both horizontal and curved).

RESULTS

Mean-line length errors of participants 1, 2, and 3 were: horizontal line tracing, 3.33, 7.38, and.30 inches, respectively, in the baseline and 1.41, 2.70, and.24 inches, respectively, after mental practice training. With the curved line tracing, mean length errors were 3.15, 6.56, and.52 inches in the baseline and 1.85, 4.36, and.80 inches postintervention, respectively.

CONCLUSIONS

Mental practice can be an effective method to improve line tracing by persons with hemiparetic stroke. Training in horizontal line tracing showed a modest level of generalization to curved line tracing.

Strictureplasty for Crohn's disease: meta-analysis

PURPOSE

The objective of this study was to analyze patient outcome after strictureplasty for management of intestinal stricture caused by Crohn's disease based on differences in surgical procedures.

METHODS

A MEDLINE search was performed using a medical subject heading analysis for strictureplasty in Crohn's disease. Meta-analysis of multiple variables for outcome was performed using random-effects models.

RESULTS

Five hundred six patients underwent 1,825 strictureplasties for Crohn's disease with minimal morbidity and zero mortality. Ninety percent of strictures were less than 10 cm in length. Approximately 85 percent of these procedures used the Heineke-Mikulicz technique and 13 percent used Finney strictureplasty. Forty-four percent of procedures included concurrent bowel resection. Recurrence rate of Crohn's disease after strictureplasty was increased in patients with longer study duration after surgery (P = 0.04), who showed symptoms of active disease (P = 0.02), who experienced preoperative weight loss (P = 0.02), or who received the Heineke-Mikulicz procedure (P = 0.008). The proportion of patients requiring additional surgery was increased with longer study duration (P = 0.006), with preoperative weight loss (P = 0.001), or with the Heineke-Mikulicz procedure (P = 0.005). The proportion of patients requiring additional surgery was decreased when a Finney strictureplasty was used (P = 0.008) as compared with those treated by the Heineke-Mikulicz procedure.

CONCLUSION

Although the Heineke-Mikulicz technique is most often used for Crohn's strictureplasty, outcome analysis revealed the Finney strictureplasty may reduce the reoperation rate.

Expression of vascular endothelial growth factor and microvessel density in head and neck tumorigenesis

Angiogenesis is a fundamental process in tumor growth and metastasis, and its significance and that of vascular endothelial growth factor (VEGF) expression as prognostic indicators have been documented for various types of human tumors. However, the mechanisms responsible for angiogenesis in head and neck squamous cell carcinoma are not well defined. To examine the relationship between angiogenesis and the phenotypic progressions of head and neck tumorigenesis, we used immunohistochemistry to analyze VEGF expression and microvessel density in 70 paraffin-embedded specimens that contained adjacent normal epithelium, premalignant lesions, or both from 57 patients with head and neck squamous cell carcinoma. Ten samples of normal oral mucosa were obtained from people who did not smoke or drink alcohol and included in the analysis as normal controls. Microvessel density was evaluated by averaging 10 microscopic fields (x400) in a defined area of each specimen. The degree of VEGF expression was assessed on a cell-by-cell basis in 10 microscopic fields (x200) in a defined area on a scale ranging from 0 (no expression) to 3+ (highest level of expression). In addition, the weighted mean index of VEGF expression was calculated. The mean +/- SD weighted mean index of VEGF expression in normal control epithelium (1.10 +/- 0.38, n = 10) was higher than it was in adjacent normal epithelium (0.82 +/- 0.27, n = 13; P = 0.04). VEGF expression decreased as samples ranged from normal adjacent epithelium to hyperplasia (0.78 +/- 0.28, n = 21), mild dysplasia (0.70 +/- 0.29, n = 28), moderate dysplasia (0.67 +/- 0.29, n = 11), severe dysplasia (0.51 +/- 0.39, n = 6), and squamous cell carcinoma (0.20 +/- 0.27, n = 70; overall P = 0.0001). VEGF expression was two times lower in cases with nodal disease (0.17 +/- 0.26, n = 29) than it was in nonnodal disease (0.32 +/- 0.29, n = 16; P = 0.02). Microvessel density showed no significant difference from adjacent normal epithelium premalignant lesions to cancer. In tumor, no correlation was seen between VEGF expression or microvessel density and differentiation, primary tumor site, T stage, or smoking status. These findings indicate that VEGF expression is down-regulated during head and neck tumorigenesis. However, further studies are required to better understand the mechanism of VEGF down-regulation in head and neck tumorigenesis.

Tongue volume in human female adults with mandibular prognathism

It has often been hypothesized that a large tongue leads to an enlargement of the mandible and therefore contributes to the development of mandibular prognathism. We examined (1) whether the tongue volume in human subjects with mandibular prognathism was larger than that in subjects with good occlusion and (2) whether the tongue volume and the pharyngeal capacity correlated with the morphological characteristics of dento-skeletal structures. Magnetic resonance images of the tongue and its surrounding structures were recorded for female adult volunteers with good occlusion (control group, n = 10) and patients with mandibular prognathism (test group, n = 16). Lateral cephalograms were obtained for the patients. No significant differences were determined for the tongue volume or the pharyngeal capacity between the two groups. The tongue volume did not correlate with the pharyngeal capacity (r = 0.280, p = 0.166). The tongue volume correlated with the facial angle (r = 0.548, p = 0.028), the Y-axis (r = 0.539, p = 0.031), and the angle nasion-A point-pogonion (r = 0.540, p = 0.031). These results suggest that the tongue volume is accounted for by the combined horizontal and vertical location of the chin and symphysis, but do not support the conventional clinical surmise that large tongue volume is inherent in patients with mandibular prognathism.

Measurements of n-p correlations in the reaction of relativistic neon with uranium

We report a preliminary measurement of coincident neutron-proton pairs emitted at 45 degrees in the interaction of 400, 530, and 650 MeV/A neon beams incident on uranium. Charged particles were identified by time of flight and momentum, as determined in a magnetic spectrometer. Neutral particles were detected using a thick plastic scintillator, and their time of flight was measured between an entrance scintillator, triggered by a charged particle, and the neutron detector. The scatter plots and contour plots of neutron momentum vs. proton momentum appear to show a slight correlation ridge above an uncorrelated background. The projections of this plane on the n-p momentum difference axis are essentially flat, showing a one standard deviation enhancement for each of the three beams energies. At each beam energy, the calculated momentum correlation function for the neutron-proton pairs is enhanced near zero neutron-proton momentum difference by approximately one standard deviation over the expected value for no correlation. This enhancement is expected to occur as a consequence of the attractive final state interaction between the neutron and proton (i.e., virtual or "singlet" deuterons). The implications of these measurements are discussed.