A Metabolic Intravascular Platform to Study FDG Uptake in Vascular Injury

PURPOSE

Metabolic alterations underlie many pathophysiological conditions, and their understanding is critical for the development of novel therapies. Although the assessment of metabolic changes in vivo has been historically challenging, recent developments in molecular imaging have allowed us to study novel metabolic research concepts directly in the living subject, bringing us closer to patients. However, in many instances, there is need for sensors that are in close proximity to the organ under investigation, for example to study vascular metabolism.

METHODS

In this study, we developed and validated a metabolic detection platform directly in the living subject under an inflammatory condition. The signal collected by a scintillating fiber is amplified using a photomultiplier tube and decodified by an in-house tunable analysis platform. For in vivo testing, we based our experiments on the metabolic characteristics of macrophages, cells closely linked to inflammation and avid for glucose and its analog ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG). The sensor was validated in New Zealand rabbits, in which inflammation was induced by either a) high cholesterol (HC) diet for 16 weeks or b) vascular balloon endothelial denudation followed by HC diet.

RESULTS

There was no difference in weight, hemodynamics, blood pressure, or heart rate between the groups. Vascular inflammation was detected by the metabolic sensor (Inflammation: 0.60 ± 0.03 AU vs. control: 0.48 ± 0.03 AU, p = 0.01), even though no significant inflammation/atherosclerosis was detected by intravascular ultrasound, underscoring the high sensitivity of the system. These findings were confirmed by the presence of macrophages on ex vivo aortic tissue staining.

CONCLUSION

In this study, we validated a tunable very sensitive metabolic sensor platform that can be used for the detection of vascular metabolism, such as inflammation. This sensor can be used not only for the detection of macrophage activity but, with alternative probes, it could allow the detection of other pathophysiological processes.

Impact of unilateral vocal fold mobility impairment on laryngopulmonary physiology

OBJECTIVE

To examine the impact of unilateral vocal fold mobility impairment (UVFMI) on airway physiology.

STUDY DESIGN

Cross-sectional observational study.

PARTICIPANTS

There were 21 patients with UVFMI and 53 controls.

MAIN OUTCOME MEASURES

All patients and patient controls underwent a maximum-effort flow-volume loop examination. Forced expiratory flow in one second (FEV1 ), forced expiratory volume (FVC), peak inspiratory flow rate and peak expiratory flow rate (PIFR and PEFR, respectively) and area under the inspiratory and expiratory flow-volume loops (AUCI nspiratory and AUCE xpiratory, respectively) were measured. The ratio of PEFR to PIFR and AUCE xpiratory to AUCI nspiratory was derived.

RESULTS

There were 48 males and 26 females. Mean age at measurement was 39 ± 11 years. Patients and controls were matched for age, sex, height and weight. None of the expiratory variables were significantly different between the groups. PIFR was significantly lower in UVFMI patients compared with controls (3.4 ± 1.2 versus 5.3 ± 1.8; P < 0.0001), as was AUCI nspiratory (11.5 ± 6.3 versus 17.5 ± 8.5; P = 0.0002). PEFR/PIFR provided the best differentiation between patients with UVFMI and controls with an area under the Receiver Operating Characteristic (ROC) curve of 0.96 and at a threshold of 1.9, and PEFR/PIFR had sensitivity and specificity of 95.2% and 90.6%, respectively.

CONCLUSIONS

Flow-volume loops are a non-invasive method of studying vocal abduction and could compliment voice assessment and laryngoscopy in UVFMI. With further research, they could provide an outcome measure for laryngeal rehabilitative procedures, and a shared physiological language for screening and surgical quality assurance.

Outcome of a multimodality approach to the management of idiopathic subglottic stenosis

OBJECTIVES/HYPOTHESIS

To assess the results of treating idiopathic subglottic stenosis (ISS), determine predictors of treatment success and outcome, and better define roles and limitations of endoscopic and open surgery.

STUDY DESIGN

Prospective observational study.

METHODS

Fifty-four consecutive patients were treated between 2004 and 2012. Patient, stenosis and treatment details, complications, open surgery rates, and outcomes were recorded. Regression analyses were used to identify predictors of endoscopic treatment success; treatment frequency; and functional outcomes in airway, dyspnea, voice, and swallowing domains.

RESULTS

All patients were female and mean age at diagnosis was 48 ± 12 years. Symptoms-to-diagnosis latency was 21 ± 20 months. There were 10 concomitant glottic and subglottic stenoses. Most lesions were Myer-Cotton grade 3 (48%). Overall, 78% of patients were managed endoscopically. Treatment included intralesional corticosteroids, laser surgery, balloon dilation, and temporary silastic stenting in selected cases. Annual intervention rate was 1.07 ± 0.79. Mean follow-up was 45 months. Factors associated with intervention frequency were stenosis location and severity. Twelve patients underwent anteroposterior laryngotracheal reconstruction with biological inhibition. This resulted in disease remission in all patients with subglottic stenosis, and in most patients with concomitant glottic and subglottic stenosis. Patients with total laryngotracheal stenosis required ongoing treatment for glottic disease. All patients maintained prosthesis-free airways, but in one patient this required a laryngectomy. Most patients achieved good functional outcomes. Stenosis location was the only independent predictor of dyspnea and voice outcomes.

CONCLUSIONS

ISS can be effectively treated with endoscopic surgery or a bespoke open reconstructive procedure that does not compromise on female voice quality.

LEVEL OF EVIDENCE

4.

Automatic conformal prescription of very selective saturation bands for in vivo 1H-MRSI of the prostate

An important step in the implementation of three-dimensional in vivo proton magnetic resonance spectroscopic imaging ((1)H-MRSI) of the prostate is the placement of spatial saturation pulses around the region of interest (ROI) for the removal of unwanted contaminating signals from peripheral tissue. The present study demonstrates the use of a technique called conformal voxel magnetic resonance spectroscopy (CV-MRS). This method automates the placement, orientation, timing and flip angle of very selective saturation (VSS) pulses around an irregularly-shaped, user-defined ROI. The method employs a user adjustable number of automatically positioned VSS pulses (20 used in the present study) which null the signal from periprostatic lipids while closely conforming the shape of the excitation voxel to the shape of the prostate. A standard endorectal coil in combination with a torso-phased array coil was used for all in vivo prostate studies. Three-dimensional in vivo prostate (1)H-MRSI data were obtained using the proposed semi-automated CV-MRS technique, and compared with a standard point resolved spectroscopy (PRESS) technique at TE = 130 ms using manual placement of saturation pulses. The in vivo prostate (1)H-MRSI data collected from 12 healthy subjects using the CV-MRS method showed significantly reduced lipid contamination throughout the prostate, and reduced baseline distortions. On average there was a 50 ± 17% (range 12% - 68%) reduction in lipids throughout the prostate. A voxel-by-voxel benchmark test of over 850 voxels showed that there were 63% more peaks fitted using the LCModel when using a Cramer-Rao Lower Bound (CRLB) cut-off of 40% when using the optimized conformal voxel technique in comparison to the manual placement approach. The evaluation of this CV-MRS technique has demonstrated the potential for easy automation of the graphical prescription of saturation bands for use in (1)H-MRSI.

Comparison of brain MR images at 1.5T using BLADE and rectilinear techniques for patients who move during data acquisition

BACKGROUND AND PURPOSE

MR imaging of moving patients can be challenging and motion correction techniques have been proposed though some have associated new artifacts. The objective of this study was to semiquantitatively compare brain MR images of moving patients obtained at 1.5T by using partially radial and rectilinear acquisition techniques.

MATERIALS AND METHODS

FLAIR, T2-, T1-, and contrast-enhanced T1-weighted image sets of 25 patients (14-94 years) obtained by using BLADE (like PROPELLER, a partially radial acquisition) and rectilinear techniques in the same imaging session were compared by 2 neuroradiologists in terms of extent of the motion artifact, image quality, and lesion visibility. ICC between opinions of the evaluators was calculated.

RESULTS

Of the total of 70 image sets, the motion artifact was small in the partially radial images in 43 and in the rectilinear images in 13, and the opinions of the evaluators were discordant in the remaining 14 sets (ICC = 0.63, P < .05). The quality of partially radial images was higher for 36 sets versus 9 rectilinear sets, with disagreement between the 2 evaluators in the remaining 25 (ICC = 0.15, P < .05). Pathologic lesions were better characterized on 37 sets of partially radial images versus 13 sets of rectilinear images, and opinions of the evaluators differed in 20 sets (ICC = 0.90, P < .05). The neuroradiologists deemed 4 sets of rectilinear images nondiagnostic compared with only 1 set of radial images.

CONCLUSIONS

The data demonstrate that our application of BLADE sequences reduces the extent of motion artifacts in brain images of moving patients, improving image quality and lesion characterization.

Admission Cardiotocography Screening of High Risk Obstetric Patients

BACKGROUND

To predict the neonatal outcome in high risk obstetric cases by admission cardiotocography (CTG) testing.

METHODS

A total of 150 consecutive high risk obstetric patients meeting the inclusion criteria were subjected to admission CTG testing in this prospective study. The CTG tracing was categorized based on Royal College of Obstetricians and Gynaecologists (RCOG) criteria. Specific foetal and neonatal outcome measures were studied and correlated with the admission CTG testing.

RESULT

Foetal distress during labour developed in 15% of patients with a normal test and in 73% of patients with an abnormal test. The admission test had a sensitivity of 66.7%, specificity of 93.3% and a positive predictive value of 53.3% for predicting an Apgar score < 5 at birth. Neonatal admission to neonatal intensive care unit was required in 1% of patients with a normal test and 33% of patients with an abnormal test (p <0.01).

CONCLUSION

The result of admission cardiotocography testing could be used to identify patients likely to develop adverse foetal outcomes and help in optimal utilization of labour room resources.

Toxic impacts of cypermethrin on behavior and histology of certain tissues of albino rats

In the present investigation, the behavioral, morphological, and histopathological effects of cypermethrin, a widely used synthetic pyrethroid insecticide, was ascertained in male and female albino rats (Rattus norvegicus). Cypermethrin administered at repeated oral doses of 5 and 20 mg/kg/day for 30 days produced varying degree of mild to moderate toxic symptoms and behavioral changes in both male and female rats. The lower dose produced very mild toxicosis characterized by intermittent diarrhea, decreased feed intake, and thick eye discharge, whereas higher dose displayed mild to moderate toxicosis with diarrhea, decreased feed intake, loss of body weight, dyspnoea, ataxia, eye discharge, and salivation. Two female and one male albino rats died between 23 to 28 days after displaying signs of incoordination and tremors. Repeated oral doses of cypermethrin for 30 days enhanced the relative weight of liver and heart, but significantly decreased that of brain, kidneys, and testes. Microscopically, cypermethrin produced neuronal degeneration and increase in glial cells in brain, and disorganization of hepatic laminae, increase in sinusoid, and necrosis of hepatocytes in liver. Section of kidney displayed hemorrhage and sloughing off renal epithelial cell in the convoluted tubules, shrinkage of glomeruli, and necrosis of renal tubules. Repeated administration of cypermethrin also produced hemorrhages within myocardium, disruption of branching structure, and loss of striation of cardiac tissue; thickening of alveolar septa in lungs, partial to extensive loss of various stages of spermatogenesis in testes, and loss of follicular cells and oocytes in ovaries. The study suggested that repeated oral exposure of cypermethrin has considerable harmful effects on body organs in R. norvegicus.

Regrowth of Damaged Layers in Diamond Produced by Ion Implantation

We have used RBS/Channeling, perturbed angular correlation (PAC) and optical absorption to study the regrowth of disordered layers in diamond produced by implantation with carbon, or with carbon plus boron or indium ions. For C or C plus B implantation doses of 2 ×1015 cm−2 or less, complete recovery of channeling damage occurred after RTA at 1100°C or furnace annealing at 900°C. Optical measurements on samples implanted with high energy carbon ions show better recovery compared to the shallower implantations. PAC results showed that co-implantation with C and In caused a considerable fraction (∼15%) of the In-atoms to occupy well-defined lattice sites characterized by an electric field gradient having its major component along <111>, and a frequency of 116 MHz.

Evaluation of image quality of a 32-channel versus a 12-channel head coil at 1.5T for MR imaging of the brain

BACKGROUND AND PURPOSE

Multichannel phased-array head coils are undergoing exponential escalation of coil element numbers. While previous technical studies have found gains in SNR and spatial resolution with the addition of element coils, it remains to be determined how these gains affect clinical reading. The purpose of this clinical study was to determine if the SNR and spatial resolution characteristics of a 32-channel head coil result in improvements in perceived image quality and lesion evaluation.

MATERIALS AND METHODS

Twenty-one patients underwent MR imaging of the brain at 1.5T sequentially with both a 12-channel and a 32-channel receive-only phased-array head coil. Axial T2WIs, T1WIs, FLAIR images, and DWIs were acquired. Anonymized images were compared side-by-side and by sequence for image quality, lesion evaluation, and artifacts by 3 neuroradiologists. Results of the comparison were analyzed for the preference for a specific head coil.

RESULTS

FLAIR and DWI images acquired with the 32-channel coil showed significant improvement in image quality in several parameters. T2WIs also improved significantly with acquisition by the 32-channel coil, while T1WIs improved in a limited number of parameters. While lesion evaluation also improved with acquisition of images by the 32-channel coil, there was no apparent improvement in diagnostic quality. There was no difference in artifacts between the 2 coils.

CONCLUSIONS

Improvements in SNR and spatial resolution attributed to image acquisition with a 32-channel head coil are paralleled by perceived improvements in image quality.

Association of marital status with access to renal transplantation

In this report we evaluated the association of marital status with access to renal transplantation. We analyzed data from the USRDS. In patients with ESRD aged ≥ 27 (mean age of first marriage in the US), we analyzed the association of marital status with two outcomes: (1) likelihood of being placed on the waiting list for renal transplantation or first transplant, (2) likelihood of receiving kidney transplant in patients already listed. We analyzed marital status as a categorical variable: (1) not married (including never been married and widowed); (2) divorced or separated; and (3) currently married. Subgroups based on age, race, sex, donor type and diabetic status were also analyzed. After adjustments for the included independent variables and compared to individuals never married or widowed, those who were divorced/separated (HR 1.55, p < 0.001) and currently married (HR 1.54, p < 0.001) had a higher likelihood of being placed on the transplant waiting list. Once listed, married individuals had higher chances of getting transplanted as well (HR 1.28, p = 0.033). This trend was consistent in most of the subgroups studied. We demonstrated that being married is associated with better access to renal transplantation compared to those who were never married/widowed.

Advances in volume monitoring in dialysis patients

Estimating volume status in patients on chronic dialysis is of great clinical value. Both hypervolemia and hypovolemia are associated with serious short term and long term complications, and volume status is often difficult to assess due to multiple factors affecting intravascular and extravascular volume compartments, as well as variability between patients in baseline blood pressures and physical exams. Traditional methods such as estimated dry weight (EDW) and physical exams are often not accurate because of the subjective nature of these indicators and variability between patients' baselines. This can lead to inaccurate volume status estimation and the associated complications. Furthermore, the concept of estimated dry weight is often defined based on measurements of blood pressure which may not accurately reflect volume status. In this review we describe several methods of measuring volume status in dialysis patients that may be more accurate than traditional measurements of blood pressure and dry weight estimation. These methods include dilutional techniques, imaging of vascular structures, use of biomarkers, bioimpedance analysis and online monitoring of biochemical variables during dialysis itself. We also discuss the clinical applicability and comparisons between these methods including the benefits and drawbacks of these methods and areas for future research.

Validation of the Clinical COPD Questionnaire as a psychophysical outcome measure in adult laryngotracheal stenosis

OBJECTIVES

To validate the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ), a patient-administered instrument developed for bronchopulmonary disease as a disease-specific psychophysical outcome measure for adult laryngotracheal stenosis.

DESIGN

Prospective observational study.

SETTINGS

Tertiary/National referral airway reconstruction centre.

PARTICIPANTS

Thirty-three tracheostomy-free patients undergoing endoscopic laryngotracheoplasty.

MAIN OUTCOME MEASURES

CCQ and the Medical Research Council (MRC) Dyspnoea scale, a previously validated but more limited scale, were administered to patients 2 weeks before surgery, preoperatively, and 2 weeks after endoscopic laryngotracheoplasty. Pulmonary function was assessed preoperatively. Internal consistency was assessed with Cronbach alpha statistics and test-retest reliability was determined using intraclass correlation. Correlations between CCQ and MRC scale, and pulmonary function were used to assess convergent and divergent validity respectively. Instrument responsiveness was assessed by correlating total and domain-specific CCQ scores with anatomical disease severity and post-treatment effect size.

RESULTS

There were 12 males and 21 females. Mean age was 44 +/- 15 years. Cronbach alpha coefficient and intraclass correlation coefficient were 0.88 and 0.95 respectively. Total and domain-specific CCQ scores significantly correlated with the MRC scores (P < 0.001) and significant correlations between CCQ and peak expiratory flow rate and FEV(1) were identified (P < 0.03). There were statistically significant changes in total and domain-specific CCQ scores when different stenosis severities were compared. Clinical COPD Questionnaire scores also changed significantly and congruently following surgery (P < 0.05 in both cases).

DISCUSSION

Clinical COPD Questionnaire is a valid and sensitive instrument for assessing symptom severity and levels of function and well-being in adult patients with laryngotracheal stenosis and can be used as a patient-centred disease-specific outcome measure for this condition.

A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial, managerial and clinical governance considerations under payment-by-results

OBJECTIVES

To audit the accuracy of otolaryngology clinical coding and identify ways of improving it.

DESIGN

Prospective multidisciplinary audit, using the 'national standard clinical coding audit' methodology supplemented by 'double-reading and arbitration'.

SETTINGS

Teaching-hospital otolaryngology and clinical coding departments.

PARTICIPANTS

Otolaryngology inpatient and day-surgery cases.

MAIN OUTCOME MEASURES

Concordance between initial coding performed by a coder (first cycle) and final coding by a clinician-coder multidisciplinary team (MDT; second cycle) for primary and secondary diagnoses and procedures, and Health Resource Groupings (HRG) assignment.

RESULTS

1250 randomly-selected cases were studied. Coding errors occurred in 24.1% of cases (301/1250). The clinician-coder MDT reassigned 48 primary diagnoses and 186 primary procedures and identified a further 209 initially-missed secondary diagnoses and procedures. In 203 cases, patient's initial HRG changed. Incorrect coding caused an average revenue loss of 174.90 pounds per patient (14.7%) of which 60% of the total income variance was due to miscoding of a eight highly-complex head and neck cancer cases. The 'HRG drift' created the appearance of disproportionate resource utilisation when treating 'simple' cases. At our institution the total cost of maintaining a clinician-coder MDT was 4.8 times lower than the income regained through the double-reading process.

CONCLUSIONS

This large audit of otolaryngology practice identifies a large degree of error in coding on discharge. This leads to significant loss of departmental revenue, and given that the same data is used for benchmarking and for making decisions about resource allocation, it distorts the picture of clinical practice. These can be rectified through implementing a cost-effective clinician-coder double-reading multidisciplinary team as part of a data-assurance clinical governance framework which we recommend should be established in hospitals.

Results of endoscopic surgery and intralesional steroid therapy for airway compromise due to tracheobronchial Wegener's granulomatosis

BACKGROUND

Upper airway compromise due to tracheobronchial stenosis commonly occurs in patients with Wegener's granulomatosis (WG). There is at present no consensus on the optimal management of this life threatening condition.

OBJECTIVE

To assess the results of laryngo-tracheo-bronchoscopy, intralesional steroid therapy, laser surgery and dilatation in managing obstructive tracheobronchial WG.

METHODS

Records of 18 previously untreated stridulous patients with obstructive tracheobronchial WG, treated between 2004 and 2006, were prospectively recorded on an airway database and retrospectively reviewed. Information about patient and lesion characteristics and treatment details were recorded. Treatment progress was illustrated using a timeline plot, and intervention-free intervals were calculated with actuarial analysis.

RESULTS

There were nine males and the average age at presentation was 40 (16) years (range 13-74). There were 13 patients with tracheal and five with tracheal and bronchial lesions. The average tracheal lesion height was 8 (3) mm, located 23 (9) mm below the glottis. There were 1, 10 and 7 Myer-Cotton grade I, II and III lesions, respectively. Mean intervention-free interval following minimally invasive treatment was 26 (2.8) months. Following endobronchial therapy, the median intervention-free interval was 22 months (p>0.8 vs tracheal lesions). No patient required a tracheostomy or endoluminal stenting.

CONCLUSIONS

Intralesional steroid therapy and conservative endoluminal surgery is an effective strategy for treating airway compromise due to active tracheal and bronchial WG, obviating the need for airway bypass or stenting. We recommend the combination of endotracheal dilatation, conservative laser surgery and steroid therapy as the standard of care for treating airway compromise due to obstructive tracheobronchial WG.

Reducing referral-to-treatment waiting times in cancer patients using a multidisciplinary database

INTRODUCTION

Modern delivery of cancer care through patient-centred multidisciplinary teams (MDT) has improved survival. This approach, however, requires effective on-going co-ordination between multiple specialties and resources and can present formidable organisational challenges. The aim of this study was to improve the efficiency of the MDT process for head and neck cancer.

PATIENTS AND METHODS

A systems analysis of the MDT process was undertaken to identify bottlenecks delaying treatment planning. The MDT process was then audited. A revised process was developed and an Intranet-based data management solution was designed and implemented. The MDT process was re-evaluated to complete the audit cycle.

RESULTS

We designed and implemented a trust-wide menu-driven database with interfaces for registering and tracking patients, and automated worklists for pathology and radiology. We audited our MDT for 11 and 10 weeks before and following the introduction of the database, with 226 and 187 patients being discussed during each period. The database significantly improved cross-specialtity co-ordination, leading to a highly significant reduction in the number of patients whose treatment planning was delayed due to unavailability of adjunctive investigations (P < 0.001). This improved the overall efficiency of the MDT by 60%.

CONCLUSIONS

The NHS Cancer Plan aspires to reduce the referral-to-treatment time to 1 month. We have shown that a simple, trust-wide database reduces treatment planning delays in a sizeable proportion of head and neck cancer patients with minimal resource implications. This approach could easily be applied in other MDT meetings.

An approach to the management of paroxysmal laryngospasm

OBJECTIVE

To review the presentation, risk factors and management of paroxysmal laryngospasm.

STUDY DESIGN

Retrospective review of cases.

SETTING

A teaching hospital otolaryngology department with a subspecialty interest in airway disorders.

PATIENTS

All patients diagnosed with laryngospasm over a two-year period were reviewed. Information was obtained about disease presentation, risk factors, management and symptom resolution.

RESULTS

Laryngospasm was diagnosed in nine women and six men. The average age at presentation was 56+/-6.5 years, and there was an 80 per cent association with gastroesophageal reflux disease. Proton pump inhibitors led to complete symptom resolution in six patients and to partial symptomatic relief, requiring no further treatment, in a further four patients. Of the remaining five patients unresponsive to proton pump inhibitor therapy, two continued to experience syncopal episodes due to laryngospasm. Both these patients achieved complete remission after laryngeal botulinum toxin injection. Symptoms recurred after three to four months and were successfully treated with a repeat injection.

CONCLUSIONS

The primary risk factor for spontaneous laryngospasm is laryngopharyngeal reflux. Symptoms are distressing and may be relieved in most cases by treatment aimed at suppressing gastric acid secretion. Laryngeal botulinum toxin injection appears to be a viable treatment modality in selected patients with refractory symptoms.

Management of Rh-isoimmunised Pregnancies : Our Experience

BACKGROUND

The aim of this study was to assess the role of middle cerebral artery peak systolic velocity (MCA-PSV), as measured by doppler ultrasound, in detecting foetal anaemia in Rh- isoimmunised pregnancies. Intra-uterine foetal blood transfusion was performed in such anaemic foetuses to tide over the crisis of foetal immaturity till considered fit for extra-uterine survival.

METHODS

Rh-isoimmunised pregnancies reporting to a tertiary institute from 2003 to 2005, were screened by doppler ultrasound to estimate MCA-PSV to detect foetal anaemia. If the foetus developed MCA-PSV of more than 1.5 multiple of median (MoM) for the gestational age, foetal blood sampling through cordocentesis was performed to confirm foetal anaemia, followed by intrauterine foetal blood transfusion to all anaemic foetuses at the same sitting. Neonatal outcome was evaluated by recording gestational age at the time of delivery, duration of gestational time gained and need for blood transfusion in the neonatal period.

RESULTS

A total of thirteen isoimmunised pregnancies were evaluated. Three pregnancies did not require in-utero foetal blood transfusion. Twenty-one intrauterine foetal blood transfusions were performed in the remaining ten patients. Five received blood transfusion in the neonatal period. Intra uterine foetal death occurred in one grossly hydropic foetus and favourable neonatal outcome was recorded in the rest.

CONCLUSION

The clinical outcome of these pregnancies justifies the use of doppler studies of MCA-PSV in detecting foetal anaemia and intra uterine foetal blood transfusion is the only hope of prolonging pregnancy and salvaging such foetuses.

How we do it: transnasal fibreoptic oesophagoscopy

KEYPOINTS: Transnasal fibreoptic oesophagoscopy (TFO) allows the upper aerodigestive tract, from the nasal vestibule to the gastric cardia to be examined in the outpatients department without sedation. This permits patients with symptoms of upper aerodigestive pathology to be investigated at the initial consultation without the need for inpatient endoscopy or swallow studies. The technique is easily learned, and is statistically comparable with standard flexible nasoendoscopy in respect of procedural pain and discomfort. It is highly cost-efficient, paying for itself within 1 year, and thereafter leading to cost savings of over 80%. Its role can be expanded to encompass investigating patients with potentially malignant disease processes, as well as outpatients "panendoscopy" and biopsy, and a number of therapeutic interventions.

Metastasizing Pleomorphic Salivary Adenoma

OBJECTIVE

To address questions about the etiology, behavior, optimal treatment, and prognosis of metastasizing pleomorphic adenoma (MPA), we undertook a review of the literature (1953-2005) and constructed a virtual series of all identified cases of MPA, metastatic lesions that are very occasionally identified in patients with a history of pleomorphic salivary adenoma and, on detailed pathological evaluation, found to exhibit all the histological hallmarks of the preceding benign lesions.

DATA SOURCES

A review of the English-language literature between 1953 and 2005 using MEDLINE, secondary references identified from bibliographies of pertinent articles, and a further case from one of our institutions.

DATA SYNTHESIS

A virtual case series was constructed and quantitatively analyzed. Forty-two patients with an average age of 33 years were identified. There were 20 male and 22 female patients. There was an overwhelming history of incomplete surgery for pleomorphic salivary adenoma. Most patients had locoregional recurrences before metastasis, and the mean presentation-to-metastasis latency was 16 years. Bone was the most common site for metastases (45%), followed by the head and neck (43%) and lung (36%). There was significant morbidity and mortality from distant disease, with 5-year disease-specific and disease-free survival of 58% and 50%, respectively. Developing distant lesions within 10 years of the primary tumor and presence of metastases in multiple sites were independent predictors of survival on Cox regression analysis. Metastasectomy conferred significant survival advantage over nonoperative treatment (log-rank analysis, P<.02). Chemotherapy and radiotherapy were of limited value.

CONCLUSIONS

Meticulous surgery is crucial in preventing MPA. Metastatic disease carries significant morbidity and mortality and should be treated surgically when feasible.

Objective sizing of upper airway stenosis: a quantitative endoscopic approach

OBJECTIVE

In patients with airway stenosis, anatomy of the lesion determines the magnitude of the biomechanical ventilatory disturbance and thus the nature and severity of symptoms. It also gives information about biology, likelihood of response to treatment, and prognosis of laryngotracheal lesions. Accurate airway sizing throughout treatment is therefore central to managing this condition. We developed a method for objective assessment of airway lesions during endoscopy.

METHODS

We used airway simulations to investigate the effects of endoscope tilt and lens distortions on measurement accuracy, devising and validating clinical rules for quantitative airway endoscopy. A calibrator was designed to assess lesion length, location, and cross-section during tracheoscopy.

RESULTS

It proved possible to calculate the length and location of the stenosis using simple mathematics. Cross-section measurements were more than 95% accurate, independent of endoscope tilt and without making assumptions about endoscope optics and visuospatial distortion, for both pediatric and adult airway dimensions. The technique was used to characterize airway lesions in 10 adult patients with an average age of 48 years undergoing therapeutic laryngotracheoscopy. Lesions occurred on average 36 mm below the glottis (range, 21-54 mm) and were 9.3 mm long (5-17 mm). The average pretreatment airway cross-section was 48.3 mm, increasing to 141.1 mm after laser therapy. Two independent observers calculated airway cross-sections, achieving an interobserver concordance of 0.98.

CONCLUSIONS

This method can be used to objectively and precisely determine the anatomy of airway lesions, allowing accurate documentation of lesion characteristics and surgical results, serial monitoring throughout treatment, and comparison of outcomes between different centers.

Haemodynamic instability during thyroid surgery: a baroreflex-mediated neurogenic phenomenon?

We present a case of marked intra-operative blood pressure instability in a euthyroid, fit 33-year-old female undergoing elective hemithyroidectomy. This led to significant haemodynamic compromise, cardiac failure and end-organ damage. There was no evidence of a vasoactive endocrine cause, and the nature and timing of the event strongly pointed towards baroreflex-mediated neurogenic sympathetic dysfunction. This can occur during carotid surgery and neck dissection. Although haemodynamic fluctuations may happen during thyroid surgery, their severity in this case was unusual. We believe this could have been a rebound phenomenon in response to acute decompression of the carotid artery which had been compressed by an enlarging cyst. We suggest that in similar cases blockade of the carotid sinus could attenuate such responses.

Somnoplasty for simple snoring--a pilot study

A prospective pilot study was conducted to investigate the efficacy of radiofrequency thermal ablation (RFTA) of the soft palate to treat simple snoring. Ten consecutive, consenting patients were recruited following history, examination, Epworth scoring, sleep nasendoscopy and full polysomnography. All the patients received two treatments of three lesional RFTA of the soft palate under local anaesthesia, using the Somnus S2 generator. Each treatment was separated by 6 weeks. Patients completed a questionnaire which used visual analogue scales to score pain during the procedure as well as the postoperative period. Snoring was also scored on visual analogue scales by both the patient and the partner. Objective assessment was based on full polysomnography 3 months after the second treatment. Sixty per cent of patients subjectively reported improvement in snoring. Objectively, only 30% showed improvement in duration of snoring (38-48% better) with no change in intensity. There was high patient acceptability of the procedure.

Specialist Registrars in Otolaryngology: their training programme and career aspirations

The Calman reforms were introduced to Otorhinolaryngology in July 1996 and we are half-way through its first cycle. Further changes may become necessary with expansion of our specialty and because of the need to incorporate super-specialization into current training programmes. We felt that it was an appropriate to evaluate these reforms through the eyes of the Specialist Registrars and at the same time to take the opportunity to investigate their career aspirations. In August 1999 a postal questionnaire was sent to all 184 Specialist Registrars in otorhinolaryngology in England and Wales, of which 123 (66.85%) responded. The results are presented in this paper.

Publishing trends in otorhinolaryngology from January 1997 to December 1999 in the UK

In the last 10 years there have been many changes in otorhinolaryngology training and academic resources. The Calman reforms were introduced to our speciality in July 1996 and the last decade has also seen the number of professorial chairs in the UK rise from two to 12. One would therefore expect an increase in academic output, in terms of published works, despite the impediments generated by the Calman Training System. A search of eight leading English language otorhinolaryngology journals was carried out from January 1997 to December 1999 looking for articles with British authors. The results were compared with similar research carried out 10 years ago. There has been no major growth in the output of otorhinolaryngological publications from the UK in the last 10 years.

The Foley catheter in the management of epistaxis

The Foley urinary catheter has been used in the management of epistaxis for many years, yet it has never been designed or licensed for this purpose. We performed a telephone questionnaire of senior house officers in 90 ENT departments in England and Wales. The aim was to determine how many departments used the Foley catheter for epistaxis management, whether licensed nasal balloon devices were available and if there had been any complications associated with their use. Eighty-three (92%) ENT departments in the study used the Foley catheter for epistaxis management and 44 (49%) departments had licensed balloon devices available. Only 22% of ENT senior house officers questioned were aware that the Foley catheter was not licensed for use in the nose. Most complications associated with the use of nasal balloon devices appear to be due to Foley catheters.

In situ hybridization in paracoccidioidomycosis

In situ hybridization (ISH) was performed using oral biopsies from patients with paracoccidioidomycosis and guinea pig testes inoculated with a culture of Paracoccidioides brasiliensis isolated from soil, employing both a 14 base-pair specific oligoprobe (ACT CCC CCG TGG TC) and its complementary sequence. When combining ISH with the Gridley stain which detects fungal cell walls, about 2-3% of the fungal cells present in the tissues were labelled. When the complementary probe was used, labelling was higher, reaching the 3% level.

Laboratory diagnosis of Pneumocystis carinii infections by PCR directed to genes encoding for mitochondrial 5S and 28S ribosomal RNA

PCR with 5S mitochondrial ribosomal RNA (5S) target is a sensitive and specific assay for the detection of Pneumocystis carinii in clinical specimens from the respiratory tract. We developed an oligonucleotide probe directed to a 200 bp amplicon generated by fungal-specific universal primers that anneals with sequences specific for P. carinii in the 28S ribosomal RNA gene (28S). Of 50 archived bronchoalveolar lavage 1(BAL) specimens, 46 of 50 samples (92% agreement) gave the same result (23 positive, 23 negative) by PCR directed to the 5S and 28S assays. Results of calcofluor white staining of BAL smears on slides indicated agreement with the molecular results in 43 of 46 (93.5%) assays. PCR detection of P. carinii by amplification of 28S ribosomal gene target by fungal-specific primers and an organism-specific probe provides an alternate genomic target for the laboratory diagnosis of this organism.

Granulocytic sarcoma presenting as cauda equina syndrome

Granulocytic sarcoma (GS) is a tumour formed by myeloid precursors in an extramedullary site and is associated with myeloid leukaemias and other myeloproliferative disorders. We present a patient with symptoms of cauda equina compression where MRI of the spine showed extradural lesions at S1 and L3 levels. This patient had normal bone marrow and peripheral blood for a further 6 weeks from onset of symptoms. Such aleukaemic presentations of GS are rare and have potential for misdiagnosis and delay in treatment. Therefore we recommended early open biopsy of such tumours.

Haematological and biochemical studies on experimental Theileria annulata infection in crossbred calves

Administration of ground-up tick tissue stabilate (0.75 tick equivalent) by the subcutaneous route to crossbred calves aged 1 week to 1 month led to the development of acute theileriosis. Haematological studies revealed significant progressive decreases in haemoglobin concentration, packed cell volume and red blood cell count, whereas the total leukocyte count showed an initial non-significant leukocytosis followed by a significant leukopenia. Analysis of serum revealed significant increases in levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, creatinine kinase and gamma-glutamyltransferase, and in the concentrations of uric acid, blood urea nitrogen and bilirubin. The concentrations of total protein, albumin, glucose, cholesterol and calcium showed non-significant decreases, while phosphorus decreased significantly during the terminal stages of the disease.

A randomized prospective trial to compare four different ear packs following permeatal middle ear surgery

Surgeons choice of an ear pack is dictated by availability, previous training and personal preference. There has been no recent prospective study evaluating the use of different types of ear packs. This randomized prospective study compares the use of BIPP impregnated ribbon gauze (Aurum), Pope wicks (Xomed-Teace), silastic sheeting (Dow Corning) and tri-adcortyl ointment (Squibb) as an ear dressing following 'clear' middle ear procedures via a permeatal approach. The results showed that there was no statistically significant difference in post-operative pain and discomfort experienced, neither was there any significant difference regarding the otolaryngologist's assessment of the degree of canal granulation, stenosis or discharge with the above named packs. This study concludes that non-traditional dressings such as tri-adcortyl ointment or simply a thin silastic sheet placed on the drum are no worse than time honoured BIPP. They have, as well, the advantage of being well-tolerated by the patients.

Molecular detection and identification of Paracoccidioides brasiliensis

Nearly 800 nucleotides from the 5' terminus of the 28S ribosomal gene of Paracoccidioides brasiliensis were sequenced, and a 14-base DNA probe specific for this species was identified. Hybridization results showed that the probe identified P. brasiliensis ribosomal DNA in a panel of ribosomal DNAs representing a total of 48 species of fungi.

Oxidized cellulose (Surgicel) granulomata mimicking tumour recurrence

Oxidized cellulose (Surgicel) has been used as a haemostatic agent in neurosurgery for five decades. Complications have been few. Two cases are reported of granulomatous reaction to oxidised cellulose two months and twelve months after removal of intracranial meningiomas. Both appeared as contrast enhancing space occupying lesions on CT scan and were taken for recurrence of the tumour.

Molecular probes for diagnosis of fungal infections

We have developed 21 specific nucleic acid probes which target the large subunit rRNA genes from Aspergillus flavus, Aspergillus fumigatus, Aspergillus glaucus, Aspergillus niger, Aspergillus terreus, Blastomyces dermatitidis, Candida albicans, Candida (Torulopsis) glabrata, Candida guilliermondii, Candida kefyr, Candida krusei, Candida lusitaniae, Candida parapsilosis, Candida tropicalis, Coccidioides immitis, Cryptococcus neoformans var. gattii, Cryptococcus neoformans var. neoformans, Filobasidiella neoformans var. bacillispora, Filobasidiella neoformans var. neoformans, Histoplasma capsulatum, Pseudallescheria boydii, and Sporothrix schenckii. A section of the 28S rRNA gene from approximately 100 fungi, representing about 50 species of pathogens and commonly encountered saprophytes, was sequenced to develop universal PCR primers and species-specific oligonucleotide probes. Each step in the process of detection and identification was standardized to a common set of conditions applicable without modification to all fungi of interest and all types of clinical specimens. These steps consist of DNA extraction by boiling specimens in an alkaline guanidine-phenol-Tris reagent, amplification of a variable region of the 28S rRNA gene with universal primers, and amplicon identification by probe hybridization or DNA sequencing performed under conditions identical for all fungi. The results obtained by testing a panel of fungal isolates and a variety of clinical specimens indicate a high level of specificity.

Non-specific abdominal pain: a safe diagnosis?

Non-specific abdominal pain (NSAP) is a benign condition with low morbidity. This follow-up study of 82 patients discharged from an emergency department after presenting with abdominal pain, during 1 calendar month, has shown that only 9.6% were diagnosed as having NSAP. It has been shown previously that 34.9% to 45.6% of patients presenting to an emergency department with abdominal pain will have NSAP. One large study showed that 88% of NSAP had improved or resolved at 2-3 weeks without specific treatment and few required subsequent hospitalization. In this study a number of patients were given diagnoses which could not be supported from the history or investigations. This is a potentially dangerous practice. NSAP is a diagnosis of exclusion and the patient may be reassured that the condition is most likely benign or self limiting and allowed home.

Adenosine deaminase inhibitors attenuate ischemic injury and preserve energy balance in isolated guinea pig heart

We investigated the effect of the adenosine deaminase inhibitors erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA) and coformycin on high-energy phosphate metabolism, tissue nucleotides and nucleosides, and recovery of contractile function in isolated, perfused guinea pig hearts. EHNA and coformycin (10 microM) improved postischemic recovery of contractile function approximately 85% and enhanced coronary flow rate in reperfused tissue approximately 40%. The protective effect of EHNA on recovery of contractile function was concentration dependent. Although adenosine (10 microM) increased coronary flow rate on reperfusion approximately twofold over vehicle, it failed to improve postischemic recovery of contractile function. EHNA and coformycin preserved cardiac ATP levels and increased endogenous tissue adenosine during ischemia. During reperfusion, these agents enhanced recovery of high-energy phosphates approximately twofold and potentiated adenosine release into the perfusate with concentration dependency. Furthermore, EHNA and coformycin reduced the extent of myocardial ischemia-reperfusion injury, as indicated by the approximately 55% reduction in creatine phosphokinase release. We conclude that inhibitors of adenosine deaminase attenuate myocardial ischemic injury and improve postischemic recovery of contractile function and metabolism through endogenous myocardial adenosine enhancement and ATP preservation.

Gene identification by arrested primer extension

This paper reports a novel method for the identification of nucleic acid target sequences when these targets have high sequence identity. Homologous genes are currently identified by sequencing. We hypothesize that by primer extension in the presence of selected nucleotides, genes with similar sequence can be identified by the length of the extension products on gel electrophoresis. This simple procedure eliminates the much-demanding process of sequencing. We term this process Arrested Primer Extension (APE). As a demonstration of the feasibility of this method, we have used APE to speciate a known set of cultured mycobacteria. There should be many other applications of this method.