RARE LARYNGEAL HAMARTOMA: A CASE REPORT

Hamartoma (from the Greek language, where hamartia means defect or an error and -oma denoting a tumor or neoplasm) is a benign tumor-like mass composed of mature tissue or cells that are present in abnormal proportions or show a disorganized arrangement. Hamartomas are rarely seen in the head and neck area and especially rare in the larynx. Only few cases of laryngeal hamartoma have been reported in the literature so far. They are usually manifested by stridor, dysphonia and symptoms associated with airway obstruction. The diagnosis must be confirmed histologically and the method of choice in treatment is complete excision of the lesion. The authors present a case of laryngeal hamartoma of a 43-year-old woman treated for hoarseness and paralysis of the left vocal cord.

Comparison of Different Out-of-Hospital Airway Management Techniques in Patients with Cardiac Arrest in Slavonia Region

Endotracheal intubation is the gold standard in inpatient treatment of cardiac arrest patients; however, there are conflicting research results in out-of-hospital conditions. This prospective study included 92 patients with confirmed cardiac arrest occurring outside a hospital facility, who fulfilled the inclusion criteria and whom the emergency ambulance team reached within 20 minutes from the event. Medical data on each patient (age, gender, cause of arrest, estimated time of arrest, time to arrival of the ambulance team, resuscitation commenced prior to arrival of the ambulance team, initial electrocardiographic rhythm, method of airway management, and success of resuscitation) were recorded. The airway maintenance techniques applied in the patients were endotracheal intubation and I-gel laryngeal mask (LMA). The rate of spontaneous circulation recovery resulting from different techniques of airway management and the incidence of spontaneous circulation recovery between the defibrillation rhythm and non-defibrillable rhythm groups were recorded for each patient. Forty-seven patients received endotracheal tube and the rest of 45 patients I-gel LMA treatment. The ratio of achieving spontaneous circulation with intubation versus I-gel LMA was 13 (28%) to 11 (24%) (p=0.725). The best return of spontaneous circulation results was recorded in patients suffering from ventricular fibrillation; however, there was no statistically significant difference between the intubation and I-gel LMA treatments (8 (47%) vs. 7 (41%); p=0.916). No statistically significant difference was observed between the outcomes of patients resuscitated by endotracheal intubation and I-gel LMA methods either.

Presence of Helicobacter Pylori in the Stomach and Laryngeal Mucosal Linings in Patients with Laryngeal Cancer

SUMMARY – Helicobacter (H.) pylori is the cause of one of the most common chronic bacterial infections in humans. Risk factors for the development of laryngeal cancer are cigarette smoke, alcohol, and human papillomavirus. Several papers report on H. pylori isolated in tooth plaque, saliva, middle ear and sinuses. Many articles describe the presence of H. pylori in laryngeal cancer cases, however, without noting the possible source of infection, i.e. stomach or oral cavity. The aim of this study was to determine which patients and to what extent simultaneously developed H. pylori colonization in the stomach and the larynx. Prospective examinations were performed in 51 patients with laryngeal squamous cell carcinoma. The study group included patients with laryngeal squamous cell carcinoma histopathologically confirmed by two independent pathologists. The patients underwent fiber esophagogastroduodenoscopy with tumor tissue biopsy. Laryngeal and gastric biopsies were examined by histologic staining technique for histopathologic detection of H. pylori and with DNA analyses using the standardized fluorescent ABI Helicobacter plus-minus PCR assay. Laryngeal carcinoma patients showed positive H. pylori test results simultaneously in the laryngeal and stomach areas, implying H. pylori transmission from the stomach to the laryngeal area. In addition, H. pylori positive test results along with negative H. pylori results in the stomach region were also recorded, suggesting a possible bacteria migration from the oral cavity. In conclusion, H. pylori was found in the area of laryngeal carcinoma, and its migration appeared likely to occur both upwards (from the stomach to the mouth) and downwards (from the oral cavity to the stomach).

Postoperative quality of life after two different methods of tonsillectomy

BACKGROUND AND OBJECTIVES

Tonsillectomy is a very painful procedure. Pain may be severe, and patients are often unable to perform in school or eat regular food for a number of days after the surgery. The aim of this study was to compare the quality of life after undergoing two different surgical techniques of tonsillectomy, harmonic scalpel and classic tonsillectomy with bipolar cauterization.

DESIGN AND SETTING

Prospective randomized double-blind, clinical trial study conducted in the ENT Department, Dr. Josip Benčević General Hospital, Slavonski Brod, Croatia.

PATIENTS AND METHODS

Data were collected, according to the type of operation, on pain persistence and intensity and returning to normal eating with tonsillectomy patients during the first seven postoperative days. Group A consisted of 50 children submitted to classic tonsillectomy with bipolar cauterization, while group B included 50 children operated on using the harmonic scalpel. Data on pain intensity were obtained using pain measuring scales adjusted to children's age (Faces scales, visual analog scale). The first day of normal oral food intake was recorded.

RESULTS

The analysis of variance revealed that the grade of pain significantly differs by a surgical technique employed, and that it significantly varied over the first seven postoperative days. The pain was more severe after undergoing the harmonic scalpel technique and children started to eat later compared with the classic tonsillectomy.

CONCLUSION

The classic tonsillectomy method with bipolar cauterization is the method of choice due to lower postoperative pain levels and sooner normal eating. The quality of life is better after undergoing the classic tonsillectomy method.

The prevalence of neurocranium injury in children in Brod-Posavina County

Head injuries are very common in children and are the most frequent cause of disability and death among children. This retrospective study included 350 children hospitalized for injury of neurocranium over a 5-year period at Dr Josip Bencević General Hospital in Slavonski Brod. Boys were more commonly injured (63.4%) than girls. The most common injuries were recorded in children aged 7-14 (47.1%), followed by those aged 1-6 (33.8%) years. The injuries occurred slightly more often in urban (50.9%) than in rural (46.6%) setting. Children were more commonly injured in the street or on the road (38.6%), followed by injuries sustained at home (35.2%), at school (9.3%) and on playgrounds (5.7%). They were most commonly injured by fall (50%), followed by traffic injuries (33.5%). Statistically significant differences were found in the following age groups: all children younger than one year were injured by fall; children aged 1-14 were mostly injured by fall (less in traffic, and due to hitting), and those aged 15-18 mostly in traffic (less by fall and due to hitting). Children were mostly injured in the street or on the road (in traffic accidents), followed by injuries at home (mostly by fall), at school and around the house or in the yard (mostly by fall); on the playground (due to hitting) and on the road (in traffic accidents) (statistically significant difference). Most of them had head contusion and cerebral commotion combined (46.8%), followed by head contusion alone (12.5%) and skull fractures (10.5%). Hemorrhages and hematomas were rare (epidural, subdural, subarachnoid hemorrhage), found in 3.2% of cases. We hope that our results will prove helpful in planning preventive measures and treatment of injured children.

Temporal patterns of genetic and phenotypic variation in the epidemiologically important drone fly, Eristalis tenax

Eristalis tenax L. (Diptera: Syrphidae) is commonly known as the drone fly (adult) or rat-tailed maggot (immature). Both adults and immature stages are identified as potential mechanical vectors of mycobacterial pathogens, and early-stage maggots cause accidental myiasis. We compared four samples from Mount Fruška Gora, Serbia, with the aim of obtaining insights into the temporal variations and sexual dimorphism in the species. This integrative approach was based on allozyme loci, morphometric wing parameters (shape and size) and abdominal colour patterns. Consistent sexual dimorphism was observed, indicating that male specimens had lighter abdomens and smaller and narrower wings than females. The distribution of genetic diversity at polymorphic loci indicated genetic divergence among collection dates. Landmark-based geometric morphometrics revealed, contrary to the lack of divergence in wing size, significant wing shape variation throughout the year. In addition, temporal changes in the frequencies of the abdominal patterns observed are likely to relate to the biology of the species and ecological factors in the locality. Hence, the present study expands our knowledge of the genetic diversity and phenotypic plasticity of E. tenax. The quantification of such variability represents a step towards the evaluation of the adaptive potential of this species of medical and epidemiological importance.

Mechanical ventilation in chronic obstructive pulmonary disease patients, noninvasive vs. invasive method (randomized prospective study)

Acute respiratory failure due to chronic obstructive pulmonary disease (COPD) presents an increasing problem throughout the world. The aim of this study was to compare invasive and non-invasive mechanical ventilation (MV) for patients with COPD. A prospective, randomized trial was performed in a multidisciplinary intensive care unit for the period of 36 months and included 156 patients with COPD. MV procedure was performed using standard methods, and was applied as either invasive MV (IMV) or noninvasive MV (NIMV). Patients were randomized in two groups for application of MV using closed, nontransparent envelops. Comparison was made based on patient characteristics, objective parameters on admission and 1h, 4h, 24h, and 48h after admission and based on treatment outcome. We have confirmed that NIMV method is superior to IMV for patients with COPD. MV duration NIM:IMV was 94:172 hours, p < 0.001, time spent in Intensive Care Unit 120:223 hours, p < 0.001. Ventilator associated pneumonia 5(6%):29(37%), p < 0.001. The advantage of NIMV in COPD patients, especially in the early stages was confirmed.

The effect of stress hormones on cerebral hemodynamics in patients with chronic posttraumatic stress disorder

The aim of the study was to assess the possible correlation between catecholamine and cortisol levels and changes in cerebral hemodynamics in patients with chronic posttraumatic stress disorder (PTSD). The study included 50 patients with chronic PTSD first ever hospitalized for psychiatric treatment and 50 healthy control subjects. All study subjects were aged 30-50. In PTSD patients, 24-h urine levels of the epinephrine and norepinephrine metabolites vanillylmandelic acid (VMA) and cortisol were determined and transcranial Doppler ultrasonography was performed on day 1 of hospital stay and repeated after 21-day psychiatric medicamentous treatment. On initial testing, increased level of 24-h VMA, decreased cortisol level and elevated mean blood flow velocity (MBFV) in the circle of Willis vessels were recorded in 25 (50.00%) patients. Repeat findings obtained after 21-day psychopharmaceutical therapy showed increased 24-h VMA, decreased cortisol and elevated MBFV in the circle of Willis vessels in seven (14.00%) patients (initial vs. repeat testing, P = 0.0002). Such parameters were not recorded in any of the control subjects (initial PTSD patient testing vs. control group, P = 0.0000). Study results pointed to a significant correlation between increased catecholamine levels, decreased cortisol level and elevated MBFV in the circle of Willis vessels caused by cerebral vasospasm. Psychiatric medicamentous therapy administered for three weeks significantly reduced the proportion of patients with concurrently altered cerebral hemodynamics, increased levels of catecholamine metabolites and decreased level of cortisol.

Pulmonary compliance values provide prognosis in mechanically ventilated patients--a randomized prospective study

Our aim was to evaluate the influence of static pulmonary compliance (Cst) on the choice of Mechanical Ventilation(MV) method and treatment outcome. A prospective, randomized trial conducted out at the multidisciplinary Intensive Care Unit (ICU) included 387 patients, randomized in two groups: noninvasive MV group and invasive MV group. Furthermore, each group was divided in two groups: Cst < or = 0.025 and Cst > 0.025 L/cm H2O. In patients with Cst > 0.025 L/cm H2O MV duration, noninvasive vs invasive, was 92 vs 114 h, p = 0.039, time spent in ICU 118 vs 164 h, p = 0.004. In patients with Cst < or = 0.025, MV duration was 141 vs 189 h, p < 0.001, time spent in ICU 190 vs 246 h, p = 0.001, all patients were intubated. Need for tracheostomy was 6 (11%) vs 39 (46%) patients, p = 0.005, and ICU mortality was 15 (26%) vs 21 (25%) patients. Statistical significance in favor of noninvasive method was confirmed in patients with Cst > 0.025 L/cm H2O in MV duration, time spent in ICU, need for tracheostomy and intubation rate. In the group with Cst < or = 0.025 no significant difference in treatment failure was recorded between the two MV methods.

Chronic obstructive pulmonary disease and weaning of difficult-to-wean patients from mechanical ventilation: randomized prospective study

AIM

To compare T-tube and pressure support ventilation (PSV) as two methods of mechanical ventilation weaning of patients with chronic obstructive pulmonary disease (COPD) after failed extubation.

METHODS

A prospective randomized trial carried out at the multidisciplinary intensive care unit (ICU) over 2 years included 136 patients with COPD who required mechanical ventilation longer than 24 hours. The patients who could be weaned from mechanical ventilation were randomized to either a T-tube or PSV 2-hour spontaneous breathing trial. The patients in whom 2-hour trial was successful were extubated and excluded from further research. Patients in whom 2-hour trial failed had mechanical ventilation reinstated and underwent the same weaning procedure after 24 hours in case they fulfilled the weaning criteria. The weaning outcome was assessed according to the following parameters: extubation success, mechanical ventilation duration, time spent in ICU, reintubation rate, and mortality rate.

RESULTS

Two-hour trial failed in 31 patients in T-tube and 32 patients in PSV group, of whom 17 and 23, respectively, were successfully extubated (P<0.001, chi(2)test). Mechanical ventilation lasted significantly longer in T-tube than in PSV group (187 hours vs 163 hours, respectively, P<0.001, Mann-Whitney test). Also, patients in T-tube group spent significantly more time in ICU than patients in PVS group (241 hours [interquartile range 211-268] vs 210 hours [211-268], respectively, P<0.001, Mann-Whitney test). Reintubation was required in 8 and 6 patients in T-tube and PVS group, respectively, and death occurred in 4 and 2 patients, respectively, during ICU stay.

CONCLUSION

Patients with COPD who failed the 2-hour spontaneous breathing trial had more favorable outcome when PVS rather than T-tube method was used for weaning from mechanical ventilation.

Comparison of pressure support and T-tube weaning from mechanical ventilation: randomized prospective study

AIM

To compare T-tube and pressure support ventilation (PSV) as two methods of weaning patients from mechanical ventilation.

METHODS

A randomized prospective study included 260 patients who received mechanical ventilation for more than 48 h, and who were admitted to the intensive care unit (ICU) at Dr. Josip Bencevic General Hospital in Slavonski Brod, between August 1999 and October 2000. After fulfilling the clinical criteria for weaning, the patients were randomly assigned to a 2-h trial of spontaneous breathing either with a T-tube system (n=110) or PSV of 8 cm H2O (n=150). The patients who fulfilled weaning criteria at the end of the 2-h trial were extubated. If any signs of poor procedure tolerance were observed during the 2-h trial, the mechanical ventilation was reinstituted. In such patients, the same weaning procedure was repeated after 24 h, or when the patient's clinical condition permitted. Two methods of weaning were compared according to the patient's clinical characteristics, objective parameters, and procedure outcome.

RESULTS

Eighty (73%) patients in the T-tube group and 120 (80%) patients in PSV group successfully completed the 2-h trial and were extubated. Thirty patients in the T-tube group and 30 in the PSV group had weaning difficulties. Total length of additional mechanical ventilation and total length of stay at ICU were significantly shorter in patients undergoing PSV weaning (p<0.001 for all, Man-Whitney test). For the patients with weaning difficulties and Acute Physiology and Chronic Health Evaluation (APACHE) II score >20 on admission, PSV was the superior method of weaning according to rate of successful extubation, time of weaning from mechanical ventilation, total time of mechanical ventilation, and length of ICU stay (p<0.001 for all, Man-Whitney test).

CONCLUSION

In patients with weaning difficulties, PSV with 8 cm H(2)O was more successful weaning method than T-tube.

Genetic variability and adaptation to stress

Besides an immediate cellular adaptation to stress, organisms can resist such challenges through changes in their genetic material. These changes can be due to mutation or acquisition of pre-evolved functions via horizontal transfer. In this chapter we will review evidence from bacterial genetics that suggests that the frequency of such events can increase in response to stress by activating mutagenic response (e.g. the SOS response) and by inhibiting antimutagenic activities (e.g. mismatch repair system, MRS). Natural selection, by favoring adaptations, can also select for the mechanism(s) that has/have generated the adaptive changes by hitchhiking. These mutator mechanisms can sometimes respond very specifically, though blindly, to the challenge of the environment. Such stress-induced increases in mutation rates enhance genetic polymorphism, which is the structural component of the barrier to genetic exchange. Since SOS and MRS are the enzymatic controls of this barrier, the modulation of these systems can lead to a burst of speciation.

Repair of cytotoxic lesions induced by N-methyl-N'-nitro-N-nitrosoguanidine in Salmonella typhimurium and Escherichia coli

The role of nucleotide excision repair and 3-methyladenine DNA glycosylases in removing cytotoxic lesions induced by N-methyl-N'-nitro-N-nitrosoguanidine (MNNG) in Salmonella typhimurium and Escherichia coli cells was examined. Compared to the E. coli wild-type strain, the S. typhimurium wild-type strain was more sensitive to the same dose of MNNG. Nucleotide excision repair in both bacterial species does not contribute significantly to the survival after MNNG treatment, indicating that the observed differences in survival between S. typhimurium and E. coli should be attributed to DNA-repair systems other than nucleotide excision repair. The survival of the E. coli alkA mutant strain is seriously affected by the lack of 3-methyladenine DNA glycosylase II, accentuating the importance of this DNA-repair enzyme in protecting E. coli cells against the lethal effects of methylating agents. Following indications from our experiments, the existence of an alkA gene analogue in S. typhimurium has been questioned. Dot-blot hybridisation, using the E. coli alkA gene as a probe, was performed, and such a nucleotide sequence was not detected on S. typhimurium genomic DNA. The existence of constitutive 3-methyladenine DNA glycosylase, analogous to the E. coli Tag gene product in S. typhimurium cells, suggested by the results is discussed.

The influence of the nucleotide excision-repair system on mutagenesis in Salmonella typhimurium LT2 after exposure to low doses of monofunctional alkylating agents

The role of nucleotide excision repair in the mutagenicity of the monofunctional alkylating agents N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), methyl methanesulfonate (MMS), N-ethyl-N'-nitro-N-nitrosoguanidine (ENNG), and N-ethyl-N-nitrosourea (ENU) in Salmonella typhimurium was examined. The mutagenic potential of the mutagenic agents used increased in the following order: MMS less than ENU less than ENNG less than MNNG. The results obtained confirm the involvement of nucleotide excision repair in the removal of mutagenic lesions from the DNA of S. typhimurium cells exposed to high doses of methylating as well as ethylating agents. At the low doses of all the alkylating agents used, the nucleotide excision repair-proficient strain was mutagenized more efficiently than the uvrB mutant. This phenomenon, a consequence of competition between nucleotide excision-repair enzymes and constitutive O6-methylguanine-DNA methyltransferase, is discussed.