New onset sarcoidosis following biologic treatment in patients with seronegative inflammatory arthritis: A case series and systematic literature review

OBJECTIVE

To report cases of new onset sarcoidosis upon biologic (bDMARDs) treatment administration in patients with seronegative inflammatory arthritis in a real-life cohort, alongside a systematic literature review (SLR) on this topic.

METHODS

We performed a retrospective analysis on clinical records of patients with seronegative arthritis followed up in a monocentric cohort who underwent bDMARDs treatment due to the underlying rheumatic disease and described any newly diagnosed sarcoidosis in this cohort. Only ascertained cases with available radiological and/or histological documentation were considered. A SLR on new-onset sarcoidosis in seronegative arthritis receiving bDMARDs was performed across MEDLINE (through PubMed), Scopus and Ovid (Cochrane, Embase) electronic databases using appropriate strings.

RESULTS

In our cohort, 4 new-onset cases of sarcoidosis were reported among patients with seronegative inflammatory arthritis receiving biologics. Three out of 4 patients were receiving anti-tumor necrosis factor alpha (TNFα) while 1 patient was on secukinumab (anti-IL17A) prior to sarcoidosis onset. The SLR disclosed 46 new-onset sarcoidosis cases upon biological treatment for seronegative arthritis, of whom 43 occurred during treatment with anti-TNFα, while 3 during anti-IL-17A therapy. In our cohort as well as in the majority of cases reported in the SLR, sarcoidosis presented with lymph nodal and lung involvement and displayed a benign course with spontaneous resolution in about 1 fourth of the cases.

CONCLUSION

The use of biologics may relate to the onset of sarcoidosis; hence, clinicians must remain aware of the potential occurrence or reactivation of sarcoidosis when starting biologic treatment in patients with inflammatory arthritis, performing adequate patient assessment and surveillance. Since TNFα inhibitors may represent a therapeutic option for sarcoidosis, further evaluation on larger cohorts is needed to investigate any causal link with the development of sarcoidosis.

Ultrasound features of polypoid endometriosis: a case report and a short review of Literature

Introduction:

Polypoid endometriosis is a rare variant of endometriosis characterized by histological features resembling an endometrial polyp. Lesions frequently affect the ovaries presenting as adnexal masses which may mimic malignancy, with an extremely complex differential diagnosis due to the poor evidence reported in Literature.

Case description:

In this report, we describe the case of a 43 years old woman referred to pelvic transvaginal ultrasound examination for recurrent abdominal pain, in whom sonography revealed a pelvic mass with features highly suspicious for ovarian carcinoma. Surgical removal allowed histopathological diagnosis of polypoid endometriosis, with no signs of malignancy. At ultrasound examination, the lesion appeared as a multilocular-solid mass, with low-level echogenicity of cystic content, multiple papillary projections, and solid areas with high vascularization and apparent infiltration of the uterus. At retrospective review of the sonographic images after pathological examination, some features mirroring the histological architecture of polypoid endometriosis could be identified in the solid components of the mass: these included the hyperechoic appearance, the rounded outline of the intracystic projections, and the vascularization pattern with a single central vessel with branching.

Conclusions:

To date, this is the first work providing a detailed ultrasonographic description of polypoid endometriosis using shared terms and definitions and relating these findings with available evidence about radiologic and histopathologic features. The report shows how this condition could strongly mimick ovarian malignancy, though several sonographic features can be identified reflecting the histopathological patterns of those lesions.

Radiofrequency volume turbinate reduction versus partial turbinectomy: clinical and histological features

BACKGROUND

Nasal obstruction is a common symptom related to turbinate hypertrophy in 20% of cases. When medical treatment failed different surgical options were available. Actually, nasal physiology impairment after surgical treatment is not fully clear. This study evaluates microscopic mucosal changes and physiological function, by means of mucociliary transport time (MCT), after radiofrequency volume turbinate reduction and partial inferior turbinectomy.

METHODS

Forty-eight nonallergic patients were treated for chronic nasal obstruction. Twenty-six patients (group A) underwent radiofrequency turbinate reduction and 22 patients (group B) underwent partial turbinectomy associated with septoplasty. Mucosal specimens obtained before T(0) and 6 months (T(1)) after surgery were compared by means of optical microscope and transmission electron microscope. All patients were evaluated using MCT at T(0) and T(1).

RESULTS

Optical analysis showed circumscribed squamous metaplasia and fibrosis in specimens obtained from group A. Same changes were more evident in group B. Ultrastructural analysis evidenced loss of ciliated epithelium in group B, whereas in group A a normal number of cilia was found. In all patients at T(1), MCT time was prolonged in comparison with the preoperative values. After surgery, group B showed significantly prolonged MCT in comparison with group A (p < 0.05).

CONCLUSION

In our study both surgical techniques achieved good clinical outcomes with improved nasal function, although the ciliated epithelium appeared partially impaired. These findings resulted in a prolonged MCT in all patients, especially in those treated with partial turbinectomy. Compared to partial resection, intraturbinal turbinate reduction seems to be the method of choice to better preserve nasal physiology.

Nodular fasciitis in the maxillary region

We describe the imaging and histologic findings of a case of nodular fascitiis in the maxillary region in a 54-year-old man. The rapid growth and tissue distortion of this lesion may mimic malignant tumors. Therefore, proper diagnosis is essential to avoid unnecessarily aggressive treatment.

Chronic kidney disease, severe arterial and arteriolar sclerosis and kidney neoplasia: on the spectrum of kidney involvement in MELAS syndrome

BACKGROUND

MELAS syndrome (MIM ID#540000), an acronym for Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-like episodes, is a genetically heterogeneous mitochondrial disorder with protean manifestations and occasional kidney involvement. Interest in the latter is rising due to the identification of cases with predominant kidney involvement and to the hypothesis of a link between mitochondrial DNA and kidney neoplasia.

CASE PRESENTATION

We report the case of a 41-year-old male with full blown MELAS syndrome, with lactic acidosis and neurological impairment, affected by the "classic" 3243A > G mutation of mitochondrial DNA, with kidney cancer. After unilateral nephrectomy, he rapidly developed severe kidney functional impairment, with nephrotic proteinuria. Analysis of the kidney tissue at a distance from the two tumor lesions, sampled at the time of nephrectomy was performed in the context of normal blood pressure, recent onset of diabetes and before the appearance of proteinuria. The morphological examination revealed a widespread interstitial fibrosis with dense inflammatory infiltrate and tubular atrophy, mostly with thyroidization pattern. Vascular lesions were prominent: large vessels displayed marked intimal fibrosis and arterioles had hyaline deposits typical of hyaline arteriolosclerosis. These severe vascular lesions explained the different glomerular alterations including ischemic and obsolescent glomeruli, as is commonly observed in the so-called "benign" arteriolonephrosclerosis. Some rare glomeruli showed focal segmental glomerulosclerosis; as the patient subsequently developed nephrotic syndrome, these lesions suggest that silent ischemic changes may result in the development of focal segmental glomerulosclerosis secondary to nephron loss.

CONCLUSIONS

Nephron loss may trigger glomerular sclerosis, at least in some cases of MELAS-related nephropathy. Thus the incidence of kidney disease in the "survivors" of MELAS syndrome may increase as the support therapy of these patients improves.

Objective measurement of motor speech characteristics in the healthy pediatric population

OBJECTIVE

To obtain objective measurements of motor speech characteristics in normal children, using a computer-based motor speech software program.

METHODS

Cross-sectional, observational design in a university-based ambulatory pediatric otolaryngology clinic. Participants included 112 subjects (54 females and 58 males) aged 4-18 years. Participants with previously diagnosed hearing loss, voice and motor disorders, and children unable to repeat a passage in English were excluded. Voice samples were recorded and analysed using the Motor Speech Profile (MSP) software (KayPENTAX, Lincoln Park, NJ). The MSP produced measures of diadochokinetics, second formant transition, intonation, and syllabic rates.

RESULTS

Demographic data, including sex, age, and cigarette smoke exposure were obtained. Normative data for several motor speech characteristics were derived for children ranging from age 4 to 18 years. A number of age-dependent changes were indentified, including an increase in average diadochokinetic rate (p<0.001) and standard syllabic duration (p<0.001) with age. There were no identified differences in motor speech characteristics between males and females across the measured age range. Variations in fundamental frequency (Fo) during speech did not change significantly with age for both males and females.

CONCLUSIONS

To our knowledge, this is the first pediatric normative database for the MSP progam. The MSP is suitable for testing children and can be used to study developmental changes in motor speech. The analysis demonstrated that males and females behave similarly and show the same relationship with age for the motor speech characteristics studied. This normative database will provide essential comparative data for future studies exploring alterations in motor speech that may occur with hearing, voice, and motor disorders and to assess the results of targeted therapies.

Review of 43 osteomas of the craniomaxillofacial region

PURPOSE

To present and discuss the demographic and clinical aspects and the management of 44 cases of osteomas of the craniomaxillofacial region.

MATERIALS AND METHODS

A retrospective chart review was performed of all cases of osteoma diagnosed from 2000 through 2010. The data collected included age at diagnosis, gender, lesion location, presenting symptoms, type of osteoma, treatment, and outcomes.

RESULTS

Forty-two patients with 43 osteomas were diagnosed during the study period. Their mean age was 48 years. The male-to-female ratio was 0.4:1. Twenty-one patients were asymptomatic, whereas 10 patients complained about headache and neuralgia, and 11 patients presented with facial asymmetry. Only 21 symptomatic osteomas were surgically removed after histologic diagnosis, whereas for the asymptomatic lesions a careful follow-up was maintained.

CONCLUSIONS

The slow growth of osteomas allows a conservative attitude toward asymptomatic lesions. Thus, when surgery is performed, it is extremely important to plan a surgical approach that minimizes any damage to the adjacent structures.

Nasopharyngeal polymorphous low-grade adenocarcinoma in a patient with nonfunctioning pituitary macroadenoma

BACKGROUND

Polymorphous low grade adenocarcinoma (PLGA) is a rare malignant neoplasm of the minor salivary glands occurring in the fifth and sixth decade with a 2:1 female predominance. The nasal cavity is involved in less than 1% of cases. The incidence of clinically recognisable pituitary adenoma is 15 cases/million/year. The prevalence of non-functioning pituitary adenoma (NFPA) is estimated to be 70-90 cases/million. Both types of adenoma represent 20-45% of pituitary tumours.

CASE REPORT

The report describes the first case of PLGA associated with NFPA, both incidentally diagnosed. Three months after the exeresis of the NFPA using a trans-sphenoidal approach, an endoscopic resection of the PLGA was performed. No recurrence was observed during a 13 months follow-up.

CONCLUSIONS

Complete surgical excision is the preferred management for PLGA. Radiotherapy has not been demonstrated to be effective in treating PLGA. The prognosis is good with a very low rate of metastasis and local recurrence.

Acoustic analysis of voice in cochlear implant recipients with post-meningitic hearing loss

The objective of this study was to evaluate the critical time period between the onset of sensorineural hearing loss and cochlear implantation with respect to normal voice production in children with post-meningitic hearing loss. Acoustic measures of voice production were obtained from ten paediatric cochlear implant recipients with post-meningitic hearing loss. Acoustic measures were obtained utilising the Multi-Dimensional Voice Program and Computerized Speech Laboratory (Kay Elemetrics Corp.). Measures were based on sustained phonation of the vowel /a/. Acoustic parameters included fundamental frequency, short- and long-term frequency perturbation, and short- and long-term amplitude perturbation. Measures of fundamental frequency and short-term frequency and amplitude perturbation were comparable to values of children with normal hearing. Long-term control of frequency was within normal limits for subjects with a period of auditory deprivation of less than four months. Measures of long-term amplitude perturbation were normal for all patients except those with cochlear ossification. Early restoration of auditory feedback with cochlear implantation, the absence of cochlear ossification, residual aided hearing following meningitis, and auditory-verbal therapy were identified as factors in preserving the long-term control of frequency and amplitude in the setting of post-meningitic hearing loss.

Accuracy of CT-guided transthoracic needle biopsy of lung lesions: factors affecting diagnostic yield

PURPOSE

This study was performed to analyse the variables affecting the diagnostic accuracy of computed tomography (CT)-guided transthoracic needle biopsy of pulmonary lesions.

MATERIALS AND METHODS

A retrospective study of 612 consecutive procedures with confirmed final diagnoses was undertaken. Benign and malignant needle biopsy results were compared with final outcomes to determine diagnostic accuracy. A statistical analysis of factors related to patient characteristics, lung lesions and biopsy technique was performed to determine possible influences on diagnostic yield. A p value less than 0.05 was interpreted as statistically significant.

RESULTS

There were 508 (83%) malignant and 104 (17%) benign lesions. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy for a diagnosis of malignancy were 90.2%, 99.0%, 99.8%, 67.3% and 91.7%, respectively. Overall diagnostic accuracy was 83.3%. Variables affecting diagnostic accuracy were the final diagnosis (benign 67%, malignant 92%; p<0.001) and lesion size (lesions<1.5 cm 68%, lesions 1.5-5.0 cm 87%, lesions>5 cm 78%; p<0.05).

CONCLUSIONS

In CT-guided transthoracic needle biopsy, the final diagnosis and lesion size affect diagnostic accuracy: benign lung lesions and lesions smaller than 1.5 cm or larger than 5.0 cm in diameter provide lower diagnostic yield.

The current state of congenital tracheal stenosis

Congenital tracheal stenosis (CTS) is an uncommon condition that has challenged pediatric surgeons for decades. Patients with CTS can present with a wide spectrum of symptoms and varying degrees of severity. In addition, a variety of techniques have been devised to repair this malformation. A review of these procedures and our suggestions for clinical standards and practice guidelines will be presented in this paper. A retrospective review of the literature on CTS from 1964 to 31 March, 2006. There is not one standard technique for the repair of CTS, as individualized approach to each patient and airway lesion is necessary to optimize patient management; nevertheless there is a consensus about segmental resection and anastomosis being best for short segment stenosis while slide tracheoplasty is most effective for the long-segment ones. Conservative management is also an option for select group of patients with careful and close follow up. Survival following surgery over the years has improved, but mortality remained high, particularly in a specific subset of patients presenting at the age less than 1 month with associated cardiac malformations. In conclusion, CTS remains a significant challenge for pediatric surgeons. Additional research is required to improve our understanding of the pathogenesis of CTS, and to develop evidence-based treatment protocols for the entire spectrum of presentation including conservative management.

[On-site evaluation and triage for endoscopic ultrasound-guided fine needle aspiration cytology. The Turin experience]

AIM

Evaluation of the importance of the on-site presence of a skilled cytopathologist during endoscopic ultrasound-guided fine needle aspiration at determining samples' adequacy and performing ancillary techniques which can be helpful for the diagnosis.

METHODS

A retrospective analysis of our institute's experience with EUS-FNA sampling is presented. From January 2001 to May 2007, 404 patients underwent the EUS-FNA evaluation. From 2003 a cytopathologist was present during the procedure and started making an extemporary evaluation of the samples' adequacy.

RESULTS

Before 2003, a final cytological diagnosis was available in only 70% of the cases (without an on-site cytopathologist). After 2003, in 90% of the cases (with an on-site cytopathologist). It is possible planning and performing: immunocytochemistry on cell block material including evaluation of the proliferation index; to obtain a sample for the flow cytometry in cases of lymphomas or a microbiologic workup in cases of infective lesions.

CONCLUSION

The quality of the specimens and the proper handling of the aspirated sample are very important to succesfully obtain a definitive cytological diagnosis in EUS-FNA. On-site evaluation and triage of the material allow to improve the accuracy of the diagnosis.

Severity of juvenile onset recurrent respiratory papillomatosis is not associated with socioeconomic status in a setting of universal health care

BACKGROUND

Juvenile onset recurrent respiratory papillomatosis (JORRP) results from HPV transmission. Cervical cancer, also transmitted via HPV, is known to be correlated with socioeconomic status (SES). This study aims to determine if an association exists between SES and severity of JORRP.

METHODS

Cross-sectional study of all active JORRP patients at the Hospital for Sick Children in Toronto in 2005. SES information from Hollingshead surveys, Postal walk Census data, and Low Income Cutoff Data were compared with Derkay-Wiatrak disease severity scores, peak annual surgical frequency, and age of diagnosis. Statistical analysis was performed using Spearman, Mann-Whitney, and linear regression analyses.

RESULTS

Twenty-one patients were surveyed. Hollingshead results were as follows: two patients (10%) were class I (major business and professional); 11 patients (52%) were class II (medium business, minor professional, technical); 4 patients (19%) were class III (skilled craftsmen, clerical, sales workers); 4 patients (19%) were class IV (machine operators, semiskilled workers); 0% were from class V (unskilled laborers, menial service workers). Interestingly, based on postal code data nine patients (45%) were below the low income cutoff as compared to the Toronto (metropolitan) and Ontario (provincial) rates of low income (17% and 14%, respectively). There was significant correlation between each of the SES measures and between disease severity measures. However, analysis of the SES measures versus disease severity measures did not demonstrate any significant relationship.

CONCLUSIONS

Though almost half the patients lived below the low income cutoff, this study did not demonstrate a significant correlation between socioeconomic status and severity of disease in JORRP. One possible explanation is that universal access to the Canadian health care system is able to provide support despite a large proportion of patients being socioeconomically vulnerable. A national level study is underway to further detect any relationship between SES and JORRP severity in the general population.

Prognostic value of quantitative analysis of WT1 gene transcripts in adult acute lymphoblastic leukemia

We quantified Wilm's tumor gene (WT1) using a real time quantitative polymerase chain reaction in 20 adult patients with acute lymphoblastic leukemia at presentation. A WT1 level greater than 906 (median value for the whole series) was a significant predictor of a poor disease-free and overall survival in uni- and multivariate analyses.

Head and neck squamous cell carcinoma: role of the human papillomavirus in tumour progression

High risk human papilloma viruses (HPVs) have been shown to be independent risk factors for anogenital tract cancers, and have also been detected in head and neck squamous cell carcinomas (HNSCC). The aim of our study was to determine the prevalence of HPV DNA in a group of 47 squamous cell carcinomas of the oropharynx and the oral cavity, and to compare the clinical behaviour of HPV positive and negative tumours. We also assessed the proliferation index, as evaluated by Ki67 immunohistochemistry positivity, and the level of p53 reactivity. HPV DNA was found in 50% of carcinomas of the oropharynx and 36% in those of the oral cavity, the only genotype detected being HPV 16. Patients with HPV-positive carcinomas had a better overall survival than those with HPV-negative carcinomas. Our data suggest that HPV-positive oropharyngeal cancers comprise a distinct disease entity with an improved prognosis.

Mitek QuickAnchor fixation of cochlear implants using a minimal access technique

RATIONALE

In children with thick cortical bone, surgical exposure for cochlear implant fixation is difficult when using a minimal access technique. We report our experience in these children using the Mitek QuickAnchor system.

METHODS

A retrospective review of all children undergoing cochlear implantation over a 12-month period was performed to identify those children in which a Mitek QuickAnchor was used. Measurements of cortical bone thickness at the receiver-stimulator well site were obtained from pre-operative CT scans of temporal bones of all children. The application of the Mitek QuickAnchor system was also reviewed.

RESULTS

Cochlear implant fixation using the Mitek QuickAnchor system was performed in 14 children (mean age 12 years) during the study period. The mean cortical bone thickness was 5.6mm in patients receiving the Mitek QuickAnchor system and 3.2mm in patients undergoing conventional fixation. The difference in cortical thickness was highly statistically significant. Successful secure fixation was obtained in all cases.

CONCLUSIONS

The Mitek QuickAnchor system provides an effective method of cochlear implant fixation when using a minimal access technique in children with thick cortical bone.

Acoustic Analysis of the Voice in Pediatric Cochlear Implant Recipients: A Longitudinal Study

OBJECTIVE

To characterize inherent acoustic abnormalities of the deaf pediatric voice and the effect of artificially restoring auditory feedback with cochlear implantation.

DESIGN

Inception cohort.

SETTING

Academic referral center.

PATIENTS

Twenty-one children with severe to profound hearing loss (15 prelingually deaf, 6 postlingually deaf) accepted into the cochlear implant program were followed for up to 6 months. Patients unable to perform the vocal exercises were excluded.

INTERVENTIONS

Objective voice analysis was performed using the Computerized Speech Laboratory (Kay Elemetrics) prior to cochlear implantation, at the time of implant activation and at 2 and 6 months postactivation. Assessments were based on sustained phonations and dynamic ranges.

MAIN OUTCOME MEASURE

Fundamental frequency, long-term control of fundamental frequency (vF0) and long-term control of amplitude (vAM) were derived from sustained phonations. The dynamic frequency range was derived from scale exercises. Formant frequencies (F1, F2, F3) were determined using linear predictive coding.

RESULTS

Fundamental frequency was not altered by implant activation or experience (P = 0.342). With profoundly deaf subject, the most prevalent acoustic abnormality was a poor long-term control of frequency (vF0, 2.81%) and long-term control of amplitude (vAm, 23.58%). Implant activation and experience had no effect on the long-term control of frequency (P = 0.106) but normalized the long-term control of amplitude (P = 0.007). The mean frequency range increased from 311.9 Hz preimplantation to 483.5 Hz postimplantation (P = 0.08). The F1/F2 ratio remained stable (P = 0.476).

CONCLUSION

In children, severe to profound deafness results in poor long-term control of frequency and amplitude. Cochlear implantation restores control of amplitude only and implies the need for additional rehabilitative strategies for restoration of control of frequency.

Cochlear implant positioning in children: a survey of patient satisfaction

INTRODUCTION

The past decade has been witness to significant diminution in incision size and placement for pediatric cochlear implantation at our institution. Furthermore, the orientation of the long axis of the implant relative to the skull base plane has generally evolved from a retro-verted to ante-verted direction to accommodate the ear level receiver stimulator and the new minimal access technique.

OBJECTIVE

To characterize the cosmetic, functional and clinical implications of this evolution in cochlear implant positioning by means of a patient satisfaction survey.

METHODS

A survey of patient satisfaction was administered to 100 cochlear implant recipients or their parents. The survey elicits the patient's level of satisfaction with respect to implant position and functional limitations. In addition, the angle formed by the long axis of the implant and the skull base plane (implant angle) was determined from lateral skull radiographs to detect the temporal evolution in implant positioning.

RESULTS

Analysis of the radiographs revealed an implant angle of 65.4-125 degrees in patients implanted prior to 1997, an implant angle of 56.3-87.5 degrees in patients implanted from 1997 to 2001, and an implant angle of 35.1-78.1 degrees after 2002. In spite of this evolution in positioning, the patient satisfaction survey did not reveal any change in incidence of cosmetic, functional or clinical problems.

DISCUSSION

The significant changes in incision and implant positioning represent a technical evolution in pediatric cochlear implant surgery. The fact that patients have been consistently satisfied over time suggests that the cosmetic, functional and clinical implications are minimal.

Hyalinizing trabecular adenoma versus papillary thyroid carcinoma in a child

Hyalinizing trabecular adenoma (HTA) of the thyroid gland is a rare, benign neoplasm predominantly diagnosed in middle-aged women. There is mounting evidence in the medical literature, however, to suggest that HTA may represent an encapsulated variant of papillary thyroid carcinoma (PTC). This report describes an unusual case of PTC in a child initially diagnosed as HTA. Establishing an accurate diagnosis has important management implications for the pediatric patient.

Sequential parapharyngeal abscesses

Deep neck infections are not unusual in either the pediatric or adult populations. Multiple, and recurrent abscesses are found not infrequently, especially in immunocompromised and debilitated persons. It is very rare to find sequential parapharyngeal abscesses without identifiable etiology in an otherwise healthy pediatric patient while receiving appropriate, culture-directed, intravenous antibiotics. This could be due to underestimation of the extent of the infection by CT scanning. The use of intravenous clindamycin as a first-line therapy may not be sufficient if a large phlegmon exists. We describe a case of sequential, bilateral parapharyngeal abscesses in a 3-year-old patient.

MultiDimensional Voice Program analysis in children with vocal cord nodules

Computer-assisted voice analysis has recently been introduced as a noninvasive approach to the management of paediatric dysphonia. The aim of this study was to determine which parameters of voice analysis distinguish vocal cord nodules from normal patterns. Following diagnosis by flexible nasolaryngoscopy, 12 male children with vocal cord nodules, aged 7 to 12, underwent voice analysis by MultiDimensional Voice Program (MDVP; Kay Elemetrics, Lincoln Park, NJ, USA). These subjects were divided into two age groups (7-9 years, n = 5; 10-12 years, n = 7) and compared to age-matched controls. Results suggest that across all age groups, subjects with vocal cord nodules had statistically significant (p < .01) elevations in absolute jitter, jitter percent, relative average perturbation, pitch period perturbation quotient, smoothed amplitude perturbation quotient, and fundamental frequency variation. Further studies are required to assess the role of MDVP in the diagnosis of other voice pathologies and the monitoring of voice therapy.

Foreign body aspiration following unconventional use of a metered dose inhaler

PURPOSE

Aspiration of a foreign body may be life-threatening. This report describes laryngeal obstruction after inhalation of a piece of a Turbuhaler which resulted from a patient tampering with the device.

CLINICAL FEATURES

A 27-yr-old man disassembled a Turbuhaler and inadvertently aspirated a plastic dispensing medication disc (22 mm diameter) while attempting to inhale the remnant terbutaline sulfate which accumulated on it. Although the patient was hoarse, he was not in acute respiratory distress. X-ray revealed the disc lodged in the larynx below the vocal cords. The patient was immediately transferred to an operating theatre, and a drying agent (glycopyrrolate), judicious sedation (midazolam and fentanyl) and O2 were administered. The airway was anesthetized with lidocaine 4% delivered using high-flow O2 through an atomizer. Direct laryngoscopy revealed a partially obstructed view of the disc lodged distal to the vocal cords which was inaccessible for retrieval. Loss of consciousness was subsequently induced by spontaneous mask ventilation with sevoflurane (in O2). The airway was visualized using a suspension laryngoscope and the foreign body was removed with grasping forceps. The patient was awakened, transferred to the ICU and given 4 mg decadron i.v. every eight hours (two doses). Laryngoscopy prior to discharge indicated good mobility of the vocal cords and normal glottic structure.

CONCLUSION

Aspiration of a foreign body is a potentially life-threatening situation requiring coordination between anesthesiologist, surgeon, and nursing staff. Anesthetic goals include avoidance of upper airway obstruction and maintenance of adequate ventilation while the foreign body is retrieved. Provisions must be made for tracheostomy if these goals cannot be realized.

Reduced complexity modeling and reproduction of colored textures

An unsupervised color texture synthesis-by analysis method is described. The texture is reproduced to appear perceptually similar to a given prototype by copying its statistical properties up to the second order. The synthesized texture is obtained at the output of a single-input three-output nonlinear system driven by a realization of a white Gaussian random field. Significant complexity reduction is gained by exploiting the rank deficiency of the cross power spectral density matrix of the color texture samples.

A perceptually lossless, model-based, texture compression technique

In natural scenes, still images as well as sequences, backgrounds, and objects' surfaces usually have a textural structure. Therefore, in order to efficiently code images it is crucial to investigate the texture compression problem. In this paper, a perceptually lossless, synthesis-by-analysis texture coding method is presented. The proposed approach is model based; the parameters of the model consist of a binary excitation signal and the parsimonious representation of the reconstruction filter. The estimated parameters, which allow to one synthesize, at the decoder site, a texture that is perceptually indistinguishable from the original one, are then compressed using a lossless strategy, which is based on a fast binary wavelet transformation specifically tailored to binary images. The proposed method leads to very good perceptual results superior to those of existing techniques.

Postoperative hypocalcemic tetany caused by fleet phospho-soda preparation in a patient taking alendronate sodium: report of a case

This case report describes a patient who was previously prescribed alendronate (Fosamax) and presented with postoperative hypophosphatemia and hypocalcemic tetany after bowel preparation with Fleet Phospho-Soda. This report suggests that patients taking bone metabolism regulators may not be able to respond appropriately to hypocalcemic stressors.

Enhanced in vivo alpha1- and alpha2-adrenoceptor-mediated venoconstriction with indomethacin in humans

Vasodilator prostaglandins are released in vitro from endothelium during adrenergic stimulation. We hypothesized that indomethacin would block this production in vivo and increase venoconstriction to alpha1- and alpha2-stimulation but not to the nonadrenergic agonist PGF2alpha. Hand vein distension was measured in 24 normal subjects (23.0 +/- 0.5 yr) during local infusions of phenylephrine (8-12,000 ng/min), clonidine (3-7,000 ng/min), or PGF2alpha (1-2,048 ng/min) plus indomethacin (3 microg/min) versus saline on two separate days. Dose-dependent venoconstriction to phenylephrine occurred in all subjects, with a parallel shift to the left with indomethacin (P = 0. 003) and a decrease in the phenylephrine 50% effective dose (1,009 vs. 241 ng/min, geometric means, P = 0.012). Venoconstriction to clonidine was more variable, with most subjects eliciting a biphasic response (initial venoconstriction followed by attenuation). With indomethacin, the dose-response curve was displaced up and to the left (P = 0.005), and peak venoconstriction was increased (51.1 +/- 6.8 vs. 27.2 +/- 5.3% of control, P = 0.018) without a biphasic response. In all subjects, PGF2alpha elicited dose-dependent venoconstriction that was not altered by indomethacin. Thus venous alpha1- and alpha2-stimulation results in release of vasodilator prostaglandins that antagonize the venoconstrictor response. This modulates the sympathetic response of venous smooth muscle and may be important in diseases with endothelial dysfunction.

Role of adenosine in the ethanol-induced potentiation of the effects of general anesthetics in rats

Acetate, derived from ethanol metabolism in the liver, is released into the circulation and utilized in many tissues including the brain. The subsequent metabolism of acetate results in the production of adenosine that has a number of effects in the central nervous system. The purpose of the present studies, therefore, was to investigate the contribution of metabolically generated adenosine to the ethanol-induced potentiation of the inhalational agents isoflurane and sevoflurane. Changes in the anesthetic requirement for isoflurane and sevoflurane were determined in rats using the tail-clamp procedure. Both ethanol and sodium acetate reduced anesthetic requirement for isoflurane and sevoflurane in a dose-dependent fashion. The effect of acetate on anesthetic requirement was completely blocked by the administration of the adenosine receptor blocker, 8-phenyltheophylline. The ethanol-induced reduction in anesthetic requirement, however, was only partially blocked by 8-phenyltheophylline. Direct intracerebroventricular (i.c.v.) administration of the water-soluble adenosine receptor blocker, 8-sulfophenyltheophylline, also completely blocked the effect of acetate and partially blocked the effect of ethanol. This i.c.v. administration demonstrates that the actions of ethanol and acetate on anesthetic requirement are a central nervous system effect. The i.c.v. administration of the adenosine A1 receptor subtype agonist, R-phenylisopropyl adenosine, potentiated the anesthetic effects of isoflurane and suggests that the A receptor mediates the observed potentiation of anesthetic effect. This is further supported by the concomitant administration of 5-N-ethylcarboxamido adenosine, a non-selective adenosine agonist, with the selective A1 antagonist, 8-cyclopentyltheophylline, showing A1 receptor potentiation of anesthetic requirements. The studies show that (1) acetate potentiates the anesthetic effects of the inhalational anesthetics, sevoflurane and isoflurane; (2) acetate contributes in part to the effect of ethanol on anesthetic potency through metabolically generated adenosine; (3) these effects are likely mediated via adenosine A1 receptor subtypes.

Outpatient treatment of spontaneous pneumothorax in a community hospital using a Heimlich flutter valve: a case series

This is a case series of 14 consecutive patients treated as outpatients for spontaneous pneumothorax (SP) (1 January 1992 to 31 December 1995) by one surgeon in a community hospital setting. The purpose of this study was to examine the appropriateness and financial implications of routine outpatient management of SP with closed tube thoracostomy and the Heimlich valve. All 14 patients reviewed were successfully managed as outpatients, although 3 required an overnight admission because of anxiety, pain, or vasovagal reaction. The routine outpatient treatment of all cases of SP not requiring definitive surgical intervention may have saved more than $16,000.00 for the hospital and an estimated $500,000.00 for the province of Ontario during the 1993-1994 fiscal year. Our findings suggest that the Heimlich valve is an appropriate alternative for the management of SP in a nonteaching community hospital setting, with benefits to the patient and to the health care system.

Central nervous system effects of acetate: contribution to the central effects of ethanol

Acetate, resulting from ethanol metabolism in the liver, is released into the circulation and is utilized in a number of tissues, including the brain. In its metabolism, acetate leads to the production of adenosine, a powerful physiological mediator. We have investigated the effect of acetate on central nervous system (CNS) function in rodents. Sodium acetate in doses resulting in blood concentrations comparable to those attained after the administration of 1 to 2 g/kg ethanol, had significant CNS effects. Both ethanol and acetate produced a dose-dependent impairment of motor coordination. This effect of acetate was fully blocked by the adenosine receptor blocker 8-phenyltheophylline (8PT), whereas the dose-response relationship for ethanol was shifted to the right by about 30%. The inspired concentration of sevoflurane to achieve anesthesia was significantly reduced by both these agents. General anesthesia was potentiated in a dose-dependent fashion by ethanol and by acetate. The effect of acetate on anesthetic requirements was fully blocked by 8PT. The effect of ethanol on sevoflurane anesthetic requirements was inhibited by 22 to 35% by 8PT. Locomotor activity in mice was reduced by acetate in a dose-dependent fashion, an effect that was also fully blocked by 8PT. On the other hand, ethanol at a dose of 1 to 2 g/kg increased locomotor activity. This likely results from a direct stimulatory effect of ethanol, opposed by an inhibitor effect of acetate. The administration of 8PT enhanced the stimulation of locomotor activity induced by ethanol. In conclusion, acetate, a product of ethanol metabolism has significant CNS effects that can either potentiate or antagonize the effects of the ethanol molecule per se.(ABSTRACT TRUNCATED AT 250 WORDS)

[An epidemiological study of psychiatric emergencies at the Biella Department of Emergencies and Admissions in the 5 years of 1983-1987]

The psychiatric intervention procedure at the Emergency and Registration Department (ERD) of Biella Hospital is examined. After a short introduction in which some general data are provided regarding Health Unit no. 47 of Biella and Unit no. 48 of Cossato, the data collected by the ERD psychiatric register are analysed. Data on ERD arrival modalities are reviewed and the type of diagnosis attributed by the psychiatrist to patients examined at the ERD is examined. The various types of responses given by the psychiatrist after consultancy are then presented. The time bands in which the request for psychiatric intervention mainly fall are then noted. The paper closes with remarks on the effectiveness over time of psychiatric intervention at the ERD.

[An examination of the correlations between the general population and the users of the Biella Mental Health Service]

This paper correlates certain general population variables with that of the users of the Biella Mental Health Service. Age, sex, civic status and schooling are considered. Analysis of the data points to certain risk zones. The significance of these correlations is considered.

[The activity of psychiatric consultancy within a general hospital. The relationship and institutional implications]

The consultancy activity performed by Biella Ward of the local general hospital in 1979-1987 is described. After presenting data regarding the quantity and nature of consultancy requests, the medico-hospital cultural background relating to mental suffering is analysed. The hospital often tends to address only the patient's bidimensional aspects, excluding his internal being. Because of a mutual, tacit contact between physician and patient, the moment of admission is seen as a "somatic repair service". The psychological crisis usually arises in the form of the breakdown of the contract when the possible uncertainty of diagnosis and the prolongation of clinical examination affects the personality. In the specific case of Biella Psychiatry, the forced closure of the Psychiatric Diagnosis and Care Service about six years ago helped push the Psychiatrist towards a "liaison" role.

[Psychopharmacologic prescription at a public service. Examination of a group of patients admitted to the psychiatric service of diagnosis and therapy]

The use of psychodrugs in patients admitted to an SPDC over a period of thirty days is considered. During this period two questionnaires were administered, addressed respectively to the nursing staff and their patients. The purpose of the questionnaires was to investigate experience relative to the psychodrug on the part of the patient and the nurse who administers it. The results tend to confirm basic hypotheses: the psychodrug often takes on meanings that go beyond pure biochemical action to become mediators of complex, significant relational exchanges. Precaution in the of the psychodrug must therefore consider biological side-effects as well as relational ones.