Risk factors for recurrent acute otitis media: a real-life clinical experience.

Acute otitis media (AOM) is the most common bacterial infection in children. Some children with AOM tend to be otitis-prone, such as frequent recurrence of AOM (RAOM). Possible RAOM risk factors are widely debated. The current study was performed in a real-life setting, such as an otorhinolaryngologic (ORL) clinic, to identify predictive factors, including clinical data and endoscopic findings, for RAOM in children. In this study, 1,002 children (550 males, 452 females, mean age 5.77 + 1.84 years) complaining of upper airway symptoms were consecutively visited. Detailed clinical history and nasal endoscopy were performed. Throughout the ORL visit, it was possible to define some factors involved in the recurrence of AOM, including female gender, artificial feeding, tonsillar and adenoid hypertrophy. Adenoid and tonsillar hypertrophy, female gender, and artificial are factors significantly associated with RAOM. Therefore, reducing adenoid and tonsil size, also using topical corticosteroids or glycyrrhizin, could be a reasonable strategy to potentially reduce adenoid and tonsil size. The current study suggests that also in a primary care setting, it is possible to achieve meaningful information that is relevant in clinical practice.

Sleep-disordered breathing in the otorhinolaryngological practice.

Sleep-disordered breathing (SDB) is a common disorder in childhood. Snoring and obstructive sleep apnea represents a demanding challenge for both paediatricians and otolaryngologists. This real-life study investigated the association of demographic and clinical factors on snoring and sleep apnea in children consecutively visited. In this study, 1,002 children (550 males, mean age 5.77 + 1.84 years), complaining upper airway symptoms, were prospectively enrolled during 2015-2017. Medical history, clinical examination, and fiberoptic nasopharyngoscopy were performed in all children. Tonsil hypertrophy significantly predicted sleep apnea (OR 95.08) and snoring (OR 5.44). Asthma comorbidity significantly predicted snoring (OR 2.26). Breastfeeding could be a protective factor for sleep apnea (OR =0.37). SDB is a frequent disorder observable in otorhinolaryngological practice. Tonsil hypertrophy and asthma could be considered predicting factors for both snoring and sleep apnea, whereas breastfeeding was a protective factor for SDB.

Search for Axionlike Particles Produced in e

We present a search for the direct production of a light pseudoscalar a decaying into two photons with the Belle II detector at the SuperKEKB collider. We search for the process e^{+}e^{-}→γa, a→γγ in the mass range 0.2

Sinerga may prevent recurrent respiratory infections in allergic children.

Recurrent respiratory infections (RRI) are an intriguing challenge for both otolaryngologists and paediatricians. Therefore, to prevent RRI is an ambitious target in clinical practice. In this regard, modulation of the immune system may have a critical role. Sinerga, a dietary supplement (containing: palmitoylethanolamide (PEA), Kluyveromyces marxianus B0399, bovine colostrum, and phenylalanine), was supplemented in 20 allergic children with RRI (20/30 days per 3 months) and treated with standard therapy (antihistamine plus intranasal corticosteroid). Other 20 allergic children with RRI were treated only with standard therapy. Sinerga significantly reduced the number of RI and the size of both inferior and middle turbinate consistently with the postulated mechanisms of action. In conclusion, the current study demonstrated that Sinerga supplementation in allergic children with RRI may significantly prevent RI and reduce events depending on allergic inflammation.

Can an otorhinolaryngological visit induce the suspect of allergic rhinitis in children?

Summary: Allergic rhinitis (AR) is very frequent in childhood. AR is commonly associated with some co-morbidities and typical clinical features. This study aimed to test the hypothesis whether an otorhinolaryngological (ORL) visit could induce the suspect of AR. Globally, 1,002 children (550 males, mean age 5.77 years) were consecutively visited at an ORL clinic. Clinical visit, nasal endoscopy, and skin prick test were performed in all patients. In particular, history investigated atopic familiarity, birth, feeding type, passive smoking, comorbidities, including asthma, respiratory infections, otitis media, respiratory sleep disorder. Endoscopy assessed the tonsil and adenoid volume, turbinate contacts, mucosal color, and nasal discharge. Univariate and multivariate analysis were performed. The study showed that 547 (54.6%) children had AR. Some parameters were predicting factor for suspecting AR: middle turbinate contact (OR = 9.27), familial atopy (OR = 6.24), pale nasal mucosa (OR = 4.95), large adenoid volume (OR = 3.02 for score 4), and asthma co-morbidity (OR = 2.95). In conclusion this real-life study showed that during an ORL visit it is possible to suspect AR in children with turbinate hypertrophy, familial atopy, nasal pale mucosa, adenoid enlargement, and asthma comorbidity.

Churg-Strauss syndrome presenting with conjunctival and eyelid masses: a case report.

Churg-Strauss syndrome, a small and medium vessel vasculitis, was first described by Churg and Strauss in 1951. It is characterised by the presence of asthma, prominent tissue and blood eosinophilia, systemic vasculitis, and pulmonary and systemic necrotising allergic granulomas. Involvement of the skin, heart and gastrointestinal tract is well documented, but ocular presentation is unusual. We describe a 40-year-old lady who presented with recurrent upper eyelid swelling due to conjunctival lesions. Although she has chronic asthma, Churg-Strauss syndrome was never suspected. The diagnosis of Churg-Strauss syndrome was only made following histological examination of the conjunctival lesions.

Metastatic testicular tumor requiring inferior vena cava resection.

A patient undergoing radical retroperitoneal lymphadenectomy for metastatic embryonal cell testicular carcinoma is presented. Tumor resection required removal of the inferior vena cava due to transmural invasion. The inferior vena cava was replaced using externally stented polytetrafluoroethylene (PTFE) graft. Patency was documented by postoperative Doppler studies, duplex scanning, and computed tomographic scanning. Stented PTFE is currently the graft of choice for inferior vena caval replacement.

5-Fluorouracil dose intensification and granulocyte-macrophage colony-stimulating factor in cisplatin-based chemotherapy for relapsed squamous cell carcinoma of the head and neck: a phase II study.

A previous phase I study showed that in a 5-day combination of cisplatin (CDDP) 20 mg/m2/day and 5-fluorouracil (5-FU) intravenous bolus, the maximum tolerable dose of 5-FU is 200 mg/m2/day without the use of growth factors and 300 mg/m2/day with recombinant human granulocyte-monocyte colony-stimulating factor (rhGM-CSF) support. In the present phase II study, 26 patients with relapsed and/or metastatic squamous cell carcinoma of the head and neck (SCCHN) were treated with CDDP, 20 mg/m2/day, and 5-FU, 300 mg/m2/day intravenous bolus, for 5 consecutive days every 3 weeks. Granulocyte-macrophage colony-stimulating factor, 5 mg/kg/day subcutaneously, was administered from days 8 to 19. All patients had previously undergone surgery and/or radiation treatment. None had previously received chemotherapy. Mucositis (19% of the patients) and thrombocytopenia (42%) were the most frequent, but generally mild, toxicities. Relevant, GM-CSF-related side effects were detected in 12% of the patients. The median number of cycles delivered was four. Three complete and five partial responses were recorded (31% overall response rate). Further investigation of this regimen is unwarranted because of both its lack of improvement in antitumoral activity and the high costs incurred with the use of growth factors.

Ruptured Baker's cyst causes ecchymosis of the foot. A differential clinical sign.

Three consecutive patients with ruptured Baker's cysts, verified by duplex scan, were found to have ecchymosis on the dorsum of the foot. The appearance of ecchymosis can be helpful in differentiating a ruptured cyst from cellulitis or deep-vein thrombosis.

Preoperative diagnosis and management of the hypoplastic vessel syndrome.

From 1972 to 1979, 142 aortofemoral bypass grafts were carried out with 5 failures. In 3 of the cases the etiological factor appeared to be hypoplasia of the vessels. After reviewing the charts and arteriograms of the other patients, a further 9 cases in the hypoplastic category were collected. The mean age of the patients was 57 years, all were smokers and 3 were diabetic. Three patients had hyperlipidemia. The 12 patients falling into the hypoplastic group had mean diameter of the aorta of 1.1 cm. The diameter of the femoral artery was 3 mm. From the aortograms done on 20 patients without evidence of vascular disease, the average diameter of the aorta was 1.97 cm. In 20 patients with aorto iliac disease the aorta measured 1.9 cm and the common femoral artery 9 mm. A comparison was made of the ratio of the aorta to the transverse diameter of the vertebral body. In the hypoplastic patient the percentage was 22% and in patients with aorto iliac disease 39.5%. Hypoplasia appears to involve both the aorta and the distal vessels. Although variations in the size of the aorta and its branches are common, these patients with hypoplastic vessels appear to form a distinct group. This group of patients are high risk in terms of surgery. The importance of pre-operative diagnosis is stressed and a method of diagnosing the situation pre-operatively is described.

Fibromuscular dysplasia of the posterior auricular artery: an unusual aneurysmal lesion.

A 67-year-old patient was admitted to hospital with a pulsatile mass behind his left ear. The clinical diagnosis was a posterior auricular artery aneurysm, and this was confirmed on Digital Subtraction Angiography. The aneurysm was excised and sent for pathology. The findings were felt to be consistent with fibromuscular dysplasia. This appears to be only the second reported case in the literature of a posterior auricular artery aneurysm.

Selection of amputation level and prediction of healing using transcutaneous tissue oxygen tension (PtcO2).

Pre-operative measurement of transcutaneous tissue oxygen tension (PtcO2) by reflecting oxygen delivery at proposed amputation sites may allow accurate prediction of post-operative healing. Thirty-eight patients requiring amputation had PtcO2 measured with a Clark electrode on the foot, anteriorly and posteriorly below knee and above the knee while lying supine. PtcO2 greater than 24 mmHg was chosen to predict healing and indicated 13 above-knee (AK) and 25 below-knee (BK) amputations. Clinical criteria indicated 12 AK and 26 BK amputations. PtcO2 and clinical judgement differed on five occasions, a lower amputation was indicated by PtcO2 twice and by clinical selection three times (PtcO2 16 mmHg). Amputation was performed at the more distal level indicated (25 BK, 13 AK). Foot PtcO2 in both groups did not differ significantly, 4.08 +/- 2.00 mmHg (BK) and 3.9 +/- 1.29 mmHg (AK) (p greater than 0.5), nor did above knee PtcO2 (p greater than 0.3). Anterior below knee PtcO2 in both groups differed significantly, 34.92 +/- 10.84 mmHg (BK) and 9.5 +/- 5.60 mmHg (AK) (p less than 0.001). Likewise, posterior PtcO2, 39.64 +/- 6.85 mmHg (BK) and 14.1 +/- 4.43 mmHg (AK) (p less than 0.001). Amputation sites healed primarily within two weeks except the site with a pre-operative PtcO2 of 16 mmHg, where healing was delayed and occurred by second intention. These results indicate that PtcO2 is a valid predictor of primary healing following amputation.

Etiology and management of aorto-femoral bypass graft failure.

Over a nine-year period 1973 to 1982, 364 aorto-bifemoral bypass grafts were inserted for aorto-iliac occlusive disease and 45 graft failures were encountered. Twelve patients developed acute graft occlusion, occurring less than 30 days postoperatively (Group I). These failures were almost all due to technical problems, the most common cause was elevation of an intimal flap following local endarterectomy. Five patients (Group II) developed recurrent symptoms without actual thrombosis or occlusion of the graft, but were associated with neointimal hyperplasia at the distal anastomosis and evidence of distal atherosclerosis. Twenty-eight patients were late failures (Group III). These patients thrombosed their grafts more than 30 days postoperatively. Four patients thrombosed both limbs of the graft at separate intervals. Nineteen patients were found to have progressive atherosclerosis affecting their run-off vessels. Six patients were found to have stenosis limited to the distal anastomosis. False aneurysm, kinking of the graft, and proximal suture line stenosis were felt to be determining factors in 3 other incidences of graft failure. The most common treatment in Group I was thrombectomy and securing of the raised intimal flap. The patients in Group II were treated with local endarterectomy and patch angioplasty. Of the patients in Group III, the most common inflow procedure was thrombectomy, carried out in 17 cases. In Group III, 13 of 28 patients underwent profundaplasty to improve outflow. The importance of pre and postoperative angiography in defining the etiology of graft failure is stressed. It is important to rule out problems with the proximal anastomosis. Once inflow has been established, angiography should ensure that an adequate outflow procedure has been performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Unusual aneurysms of the extracranial carotid artery.

Aneurysms of the extracranial internal carotid artery are rare and only 4 cases have been treated at the Wellesley Hospital since 1969. These aneurysms usually present as a painless lump in the neck and the 4 cases to be described manifest unusual presentations. One patient with a history of facial sepsis presented in the Emergency Department with what was thought to be a neck abscess. This was incised and drained before the true nature of the swelling was appreciated. Two patients presented with nerve palsies, one with a hypoglossal palsy due to stretching of the hypoglossal nerve over a large aneurysm and the second with recurrent laryngeal nerve palsy as a result of rupture of a false aneurysm from disruption of a saphenous vein patch inserted following carotid endarterectomy 9 months earlier. The fourth patient presented with a carotid bruit and had a stenosis distal to the aneurysm. Although rare, carotid aneurysms require recognition and early treatment if neurological sequelae are to be avoided.

Predictors of surgical outcome in patients undergoing aortobifemoral bypass reconstruction.

We report a prospective study with 2 years of follow-up including 105 consecutive symptomatic patients (58.1% claudication and 41.9% severe ischemia) undergoing aortobifemoral bypass surgery (ABF/BP). Proportional-hazards, stepwise regression, and life-table analyses were used to determine predictors of the following outcome criteria: graft patency, amputation, mortality, symptomatic recurrence, and palliation. The operative mortality was 5.7% and the 2-year cumulative mortality was 15.5%. Most deaths (61.5%) were cardiac-related. There were 3 predictors of mortality: the presence of more than 1 surgical risk factor (relative risk [RR] 6.2; p less than 0.001), advanced age (RR 2.9; p = 0.03) and the presence of ischemic heart disease (RR 1.5; p = 0.045). No patient required amputation. Early graft patency rate was 94.3% and the 2-year cumulative patency was 92.8%. The only predictor of graft failure was preoperative ankle/brachial index (ABI) of less than 0.4 (RR 6.1; p = 0.003). Early symptomatic relief was 98.1% and at 2 years it was 77.3%. There were 2 predictors of symptomatic recurrence: postoperative smoking (RR 2.4; p less than 0.001) and impaired runoff (RR 2.5; p = 0.017). Cumulative palliation was 87.6% at 1 month and 66.5% at 2 years postoperatively. There were 2 predictors of palliation: the presence of more than 1 surgical risk-factor (RR 1.8; p = 0.001) and postoperative transcutaneous oximetry (PtcO2) of less than 35 mmHg (RR 3.1; p = 0.04). We conclude that the best predictors of outcome in patients undergoing ABF/BP surgery were the number of preoperative risk factors, age, ischemic heart disease, ABI, PtcO2, postoperative smoking, and angiographic runoff.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of cigarette smoking on outcome of femoral popliteal bypass for limb salvage.

A retrospective 5-year follow-up study of 83 femoral-popliteal bypass operations for severe ischemia (79 patients) is presented. There were no operative deaths. At one month, cumulative patency rates (CPR) and limb salvage rates (LSR) were 86.8% and 96.4% respectively. At 5 years, CPR, LSR and cumulative survival were 50%, 79.4% and 71.6% respectively. Post-operative smoking habits were strongly related to CPR and LSR. Smoking more than 5 cigarettes per day adversely affected CPR's. At 5 years, CPR of non-smokers and smokers of up to 5 cigarettes per day (47 patients) was 67.7% and for smokers of more than 5 cigarettes per day (32 patients) it was 44.7% (P less than 0.045). Smoking more than 15 cigarettes per day had an adverse effect on LSR's. Smokers of more than 15 cigarettes per day (17 patients) had a 5-year LSR of 58.5% compared with 89% for non-smokers and smokers of up to 15 cigarettes per day (62 patients) (P = 0.009). For 20 limbs requiring thrombectomy LSR was 100% at 1 year and 57.5% at 5 years. CPR's and LSR's were not significantly influenced by pre-operative smoking, diabetes, run off or level of distal anastomosis relative to the knee joint. Based on zero operative mortality and 96.4% limb salvage at 1 year, it is concluded that an aggressive approach toward revascularization for limb salvage is well justified in most patients.(ABSTRACT TRUNCATED AT 250 WORDS)

On the delineation of the gross tumor volume and clinical target volume for head and neck squamous cell carcinomas.

Gross tumor volume (GTV) and clinical target volume (CTV) delineation on planning computed tomography (pICT) for head and neck squamous cell carcinomas can be troublesome. We highlight the factors which can be crucial for the radiation oncologist in delineating GTV and CTV on pICT and provide some pratical solutions. Regarding GTV, uncertainties are correlated with transfer of information collected by physical examination and diagnostic radiology to pICT. Moreover, reproducibility of delineation can also be highly variable, particularly when diagnostic imaging quality and pICT quality are poor. Once the prescription has been made, clinical target volume identification on pICT is rarely straightforward. Whereas there are some data about the location of major lymph node stations of the neck, there are no reported guidelines on how to draw subclinical extention of primary head and neck tumors on pICT. Such volumes can be derived from those currently included in simulator films or from those addressed by the surgeon. Some examples are provided. A particular situation is represented by the adjuvant setting, when the primary tumor is removed (by surgery) or reduced (by chemotherapy). In conclusion, this paper shows some major problems associated with identification of GTV and CTV on pICT. Apart from selected cases, the use of pICT for target volume delineation (and thus for field shaping) for head and neck squamous cell carcinoma is still to be considered investigational.

Nasal endoscopy in asthmatic children: clinical role in the diagnosis of rhinosinusitis.

The aim of the study was to determine the role of rigid nasal endoscopy in the diagnosis of rhinosinusitis and adenoiditis in asthmatic children. Hundred-forty-five asthmatic children (aged 2-15 years) with recurrent upper respiratory symptoms were evaluated with complete ENT examination and nasal endoscopy by rigid endoscope during local anaesthesia. A step by step endoscopic procedure is described. Endoscopy was successfully performed in 128 patients (88.3%). Purulent rhinosinusitis was diagnosed in 61 subjects (47.6%) and adenoiditis in 45 subjects (35.1%). Rhinosinusitis was associated with adenoiditis in 35 subjects (27.3%), more frequently in younger children (i.e. 2-5 years). Nasal bacteria occurred in 90% of rhinosinusitis patients. Numerous anatomical anomalies were identified. Endoscopy of nasal cavity and rhinopharynx is less traumatic and more readily accepted than other methods. Nasal endoscopy may be proposed as an appropriate routine diagnostic tool in children since it is well tolerated, easily and quickly performed, cost-efficient, and useful in diagnosing rhinosinusitis.

Failure of bicycle exercise electrocardiograms to predict major post-operative cardiac complications in patients undergoing abdominal aortic surgery.

To determine if exercise electrocardiograms (EECGs) are justified in routine pre-operative screening for cardiac disease, we performed a prospective study on 77 consecutive patients scheduled for infrarenal aortic reconstructive surgery. All patients had EECGs performed 1-12 days prior to elective surgery. In addition to routine clinical assessment of cardiac disease, all patients were allocated a Goldman risk score. Four patients developed major post-operative cardiac complications of whom one patient died. EECG was not a significant predictor of outcome, as 48.6% of all EECGs were inadequate due to non-completion of the exercise protocol. Significant pre-operative predictors of outcome were a history of angina (p less than 0.01), myocardial infarction (p less than 0.001), congestive cardiac failure (p less than 0.0001), or a Goldman score of greater than 14 (p less than 0.05). By multivariate analysis of the pre-operative risk factors a history of congestive cardiac failure was found to be the most significant independent predictor of post-operative cardiac complications.

Effect of repetition of Semont's manoeuvre on benign paroxysmal positional vertigo of posterior semicircular canal.

If Semont's liberating manoeuvre does not lead to relief of symptoms in benign paroxysmal positional vertigo of posterior semicircular canal after the first session, it can be repeated once again, in refractory cases, whilst symptomatic patients after second manoeuvre require rehabilitation therapy Repeating Semont's manoeuvre several times has proven to progressively increase the percentage of cured patients or it may convert posterior semicircular canal forms to typical incomplete or lateral semicircular canal forms, hence requiring other manoeuvres to achieve vertigo resolution. Aim of study was to assess the effect of liberating manoeuvres repeated up to 4 times and to establish possible passages from one canal to the other during manoeuvres as well as percentage of cases refractory to this therapy, who would then need rehabilitation. Benign paroxysmal positional vertigo was diagnosed in 448 cases of whom 344 (76.8%) of the posterior semicircular canal, 20 (0.45%) the incomplete form of the posterior semicircular canal, 20 (0.45%) subjective positional vertigo and 74 of the lateral semicircular canal (4.2%). Right side was affected in 58.4% of cases, left in 34.5%, and bilateral in 7.1%. All 344 patients underwent Semont's liberating manoeuvre (1st manoeuvre) with first control after 48 hours: if symptoms (typical, atypical nystagmus or paroxysmal vertigo evoked by Dix-Hallpike's manoeuvre) persisted, Semont's liberating manoeuvre was repeated (2nd manoeuvre). In presence of lateral semicircular canal benign paroxysmal positional vertigo conversion, Lempert's manoeuvre was performed instead. Second control was performed after 48 hours and in cases of persistent typical, atypical or lateral semicircular canal nystagmus 3rd manoeuvre was performed. After further 48 hours, third control was carried out: symptomatic patients with typical forms were submitted to 4th manoeuvre, while typical incomplete forms or forms of the lateral semicircular canal underwent Lempert's manoeuvre. In conclusion, symptoms disappeared after 1st manoeuvre in 61.6% of cases; further manoeuvres, carried out in view of possible changes in semeiology of vertigo, increased the percentage of cured patients to 82.5% after the 2nd, 90.7% after 3rd and 94.1% after the 4th. Repeated positioning manoeuvres in benign paroxysmal positional vertigo led to a progressive increase in percentage of cured vertigo, at the same time, allowing detection of those cases converted to multicanal pathology, hence offering the possibility to proceed with appropriate liberating manoeuvres.