The clinical spectrum of laryngeal dystonia includes dystonic cough: observations of a large series.

Laryngeal dystonia is a movement disorder of the muscles within the larynx, which most commonly manifests as spasmodic dysphonia (SD). Rarer reported manifestations include dystonic respiratory stridor and dyscoordinate breathing. Laryngeal dystonia has been treated successfully with botulinum neurotoxin (BTX) injections since 1984. We reviewed prospectively collected data in a consecutive series of 193 patients with laryngeal dystonia who were seen at St. Vincent's Hospital between 1991 and 2011. Patient data were analyzed in Excel, R, and Prism. Laryngeal dystonia manifested as SD (92.7%), stridor (11.9%), dystonic cough (6.2%), dyscoordinate breathing (4.1%), paroxysmal hiccups (1.6%), and paroxysmal sneezing (1.6%). There were more women (68.4%) than men (31.6%), and the average age at onset was 47 years. A positive family history of dystonia was present in 16.1% of patients. A higher incidence of extra-laryngeal dystonia (ie, torticollis and blepharospasm) and concurrent manifestations of laryngeal dystonia were present in patients with dystonic cough, dyscoordinate breathing, paroxysmal sneezing, and hiccups than in other patients (P = 0.003 and P < 0.0001, respectively). The average starting dose of BTX decreased from 2.3 to 0.5 units between 1991 and 2011. The median treatment rating was excellent across all subgroups. Patients with adductor SD, stridor, extra-laryngeal dystonia and male patients had relatively better treatment outcomes. Technical failures were rare (1.1%). Dysphonia secondary to vocal cord paresis followed 38.7% of treatments. Laryngeal dystonia manifests predominantly as SD, but other manifestations include stridor, dyscoordinate breathing, paroxysmal cough, hiccups, and sneezing. BTX injections are very effective across all subgroups. Severe adverse events are rare.

Ultrasound measurements of the saphenous vein in the pediatric emergency department population with comparison to i.v. catheter size.

BACKGROUND: Saphenous vein cutdown is a rare venous access procedure. Ultrasound (US) can assist with many vascular access procedures. OBJECTIVES: Our objective was to identify the saphenous veins (SVs) using US in pediatric emergency department (ED) patients, and to determine if the SV size allows for potential cannulation by different standard-size intravenous (i.v.) catheters. METHODS: This study was a prospective, observational convenience sample of 60 pediatric patients at an urban, regional referral pediatric ED. Inclusion criteria were children ages 1 through 12 years categorized into four age groups: 1-<2, 2-4, 5-7, and 8-12 years, with informed consent and assent. Investigators performed US examination using a 10-MHz multi-frequency transducer to identify the SV on both legs and measure the SV in short-axis view. The US measurements were then used to calculate the SV areas. Diameters of typical pediatric gauge (G) catheters (24G, 22G, 20G, 18G) were used to calculate catheter areas. RESULTS: Sixty patients were enrolled, with five SVs unable to be measured in 4 patients (1 patient with both SVs). For the remaining 115 (96%) SVs available for further analysis, the median age was 4 years (interquartile range [IQR] 2) and median weight was 22.7 kg (IQR 14.5). Mean area (mm(2)) of the right SV was 2.85 ± 1.9 and for the left SV, 2.88 ± 1.8. For our study group, the compatibility rates of different size i.v. catheters to fit the measured SV areas were as follows: 24G = 100%, 22G = 100%, 20G = 97.3%, and 18G =86.1%. CONCLUSIONS: US can localize the SV in pediatric ED patients. US size of the SV in various pediatric age ranges suggests that the SV may be a potential US venous access site with multiple-size i.v. catheters up to 18G.

Protocols for establishment of an in vitro collection of medicinal plants in the genus Scutellaria.

The study of medicinal plants has many unique challenges and special considerations. These plants are studied for their specific chemistry, or pharmacologic activity. Plants are highly sensitive to their environment and respond through changes in their chemistry. To date, one of the biggest problems in the study of medicinal plants has been the acquisition of consistent, positively identified material for chemical analysis. Successful protocols for the collection, identification, and establishment of medicinal plants species in tissue culture is invaluable for future studies. This protocol outlines methods to establish Scutellaria baicalenisis, and Scutellaria lateriflora from commercial seed sources, and collection and establishment of Scutellaria racemosa from wild populations.

Does physician communication influence older patients' diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS).

BACKGROUND: Effective chronic disease self-management among older adults is crucial for improved clinical outcomes. We assessed the relative importance of two dimensions of physician communication-provision of information (PCOM) and participatory decision-making (PDM)-for older patients' diabetes self-management and glycemic control. METHODS: We conducted a national cross-sectional survey among 1588 older community-dwelling adults with diabetes (response rate: 81%). Independent associations were examined between patients' ratings of their physician's PCOM and PDM with patients' reported diabetes self-management (medication adherence, diet, exercise, blood glucose monitoring, and foot care), adjusting for patient sociodemographics, illness severity, and comorbidities. Among respondents for whom hemoglobin A1c (HbA1c) values were available (n=1233), the relationship was assessed between patient self-management and HbA1c values. RESULTS: In separate multivariate regressions, PCOM and PDM were each associated with overall diabetes self-management (p<.001) and with all self-management domains (p<.001 in all models), with the exception of PDM not being associated with medication adherence. In models with both PCOM and PDM, PCOM alone predicted medication adherence (p=.001) and foot care (p=.002). PDM alone was associated with exercise and blood glucose monitoring (both p<.001) and was a stronger independent predictor than PCOM of diet. Better patient ratings of their diabetes self-management were associated with lower HbA1c values (B= -.10, p=.005). CONCLUSION: Among these older adults, both their diabetes providers' provision of information and efforts to actively involve them in treatment decision-making were associated with better overall diabetes self-management. Involving older patients in setting chronic disease goals and decision-making, however, appears to be especially important for self-care areas that demand more behaviorally complex lifestyle adjustments such as exercise, diet, and blood glucose monitoring.

Relationship Between Laryngeal Electromyography and Video Laryngostroboscopy in Vocal Fold Paralysis.

OBJECTIVES/HYPOTHESIS: The objective of this study was to better define the relationship of laryngeal electromyography and video laryngostroboscopy in the diagnosis of vocal fold paralysis. STUDY DESIGN: Retrospective diagnostic cohort study with cross-sectional data analysis METHODS: Data were obtained from 57 patients with unilateral vocal fold paralysis who attended a large tertiary voice referral center. Electromyographic findings were classified according to recurrent laryngeal nerve, superior laryngeal nerve, and high vagal/combined lesions. Video laryngostroboscopy recordings were classified according to the position of the immobile fold into median, paramedian, lateral, and a foreshortened/hooded vocal fold. The position of the paralyzed vocal fold was then analyzed according to the lesion as determined by electromyography. RESULTS: The recurrent laryngeal nerve was affected in the majority of cases with left-sided lesions more common than right. Vocal fold position differed between recurrent laryngeal and combined vagal lesions. Recurrent laryngeal nerve lesions were more commonly associated with a laterally displaced immobile fold. No fold position was suggestive of a combined vagal lesion. The inter-rater reliability for determining fold position was high. CONCLUSION: Laryngeal electromyography is useful in diagnosing neuromuscular dysfunction of the larynx and best practice recommends its continued implementation along with laryngostroboscopy. While recurrent laryngeal nerve lesions are more likely to present with a lateral vocal fold, this does not occur in all cases. Such findings indicate that further unknown mechanisms contribute to fold position in unilateral paralysis.

p14ARF protein expression is a predictor of both relapse and survival in squamous cell carcinoma of the anterior tongue.

PURPOSE: The INK4A-ARF locus at chromosome 9p21 is frequently altered in head and neck squamous cell carcinoma (SCC) and encodes two distinct tumor suppressors, p16(INK4A) and p14(ARF). This study addressed the role of p14(ARF) as a potential prognostic marker in this disease. EXPERIMENTAL DESIGN: p14(ARF) protein expression was assessed by immunohistochemistry in a cohort of 140 patients with SCC of the anterior tongue. Using univariate and multivariate Cox's proportional hazards models, the outcomes examined were time to disease recurrence or death, with or without clinicopathologic covariates, including nodal status, disease stage, treatment status, Ki-67 staining, and molecular markers with known functional or genetic relationships with p14(ARF) (p16(INK4A), p53, pRb, p21(WAF1/CIP1), E2F-1). RESULTS: On multivariate analysis, p14(ARF) positivity (nucleolar p14(ARF) staining and/or nuclear p14(ARF) staining in >/=30% of tumor cells) was an independent predictor of improved disease-free survival (DFS; P = 0.002) and overall survival (OS; P = 0.002). This was further enhanced when p14(ARF) positivity was cosegregated with positive (>/=1%) p16(INK4A) staining (DFS, P < 0.001; OS, P < 0.001). Patients whose cancers were p14(ARF) negative and p53 positive (>50%) had the poorest outcome (DFS, P < 0.001; OS, P < 0.001) of any patient subgroup analyzed. CONCLUSIONS: These data show that in patients with SCC of the tongue, combined nuclear and nucleolar expression of p14(ARF) protein predicts for improved DFS and OS independent of established prognostic markers.

Deregulated cyclin D1 expression is associated with decreased efficacy of the selective epidermal growth factor receptor tyrosine kinase inhibitor gefitinib in head and neck squamous cell carcinoma cell lines.

PURPOSE: Despite promising initial results, recent Phase III trials of the selective epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor gefitinib ("Iressa"; AstraZeneca, Wilmington, Delaware) in advanced head and neck squamous cell carcinoma (HNSCC) have been equivocal. Cyclin D1, an EGFR target gene, is frequently overexpressed in HNSCC, has been implicated in its pathogenesis, and is strongly associated with poor prognosis in this disease. Therefore, we examined the relationship between deregulated cyclin D1 expression and sensitivity to gefitinib to determine whether this frequently occurring oncogenic change affected the cellular response to gefitinib. EXPERIMENTAL DESIGN: A panel of six EGFR-overexpressing HNSCC cell lines was used to correlate CCND1 gene copy number, cyclin D1 expression, and response to gefitinib. The effect of constitutive overexpression of cyclin D1 was assessed by establishing stably transfected clonal SCC-9 cell lines. RESULTS: Three of six cell lines displayed cyclin D1 amplification and/or overexpression, and these cell lines were resistant to gefitinib. SCC 9 clones overexpressing cyclin D1 continued to proliferate and maintained their S-phase fraction when treated with gefitinib, whereas empty vector control clones and the parental SCC 9 cells were profoundly inhibited and displayed marked reductions in S-phase. The resistance of cyclin D1-overexpressing clones and cyclin D1-amplified cell lines was associated with maintenance of cyclin D1 expression after gefitinib treatment. CONCLUSIONS: These data suggest that deregulated cyclin D1 overexpression may be associated with resistance of HNSCC to EGFR inhibitors. Therefore, the role of cyclin D1 as a marker of therapeutic response and its utility as a prognostic marker in HNSCC warrant additional analysis.

Overexpression of E2F-1 is associated with increased disease-free survival in squamous cell carcinoma of the anterior tongue.

PURPOSE: Overexpression of E2F-1 is associated with increased invasiveness in head and neck squamous cell carcinoma cell lines in vitro, but its significance in vivo is unknown. This study sought to determine the relationship between E2F-1 and retinoblastoma protein (pRb) expression and disease outcome in squamous cell carcinoma (SCC) of the anterior tongue. EXPERIMENTAL DESIGN: pRb and E2F-1 protein expression was assessed by immunohistochemistry in a cohort of 145 patients with SCC of the anterior tongue. The outcomes examined were time to disease recurrence or death. The relationships between E2F-1 or pRb expression and outcome were assessed by univariate and multivariate Cox's proportional hazards model, with or without clinicopathological covariates, including nodal status, disease stage, treatment status, and molecular markers (cyclin D1, p16(INK4A), and Ki-67) previously measured in this cohort. RESULTS: On univariate analysis, increased expression of E2F-1 (>35% of positive-stained nuclei) was associated with increased disease-free survival (DFS; hazard ratio [HR]: 0.35; P = 0.04) and increased overall survival (OS; HR: 0.33; P = 0.06). Decreased expression of pRb (<50% positive nuclei) was associated with increased DFS (HR: 1.81; P = 0.06) but not with OS (P = 0.11). However, when considered simultaneously with other significant factors, i.e. lymph node status, p16(INK4A) protein expression, and histopathological grade, in the multivariate Cox's proportional hazards model, the additional contributions of E2F-1 and/or pRb expression to DFS and OS were not statistically significant. CONCLUSIONS: These data demonstrate that in patients with SCC of the tongue, overexpression of E2F-1 is associated with increased DFS and OS. However, this association is not independent of lymph node status, tumor grade, and p16(INK4A) expression. Among the cell cycle-regulatory molecules studied, p16(INK4A) expression is the most predictive molecular marker of disease outcome.

Neck dissection of level IIb: is it really necessary?

OBJECTIVES: To determine whether resection of level IIb is necessary in elective or therapeutic neck dissections. STUDY DESIGN: Prospective case series. METHODS: Level IIb nodes were analyzed for micrometastases as separate specimens in 160 neck dissections on 148 patients with squamous cell carcinoma of the head and neck. RESULTS: In 106 elective neck dissections (N0 necks) from upper aerodigestive tract (UADT) and skin/parotid squamous carcinoma primaries, level IIb was involved in 4.5% and 33%, respectively. In 54 therapeutic neck dissections (N+ necks) from UADT and skin/parotid squamous carcinoma primaries, level IIb was involved in 25% and 71%, respectively. Apart from skin/parotid squamous carcinoma primaries, level IIb was never involved unless level IIa was also involved. CONCLUSIONS: Level IIb nodes can be left in situ in UADT primary carcinomas in nontonsillar N0 necks without significantly compromising regional clearance of micrometastases.

Salvage vertical partial laryngectomy for radiation failure in early glottic carcinoma.

BACKGROUND: Partial laryngectomy after failure of radiotherapy for early glottic cancer is an accepted surgical salvage procedure. However, there have been only a few studies on recurrent disease or long-term survival. METHODS: Twenty-one patients who were treated with salvage partial vertical laryngectomy (PVL) following failure of primary radiotherapy were prospectively studied. Median follow up was 69 months (range 24-204 months). Patients were seen at two- monthly intervals for the first 24 months and then 3-4 monthly for 5 years after their partial surgery or until death. RESULTS: Local control was 71.4% (15/21). Among the six patients who recurred within the larynx, two patients developed a second primary; one on the ipsilateral false cord at 24 months and the other on the contra-lateral vocal cord at 10 years. The no evidence of disease rate following salvage PVL was 95%, 85% and 73% at 12,24 and 36 months, respectively, with a mean disease free interval of 34.9 months (range 7-120). Survival was 90%, 85% and 80% at 12, 24 and 36 months,respectively, with a median survival of 152 months for the group. Three patients died of their disease and four from other causes. Four local recurrences occurred within 32 months. Two developed neck metastases and died of their disease. Four patients were treated successfully with completion laryngectomy. Only one of these died, but this was due to a second primary squamous cell carcinoma in the lung. Three of the four patients with local recurrence shad an extended procedure. CONCLUSION: Partial vertical laryngectomy is an excellent alternative to total laryngectomy for salvage following failure of -radiation. Although local recurrence occurred more frequently in those patients having an extended partial procedure, this was not statistically different.

Novel approach of medialization thyroplasty with arytenoid adduction performed under general anesthesia with a laryngeal mask.

OBJECTIVE: To objectively assess the voice outcomes of patients with unilateral vocal fold paralysis treated with medialization thyroplasty and arytenoid adduction suture. STUDY DESIGN: Case series of patients who underwent medialization thyroplasty and arytenoid adduction suture. Preoperative and postoperative voice testing was performed and the data were compared by statistical analysis. SETTING: Tertiary referral teaching hospital in Sydney, Australia. SUBJECTS: All patients had a unilateral vocal fold paralysis, with a large posterior glottic gap and vocal symptoms affecting their quality of life. METHODS: Thirteen patients with a diagnosis of a unilateral vocal fold paralysis with a large posterior glottic gap, vocal symptoms, and total denervation of the vocal fold underwent medialization thyroplasty and arytenoid adduction suture. The surgery was performed in a novel method under a general anesthetic using a laryngeal mask and with direct intraoperative endoscopic feedback. Preoperative and postoperative measures of voice performance were compared, including acoustic analysis (fundamental frequency, speech intensity against quiet and loud background noise, speech rate) and aerodynamic assessment (airflow, maximum phonation time). RESULTS: Medialization thyroplasty with arytenoid adduction suture significantly improved aerodynamic assessment and phonation duration for both male and female subjects overall. There were 2 of 13 treatment failures. Median follow-up time was 6 months. CONCLUSION: Preliminary results indicate that in selected patients with vocal fold paralysis, medialization thyroplasty with arytenoid adduction suture leads to significant improvements in objective voice measures. Longer follow-up data are required to further quantify the voice outcomes after this procedure.

Comparisons of Scutellaria baicalensis, Scutellaria lateriflora and Scutellaria racemosa: genome size, antioxidant potential and phytochemistry.

The genus Scutellaria in the family Lamiaceae has over 350 species, many of which are medicinally active. One species, Scutellaria baicalensis, is one of the most widely prescribed plants in Traditional Chinese Medicine, used for neurological disorders, cancer and inflammatory diseases and has been the subject of detailed scientific study but little is known about the phytochemistry of other Scutellaria. The current study was designed to compare the medicinal phytochemistry of 3 species of Scutellaria used to treat neurological disorders. To accomplish this objective, the specific objectives were (a) to establish an in vitro collection of the South American native; S. racemosa, (b) to botanically characterize S. racemosa and (c) to compare the phytochemistry of S. racemosa with S. baicalensis and S. lateriflora. S. racemosa was established in vitro from wild populations in Florida. Botanically, S. racemosa is diploid with 18 chromosomes, and flow cytometry data indicated that S. baicalensis and S. racemosa have small nuclei with estimated small genomes (377 mbp and 411 mbp respectively). Antioxidant potential studies showed that there were no significant differences in the 3 Scutellaria species. Phytochemical analyses detected and quantified the flavonoids baicalin, baicalein, scutellarin, and wogonin as well as the human neurohormones melatonin and serotonin in leaf and stem tissues from S. baicalensis, S. lateriflora, and S. racemosa. These findings represent the first phytochemical analysis of S. racemosa and establish S. racemosa as a model system for study of medicinal plant secondary metabolism and as a potential source of important phytopharmaceuticals for treatment of human disease.

Innominate artery hemorrhage following tracheostomy.

OBJECTIVES: To review the clinical presentation, predisposing factors, prevention strategies, management, and outcomes of innominate artery hemorrhage following tracheostomy. STUDY DESIGN AND SETTING: We report the case of an 80-y-old patient who experienced sudden massive innominate artery hemorrhage 11 days post tracheostomy. We review the literature and present recommendations for management and prevention. RESULTS: Emergency median sternotomy with ligation and resection of the affected segment was performed with no neurological or vascular sequelae. CONCLUSIONS AND SIGNIFICANCE: The risk of innominate artery hemorrhage may be minimized with simple measures. Management by ligation and resection of the pathological segment of artery has superior outcomes to primary vascular reconstruction with maintenance of blood flow. Bypass procedures are not routinely required and have not been shown to confer any significant benefit. Resection without reconstruction is associated with a surprisingly low incidence of neurological sequelae.

A strategic approach to developing e-learning capability for healthcare.

OBJECTIVES: This article examines a strategic approach to developing e-learning capability to enhance learning opportunities for the workforce of a healthcare organization. Emphasis is given to the procurement of a bespoke Managed Learning Environment (MLE). Strategic organizational issues impacting on future e-learning developments are considered. METHODS: The 2-year implementation plan was evaluated through a two phase external research project. The first phase focused on the effectiveness of a training programme designed to build capacity for e-learning within the Northern area and also included a virtual learning environment usability study which informed the MLE specification. The second phase evaluation is ongoing during 2005 and interim findings are presented. RESULTS: The MLE has been piloted and on-line learning packages have been acquired. There has been a phased take-up of e-learning opportunities and e-tutor training. Some virtual Communities of Practice have been established. Key organizational issues have been identified and ongoing findings are informing strategic planning. CONCLUSIONS: The healthcare MLE is offering enhanced learning opportunities and assisting area healthcare providers in training their dispersed workforces. Blended learning strategies are most successful. The need for protected time for e-learning is a key issue, financial savings are available. Progress has been slowed by identified organizational constraints-the MLE's benefits are widely recognized.

Computer and information literacy in post-qualifying education.

Computer literacy and information retrieval techniques are both skills that are required to undertake further educational study effectively. In the summer of 2000, a group of post-registered nurses and midwives on undergraduate courses in one university department, completed a self-assessment questionnaire to examine their knowledge and competence of computer and information literacy. This paper describes the method and results of this study with the results indicating that these students had deficits in both computer and information literacy. The study also outlines the structural and functional difficulties that need to be resolved around the area of using computers in education for nurses and midwifes.