Effect of vitamin D deficiency on the laryngo-pharyngeal tract.

OBJECTIVE: To investigate the effect of vitamin D deficiency on the laryngopharyngeal tract. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary care center. SUBJECTS AND METHODS: A total of 38 human subjects were prospectively recruited, equally divided into two groups. The Vitamin D deficiency group defined as 25-OH<25ng/dl and the control subjects with normal vitamin D level defined as 25-OH>25ng/dl. The presence and severity of vocal tract symptoms was assessed using the Vocal Tract Discomfort score. RESULTS: There was no significant difference in vocal tract discomfort score for frequency and severity between patients with Vitamin D deficiency and patients with no vitamin D deficiency (p value 0.272). However there was a significant difference in the mean frequency of burning, aching, soreness and lump sensation (p value<0.05) in patients with vitamin D deficiency compared to those with no vitamin D deficiency. There was also a significant difference in the means of vocal tract severity symptoms, namely for burning and aching between patients with vitamin D deficiency compared to patients with no vitamin D deficiency (p value<0.05). CONCLUSION: Subjects with vitamin D deficiency do not have a higher vocal tract discomfort score than subjects with no vitamin D deficiency. However the frequency and severity of certain vocal tract discomfort symptoms was higher and can be based hypothetically on the similarity in structure between the laryngopharyngeal complex and the musculoskeletal system.

Radiation-induced rupture of the superficial femoral artery: a case report.

BACKGROUND: Radiation-induced necrosis and arteriopathy are well-known iatrogenic pathologic entities. However, radiation-induced rupture of the superficial femoral artery is an exceptional life-threatening event. REPORT: We hereby report a case of radiation-induced rupture of the superficial femoral artery that was successfully treated by fascial stitching then by an endovascular approach by stenting. RESULTS: Infection, skin stiffness, and major tissue loss in a previously irradiated field are important limiting factors to an open surgical approach. CONCLUSION: It is important to consider using a combined approach for selected patients.

The Third-Time Recurrence of a Thoracic Solitary Fibrous Tumor in a Patient Presenting With Paraneoplastic Hypoinsulinemic Hypoglycemia (Doege-Potter Syndrome).

We present a case of a 76-year-old Caucasian female with a recurrent solitary fibrous tumor (SFT) of the pleura, showcasing a rare manifestation of hypoglycemia associated with Doege-Potter syndrome (DPS). Having undergone two previous surgeries for SFT, the patient presented to the emergency department with severe fatigue, recurrent episodes of loss of consciousness, and hypoglycemia, despite lacking a history of diabetes mellitus. Radiological evaluation revealed a substantial recurrent SFT in the left lung, prompting excision through a left posterolateral thoracotomy. Remarkably, the patient's altered mental status and hypoglycemia resolved postoperatively. The case meets the criteria for aggressive SFT behavior, warranting consideration for adjuvant radiation therapy to control the risk of recurrence. This report highlights the nuanced interplay between SFT recurrence, paraneoplastic syndromes like DPS, and the potential benefits of adjuvant therapeutic strategies in managing these complex clinical scenarios.

Epithelioid trophoblastic tumor in male patients with germ cell tumor: A clinicopathologic analysis of five cases.

Epithelioid trophoblastic tumor (ETT) is an extremely rare chorionic-type neoplasm in the testis, with only seven cases reported in the literature. Here, we report five cases of testicular ETT from a single institution, constituting the largest series of this rare tumor to date. The patients had a mean age of 44 years (range, 20-68 years). Four patients had a previous history of testicular germ cell tumor (GCT) treated with chemotherapy, and they developed ETT in metastatic sites in a mean of 11 years (range, 3-15 years) after the initial diagnosis of testicular GCT. Only one patient had ETT in the testis. Three patients had a normal serum beta-human chorionic gonadotropin (ß-hCG) level, and two patients had a level that was slightly elevated, but far below that typically seen in patients with choriocarcinoma. ETT was characterized by a proliferation of intermediate trophoblastic cells with abundant eosinophilic cytoplasm, and the tumors frequently had coagulative necrosis with eosinophilic debris, mimicking keratinizing squamous cell carcinoma. The trophoblastic phenotype of ETT was supported by its immunoreactivity for trophoblastic markers, including GATA-3 (3 of 3 cases tested), α-inhibin (3/4), p63 (3/5), and ß-hCG (3/4). ETT was also positive for cytokeratin (4/4) and GCT marker SALL4 (3/3). Despite surgery and chemotherapy, two patients died of disease 17 months after ETT diagnosis, and three patients were alive with metastatic disease at a mean of 20 months (range, 15-28 months). Our results demonstrate that ETT may be an aggressive disease associated with distinct pathologic features and poor clinical outcome.

A rare association of subclavian steal syndrome with bilateral carotid artery stenosis: a case report.

Bilateral carotid artery stenosis in the context of subclavian steal syndrome is an extremely rare finding. We report the case of a 75-year-old woman who presented with a transient ischemic attack. Bilateral internal carotid stenosis associated with left subclavian steal syndrome was diagnosed. Left internal carotid endarterectomy was performed under locoregional anesthesia. Inflation of a blood pressure cuff reversed the neurologic symptoms that appeared after internal carotid clamping. This rarely reported case remains a challenge to diagnose and treat because of its complex mechanisms and multiple risk factors. Our case highlights the importance of the surgical strategy adopted and the need for a good initial assessment.

Diagnosis and management of patients with stage III non­small cell lung cancer: A joint statement by the Lebanese Society of Medical Oncology and the Lebanese Pulmonary Society (Review).

Proper management of stage III non-small cell lung cancer (NSCLC) might result in a cure or patient long-term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncologists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scanning remains a cornerstone in the discovery of a lung lesion, a positron-emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case-by-case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncologist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unresectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physician panel, available literature and evidence governing the treatment, management and follow-up of patients with stage III NSCLC.

Perforation of the aorta by a rib edge: an unusual complication after chest wall resection.

Thoracic aortic perforation in the context of a minor trauma is extremely rare. In this article, we describe a case of an 80-year-old man who presented with an aortic perforation after a fall from his height during his hospitalization. The patient had previously undergone a left superior lobectomy, a partial chest wall resection, and reconstruction for a locally invasive lung cancer. He was directly transferred to the operating room, as he presented with hemodynamic instability. A 4-mm laceration in the descending thoracic aorta was identified and repaired. The postoperative course was uneventful. This case illustrates the importance of applying a solid fixation to the rib stumps when performing a chest wall resection, irrespective of the size of the wall defect.

Recurrent lower limb abscesses as the primary manifestation of aorto-femoral graft paraprosthetic fistula.

A 62-year-old man was presented to our facility with recurrent right lower limb abscesses. He had an aortobifemoral graft for an aortoiliac occlusive disease. The diagnosis of paraprosthetic fistula was confirmed by performing a high-resolution contrast-enhanced computed tomography, whereas labeled leukocyte imaging provided a negative result. The graft present in the right limb was removed and extra-anatomical femoro-femoral bypass was performed along with segmental ileal resection of the affected loop and a side-to-side anastomosis. Recovery was unremarkable, with no recurrence of abscess 18 months after surgery. To our knowledge, this is the first report in published data on a paraprosthetic fistula presenting as recurrent lower limb abscesses. In this article, we have discussed the clinical features, principal diagnostic findings, and therapeutic options.

Severe lower limb ischemia after bee stings.

Bee stings entail allergic reactions that can be severe, sometimes even lethal. These reactions can occur immediately or several days after being stung. In this study, we report a case of severe ischemia of the left lower limb observed in a man, with no medical history, who was stung several times by bees.

Unilateral Vocal Fold Paralysis in Parkinson Disease: Case Report and Review of the Literature.

OBJECTIVE: The objective of this study was to report the first case of unilateral vocal fold paralysis in a patient with Parkinson disease (PD) and to review the literature. METHODS: This is a case report and literature review following PubMed search using the keywords "Parkinson," "vocal fold paralysis," "vocal fold palsy," "vocal fold immobility," "vocal fold adductor palsy," "airway obstruction," and "stridor." RESULTS: A total of 18 subjects diagnosed with PD and vocal fold paralysis were described. In all cases, the vocal fold paralysis was bilateral and the main presenting symptoms were stridor and shortness of breath necessitating intubation and tracheostomy. This article describes the first case of PD presenting with dysphonia secondary to unilateral vocal fold paralysis (left). The management consisted of injection laryngoplasty for medialization of the paralyzed vocal fold. CONCLUSIONS: Patients with PD can present with unilateral vocal fold paralysis. Early treatment is advocated in view of the advent of injection laryngoplasty as a safe office procedure.

Apoptosis in Vocal Fold Polyps.

OBJECTIVE: To examine the degree of apoptosis and its role in the pathogenesis of polyps of the vocal folds. MATERIAL AND METHOD: A review of the pathology department's archives for patients diagnosed with vocal fold polyps between 2010 and 2016 has been conducted. As a control group, gross and microscopically intact vocal fold from laryngectomy specimens was collected. A total of 61 vocal fold polyps from 51 patients and 41 unremarkable vocal folds from the control group were identified. Microscopically, the parameters studied were as follows: apoptosis, mitosis, inflammation, and exocytosis. Apoptotic index (number of apoptotic cells) was determined by the number of apoptotic cells per millimeter square in the epithelium. Apoptotic cells were readily identified by deeply shrunken eosinophilic cells detached from the surrounding environment with pyknotic-degenerated nuclei. RESULTS: In polyps, the apoptotic index was statistically higher than the control group (ρ = 0.000). In addition, the increased apoptotic index in polyps showed a statistically proportional increase in mitotic index, inflammation, and exocytosis, which were significantly higher compared to control group. CONCLUSION: As a key for several therapeutic modalities, manipulation of apoptosis can be a future route for approaching vocal fold polyps by deciphering the complex signal pathways that allow the specified apoptotic cell to be targeted without damaging its surrounding counterpart.

Effect of Hormonal Replacement Therapy on Voice.

OBJECTIVE: This study aimed to investigate the effect of hormonal therapy (HRT) on voice in a group of menopausal women, taking into consideration body mass index (BMI) as a confounding factor and its potential role as a substitute for HRT. SUBJECTS AND METHODS: A total of 53 menopausal women, 34 not on HRT and 19 on HRT, were recruited. Demographic variables included age, gender, smoking, and BMI. All subjects were asked about the presence or absence of the following symptoms: hoarseness, deepening of the voice, pitch breaks, throat clearing, dryness in the throat, and vocal fatigue. Acoustic analysis was performed, and Voice Handicap Index-10 was also completed. RESULTS: The mean BMI was 25.90 ± 5.39 and 25.77 ± 4.26 in patients on HRT and not on HRT, respectively. There was no statistical difference in the Voice Handicap Index-10 score and the prevalence of any of the phonatory symptoms in menopausal women not on HRT compared with menopausal women on HRT. However, menopausal women not on HRT had significantly lower habitual pitch than those on HRT (P value of 0.022). On the other hand, the jitter was significantly higher in those on HRT (P value of 0.033). CONCLUSION: Hormonal therapy has an impact on the habitual pith in menopausal women with comparable BMI. Those on HRT have a higher habitual pitch than those not on HRT.

Gastric incarceration and perforation following posttraumatic diaphragmatic hernia: case report and review of the literature.

OBJECTIVE: Herniation of abdominal contents through the diaphragm has been described in a variety of diaphragmatic defects and may occur secondary to diaphragmatic injury, either traumatic or iatrogenic. The aim of this study is to report a case of gastro-pleural fistula in a patient with traumatic diaphragmatic hernia. CASE PRESENTATION: An 18-year-old male patient, with a past history of blunt abdominal trauma, presented with epigastric abdominal pain and dyspnea. A thoracoabdominal CT scan revealed the presence of a herniated portion of the stomach with suspected perforation and free fluid in the left hemithorax. An exploratory laparotomy was performed. The esophageal hiatus was normal but a 4 cm rent was discovered in the posterior leaf of the left hemidiaphragm. Passing through the defect was the fundus of the stomach with evidence of perforation in left pleural space causing empyema. Resection of the herniated portion of the stomach and running suture of the gastric body were performed. Diaphragm was directly repaired without graft. Finally, a chest tube was placed in the left hemithorax. Postoperative course was uneventful and he recovered without complications. He was discharged from hospital 13 days after surgery.

Vocal Symptoms and Acoustic Findings in Menopausal Women in Comparison to Pre-menopause Women with Body Mass Index as a Confounding Variable.

OBJECTIVES: To compare the prevalence of phonatory symptoms in menopausal women compared to pre-menopause women with body mass index (BMI) as a confounding variable. METHODS: A total of 69 women, 34 menopausal and 35 pre-menopausal were invited to participate in this study. Demographic variables included age, smoking, and BMI. All subjects were asked about the presence hoarseness, loss of high or low frequencies, pitch breaks, throat clearing, dryness in the throat and vocal fatigue. Acoustic analysis was performed and the Voice Handicap Index (VHI)-10 was filled by all the subjects. RESULTS: There was a significantly higher prevalence of throat clearing and dryness in the menopausal group compared to the pre-menopause group with a P value of 0.035 and 0.032 respectively. When BMI was taken into account, there was no statistically significant difference in the prevalence of any of the phonatory symptoms in menopausal women with high BMI and pre-menopause. There was no statistically significant difference in the means of any of the acoustic parameters between the menopausal group and pre-menopausal group. There was no significant difference in the mean VHI-10 between the menopause group and the pre-menopause (P = 0.652). CONCLUSIONS: The results of this investigation substantiate the importance of fat as an alternative source of estrogen which can mask some of the phonatory symptoms.

Intraoperative myocardial ischemia in peripheral vascular surgery: general anesthesia vs combined sciatic and femoral nerve blocks.

STUDY OBJECTIVE: The aim of this study was to compare the frequency of intraoperative myocardial ischemia in lower extremity vascular surgery with general anesthesia vs regional anesthesia via combined sciatic and femoral nerve blocks. DESIGN: This is a prospective, randomized study. SETTING: This study was set at an academic medical center. PATIENTS: The study included 50 patients scheduled for elective lower extremity vascular surgery. INTERVENTIONS: Patients in group 1 received balanced general anesthesia, whereas patients in group 2 received combined sciatic and femoral nerve blocks with 40 mL of 0.375% bupivacaine. Monitoring included a radial artery catheter and multilead, dual-channel electrocardiogram with computerized ST-segment analysis. Blood pressure and heart rate variations were maintained within 10% of preoperative values by adjusting anesthetic depth, fluid replacement, and vasoactive drug dosages. MEASUREMENTS AND MAIN RESULTS: An ST-segment depression of at least 1 mm or elevation of at least 2 mm lasting for more than 1 minute was considered a significant episode of myocardial ischemia. Intraoperative hemodynamic data and the frequency of significant ST-segment change episodes were recorded. The number of patients with ischemic episodes and the total number of these episodes were lower in group 2 than in group 1 (1 patient vs 7 patients, P = 0.02; and 2 vs 14 episodes, P = 0.04). No significant difference was found between groups 1 and 2 regarding systolic or diastolic arterial pressures, or heart rate. CONCLUSION: Compared with general anesthesia, combined sciatic and femoral nerve blocks reduce the frequency of intraoperative myocardial ischemia in patients undergoing lower extremity vascular surgery.

Periareolar mediastinoscopy: a new technique.

Biopsy of anterior mediastinal or aortopulmonary nodes is usually accomplished through a left anterior mediastinostomy. Cosmetic concerns expressed by patients about scars in the neck or the upper chest led us to consider a new periareolar approach for mediastinoscopy. This technique has been used successfully in 10 patients.

[Rehabilitation of thoracic outlet syndrome: about 60 patients]. / Rééducation du syndrome de la traversée thoraco-brachiale: a propos de 60 malades.

Sixty patients were treated by physical therapy for thoracic outlet syndrome (TOS) between 1995 and 1999. Females were predominant (76%), the average age was 34.5 years (18 to 60). Risk factors were: hypermobility, cervical traumatism and profession. Neurological signs were predominant and positive provocation tests were found: Adson (48%), sonnette (62%), E.A.S.T. (51%). Thoracic pain inaugurated the symptoms in 3 times: pseudo-angina (2), dyspnea (1). Radiological results were positive for: cervical rib (8), apophysomegaly of C7 (25), clavicular traumatism (1). Electromyogram was positive in 2 out of 3 patients, RMI in 2 of 4, and dynamic echo Doppler in 3 of 4. After rehabilitation, immediate results were satisfactory in more than 70% of cases. After six months one patient had recurrence of symptoms, 66% were compliant with treatment, and 84% were satisfied. At one year the symptoms recurred in 2 patients, 15% were still compliant, and 81% were satisfied. Surgery was needed in 4 patients with cervical ribs.

Intrathoracic transverse colon and small bowel infarction in a patient with traumatic diaphragmatic hernia. Case report and review of the literature.

OBJECTIVE: Herniation of abdominal contents through the diaphragm has been described for a variety of diaphragmatic defects and may be secondary to diaphragmatic injury, either traumatic or iatrogenic. The sequelae of diaphragmatic hernia include intestinal obstruction, strangulation, gangrene and, eventually, perforation. The aim of this study was to report a case of intrathoracic infarction of transverse colon and two meters of small bowel in a patient with traumatic diaphragmatic hernia. PATIENT: Young man with past history of blunt abdominal trauma presented abdominal pain with dyspnea. An exploratory laparotomy was performed. The esophageal hiatus was normal but a 4.5 cm rent was discovered in the posterior leaf of the left hemidiaphragm. Passing through the defect was the transverse colon and a proximal small bowel. The herniated transverse colon and jejunum were massively dilated with evidence of infarction. Transverse colectomy and resection of two meters of jejunum with direct anastomosis were performed. Following bowel removal, diaphragm was directly repaired without graft. Finally, a chest tube was placed in the left hemithorax. RESULTS: Postoperative course was uneventful and he recovered without complications. He was discharged from hospital 10 days after surgery. CONCLUSION: Surgeons, internists and emergency medicine personnel should be aware of the possibility of diaphragmatic hernia in patients with a known history of abdominal trauma. Though uncommon, strangulation of colon and small bowel through a rent in diaphragm should be considered when there is radiologic evidence of herniation.

Staged anesthesia for combined carotid and coronary artery revascularization: a different approach.

OBJECTIVE: Combined coronary artery bypass graft (CABG) surgery and carotid endarterectomy (CEA) are performed in an attempt to reduce the risk of postoperative stroke after CABG surgery in patients with significant or symptomatic carotid artery stenosis. The choice between regional and general anesthesia for CEA is still under debate. Regional anesthesia offers an excellent monitoring technique of the neurologic status of the awake patient during carotid clamping. In an attempt to improve monitoring of the neurologic status and avoid the use of temporary shunting in patients undergoing the combined procedure, a different approach is described combining regional anesthesia for CEA followed immediately by general anesthesia for CABG surgery. DESIGN: Prospective nonrandomized case series. SETTING: University hospital. PARTICIPANTS: Twenty patients scheduled for combined CEA and CABG surgery underwent a "staged" anesthetic approach from January to December 2004. INTERVENTIONS: Pulmonary, femoral artery, and urinary catheters were inserted under local anesthesia. A deep cervical plexus block was then performed and supplemented by a superficial cervical plexus block. The patient was draped for standard combined CEA and CABG surgery. CEA was then performed using standard techniques. Without altering the surgical field, general anesthesia was given and endotracheal intubation performed following the successful CEA. Coronary revascularization was then completed. MEASUREMENTS AND MAIN RESULTS: CEA and CABG surgery were completed successfully in all patients. There was no need for conversion from local to general anesthesia. Endotracheal intubation was easily performed in all patients. There was no hospital mortality in this series. No neurologic events were observed during the CEA. A reversible ischemic stroke, ipsilateral to the CEA, occurred postoperatively on awakening from CABG surgery in 1 patient. CONCLUSIONS: This staged anesthetic approach for combined CABG and CEA surgery is an alternative in this complex subset of patients.