Frontal sinus mucocoeles: new algorithm for surgical management.

BACKGROUND: Frontal sinus mucocoeles require a structured approach to their surgical management. We share our experience of a novel method of positional classification for frontal mucocoele and corresponding surgical algorithm. METHODS: A retrospective case-note review examined all frontal sinus surgery for mucocoele, spanning three years (2008-2010). Patients had pre-operative nasendoscopy, multi-planar CT and MRI when indicated. Several important variables (position, drainage dimensions, fronto-ethmoidal cells and degree of neo-osteogenesis) were noted. A systematic algorithm was used for surgical drainage based on these characteristics. The three year outcomes using this approach are presented. RESULTS: Thirty-six patients were identified with a total of 43 frontal mucocoeles. Using our classification, 30 mucocoeles were medial; seven were intermediate; six were lateral. Thirty-four patients underwent a primary endoscopic procedure; six required a combined primary osteoplastic-flap (OPF) and endoscopic approach. Six patients required revision surgery for polypoidal change or neo-ostium stenosis. All patients were eventually rendered asymptomatic. CONCLUSION: Implementation of our positional classification and surgical algorithm was successful with a revision rate of 19%. Presence of frontal sinus wall dehiscence and extra-sinus mucocoele extension are invalid indicators for external approach. We feel our classification and treatment algorithm, with its associated indicators for surgical escalation (i.e. limited dimensions of frontal ostium, presence of Type III / IV front-ethmoidal cells etc), are applicable for future management of frontal mucocoeles.

Paediatric otogenic cerebral venous sinus thrombosis: a multidisciplinary approach.

BACKGROUND: Paediatric otogenic cerebral venous sinus thrombosis is a rare, heterogeneous and life-threatening condition, with possible otological, neurological and ophthalmological sequelae. Its course and outcomes can be widely variable. The publications available often consider individual aspects of paediatric otogenic cerebral venous sinus thrombosis management. The condition itself and the nature of the currently available guidance can lead to uncertainties when holistically managing patients with paediatric otogenic cerebral venous sinus thrombosis. OBJECTIVES: Clear recommendations for the comprehensive assessment and management of paediatric otogenic cerebral venous sinus thrombosis are presented, along with the literature review upon which they are based. Its clinical and radiological assessment are discussed. CONCLUSION: A multidisciplinary approach to assessment and management is recommended, inclusive of infectious diseases, ENT surgery, neurology, ophthalmology and haematology. On balance, anticoagulation is recommended for three months. Follow-up imaging is not recommended in the absence of clinical concern. Follow up by ENT surgery, neurology and ophthalmology departments is recommended.

Prioritising topics for the undergraduate ENT curriculum.

OBJECTIVE: Knowledge of ENT is important for many doctors, but undergraduate time is limited. This study aimed to identify what is thought about ENT knowledge amongst non-ENT doctors, and the key topics that the curriculum should focus on. METHODS: Doctors were interviewed about their views of ENT knowledge amongst non-ENT doctors, and asked to identify key topics. These topics were then used to devise a questionnaire, which was distributed to multiple stakeholders in order to identify the key topics. RESULTS: ENT knowledge was generally thought to be poor amongst doctors, and it was recommended that undergraduate ENT topics be kept simple. The highest rated topics were: clinical examination; when to refer; acute otitis media; common emergencies; tonsillitis and quinsy; management of ENT problems by non-ENT doctors; stridor and stertor; otitis externa; and otitis media with effusion. CONCLUSION: This study identified a number of key ENT topics, and will help to inform future development of ENT curricula.

Initial assessment in the management of adult epistaxis: systematic review.

BACKGROUND: The initial assessment of epistaxis patients commonly includes: first aid measures, observations, focused history taking, and clinical examinations and investigations. This systematic review aimed to identify evidence that informs how the initial assessment of these patients should be conducted. METHOD: A systematic review of the literature was performed using a standardised methodology and search strategy. RESULTS: Seventeen articles were included. Factors identified were: co-morbidity, intrinsic patient factors, coagulation screening and ice pack use. Hypertension and anticoagulant use were demonstrated to adversely affect outcomes. Coagulation screening is useful in patients on anticoagulant medication. Four studies could not be accessed. Retrospective methodology and insufficient statistical analysis limit several studies. CONCLUSION: Sustained ambulatory hypertension, anticoagulant therapy and posterior bleeding may be associated with recurrent epistaxis, and should be recorded. Oral ice pack use may decrease severity and can be considered as first aid. Coagulation studies are appropriate for patients with a history of anticoagulant use or bleeding diatheses.

Influence of dietary protein on glomerular filtration and urinary albumin excretion in insulin-dependent diabetes.

We investigated the effects of dietary constituents on glomerular filtration (GFR) and albumin excretion rates (AERs) in a cross-sectional study in 39 young subjects with insulin-dependent diabetes. Dietary protein intake correlated significantly in patients with GFRs less than 150 mL/min per 1.73 m2 (r = 0.53, n = 23, P = 0.009), but not with AER. GFR also correlated with mean blood glucose at a concentration less than 12.0 mmol/L (r = 0.61, P = 0.0035). Protein and fat intakes were similar in patients with and without microalbuminuria (AER greater than 20 mg/L) but long-term glycemic control was worse in the former [HbA1 12.4 +/- 2.9% (mean +/- SD) and 10.6 +/- 2.1%, respectively, P = 0.043]. In seven patients, short-term reduction of dietary protein from 2.0 to 1.0 to 0.5 g.kg-1.d-1 produced a progressive fall in GFR by 11.6 +/- 6.0 and 9.6 +/- 5.9 mL/min, respectively (P less than 0.05), but did not consistently affect AER. We conclude that both dietary protein and glycemic control influence GFR but neither alone appears to explain glomerular hyperfiltration. Microalbuminuria was associated with poor glycemic control but not with dietary fat or protein consumption.

Chlorinated and brominated dioxins and dibenzofurans in human tissue following exposure.

With substantial improvements in analytic techniques over the past decade, it has become possible to measure polychlorinated dioxins (PCDDs) and dibenzofurans (PCDFs) in human tissue in a congener-specific fashion down to the low parts per trillion level. This paper reviews findings using these new techniques from a number of recent medical and environmental case studies. These studies include those of workers exposed to a polychlorinated biphenyl (PCB) transformer fire in the United States, German chemical workers exposed to 2,3,7,8-tetrachlorodibenzodioxin (2,3,7,8-TCDD) while cleaning up after an explosion, workers at a municipal incinerator in New York City, a chemist exposed to brominated and chlorinated dioxins, U.S. veterans and also Vietnamese civilians exposed to Agent Orange contaminated with TCDD in Vietnam, and victims of the polychlorinated dibenzofuran and PCB contaminated rice oil (Yusho) incident in Japan.

Recent dioxin contamination from Agent Orange in residents of a southern Vietnam city.

Marked elevation of dioxin associated with the herbicide Agent Orange was recently found in 19 of 20 blood samples from persons living in Bien Hoa, a large city in southern Vietnam. This city is located near an air base that was used for Agent Orange spray missions between 1962 and 1970. A spill of Agent Orange occurred at this air base more than 30 years before blood samples were collected in 1999. Samples were collected, frozen, and sent to a World Health Organization--certified dioxin laboratory for congener-specific analysis as part of a Vietnam Red Cross project. Previous analyses of more than 2200 pooled blood samples collected in the 1990s identified Bien Hoa as one of several southern Vietnam areas with persons having elevated blood dioxin levels from exposure to Agent Orange. In sharp contrast to this study, our previous research showed decreasing tissue dioxin levels over time since 1970. Only the dioxin that contaminated Agent Orange, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), was elevated in the blood of 19 of 20 persons sampled from Bien Hoa. A comparison, pooled sample from 100 residents of Hanoi, where Agent Orange was not used, measured blood TCDD levels of 2 parts per trillion (ppt). TCDD levels of up to 271 ppt, a 135-fold increase, were found in Bien Hoa residents. TCDD contamination was also found in some nearby soil and sediment samples. Persons new to this region and children born after Agent Orange spraying ended also had elevated TCDD levels. This TCDD uptake was recent and occurred decades after spraying ended. We hypothesize that a major route of current and past exposures is from the movement of dioxin from soil into river sediment, then into fish, and from fish consumption into people.

Verse form : A pilot study in the epidemiology of representations.

This paper presents a pilot study in the "epidemiological" program for cultural research put forward by Dan Sperber. Theory is offered to argue that verse form is so disabling that its worldwide distribution must be explained by functions other than the broad communicative, or ideological, power traditionally attributed to it. The theoretical case is confirmed by numerical data showing that in matched texts of English prose and verse the latter contain words of a lower mean length (measured in syllables). Candidate hypotheses for the epidemiology of verse are offered, including design for mnemonic properties, the registration of differences in verbal intelligence, the presentation of gestures of commitment, and the introduction of levels of quasi-randomness that lead to an impression of semantic richness and the illusion of profound and powerful communication.

Influence of elevated CO2 and mycorrhizae on nitrogen acquisition: contrasting responses in Pinus taeda and Liquidambar styraciflua.

An understanding of root system capacity to acquire nitrogen (N) is critical in assessing the long-term growth impact of rising atmospheric CO2 concentration ([CO2]) on trees and forest ecosystems. We examined the effects of mycorrhizal inoculation and elevated [CO2] on root ammonium (NH4+) and nitrate (NO3-) uptake capacity in sweetgum (Liquidambar styraciflua L.) and loblolly pine (Pinus taeda L.). Mycorrhizal treatments included inoculation of seedlings with the arbuscular mycorrhizal (AM) fungus Glomus intraradices Schenck & Smith in sweetgum and the ectomycorrhizal (EM) fungus Laccaria bicolor (Maire) Orton in loblolly pine. These plants were then equally divided between ambient and elevated [CO2] treatments. After 6 months of treatment, root systems of both species exhibited a greater uptake capacity for NH4+ than for NO3-. In both species, mycorrhizal inoculation significantly increased uptake capacity for NO3-, but not for NH4+. In sweetgum, the mycorrhizal effect on NO3- and NH4+ uptake capacity depended on growth [C02]. Similarly, in loblolly pine, the mycorrhizal effect on NO3- uptake capacity depended on growth [CO2], but the effect on NH4+ uptake capacity did not. Mycorrhizal inoculation significantly enhanced root nitrate reductase activity (NRA) in both species, but elevated [CO2] increased root NRA only in sweetgum. Leaf NRA in sweetgum did not change significantly with mycorrhizal inoculation, but increased in response to [CO2]. Leaf NRA in loblolly pine was unaffected by either treatment. The results indicate that the mycorrhizal effect on specific root N uptake in these species depends on both the form of inorganic N and the mycorrhizal type. However, our data show that in addressing N status of plants under high [CO2], reliable prediction is possible only when information about other root system adjustments (e.g., biomass allocation to fine roots) is simultaneously considered.

Suitability of process-based tree growth models for addressing tree response to climate change.

Empirical models of tree growth have been used for many years to predict timber yields and other properties of trees. However, such models rely on measured relationships between tree growth and historic environmental conditions. As anthropogenic actions alter the environment, especially atmospheric composition, empirical models become less reliable and process-based models become more useful. Process-based models are challenged to simulate growth of structurally and physiologically complex organisms using explicit mathematical expressions to capture growth response to environmental conditions. In this review we summarize the physiological requirements of process-based models and examine the capabilities of six published models (CARBON, ECOPHYS, PGSM, TREE-BGC, TREGRO, W91) for simulating tree response to changes in environmental conditions (elevated temperature, increased CO(2) concentration, and enhanced concentrations of tropospheric ozone). These analyses indicate that current models are reliable integrators of environmental effects on individual processes (e.g. photosynthesis), but may be less reliable where physiological acclimation occurs or when extrapolated to growth of specific tree compartments.

The physician's role in an aging America: taking the team approach to eldercare.

With the advent of an aging patient population, the healthcare community is sharpening its focus on geriatric medicine and on how current resources will fare under the demands of an aging America. One approach to effective eldercare is that of a "team" of physician and nonphysician providers, cooperating to meet the multifaceted needs of the elderly patient. As the traditional primary care provider, the physician is a natural choice for the role of team leader.

Long-term care coverage: the need is now.

As the world population steadily ages, the future of America's long-term healthcare system is facing a major crisis. By the year 2050, approximately 22 percent of the United States population is expected to be over the age of 65 and more than 19 million Americans will require long-term care. Long-term care financing will be increasingly important, since nursing home care can lead to financial catastrophe. The key to preventing this catastrophe for the elderly is appropriate third-party coverage. Although more insurance companies are offering long-term care policies today, three major obstacles to the success of such insurance remain: lack of knowledge about the extent of public funding for long-term care, denial of the need for such insurance, and lack of public awareness of potential liabilities inherent in financing long-term care. Congress is supporting the development of long-term care insurance, and states are placing long-term care legislation at the top of their agendas. Tax incentives have been proposed in the form of tax-free individual retirement accounts to finance long-term care, individual medical accounts, tax credits for policyholders, and favorable tax treatment for employers who offer long-term care benefits. But only coordination of public and private financiers will ensure adequate protection for all consumers of long-term care services.

Collaboration needed to bolster home care.

To survive financially and better meet the needs of the elderly, hospitals must take the lead and collaborate with community leaders to enhance home healthcare, which can help the elderly maintain their independence and prevent institutionalization. Informal home healthcare is provided mostly by women, primarily wives, daughters, and daughters-in-law. These care givers often take the elderly person into their own homes, which can increase tension and conflicts, crowd the home, and propagate adverse perceptions by the spouse or children. Many care givers quit their jobs, thereby forfeiting income and relinquishing the mental stimulation of co-workers. Care givers who remain employed sacrifice their free time, family time, and other social opportunities. Other factors that influence the degree of stress and burden on the care giver include the type, extent, and duration of care needs; the location of home care; use of formal services; and the care giver's age, health status, and relationship to the elderly patient. Without help from formal home care agencies and local support groups, informal care giving at home may diminish rapidly due to physical and emotional exhaustion, sometimes resulting in abuse of the elderly patient. Government intervention is necessary if informal home care is to continue as a viable source of long-term care. In addition, local community medical societies must develop a team approach involving physicians, social workers, and nurses to adequately supplement home care givers or help single homebound elderly. Hospital administrators must work with community leaders to implement formal networks of home care services, such as respite care, adult day care, meals on wheels, and nursing care.