Magnetic resonance imaging of dilated cardiomyopathy: prognostic benefit of identifying late gadolinium enhancement in Asian patients

INTRODUCTION@#Risk stratification in dilated cardiomyopathy (DCM) is imprecise, relying largely on echocardiographic left ventricular ejection fraction (LVEF) and severity of heart failure symptoms. Adverse cardiovascular events are increased by the presence of myocardial scarring. Late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is the gold standard for identifying myocardial scars. We examined the association between LGE on CMR imaging and adverse clinical outcomes during long-term follow-up of Asian patients with DCM.@*METHODS@#Consecutive patients with DCM undergoing CMR imaging at a single Asian academic medical centre between 2005 and 2015 were recruited. Clinical outcomes were tracked using comprehensive electronic medical records and mortality was determined by cross-linkages with national registries. Presence and distribution of LGE on CMR imaging were determined by investigators blinded to patient outcomes. Primary endpoint was a composite of heart failure hospitalisations, appropriate implantable cardioverter-defibrillator shocks and cardiovascular mortality.@*RESULTS@#Of 86 patients, 64.0% had LGE (80.2% male; mean LVEF 30.1% ± 12.7%). Mid-wall fibrosis (71.7%) was the most common pattern of LGE distribution. Over a mean follow-up period of 4.9 ± 3.2 years, 19 (34.5%) patients with LGE reached the composite endpoint compared to 4 (12.9%) patients without LGE (p = 0.01). Presence of LGE, but not echocardiographic LVEF, independently predicted the primary endpoint (hazard ratio 4.15 [95% confidence interval 1.28-13.50]; p = 0.02).@*CONCLUSION@#LGE presence independently predicted adverse clinical events in Asian patients with DCM. Routine use of CMR imaging to characterise the myocardial substrate is recommended for enhanced risk stratification and should strongly influence clinical management.

Comparison of heart failure and COVID-19 in chest CT features and clinical characteristics / 中华心血管病杂志

Objective: To identify the characteristics including clinical features and pulmonary computed tomography (CT) features of heart failure and COVID-19. Methods: This study was a retrospective study. A total of 7 patients with heart failure and 12 patients with COVID-19 in the Second Xiangya Hospital of Central South University between December 1, 2019 and February 15, 2020 were enrolled. The baseline clinical and imaging features of the two groups were statistically analyzed. Results: There was no significant difference in age and sex between the two groups(both P>0.05), but the incidence of epidemiological contact history, fever or respiratory symptoms in the COVID-19 group was significantly higher than that in the heart failure group (12/12 vs. 0, P<0.001; 12/12 vs. 4/7, P=0.013). While the proportion of cardiovascular diseases and impaired cardiac function was significantly less than that of the heart failure group(2/12 vs.7/7, P<0.001；0 vs.7/7, P<0.001). For imaging features, both groups had ground-glass opacity and thickening of interlobular septum, but the ratio of central and gradient distribution was higher in patients with heart failure than that in patients with COVID-19 (4/7 vs. 1/12, P=0.04). In heart failure group, the ratio of the expansion of pulmonary veins was also higher (3/7 vs. 0，P=0.013), and the lung lesions can be significantly improved after effective anti-heart failure treatment. Besides, there were more cases with rounded morphology in COVID-19 group（9/12 vs. 2/7, P=0.048）. Conclusions: More patients with COVID-19 have epidemiological history and fever or respiratory symptoms. There are significant differences in chest CT features, such as enlargement of pulmonary veins, lesions distribution and morphology between heart failure and COVID-19.

The clinical value evaluation of anatomic hepatectomy in the treatment for hepatic vesicular hydatidosis / 中国实用外科杂志

OBJECTIVE: To explore the clinical application value of perioperative comprehensive management of precise hepatectomy in hepatectomy for hepatic alveolar echinococcosis. METHODS: The clinical data of 62 patients with hepatic alveolar echinococcosis who underwent hemihepatectomy from January 2017 to December 2018 were collected and divided into anatomical hepatectomy group(35 cases)and non-anatomical hepatectomy group(27 cases) according to the method of hepatectomy. The differences of preoperative basic data,intraoperative situation and postoperative clinical indexes between the two groups were compared respectively. RESULTS: There was no significant difference in age,sex,hydatid number,hydatid size and preoperative liver function index between the two groups(P>0.05). However,there were significant differences between the two groups in liver function indexes(ALT,AST,DBIL and TBIL),postoperative complication(medicine) incidence rate and postoperative hospital stay(P<0.05). CONCLUSION: Accurate hepatectomy is also suitable for surgical treatment of patients with hepatic alveolar echinococcosis,and has the advantages of less liver function damage,low incidence of complication(medicine) and short hospitalization time after operation.

Relationship Between Blood Lipid Level and In-hospital Death in Patients With Aortic Dissection / 中国循环杂志

Objective: To investigate the relationship between blood lipid level and in-hospital death in patients with aortic dissection (AD). Methods: Our retrospective study included in 2 groups: AD group, n=153 patients which was further divided into 2 subgroups:Thoracic AD subgroup, n=73 and Abdominal AD subgroup, n=80; Control group, n=50 patients with isolated hypertension at the same period. Blood lipid levels were compared among different groups and subgroups; HDL-C levels were studied by correlation analysis between AD survivor and in-hospital died AD patients. Results: Compared with Control group, AD group had increased TC [3.89 (3.19, 4.61) mmol/L] vs [3.58 (2.70, 4.33) mmol/L], decreased HDL-C [1.02 (0.86, 1.25) mmol/L vs 1.52 (1.22, 1.76) mmol/L] and lower ratio of HDL-C/TC [0.28 (0.22, 0.34) vs 0.45 (0.31, 0.67)], all P<0.01. Compared with Abdominal AD subgroup, Thoracic AD subgroup had the lower ratio of HDL-C/TC [0.27 (0.20, 0.33) vs 0.30 (0.24, 0.36)], P<0.05. Compared with AD survivor, the in-hospital died AD patients had the lower HDL-C level [0.82 (0.69, 1.04) mmol/L vs 1.06 (0.89, 1.33) mmol/L], P<0.01. Spearman correlation analysis revealed that HDL-C level was negatively related to in-hospital death of AD (correlation coefficient =-0.353). Conclusion: AD patients had abnormal lipid metabolism, blood HDL-C level was negatively related to in-hospital death in AD patients.

Rhythmic chaos: irregularities of computer ECG diagnosis

Diagnostic errors can occur when physicians rely solely on computer electrocardiogram interpretation. Cardiologists often receive referrals for computer misdiagnoses of atrial fibrillation. Patients may have been inappropriately anticoagulated for pseudo atrial fibrillation. Anticoagulation carries significant risks, and such errors may carry a high cost. Have we become overreliant on machines and technology? In this article, we illustrate three such cases and briefly discuss how we can reduce these errors.

Association of Plasma Pentraxin-3 Levels on Admission with In-hospital Mortality in Patients with Acute Type A Aortic Dissection / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Acute aortic dissection is a life-threatening cardiovascular emergency. Pentraxin-3 (PTX3) is proposed as a prognostic marker and found to be related to worse clinical outcomes in various cardiovascular diseases. This study sought to investigate the association of circulating PTX3 levels with in-hospital mortality in patients with acute Type A aortic dissection (TAAD).</p><p><b>METHODS</b>A total of 98 patients with TAAD between January 2012 and December 2015 were enrolled in this study. Plasma concentrations of PTX3 were measured upon admission using a high-sensitivity enzyme-linked immunosorbent assay system. Patients were divided into two groups as patients died during hospitalization (Group 1) and those who survived (Group 2). The clinical, laboratory variables, and imaging findings were analyzed between the two groups, and predictors for in-hospital mortality were evaluated using multivariate analysis.</p><p><b>RESULTS</b>During the hospital stay, 32 (33%) patients died and 66 (67%) survived. The patients who died during hospitalization had significantly higher PTX3 levels on admission compared to those who survived. Pearson's correlation analysis demonstrated that PTX3 correlated positively with high-sensitivity C-reactive protein (hsCRP), maximum white blood cell count, and aortic diameter. Multivariate logistic regression analysis demonstrated that PTX3 levels, coronary involvement, cardiac tamponade, and a conservative treatment strategy are significant independent predictors of in-hospital mortality in patients with TAAD. The receiver operating characteristic curve analysis further illustrated that PTX3 levels on admission were strong predictors of mortality with an area under the curve of 0.89. A PTX3 level ≥5.46 ng/ml showed a sensitivity of 88% and a specificity of 79%, and an hsCRP concentration ≥9.5 mg/L had a sensitivity of 80% and a specificity of 69% for predicting in-hospital mortality.</p><p><b>CONCLUSION</b>High PTX3 levels on admission are independently associated with the in-hospital mortality in patients with TAAD.</p>

Case-control study on two osteotomy techniques for the treatment of distal radial malunion / 中国骨伤

<p><b>OBJECTIVE</b>Radial corrective osteotomy is an established but challenging treatment for distal radial malunion. There is an ongoing discussion about whether an opening or closing-wedge osteotomy between should employed. The purpose of the present study was to retrospectively compare the clinical and radio graphic results between conventional opening-wedge osteotomy and closing-wedge technique.</p><p><b>METHODS</b>From January 2004 and December 2012,42 patients with extra-articular distal radial malunion were managed with corrective osteotomy and were followed for a minimum of one year. Twenty-two patients (5 males and 17 females, ranging in age from 25 to 75 years old) were managed with radial opening-wedge osteotomy and implanting of interpositional bone graft or bone-graft substitute, and twenty patients (4 males and 16 females, ranging in age from 19 to 79 years) were managed with simultaneous radial closing-wedge and ulnar shortening osteotomy without bone graft. The selection of the surgical procedure was determined by the surgeon. Each patient was evaluated on the basis of objective radio graphic measurements, and functional outcomes were determined on the basis of clinical examinations, including range of wrist motion, grip strength, pain-rating score, Mayo wrist score, and Disabilities of the Arm, Shoulder and Hand (DASH) score.</p><p><b>RESULTS</b>The mean duration of follow-up was 36 months (ranged, 12 to 101 months) for the opening-wedge cohort and 28 months (ranged, 12 to 87 months) for the closing-wedge cohort. The two techniques were comparable in terms of complications. Post-operative volar tilt and ulnar variance were improved significantly in each cohort. The ulnar variance was more frequently restored to within defined criteria (22.5 to 0.5 mm) in the closing-wedge cohort than that in the opening-wedge cohort. The post-operative mean extension-flexion are of the wrist and Mayo wrist score were significantly better in the closing-wedge cohort. Differences in the pronation-supination arc, grip strength, pain-rating score, and DASH scores between these two cohorts were not significant.</p><p><b>CONCLUSION</b>The closing wedge osteotomy technique is an effective reconstructive procedure for the treatment of extra-articular distal radial malunion. It is significantly better than the opening-wedge osteotomy technique in terms of the restoration of ulnar variance, the extension-flexion arc of wrist motion, and the Mayo wrist score.</p>

Home-based advance care programme is effective in reducing hospitalisations of advanced heart failure patients: a clinical and healthcare cost study

<p><b>INTRODUCTION</b>In end-stage heart failure (HF) that is not eligible for mechanical assist device or heart transplant, palliative care serves to maximise symptom control and quality of life. We sought to evaluate the impact of home-based advance care programme (ACP) on healthcare utilisation in end-stage HF patients.</p><p><b>MATERIALS AND METHODS</b>Prospectively collected registry data on all end-stage HF recruited into ACP between July 2008 and July 2010 were analysed. Chart reviews were conducted on HF database and hospital electronic records. Phone interview and home visit details by ACP team were extracted to complete data entry. HF and all-cause hospitalisations 1 year before, and any time after ACP inception were defined as events. For the latter analysis, follow-up duration adjustment to event episodes was performed to account for death less than a year.</p><p><b>RESULTS</b>Forty-four patients (mean age 79 years, 39% men) were followed up for 15±8 months. Fifty-seven percent had diabetes, 80% ischaemic heart disease, and 60% chronic kidney disease. All reported functional class III/IV at enrolment. Mean serum sodium was 136±6 mmol/L, and creatinine 186±126 mmol/L. Thirty (68%) died within the programme. Mean time to death was 5.5 months. Mean all-cause and HF hospitalisations were 3.6 and 2.0 per patient before enrolment, but improved to 1.0 and 0.6 respectively after ACP. Thirty-six (71%) patients had fewer HF hospitalisations. When only those who survived more than a year were considered (n = 14), 10 (71%) and 9 (64%) experienced reduced HF (mean: 1.4 episodes per patient) and all-cause hospitalisations (mean: 2.2 episodes per patient) respectively.</p><p><b>CONCLUSION</b>Home-based advance care programme is potentially effective in reducing healthcare utilisation of end-stage HF patients, primarily by reducing HF rehospitalisations, and in probably saving costs as well.</p>

simple emergency prediction tool for acute aortic dissection

A simple emergency risk prediction tool should be developed for clinicians to quickly identify the prognosis of patients with acute aortic dissection. We enrolled 280 patients with acute aortic dissection admitted to emergency department between May 2010 and February 2013. Multivariate logistic regression analysis was performed to identify independent predictors of in-hospital death. The in-hospital mortality of our patients with acute aortic dissection was 32.5%, in-hospital deaths with surgery less than the survived [34.1% VS 54.5%]. Multivariate analysis identified that age [>/= 65 years old], Type A, blood pressure [mean systolic blood pressure /= 80%] and serum D-dimer [>/= 5.0 mg/L] were significant predictors of death. With the simple emergency risk prediction tool, scores of all in-hospital deaths were >/= 3, whereas almost all of the survivors [97.9%] had scores < 15. A score of 10 offered the best threshold value, with the highest sensitivity [81.3%] and specificity [86.8%]. The in-hospital mortality rate of patients with acute aortic dissection is high and can be predicted. Early surgery would be beneficial for in-hospital survive. This tool should be available for clinicians in the emergency department to quickly identify the prognosis of patients with acute aortic dissection

Gluteal muscle contracture release for the treatment of gluteal muscle contracture induced knee osteoarthritis: a report of 52 cases / 中国骨伤

<p><b>OBJECTIVE</b>To investigate clinical efficacy and significance of gluteal muscle contracture release for the treatment of gluteal muscle contracture induced knee osteoarthritis.</p><p><b>METHODS</b>From January 2008 to June 2010,52 patients with gluteal muscle contracture induced knee osteoarthritis were reviewed. Among the patients,15 patients were male and 37 patients were female, ranging in age from 15 to 45 years, with an average of 35 years. Eighteen patients had left knee osteoarthritis, 30 patients had right osteoarthritis, and 4 patients had double knee osteoarthritis. All the patients were treated with gluteal muscle contracture release. Lysholm knee score was used to evaluate therapeutic effects before and after operation.</p><p><b>RESULTS</b>All the patients were followed up,and the duration ranged from 12 to 37 years,with a mean of 15 months. The Lysholm knee score improved from preoperative (68.12 +/- 0.78) points to postoperative (91.23 +/- 0.47) points at the last follow-up, the difference had statistical difference (t=31.269, P<0.01).</p><p><b>CONCLUSION</b>Gluteal muscle contracture release is effective to relieve symptoms of gluteal muscles contracture and knee osteoarthritis. The patients with gluteal muscle contracture should be treated early so as to prevent effects of gluteal muscle contracture on knee joint, slow down degeneration of knee joint at early stage, and prevent occurrence of knee osteoarthritis.</p>

Rapid eye movement-related and none rapid eye movement-related classification in obstructive sleep apnea hypopnea syndrome / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To study the value of a new measurement that divided obstructive sleep apnea-hypopnea syndrome (OSAHS) into rapid-eye-movement (REM) related and non-rapid-eye-movement (NREM) related subgroups.</p><p><b>METHODS</b>According to Siddiqui classification, 137 adult patients with OSHAS were diagnosed as REM-related OSAHS [REM apnea hypopnea index (AHI)/NREM AHI > 1] or NREM-related OSAHS (REM AHI/NREM AHI < 1). Polysomnographic data were compared and discussed.</p><p><b>RESULTS</b>(1) There were 72 cases defined as REM-related OSAHS (52.6%) and 65 cases defined as NREM-related OSAHS (47.4%). (2) In all cases, total AHI and NREM AHI in REM-related OSAHS were significantly lower than those in NREM-related OSAHS, while lowest arterial oxygen saturation (LSaO₂), REM LSaO₂ and NREM LSaO₂ were significantly higher than those in NREM-related OSAHS (t were -6.466, -7.638, 3.426, 2.472, 4.873 respectively, P < 0.05). No significance was found in sleep structure, REM AHI and REM LSaO₂ between REM-related and NREM-related OSAHS (P > 0.05). (3) Given the severity of OSHAS, the constituent ratio of REM-related OSAHS decreased (77.8%, 61.5%, 37.3%) from mild to severe OSAHS, while that of NREM-related OSAHS rose (22.7%, 38.5%, 62.7%; chi² = 16.996, P < 0.01). In mild and moderate groups, REM LSaO₂ of REM-related OSAHS was significantly lower than those in NREM-related OSAHS (t were -4.273 and -2.136, P < 0.05), while the differences of total AHI and LSaO₂, NREM LSaO₂ between these two types were not significant. In severe group, AHI in NREM-related OSAHS was significantly higher than that in REM-related OSAHS, while LSaO₂, REM LSaO₂ and NREM LSaO₂ was significantly lower than those in REM-related OASHS (t were -4.943, 2.574, 1.996, 3.571, P ≤ 0.05). (4) There was no significance in sleeping latency and efficiency between REM-related and NREM-related OSHAS.</p><p><b>CONCLUSIONS</b>REM-related OSHAS mainly exists in mild and moderate OSHAS, while NREM-related one mainly exists in severe OSHAS. NREM-related OSAHS may be more severe in AHI and hypoxia than REM-related one. Whenever obstructive apnea happened in REM or NREM period, its impacts on sleep structure, efficiency and latency have no difference.</p>

DJ-1 expression in laryngeal squamous cell carcinoma and its relationship with tumor recurrence and metastasis / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To detect the expression of DJ-1 in laryngeal squamous cell carcinoma (LSCC) and to study the relationship between DJ-1 expression and clinical indexes of LSCC.</p><p><b>METHODS</b>The expressions of DJ-1 protein in 71 LSCC samples and 9 cases control samples from laryngeal mucosa tissues of non-LSCC patients were detected using streptavidin peroxidase immunohistochemistry staining and the relationships between DJ-1 protein expression and clinicopathologic characteristics were analyzed.</p><p><b>RESULTS</b>(1) The positive expression rate of DJ-1 protein in LSCC was 85.9%(61/71), which was significantly higher than the rate (55.5%, 5/9) in control laryngeal mucosa tissues (P < 0.05). (2) DJ-1 expression was related to tumor recurrence (P < 0.05), but not to sex, age, primary cancer position, T stage, clinical stage, lymph node metastasis and tumor differentiation. Tumor recurrence rate (53.3%) in the patients with higher expression of DJ-1 protein was higher than the rate (26.8%) in the patients with lower expression of DJ-1 protein (χ(2) = 5.164, P < 0.05). (3) With Kaplan-Meier curves and Cox regression analysis, the cumulative 5-year survival rates were correlated with DJ-1 expression levels in laryngeal cancer tissues or cervical lymph node metastasis (all P < 0.05), but not to sex, age, primary cancer position, T stage, clinical stage and tumor differentiation.</p><p><b>CONCLUSIONS</b>The expression of DJ-1 protein in LSCC is higher than that in control laryngeal mucous tissues. Overexpression of DJ-1 is associated with poor overall survival in LSCC patients.</p>

Analysis on an early diagnosis grading model for acute aortic dissection / 中华心血管病杂志

<p><b>OBJECTIVE</b>To investigate the value of an early diagnosis grading model derived from the clinical manifestation, laboratory and imaging data for the diagnosis of aortic dissection (AD).</p><p><b>METHODS</b>An early diagnosis grading model was established based on the clinical manifestation, laboratory and imaging data from 182 AD patients who admitted to our department during the last 3 years, 184 patients with chest and back pain served as controls.</p><p><b>RESULTS</b>The sensitivity and specificity of diagnosing AD with the score of 5 is 96.7% and 81.0%, respectively.</p><p><b>CONCLUSION</b>The emergency diagnose of AD could be improved based on the established early grading model based on the stabbing and severe pain, rapid blood pressure increase, asymmetry of the blood pressure and/or the pulse, widened aortic knob, mediastinum or descending aorta on X-ray, and significantly increased D-dimmer level.</p>

Construction and activity evaluation of pSUPER RNAi system that inhibits Smad3 / 中南大学学报(医学版)

OBJECTIVE@#To construct the expressing vector of siRNA which can inhibit the Smad3 activity.@*METHODS@#Sixty-four bases of 2 pair oligos for hairp in RNA expression which targeted Smad3 gene were chemically synthesized and annealed. pSUPER vector was linearized with BgL II and Hin d III treated with alkaline phosphatase (CIP). Anneled oligos were inserted into the downstream of the treated pSUPER's pol III H1 promoter to construct RNAi plasmid (pSUPER Smad3). Oligos with a scrambled sequence were used as a negative control. pSUPER Smad3 was transfected into human renal tubular epithelial cells (HKC).@*RESULTS@#Recombinant pSUPER Smad3 vector was identified by the digestion with Eco R I and Hin d III, and confirmed by the sequencing analysis with T3 primer. Sixty-four bases had been inserted into the expected site. Furthermore, the insertion sequence was exactly corrected. The activity evaluation indicated that mRNA and protein of Smad3 but not Smad2 were inhibited by pSUPER Smad3 in HKC.@*CONCLUSION@#The pSUPER Smad3 system has been constructed successfully, and has high inhibition and specificity in vitro.

Effect of ulinastain on the expression of hemeoxygenase-1 in oleic acid-induced acute lung injury in rats / 中南大学学报(医学版)

OBJECTIVE@#To explore the effect of ulinastain on the expression of hemeoxy genase-1 (HO-1) in oil acid-induced acute lung injury in rats.@*METHODS@#The animal model of acute lung injury was established by oil acid. Thirty SD rats were randomly divided into 3 groups: the blank control group (A), the acute lung injury group (B) and the acute lung injury group (C) followed by injecting 100 mL/kg ulinastatin. Each group consisted of 10 rats. Group A were given 0.2 mL/kg natural solution through the trial vein; Group B and C were given 0.2 mL/kg oil-acid through trial vein, while group C were injected 100mL/kg ulinastatin by the peritoneal cavity after injecting oil acid. After 4 hours, the rates of respiration were counted and blood samples were cramped out through the heart puncture for blood gas analysis. The expressions of hemeoxygenase-1 and the pathologic construction changes were determined by HE staining in the lower right lung of rats in the 3 groups.@*RESULTS@#The respiration dysfunction caused by oil acid could be prominently improved by ulinastain. There was only a little expression of hemeoxygenase-1 in the lung of Group A, but the expression increased in Group B and significatively increased in Group C.@*CONCLUSION@#Ulinastatin may protect the rats from acute lung injury through increasing the expression of HO-1.

Analysis of relevant factors causing laryngeal stenosis after partial laryngectomy / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To investigate the clinical relevant factors causing laryngeal stenosis after partial laryngectomy.</p><p><b>METHODS</b>A retrospective study was carried out to review the history clinical data from 138 patients of partial laryngectomy in the First Affiliated Hospital of Sun Yat-Sen University between January 1994 to October 2004. The clinical relevant factors causing laryngeal stenosis were included as follows: age, sex, TNM stage, tumor site, extension of thyroid cartilage defect, extension of larynx parenchyma defect, reconstruction method, laryngeal dilator, duration of using antibiotics, postoperative radiotherapy, lung infection, gastroesophageal reflux, diabetes. Multivariate stepwise logistic regression model was used for the analysis.</p><p><b>RESULTS</b>Of 138 cases after partial laryngectomy, stenosis developed in 25 cases. The occurrence rate was 18.1%. In multivariate analysis, it was confirmed that the following factors correlated to laryngeal stenosis, i. e, extension of thyroid cartilage defect (chi2 = 4.323, P = 0.038), postoperative radiotherapy (chi2 = 6.002, P = 0.014), lung infection (chi2 = 4.220, P = 0.040), and gastroesophageal reflux (chi2 = 5.614, P = 0.018).</p><p><b>CONCLUSIONS</b>The clinical relevant factors causing laryngeal stenosis after partial laryngectomy were multiple. Statistical analysis showed that extension of thyroid cartilage defect, postoperative radiotherapy, lung infection and gastroesophageal reflux were the risk factors which may cause laryngeal stenosis.</p>