Pediatric dysphonia: It's not about the nodules.

OBJECTIVE: Despite the fact that vocal nodules are the most common cause of chronic dysphonia in children, uncertainty and lack of consensus complicates practically every diagnostic and management decision. Selecting an optimal staging system is fundamental to understanding a disease process, mandatory for uniform reporting, and crucial to predicting natural history and treatment outcomes. The ideal prognostic model for vocal nodules is under intense debate. The purpose of this study was to analyze the predictive power of vocal nodule grade to severity of voice metrics in children. METHODS: Seventy-nine patients diagnosed with vocal cord nodules between 2006 and 2012 were drawn from UPMC Children's Hospital of Pittsburgh Voice, Resonance and Swallowing Center Research Registry. Subject age at time of diagnosis, nodule grade, relevant co-morbidities, scores on The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), parent-reported Pediatric Voice Handicap Index (pVHI), the phonotraumatic behaviors profile, habitual speaking pitch fundamental frequencies, pitch range, volume intensity, and s/z ratio were recorded and compiled into a de-identified database for analysis. RESULTS: Based on the Kruskal-Wallis H Test, there was no statistically significant correlation between nodule grade and total pitch range (p = .21), s/z ratio (p = .50), volume intensity (p = .33), overall CAPE-V Scores (p = .15), or pVHI Scores (p = .29). Chi-squared tests also revealed no significant associations between nodule grade and abnormality in habitual speaking pitch (p = .14 for fundamental frequency while sustaining a vowel sound, p = .37 for fundamental frequency while speaking structured tasks i.e. counting, or p = .76 while speaking in conversation). CONCLUSION: The current "gold-standard" for grading vocal nodule size suggests that the nodules themselves are not driving the standard dysphonic metrics that are most commonly collected and monitored in such children. This outcome is consistent with other studies reporting similar findings and was expected based on the inconsistencies in the reported literature to date. By extension, the conventional wisdom of avoiding surgical treatment of vocal nodules in children seems prudent as there is little evidence to suggest that the nodules themselves are "driving" the severity of the dysphonia. Ultimately identifying the true "drivers" of dysphonia in children will suggest alternative therapies that are more specific and directed to the pathophysiology. Most pediatric voice care professionals will welcome such discoveries as those in the front line of patient care are often rendered helpless and frustrated.

Improved infrared spectroscopic discrimination between gall bladder (GB) polyps and GB cancer using component-descriptive spectral features of separated phases from bile.

This study demonstrates a unique strategy for enhancing infrared (IR) spectroscopic discrimination between gall bladder (GB) polyps and cancer. This strategy includes the separation of raw bile juice into three sections of organic, aqueous, and amphiphilic phases and a cooperative combination of all IR spectral features of each separated phase for the discrimination. Raw bile juice is viscous and complex in composition because it contains fatty acids, cholesterol, proteins, phospholipids, bilirubin, and other components; therefore, the acquisition of IR spectra providing more component-discernible information is fundamental for improving discrimination. For this purpose, raw bile juice was separated into an aqueous phase, mostly containing bile salts, an organic phase with isolated lipids, and an amphiphilic phase, mainly containing proteins. The subsequent IR spectra of each separated phase were mutually characteristic and complementary to each other. When all the IR spectral features were combined, the discrimination was improved compared to that using the spectra of raw bile juice with no separation. The cooperative integration of more component-specific spectra obtained from each separated phase enhanced the discrimination. In addition, the IR spectra of the major constituents in bile juice, such as bile acids, conjugated bile salts, lecithin, and cholesterol, were recorded to explain the IR features of each separated phase.

Surgery or Rehabilitation: A Randomized Clinical Trial Comparing the Treatment of Vocal Fold Polyps via Phonosurgery and Traditional Voice Therapy with "Voice Therapy Expulsion" Training.

OBJECTIVE: Phonomicrosurgery is generally considered to be the treatment of choice for removing vocal fold polyps. However, specific techniques of voice therapy may represent, in selected cases and under certain conditions, a noninvasive therapeutic option for the treatment of such laryngeal lesions. The aim of the present study is to longitudinally assess, in terms of clinical outcomes and quality of life, two groups of patients with cordal polyps, treated either with standard surgery plus standard voice therapy or with a specific training of voice therapy alone, which we have called "Voice Therapy Expulsion." STUDY DESIGN: This study is a randomized controlled trial. METHODS: A total of 150 patients with vocal fold polyps were randomly assigned to either standard surgery or "voice therapy expulsion" protocol. The trial was carried out at the Division of Phoniatrics and Audiology of the Second University of Naples and at the Division of Communication Disorders of Local Health Unit (3 Naples South) from January 2010 to December 2013. A thorough phoniatric evaluation, including laryngostroboscopy, acoustic voice analysis, global grade of dysphonia, instability, roughness, breathiness, asthenia, and strain scale, Voice Handicap Index, and Voice-Related Quality of Life, was performed by using standardized tools, at baseline, at the end of the treatment, and up to 1 year after treatment. RESULTS: We found no significant differences between the two experimental groups in terms of clinical outcomes and personal satisfaction. However, "Voice Therapy Expulsion" was associated with higher scores for quality of life at endpoint evaluation. CONCLUSIONS: Besides phonosurgery, this specific "Voice Therapy Expulsion" technique should be considered as a valid, noninvasive, and well-tolerated therapeutic option for the treatment of selected patients with vocal fold polyps.

Intravitreal polypoidal choroidal vasculopathy in radiation retinopathy.

A 30-year-old woman diagnosed with choroidal melanoma and treated with plaque radiation and transpupillary thermotherapy 5 years earlier presented with recalcitrant proliferative radiation retinopathy despite multiple intravitreal anti-vascular endothelial growth factor injections. Swept-source and spectral-domain optical coherence tomography (OCT) demonstrated intravitreal polyps lying on the surface of atrophied chorioretinal tissue. Fluorescein angiography (FA) revealed leakage from these saccular choroidal neovasculopathic vessels adjacent to a large zone of poor choroidal perfusion. Intravitreal polypoidal choroidal vasculopathy may be associated with radiation retinopathy and is well-demonstrated with swept-source and spectral-domain OCT and FA.

Diagnosis and treatment of Gardner syndrome with gastric polyposis: a case report and review of the literature.

Gardner syndrome (GS) is an autosomal dominant disease characterized by the presence of colonic polyposis, osteoma and soft tissue tumors. It is regarded as a clinical subgroup of familial adenomatous polyposis (FAP) and may present at any age from 2 mo to 70 years with a variety of symptoms, either colonic or extracolonic. We present a case of a 23-year-old female patient with GS who presented with gastric polyposis and was successively treated with restorative proctocolectomy in combination with ileal pouch anal anastomosis (RPC/ IPAA), ileostomy, ileostomy closure operation, snare polypectomy during 8 mo. After operation, the patient took oral traditional Chinese medicine pills made of Fructus mume and Bombyx batryticatu for about 6 mo. The innutrition and anaemia of this patient were gradually improved. Gastroscopy showed that the remnant gastric polypi gradually decreased and finally disappeared 19 mo after the first operation. The patient had 2-3 times of solid stool per day at the time we wrote this paper.

Hyperplastic polyps of the gastric antrum in patients with gastrointestinal blood loss.

The significance of hyperplastic polyps of the gastric antrum in anemic patients with suspected gastrointestinal bleeding has not been determined. The aim of this study is to evaluate the prevalence and prognosis of such polyps in this patient group. Clinical records of patients referred to our endoscopy lab from November 1999 to February 2003 for the evaluation of iron deficiency anemia or suspected gastrointestinal bleeding were reviewed. There were 987 patients. Fourteen patients (1.4%) had hyperplastic polyps in the gastric antrum. Five of the patients reported melena, but the rest were asymptomatic. Multiple antral polyps were present in seven cases. The largest polyp measured 5.0 cm. Helicobacter pylori infection was present in one patient. All patients were anemic and nine had documented iron deficiency. No follow-up information was available in four patients. Hyperplastic polyps of the gastric antrum are a rare but significant cause of gastrointestinal blood loss in older patients. Removal of the polyps using endoscopic or surgical methods may be required for resolution of the blood loss along with iron supplementation. Gastroenterologists should be aware that hyperplastic polyps of the gastric antrum might result in gastrointestinal blood loss and iron deficiency anemia.

[The "intra-cordal polyp": a clinical alternative to recognize?]. / Le polype "intra-cordal" : une variante clinique à reconnaitre?

UNLABELLED: The vocal cord polyp is an inflammatory false tumour of the larynx. It is characterized mainly by the specific existence of fibrinous exsudats organized in loose network or mounds, surrounded by newly formed vascular slits. The epithelium covering the polyp is usually more or less impaired. CLINICAL CASES: The authors report two adult patients among whom the initial presentation in video-stroboscopy was that of an intracordal lesion of a cystic type, however; with unusual characteristics (purplish color, angiomatous aspect). The surgery consisted of a cordotomy, the surface epithelium appearing normal. After dissection, the two lesions seemed to be presenting the typical aspect of fibrinoïd mound of a polyp, observation confirmed by the anatomo-pathological study. In these cases, the resection was finally carried out with no mucous loss. CONCLUSION: The particular etiopathogeny of these lesions is been discussed. The treatment, medical and of rehabilitation could achieve a partial recovery. In the event of surgery, an access to the lesion through a cordotomy and not directly by removal with microcissors is advised.

Tiflitis aguda: a propósito de un caso / Acute typhlitis: a case report

Se presenta un caso clínico de un paciente varón de 51 años que ingresó en nuestro hospital por presentar rectorragia. En el enema opaco se apreció una imagen de defecto de repleción en el ciego y en la colonoscopia una masa cecal necrosada que posteriormente expulsó con la defecación, siendo el resultado histopatológico de necrosis. Se decidió realizar una laparotomía exploradora encontrando como hallazgos significativos la inflamación de todo el ciego y del apéndice, así como la escara de implantación del pólipo expulsado y una masa submucosa paraapendicular, por lo cual se continuó la intervención con una hemicolectomía derecha. El diagnóstico de anatomía patológica fue de tiflitis aguda, una rara enfermedad cecal de la cual comentaremos algunos aspectos (AU)

La radiografía simple de abdomen previa al enema opaco: ¿es exacta?, ¿es eficaz?, ¿es necesaria? / Plain abdominal radiography prior to barium enema: is it accurate? is it effective? is it necessary?

Objetivo: Valorar la eficacia de la radiografía simple de abdomen previa al enema opaco como sistema de evaluación de la limpieza intestinal.Material y métodos: Estudio observacional, transversal, unicéntrico, no controlado, abierto, fase IV, en 150 voluntarios a los que se les realizó una radiografía simple de abdomen y un enema opaco ambulatoriamente. En ambas exploraciones se valoró la limpieza intestinal como deseable o insuficiente (ausencia o presencia de restos fecales significativos que podrían dificultar la exclusión de lesiones polipoideas con diámetro 1 cm). Se determinó si la radiografía simple predijo correcta o incorrectamente la limpieza deseable y la insuficiente, utilizando como elemento de referencia la valoración en el enema opaco.Sobre la base de estos datos se calcularon la sensibilidad, la especificidad y los valores predictivos de la radiografía simple.Resultados: La radiografía simple de abdomen predijo el grado de limpieza intestinal con una sensibilidad de 96,22 por ciento, una especificidad de 20,45 por ciento, una tasa de falsos negativos de 3,77 por ciento, una tasa de falsos positivos de 79,54 por ciento, un valor predictivo negativo de 69,23 por ciento, un valor predictivo positivo de 74,45 por ciento, y un valor predictivo global (o exactitud predictiva) de 74 por ciento.Conclusiones: La radiografía simple de abdomen previa al enema opaco valora la limpieza intestinal de forma inexacta y poco efectiva (AU)

[Ambulatory hysteroscopy in evaluation of postmenopausal bleeding]. / Die ambulante Hysteroskopie in der Abklärung der postmenopausalen Blutung.

INTRODUCTION: Diagnostic hysteroscopy is the most precise procedure to evaluate diseases involving the uterine cavity. There is, however, only limited data concerning the use of hysteroscopy carried out as an outpatient procedure in patients with postmenopausal bleeding. MATERIALS AND METHODS: In this study we report on 360 postmenopausal patients with erratic bleeding, who were referred to our outpatient hysteroscopy clinic. 185 women had frank postmenopausal bleeding (PMB) and another 175 had abnormal uterine bleeding while taking hormone replacement therapy (AUB). The mean age was 57.9 years (range: 42-86). All hysteroscopies were performed using a standard 5-mm hysteroscope with a 30 degrees fore-oblique lens; the uterine cavity was generally distended with normal saline. RESULTS: Outpatient hysteroscopy was performed successfully in 339 patients (94.2%). In 166 cases (46.1%) cervical dilatation was necessary, and 138 required (38.3%) intracervical anaesthesia. Intrauterine pathology was diagnosed in 49.6% of cases, with endometrial polyps (20.9%) and fibroids (15.9%) being the most common abnormalities. While there was no difference in the incidence of intrauterine lesions between patients with AUB and those with PMB, endometrial carcinoma was more common in the latter group (PMB: n = 11 vs. AUB: n = 1; p < 0.002). CONCLUSION: Due to its high accuracy and patient acceptance, outpatient diagnostic hysteroscopy should become a first line investigation in postmenopausal patients with bleeding disorders.

Colorectal cancer screening.

Colorectal cancer is a common and devastating disease. Many authorities recommend screening asymptomatic person, although the benefit of such screening is without scientific validation. Each of the screening modalities available has been examined, and their merits and shortcomings have been discussed. Surveys have indicated that primary care physicians generally agree with screening asymptomatic patients, but only a minority actually comply with the recommendations. Patient acceptance also varies. Thus, while specialty boards and panels of experts attempt to arrive at policies for the general population, primary care physicians must interact with the individual patient. Until data from ongoing prospective screening studies are available and cost-benefit issues are resolved, screening for colorectal cancer will remain at the discretion of physicians and their patients. There is insufficient evidence to support either continuing or discontinuing the recommended examinations for asymptomatic patients. The screening examinations can be recommended on the basis of a theoretical benefit, however. They can be performed with a minimum of risk of injury or side effects. Certain patients can be identified as being at above-average risk and deserving of more consideration. If aware of the benefits and limitations of colorectal cancer screening, primary care physicians can decide how to implement colorectal cancer screening in their clinical practice.

Follow-up after colorectal polypectomy. II. Repeated examinations of the colon every 6 months after removal of sessile adenomas and adenomas with the highest degrees of dysplasia.

Fifty-five patients with colorectal sessile adenomas and adenomas with the severest dysplasia were followed up every 6 months with colonoscopy and/or double-contrast enema during 4 years, after a clean colon had been obtained, by repeated colonoscopy within 3 months after piecemeal polypectomy. The repetition at 3 months resulted in detection of two cancers. An overlooked cancer was detected at 1 year, and another cancer was diagnosed between examinations. Risk of new adenomas (19 patients) was related to original size, number, and glandular structure of the polyps. Twelve of the 19 patients had new polyps above the rectum. The 336 colonoscopies were complicated by 3 laparotomies, made necessary by perforation and bleeding. The results suggest that intervals between examinations of patients with the present type of adenomas may be prolonged, and patients are now allocated at random to colorectal follow-up examination every 6 and 12 months.

Panoramic CO2 hysteroscopy.

The method of CO2 panoramic hysteroscopy was described. It can be performed as an office procedure without the need for preliminary cervical dilatation or even a paracervical nerve block. The risks are minimal, and the benefits of being able to see the uterine cavity are manifold. Hysteroscopy is a relatively simple endoscopic procedure to learn, and its use in the diagnosis and management of abnormal uterine bleeding was emphasized.

The increasing use of fibreoptics in radiodiagnosis.

The technique of fibreoptic endoscopy has introduced a new dimension in the treatment and diagnosis of many diseases and abnormal conditions. Fibreoptic endoscopy has allowed greater visualization of the gastro-intestinal tract, and the recent years the biliary and respiratory systems. When used as a follow-up to, or in conjunction with many radiographic techniques, its findings may clarify many questionable abnormalities. The therapeutic application of fibreoptic endoscopy in the removal of bowel polyps has now become a successful alternative to surgery for many patients. The knowledge gained from these examinations has proved invaluable, and these techniques have provided an alternative to other well established and less rewarding techniques.

Screening for colorectal tumors - results of two years experience.

The experience after two years of systematic colorectal tumors screening of 603 subjects, aged between 40 and 70, is reported. All subjects were submitted to proctoscopy (P) and air filled barium enema (AFBE). Total frequency of screened tumors: 15.25%. More than 85% of the tumors were found in the recto-sigmoid. Two subgroups were identified in this population. In subgroup A, 125 subjects were submitted to P, AFBE and flexible pansigmoidoscopy (FP). Percentage of screened tumors is 19.2%. Sensitivity rate of radiology for exploration of the recto-sigmoid area, as compared to FP is rather low: 0.41. In subgroup B, 165 subjects were submitted to hemoccult, P, AFBE and colonoscopy when an abnormal or dubious image was shown by AFBE. The comparative study of these different means of investigation shows a very low rate of sensitivity of hemoccult: 0.16. In addition, the percentage of screened colorectal tumors is significantly higher (p less than 0.01) in subjects with personal or family history of polyp or carcinoma: 22%, compared to the incidence in the remaining population of 13%. Flexible pansigmoidoscopy is recommended for systematic screening of colorectal tumors in subjects older than 40.

Colitis, cancer, and colonoscopy.

Colonoscopy has added a new dimension to the diagnosis of colonic diseases. In the field of inflammatory bowel disease, colonscopy is indicated only when certain specific problems arise. Patients with acute colitis and those who are too sick to withstand cleansing enemas should not undergo colonoscopy. A major use of the colonoscope is in the detection of carcinoma in the colitic colon either in the form of colonic strictures or filling defects discovered by barium enema x-ray, or in the long-term surveillance of patients with universal ulcerative colitis. Criteria are listed to assist in the colonoscopic differential diagnosis between ulcerative and granulomatous colitis. By using different criteria than the radiographer, and with the help of biopsy specimens, a high degree of accuracy in proper diagnosis can be achieved.