Routine monitoring for heparin-induced thrombocytopenia following lower limb arthroplasty: Is it necessary? A prospective study in a UK district general hospital.

INTRODUCTION: Heparin-induced thrombocytopenia (HIT) is a potentially life-threatening condition associated with heparin administration. Many orthopaedic units routinely prescribe low-molecular-weight heparins as thromboprophylaxis after hip and knee arthroplasty. HYPOTHESIS: We postulated that routine platelet monitoring following heparin administration is of no clinical benefit. We therefore asked: firstly, what was the rate of thrombocytopenia in a large population of patients undergoing lower limb arthroplasty? Secondly, did this rate justify routine platelet monitoring? MATERIALS AND METHODS: Unless contraindicated, all patients (n=1999, 53.05% female, mean age 69.23 years) at a UK district general hospital undergoing hip and knee arthroplasty were given daily prophylactic enoxaparin. Platelet counts were obtained between the 8th and 10th postoperative days and compared to preoperative baseline. A > 50% fall in platelet count was classified as "possible HIT". The minimal acceptable risk of thrombocytopenia was defined using The American College of Chest Physicians (ACCP) 2012 guidelines, which recommend monitoring platelet counts in patients receiving heparin where the expected risk of HIT is>1% and by descriptive cost-benefit analysis based on the cost of routine platelet monitoring in the clinical setting. RESULTS: Complete results were available for 1361 (68.1%) patients, comprising: 653 primary hips, 22 revision hips, 1 hip resurfacing, 665 primary knees, 19 revision knees and 1 unicompartmental knee replacement. Mean platelet level was 281.9×109/L preoperatively and 527.83×109/L postoperatively. Forty-four patients (3.2%) experienced a postoperative fall in platelet levels. However, no patient experienced a drop in platelets to less than 50% of the preoperative value. DISCUSSION: The incidence of HIT in the elective arthroplasty population is low. Therefore, routine postoperative monitoring of platelets is not necessary in this population of patients. LEVEL OF EVIDENCE: II, prospective study.

Nasendoscopic evaluation of stress velopharyngeal insufficiency in wind musicians: a pilot study.

OBJECTIVE: To investigate the anatomy and function of the velopharyngeal mechanism in musicians who experience symptoms of stress velopharyngeal insufficiency (VPI) compared to musicians who do not. METHODS: The velopharyngeal mechanism of 13 musicians, 8 with reported symptoms of stress VPI and 5 without, were evaluated using video nasendoscopy before and after 30 minutes of playing. All nasendoscopic recordings were rated by an external speech-language pathologist and ear, nose and throat surgeon for maintenance of velopharyngeal closure, type of velopharyngeal closure pattern, and velopharyngeal gap. RESULTS: Six out of 8 cases with stress VPI had nasal air leak during the assessment, 2 of whom had fatigue-related increased symptoms. Three controls had mild nasal air leak without affecting the consistency of soft palate seal nor quality of playing, suggesting that evidence of nasal air leak is not always symptomatic of stress VPI. All cases had unusual anatomical characteristics, such as the soft palate closing against an irregular surface on the posterior nasopharyngeal wall, which may cause insufficient velopharyngeal closure. Typically the soft palate contacted the nasopharyngeal wall higher when playing a wind instrument compared to during speech. CONCLUSION: Specific anatomical features and factors such as fatigue and stress may affect maintenance of velopharyngeal closure in persons with stress VPI. It is important that musicians with stress VPI are evaluated while playing their instrument. Future studies into stress VPI would benefit by including objective assessment components and some degree of quantifiable measurements.

Muscle tension dysphonia in Vietnamese female teachers.

There has been no published research on muscle tension dysphonia (MTD) in speakers who use a tonal language. Using a sample of 47 Northern Vietnamese female primary school teachers with MTD, we aimed to discover whether professional voice users of tonal languages presented with the same symptoms of MTD as speakers of nontonal languages and whether they presented with additional symptoms as a result of speaking a tonal language. The vocal characteristics were assessed by use of a questionnaire and expert perceptual evaluation. Laryngeal features were assessed by photolaryngoscopy. The results showed that MTD was associated with a larger number of vocal symptoms than previously reported. However, the participants did not have the same vocal symptoms reported in English speakers, for example, hard glottal attack, pitch breaks, unusual speech rate, and glottal fry. Factor analysis of the vocal symptoms revealed three factors: "vocal fatigue/hyperfunction," "physical discomfort," and "voice quality," all of which demonstrated high reliability. The major laryngeal characteristic was a glottal gap. The glottal shapes observed included: 44.7% had an incomplete closure, 29.8% a posterior gap, 12.8% an hourglass-shaped gap, 8.5% a spindle-shaped gap, and 4.3% had complete glottal closure. The findings implied a potential contribution of linguistic-specific factors and teaching-related factors to the presentation of this voice disorder in this group of teachers.