Intracranial Suppurative Complications of Sinusitis.

BACKGROUND: Intracranial complications of paranasal sinusitis have become rare due to widespread and early use of antibiotics. Potentially life-threatening intracranial complications of sinusitis include subdural empyema, epidural and intracerebral abscess, meningitis, and sinus thrombosis. Patients with intracranial complication of sinusitis can present without neurological signs, which may delay diagnosis and correct treatment. AIMS: Our aim was to evaluate the diagnostics, treatment, and outcome of sinusitis-related intracranial infections at our tertiary referral hospital with a catchment area of 1.9 million people. MATERIALS AND METHODS: We retrospectively collected data on all patients diagnosed and treated with an intracranial infection at the Helsinki University Hospital, Helsinki, Finland, during a 10-year period between 2003 and 2013. RESULTS: Six patients were diagnosed to have a sinusitis-related intracranial infection. Four patients had an epidural abscess, one both an epidural abscess and a subdural empyema and one a subdural empyema. The most common presenting complaint was headache (100%) followed by fever (83%), vomiting (50%), nasal congestion (50%), forehead lump (34%), and neck stiffness (17%). All patients were managed surgically. Most (83%) patients recovered to premorbid state without neurological sequelae. One patient died intraoperatively. CONCLUSION: Patients with a sinusitis-related intracranial suppuration typically present with signs of raised intracranial pressure rather than signs of sinusitis. Most are likely to need neurosurgical intervention and evacuation of the abscess without delay.

Radiofrequency thermotherapy in the treatment of tongue base lymphoid hyperplasia: case report.

OBJECTIVE: This paper describes a case where a patient diagnosed with tongue base lymphoid hyperplasia was successfully treated with radiofrequency excision and interstitial radiofrequency-induced thermotherapy. CASE REPORT: A 53-year-old female presented with globus sensation, mild dysphagia, nocturnal breathing problems and 'hot potato voice' dysphonia. On flexible nasendoscopy, a visible tongue mass was seen to obstruct the posterior oropharynx. On magnetic resonance imaging scans, this mass looked suspicious of lymphoma, but on histology was confirmed to be benign reactive lymphoid hyperplasia. Sleep study findings indicated moderate obstructive sleep apnoea, with an apnoea-hypopnoea index of 18.1 events per hour. She was treated with radiofrequency-induced thermotherapy on three separate occasions. RESULTS: A post-operative sleep study showed a dramatic improvement in the patient's apnoea-hypopnoea index (3.8 events per hour). This correlated well with the improvement in her sleep quality and reduction of snoring. Over the follow-up period, there has been sustained resolution of dyspnoea, with almost total restoration of voice quality.

A two-decade experience of head and neck paragangliomas in a whole population-based single centre cohort.

Paragangliomas are rare neuroendocrine tumours arising from neural crest-derived tissue. In the head and neck region typical locations are the carotid bifurcation, vagal nerve or jugulotympanic region. Paragangliomas are normally benign, and malignant transformation is rare. During the past decade the understanding of the genetic and molecular aetiology has had an important clinical impact on the management of PGs. This is a retrospective review of all histologically verified paragangliomas diagnosed and managed at an academic tertiary care referral centre between 1990 and 2010. Data on age, sex, symptoms, tumour location, management and follow-up were recorded. There were 64 patients with 74 tumours. Thirty-six per cent of the tumours were located in the carotid body region, 48 % in the jugulotympanic region and 15 % in the vagal nerve. One tumour was located in the dorsal neck. Most (95 %) of the patients were treated primarily with surgery and with curative intent. Definitive radiation therapy was primarily given to two patients. Recurrent or residual tumours were treated with surgery in three patients and with radiation therapy in nine patients. The typical long-term post-operative sequel was vocal cord paralysis. Local recurrence was found in 6 % of patients. Symptoms and findings related to paragangliomas are variable and management should be individualized. Surgery remains the primary choice of the current treatment options, but often is challenging and warrants a multidisciplinary approach. We present an algorithm on the management of head and neck paragangliomas based on current knowledge.

Aerobic and combined exercise sessions reduce glucose variability in type 2 diabetes: crossover randomized trial.

PURPOSE: To evaluate the effects of aerobic (AER) or aerobic plus resistance exercise (COMB) sessions on glucose levels and glucose variability in patients with type 2 diabetes. Additionally, we assessed conventional and non-conventional methods to analyze glucose variability derived from multiple measurements performed with continuous glucose monitoring system (CGMS). METHODS: Fourteen patients with type 2 diabetes (56±2 years) wore a CGMS during 3 days. Participants randomly performed AER and COMB sessions, both in the morning (24 h after CGMS placement), and at least 7 days apart. Glucose variability was evaluated by glucose standard deviation, glucose variance, mean amplitude of glycemic excursions (MAGE), and glucose coefficient of variation (conventional methods) as well as by spectral and symbolic analysis (non-conventional methods). RESULTS: Baseline fasting glycemia was 139±05 mg/dL and HbA1c 7.9±0.7%. Glucose levels decreased immediately after AER and COMB protocols by ∼16%, which was sustained for approximately 3 hours. Comparing the two exercise modalities, responses over a 24-h period after the sessions were similar for glucose levels, glucose variance and glucose coefficient of variation. In the symbolic analysis, increases in 0 V pattern (COMB, 67.0±7.1 vs. 76.0±6.3, P = 0.003) and decreases in 1 V pattern (COMB, 29.1±5.3 vs. 21.5±5.1, P = 0.004) were observed only after the COMB session. CONCLUSIONS: Both AER and COMB exercise modalities reduce glucose levels similarly for a short period of time. The use of non-conventional analysis indicates reduction of glucose variability after a single session of combined exercises. TRIAL REGISTRATION: Aerobic training, aerobic-resistance training and glucose profile (CGMS) in type 2 diabetes (CGMS exercise). ClinicalTrials.gov ID: NCT00887094.

Cystic dilation of the distal end of the nasolacrimal duct: underrated cause of epiphora in adults and its endoscopic treatment.

Epiphora is a frequent reason for ophthalmologic consultation. Among the multiple causes, obstructions of the lacrimal excretory system are common. Sacal and postsacal obstructions are much more frequent than presacal obstructions. Obstruction at the level of the Hasner's valve is rare and likely underestimated. The authors report the clinical history and the imaging of 3 patients with a cystic dilation of the distal end of the nasolacrimal duct (NLD). These patients were easily managed by an ENT surgeon. In one case, the surgery consisted of an endonasal DCR where in the 2 other cases, a marsupialisation of the cystic expansion of the nasolacrimal duct was successfully performed with the micro- debrider. The authors review the world literature on this specific topic. They conclude that a coronal sinus CT scan and an inferior meatus endoscopy should be included in the ophthalmologic work-up performed in all cases of low obstruction of the lacrimal system. When there is a dilation of the distal end of the NLD the marsupialisation of the cystic expansion in the inferior meatus is the option of treatment instead of performing a DCR. ENTs must play a role in the assessment and treatment of low obstructions of the lacrimal excretory system.

Accuracy of continuous glucose monitoring system during exercise in type 2 diabetes.

The concordance of continuous glucose monitoring system (CGMS) and finger-stick blood glucose (FSBG) was assessed in patients with type 2 diabetes during daily activities and two different exercise sessions. Agreement between FSBG and CGMS becomes weaker during exercise, but more than 90% of the CGMS readings are within acceptable range.

Long-term survival of octogenarian patients submitted to isolated coronary artery bypass graft surgery.

INTRODUCTION: An increasing number of octogenarian patients is undergoing coronary artery bypass graft surgery (CABG). The short-term results of this procedure have been broadly studied, but there are few national reports on long-term outcomes. OBJECTIVES: To describe hospital mortality and long-term survival of patients aged > 80 years undergoing isolated CABG. METHODS: Retrospective cohort study with 142 consecutive patients aged > 80 years undergoing isolated CABG in the period between January/1996 and December/2007 in a Brazilian reference center. Mean age (± SD) was 82.3 ± 2.1 years, and 56.3% were male. The prevalence of hypertension was 73.2%, of previous myocardial infarction 30.3%, of diabetes 26.8%, and of renal dysfunction (creatinine ³ 2.0 mg/ml) was 4.9%. The median follow-up was 4.0 years, with a loss of 11.6% of patients. Survival analysis was performed by the Kaplan-Meier method. RESULTS: Overall hospital mortality was 14.8% (95% CI: 8.8 to 20.8), with a reduction of this rate during the study period (1996-1999: 25.9%, 2000-2003: 15.8%, and 2004-2007: 8.6%). Mean survival was 6.5 years (95% CI: 5.5 to 7.5), and the survival rate at 1, 3 and 5 years was 79.4, 73.4 and 65.2%, respectively. CONCLUSION: Results are in agreement with international reports. Mean survival was 6.5 years and the survival rate at 5 years was 65.2%.

The fate of patients referred to a specialist vascular unit with large infra-renal abdominal aortic aneurysms over a two-year period.

INTRODUCTION: The basic premise in managing patients with abdominal aortic aneurysms (AAA) must be to reduce overall mortality from the disease. Operative mortality is widely reported, but data on patients deemed unsuitable for repair are scarce. The purpose of the present study was to report the fate of patients referred with AAA, to define the proportion deemed unsuitable for surgery and to investigate the reasons for conservative treatment. METHODS: All patients who were referred to a regional vascular centre with large (>5.5 cm) infra-renal AAA between 1st January 2008 and 31st December 2009 were included. Patients were classified into two groups; those managed non-operatively, or those offered elective repair. Survival was reported by Kaplan-Meier analysis. Multivariate analysis investigated factors leading to non-operative management. RESULTS: 251 patients with a mean (s.d.) age of 75(8) years were assessed. Thirty-two (13%) patients were deemed unsuitable for repair, mostly because of medical co-morbidity (16/32). 219/251 (87%) patients underwent repair (25/251 (10%) open repair 194/251 (77%) EVAR) with 1/219 (0.5%) 30-day mortality. AAA repair was associated with significantly greater survival (p < 0.001, log-rank test) at 2 years. In multivariate analysis Glasgow Aneurysm Score, female gender and respiratory disease were significant predictors of the decision to treat patients conservatively (p < 0.001). CONCLUSION: Most patients were suitable for surgical intervention with low perioperative mortality. Data on "turndown" rates should be routinely reported to quantify the denominator for operative success.

Sobrevida em longo prazo de octogenários submetidos à cirurgia de revascularização miocárdica isolada / Long-term survival of octogenarian patients submitted to isolated coronary artery bypass graft surgery

INTRODUÇÃO: Um crescente número de pacientes octogenários tem sido submetido à cirurgia de revascularização miocárdica (CRM). Os resultados em curto prazo desse procedimento têm sido amplamente estudados, mas há poucos relatos nacionais até o presente momento sobre os seus desfechos em longo prazo. OBJETIVOS: Descrever a mortalidade hospitalar e a sobrevida em longo prazo de pacientes com idade 80 anos submetidos à CRM isolada. MÉTODOS: Estudo de coorte retrospectivo com 142 pacientes consecutivos de idade 80 anos submetidos à CRM isolada no período de janeiro/1996 a dezembro/2007. A idade média (±dp) foi de 82,3±2,1 anos e 56,3% eram masculinos. A prevalência de hipertensão arterial sistêmica foi de 73,2%, infarto agudo do miocárdio prévio 30,3%, diabetes melito 26,8% e disfunção renal (creatinina ³ 2,0mg/ml) 4,9%. A mediana do seguimento foi de 4,0 anos, havendo perda de 11,6% dos pacientes. A análise da sobrevida foi feita pela curva de Kaplan-Meier. RESULTADOS: A mortalidade hospitalar geral foi de 14,8% (IC95%: 8,8-20,8), observando-se uma redução desse percentual ao longo do período estudado (1996-1999: 25,9%, 2000-2003: 15,8% e 2004-2007: 8,6%). A média de sobrevida foi de 6,5 anos (IC95%: 5,5-7,5), sendo a taxa de sobrevida em 1, 3 e 5 anos de 83,3, 79,5 e 77,3%, respectivamente. CONCLUSÕES: A média de sobrevida foi de 6,5 anos, sendo a taxa em 5 anos de 77,3%, dados condizentes com a literatura internacional.

INTRODUCTION: An increasing number of octogenarian patients is undergoing coronary artery bypass graft surgery (CABG). The short-term results of this procedure have been broadly studied, but there are few national reports on long-term outcomes. OBJECTIVES: To describe hospital mortality and long-term survival of patients aged > 80 years undergoing isolated CABG. METHODS: Retrospective cohort study with 142 consecutive patients aged > 80 years undergoing isolated CABG in the period between January/1996 and December/2007 in a Brazilian reference center. Mean age (± SD) was 82.3 ± 2.1 years, and 56.3% were male. The prevalence of hypertension was 73.2%, of previous myocardial infarction 30.3%, of diabetes 26.8%, and of renal dysfunction (creatinine ³ 2.0 mg/ml) was 4.9%. The median follow-up was 4.0 years, with a loss of 11.6% of patients. Survival analysis was performed by the Kaplan-Meier method. RESULTS: Overall hospital mortality was 14.8% (95% CI: 8.8 to 20.8), with a reduction of this rate during the study period (1996-1999: 25.9%, 2000-2003: 15.8%, and 2004-2007: 8.6%). Mean survival was 6.5 years (95% CI: 5.5 to 7.5), and the survival rate at 1, 3 and 5 years was 79.4, 73.4 and 65.2%, respectively. CONCLUSION: Results are in agreement with international reports. Mean survival was 6.5 years and the survival rate at 5 years was 65.2%.

Relationships between nitric oxide-mediated endothelial function, eNOS coupling and blood pressure revealed by eNOS-GTP cyclohydrolase 1 double transgenic mice.

Endothelium-dependent relaxation in conduit vessels is mediated largely by nitric oxide (NO), produced by the enzyme endothelial nitric oxide synthase (eNOS) in the presence of the cofactor tetrahydrobiopterin (BH4) and mediated through a cGMP-dependent downstream signalling cascade. Endothelial NOS regulates blood pressure in vivo, and impaired endothelial NO bioactivity in vascular disease states may contribute to systemic hypertension. In the absence of sufficient levels of the cofactor BH4, NO becomes uncoupled from arginine oxidation and eNOS produces superoxide rather than NO. The enzymatic uncoupling of eNOS is an important feature of vascular disease states associated with increased oxidative stress. However, whether eNOS coupling, rather than overall eNOS activity, has specific effects on endothelium-dependent vasorelaxation in vitro, or on blood pressure regulation in vivo, remains unclear. In this study, we evaluate the relationships between blood pressure and endothelial function in models of eNOS uncoupling, using mice with endothelium-targeted transgenic eNOS overexpression (eNOS-Tg), in comparison with littermates in which eNOS coupling was rescued by additional endothelium-targeted overexpression of GTP cyclohydrolase 1 (eNOS/GCH-Tg) to increase endothelial BH4 levels. Despite the previously characterized differences in eNOS-dependent superoxide production between these animals, we find that blood pressure is equally reduced in both genotypes, compared with wild-type animals. Furthermore, both eNOS-Tg and eNOS/GCH-Tg mice exhibit similarly impaired endothelium-dependent vasorelaxation. We show that reduced vasorelaxation responses result from desensitization of cGMP-mediated signalling and are associated with increased NO production rather than changes in superoxide production.

Different effects of acute administration of aminophylline and nitroglycerin on exercise capacity in patients with syndrome X.

To investigate the effects of the acute administration of aminophylline and nitroglycerin on effort ischemia, 20 patients with syndrome X underwent 3 bicycle exercise tests after sublingual nitroglycerin (0.3 mg) and after 90 minutes of oral administration of aminophylline (400 mg). Compared with the basal test, only aminophylline induced a significant increase in the time to ischemic threshold and to angina; these findings support the potential therapeutic role of this adenosine receptor blocking agents and suggest a possible role of "steal phenomenon" in the pathogenesis of effort angina in patients with syndrome X.