An unusual cause for globus sensation: infected tracheal diverticulum with abscess formation.

CASE REPORT: A 43-year-old woman presented with a 3-week history of globus sensation and malaise. A computed tomography scan of her neck showed a large right paratracheal abscess secondary to an infected tracheal diverticulum. The patient was admitted under the ENT surgical team, and underwent incision and drainage of the abscess. There were no post-operative complications and she was discharged home after 2 days, on oral antibiotics. CONCLUSION: This case demonstrates that a tracheal diverticulum may become infected and present as a cervical abscess. To our knowledge, this is the fourth reported case in the international literature of abscess formation related to an infected tracheal diverticulum.

KTP laser endoscopic cricopharyngeal myotomy and pharyngeal pouch diverticulotomy: how I do it.

BACKGROUND: Various endoscopic methods of dividing the cricopharyngeus muscle and the common wall of pharyngeal pouches have been described, most commonly the carbon dioxide laser and stapler. The potassium titanyl phosphate (KTP) laser is an alternate endoscopic method of treatment. METHODS: The KTP laser is used in a similar fashion to the carbon dioxide laser to carefully divide the cricopharyngeus muscle fibres ± the common wall of the pharyngeal pouch, under microscopic visualization. CONCLUSION: The KTP laser is an alternative and safe technique for these surgeries.

Metastatic cutaneous squamous cell carcinoma of the parotid gland: prognostic factors.

BACKGROUND: Metastatic cutaneous squamous cell carcinoma is the most common parotid malignancy in Australasia. Prognostic indicators are not clearly defined and the extent of surgical resection required is controversial. METHODS: A retrospective analysis was conducted of 63 patients who underwent surgery for metastatic cutaneous squamous cell carcinoma of the parotid gland at a tertiary hospital over a 10-year period. RESULTS: The five-year overall survival rate was 53 per cent, the disease-specific survival rate was 78 per cent and the locoregional control rate was 72 per cent. Immunosuppression and no adjuvant radiotherapy were associated with a significant reduction in disease-specific survival. None of the factors analysed had a significant effect on locoregional control rates. CONCLUSION: More extensive surgery, including lateral temporal bone resection, may improve local control rates in cases of more advanced disease. The reduced survival of immunocompromised patients must be considered when planning their management.

Use of a 40-day rolling incidence to monitor pertussis in Nova Scotia, 2015.

BACKGROUND: Pertussis can cause a serious respiratory bacterial infection, especially in infants. Between January 1 and December 31, 2015, there was an increase in the number of reported pertussis cases in Nova Scotia (NS). Surveillance practices for pertussis in NS were challenging because immunization coverage data are not available and rate information was neither timely nor precise with respect to geography. Public health officials in NS decided to adopt a new surveillance technique to inform public health actions across the Province. OBJECTIVE: To assess the use of a 40-day rolling incidence rate to monitor pertussis activity in Nova Scotia. INTERVENTION: A 40-day rolling incidence rate was calculated for pertussis by age groups and various levels of geography. Public health authorities continued to anticipate new cases of pertussis if the contacts of known cases were still within the incubation period (range between six and 20 days). The 40-day incubation period was chosen to reflect twice the incubation period's upper range. Rates were calculated using Statistics Canada population projections for 2014 and then compared with traditional case counts and cumulative incidences. The usefulness of the statistics was assessed by public health decision makers. OUTCOMES: Increased pertussis activity was noted across NS, most notably in the South West region. The use of a 40-day rolling incidence rate as a surveillance tool provided more timely and geographically precise descriptions of ongoing trends in pertussis activity and helped to inform appropriate public health action. Health officials valued the information provided from the rolling incidence because it allowed them to manage activities based on weekly estimates at various levels of geography. CONCLUSION: Rolling incidence proved to be a useful tool to monitor a cyclical increase in pertussis cases in Nova Scotia and to inform related public health actions. The rolling incidence provided geographically precise and timely information that was useful to estimate new cases in the absence of reliable immunization coverage information. This method could supplement traditional epidemiological surveillance of future communicable disease events, especially those characterized by long incubation periods and low case counts.

Epigenetic therapy restores normal hematopoiesis in a zebrafish model of NUP98-HOXA9-induced myeloid disease.

Acute myeloid leukemia (AML) occurs when multiple genetic aberrations alter white blood cell development, leading to hyperproliferation and arrest of cell differentiation. Pertinent animal models link in vitro studies with the use of new agents in clinical trials. We generated a transgenic zebrafish expressing human NUP98-HOXA9 (NHA9), a fusion oncogene found in high-risk AML. Embryos developed a preleukemic state with anemia and myeloid cell expansion, and adult fish developed a myeloproliferative neoplasm (MPN). We leveraged this model to show that NHA9 increases the number of hematopoietic stem cells, and that oncogenic function of NHA9 depends on downstream activation of meis1, the PTGS/COX pathway and genome hypermethylation through the DNA methyltransferase, dnmt1. We restored normal hematopoiesis in NHA9 embryos with knockdown of meis1 or dnmt1, as well as pharmacologic treatment with DNA (cytosine-5)-methyltransferase (DNMT) inhibitors or cyclo-oxygenase (COX) inhibitors. DNMT inhibitors reduced genome methylation to near normal levels. Strikingly, we discovered synergy when we combined sub-monotherapeutic doses of a histone deacetylase inhibitor plus either a DNMT inhibitor or COX inhibitor to block the effects of NHA9 on zebrafish blood development. Our work proposes novel drug targets in NHA9-induced myeloid disease, and suggests rational therapies by combining minimal doses of known bioactive compounds.

Voice rest after vocal fold surgery: current practice and evidence.

OBJECTIVE: Voice rest is commonly recommended after vocal fold surgery, but there is a lack of evidence base and no standard protocol. The aim of this study was to establish common practice regarding voice rest following vocal fold surgery. METHOD: An online survey was circulated via e-mail invitation to members of the ENT UK Expert Panel between October and November 2011. RESULTS: The survey revealed that 86.5 per cent of respondents agreed that 'complete voice rest' means no sound production at all, but there was variability in how 'relative voice rest' was defined. There was no dominant type of voice rest routinely recommended after surgery for laryngeal papillomatosis or intermediate pathologies. There was considerable variability in the duration of voice rest recommended, with no statistically significant, most popular response (except for malignant lesions). Surgeons with less than 10 years of experience were more likely to recommend fewer days of voice rest. CONCLUSION: There is a lack of consistency in advice given to patients after vocal fold surgery, in terms of both type and length of voice rest. This may arise from an absence of robust evidence on which to base practice.

Evidence-based, multifactorial approach to addressing non-adherence to antiretroviral therapy and improving standards of care.

BACKGROUND: Near-perfect adherence to antiretroviral therapy over time is critical to achieve viral suppression and recovery of functional immunity in individuals infected with HIV. The concept of adherence as a dynamic behaviour influenced by multiple biopsychosocial factors motivated us to implement an integrated, multifactorial programme in our hospital-based setting. The aims of this study were to survey the scope and determinants of non-adherence in patients attending the Ambulatory HIV Service at Royal Perth Hospital, to develop a method for longitudinal monitoring and to implement measures tailored to support individuals. METHODS: The US Adult AIDS Clinical Trials Group self-report baseline adherence, follow-up and side-effect questionnaires were used to survey 247 patients at two time-points between September 2002 and February 2003. A longitudinal monitoring method was developed and the WA HIV Cohort Study database used to collate results with clinical markers up to December 2005. RESULTS: Adherence was associated with viral suppression and CD4 T-cell recovery and improved over the 3-year period under observation (all P < 0.001). Diminishing adherence was associated with younger age (P = 0.002), substance use (P < 0.01), perceived stress (P = 0.04) and indicators of depression (P = 0.03). The analyses showed relationships between personal experience of side-effects and the depression indicator scale in patients on antiretroviral therapy. CONCLUSION: The programme resulted in an improvement in adherence in our cohort even after adjusting for pill burden, dosing frequency and highly active antiretroviral therapy regimen and has enhanced focus on patients vulnerable to non-adherence while supporting those not currently at risk.

Current and projected annual direct costs of screening asymptomatic men for prostate cancer using prostate-specific antigen.

BACKGROUND: Concern over the cost of screening for asymptomatic prostate cancer by means of prostate-specific antigen (PSA) testing has played an important role in PSA screening policy. However, little is known about the true costs of current PSA screening in Canada and how costs may change in the future. METHODS: The authors performed a cost identification study from the perspective of provincial ministries of health. They used data from published reports, hospital discharge data, claims data from several provinces, a laboratory survey, a national survey of knowledge, attitudes and beliefs about screening, a provincial cancer registry and expert opinion to estimate current first-year screening costs. Using demographic data from Statistics Canada and various scenarios regarding changes in screening patterns, the authors derived estimates of the future costs of PSA screening. RESULTS: In 1995 PSA screening cost an estimated $45 million (range $40 million to $84 million). Treatment accounted for over 61% of total costs, whereas screening, diagnosis and staging accounted for 35%. Screening all eligible men in Canada in 1995 would have cost $317 million (range $356 million to $691 million), more than the costs of all prostate cancer care in that year. Annual recurrent screening for all eligible men in 2005 would cost $219 million (range $208 million to $412 million). Projections from existing trends suggest that annual costs of PSA screening in 2000 are likely to increase from the estimated $45 million to approximately $66 million (range $59 million to $126 million). INTERPRETATION: PSA screening is costly, but even universal screening would consume a smaller share of national health expenditures than previous studies have suggested. Costs attributable to PSA screening may increase in the future owing to changes in utilization patterns and demographic shifts.

Prophylactic use of the intra-aortic balloon pump in high-risk cardiac patients undergoing noncardiac surgery: a decision analytic view.

OBJECTIVE: As the indications for the intra-aortic balloon pump (IABP) continue to evolve, a potential new use may be the prophylactic preoperative insertion of the IABP in the high-risk cardiac patient undergoing noncardiac surgery. Our objective is to present a general approach to the high-risk cardiac patient who may benefit from the prophylactic insertion of the IABP. DESIGN: Case reports and a decision analysis. METHODS: A decision model was constructed that weighs the risk of life-threatening postoperative complications against the risk of vascular complications, including surgery and possible amputation, from IABP insertion. RESULTS AND CONCLUSIONS: A review of the literature identified 10 patients who underwent IABP placement prior to noncardiac surgery. These patients, along with our three cases, define a population of patients for whom the prophylactic IABP may be useful. This population includes patients with coronary artery disease (CAD) for whom bypass grafting is not an option due to: (1) inoperable CAD; (2) a severe coexisting disease process (such as a malignancy); or (3) the emergent nature of the noncardiac procedure. The decision analysis suggests that patients whose preoperative assessment places them at very high risk for postoperative complications (Goldman class IV or Detsky class III undergoing major surgery) may benefit the most from prophylactic placement of an IABP prior to noncardiac surgery.

Effects of peroxide and catalase on near ultraviolet radiation sensitivity in Escherichia coli strains.

The role of peroxide and catalase on NUV radiation sensitivity was examined in two repair competent E. coli strains, AB1157 and B/r. Exponential phase B/r is considerably more sensitive to NUV radiation than exponential phase AB1157. However, resistance to 5 mmol dm-3 H2O2 was induced in both AB1157 and B/r by pretreating growing cells with 30 mumol dm-3 H2O2. Pretreatment also induced resistance to broad-band NUV radiation in these strains. The addition of catalase to the post-irradiation plating medium increased survival to the same extent as that provided by pretreatment with 30 mumol dm-3 H2O2, in both strains. The NUV radiation sensitivity seen in B/r does not appear to be due to a deficiency in enzymes that scavenge H2O2, as a catalase deficient mutant, E. coli UM1, is more resistant to NUV radiation than B/r. Also, assays for H2O2 scavenging ability show little difference between AB1157 and B/r in this respect. Two hypotheses are put forward to account for the sensitivity of exponential phase B/r. Whilst it is apparent that peroxides and catalase do have a role in NUV radiation damage, it is clear that other factors also influence survival under certain conditions.

Dietary sources of energy, protein, fat and fibre in 375 English adolescents.

The aim of this report of the dietary sources of energy, protein, fat and fibre in 375 English adolescents aged 11-14 years is to contribute to the development of health education. Each child recorded their dietary intake five times over a 2-year period using a 3-day diary with interview. Food tables (Paul & Southgate, 1978) were used to calculate nutrient intake. The results are the mean of all 15 days intake. Potatoes (chips and crisps) were the largest single source of energy but 'meat' was the main source of protein and fat, other important sources of fat were the spreading fats, milk, chips and crisps. Chips were the main source of fibre but white bread, crisps and baked beans also contributed similar proportions of fibre. Some differences between the sexes and social classes were observed; the lower social class children appeared to have more undesirable eating habits.

Rotational moulding in the production of prostheses.

This paper discusses the place of rotational moulding in the provision of prosthetic shanks and shank sections. It covers the selection of thermoplastic material, the moulding conditions and their automation in a machine process, and the development of a suitable range of moulds. Also covered is the question of interfacing between the moulded shank sections and other limb components, fatigue strength as tested to date and early results of patient field trials. The most developed of the possible prosthetic options available consists of a hollow tapered column having inserts at each end by which it is clamped through alignment couplings to the socket and foot respectively. For a below-knee application, the complete tapered column prosthesis weighs typically 1 kg. Static and fatigue testing of representative samples by the simultaneous application of compressive and bending loads to the maximum values specified by international standards exposed no failures by the time a million cycles had been reached. This method of fabrication has the merit of being capable of implementation locally on an "as required" basis. Additional advantages include the low cost of the mould tooling and the flexibility to mould a variety of shapes. Prosthetic feet are a possibility as are special shoes and orthotic parts. These may require other materials and experimentation is proceeding using structural and resilient foams.

Thermoplastic alignment couplings for prostheses.

In the context of modern engineering practice, this paper describes the exploitation of thermoplastic materials for the provision of lightweight, low cost, corrosion free, alignment devices for lower limb prostheses. After setting out design requirements, four newly developed devices are described and discussed. These are respectively a four jack system, a serrated wedge system, a spherical alignment system and a serrated slider. The level of laboratory fatigue testing and experimental field performance is reported and examples are shown of the application of these systems to tapered column thermoplastic below-knee prostheses.

Drug testing using a soft agar stem cell assay on patient and xenograft tumor material.

Since 1981 we have received 50 tumor samples from 10 different sites; over half were breast or ovary. Of the 27 that were considered suitable for cloning, 11 produced colony formation and 6 of these were drug tested. One ovarian granulosa cell tumor and its xenograft (V7) were tested against several cytotoxic agents. During a period of 16 months, sensitivity to cisplatin was relatively stable but sensitivity to vinblastine was markedly changed when the original tumor cells and original cells stored in liquid nitrogen were compared with xenograft cells. These changes may be related to patient treatments prior to tumor sample collection. This xenograft V7 exhibited chromosome karyotype and iso-enzyme Glucose-6-phosphate dehydrogenase consistent with it being of human origin. Gross histology of original tumor and xenograft were similar. Chemosensitization in vivo of a breast xenograft (Hx99) to melphalan by misonidazole was investigated. Misonidazole at a total dose of 0.5 g/kg given prior to melphalan (14 mg/kg) was an effective chemosensitizer.