Pneumocephalus and orbital emphysema associated with the use of an autoinflation device: a unique case report and review of the literature.

BACKGROUND: Autoinflation devices are commonly used for otitis media with effusion and Eustachian tube dysfunction. Generally, these are very safe devices, with few or no complications.Case reportThis paper presents a case study of pneumocephalus and orbital emphysema, associated with the use of an autoinflation device, in a 73-year-old woman with Eustachian tube dysfunction and otitis media with effusion, and a history of extensive endoscopic sinus surgery 13 years previously. CONCLUSION: A literature review showed autoinflation-related pneumocephalus in patients with skull base defects relating to cranial surgery or tumours; however, this has not been described previously with the Otovent system or its use in relation to functional endoscopic sinus surgery. Given the theoretical risk of undetected bony abnormalities in post-operative functional endoscopic sinus surgery patients, it is suggested that autoinflation devices are used cautiously in patients with a history of sinus surgery.

Endoscopic airway management of acute upper airway obstruction.

The conventional treatment for patients with acute upper airway obstruction is tracheostomy, which is a safe, definitive procedure in most hands. Alternatively, a debulking procedure can be considered but this requires both surgical and anaesthetic skill and expertise. However, where possible, it provides a good alternative with the advantages of removing the cause of obstruction and yielding tissue for histopathological analysis, and avoiding the need for a tracheostomy, with its associated morbidity. We evaluated all patients who presented with acute upper airway obstruction and underwent endoscopic laser debulking surgery performed by the senior author, over a three and a half year period. We recorded patient demographic data, their underlying pathologies, complication rates associated with laser debulking surgery and the conversion to tracheostomy. Thirty patients were identified, including 19 males and 11 females, with a mean age of 57.10 ± 17.20 years (19-93 years). All patients underwent debulking procedures with carbon dioxide laser under general anaesthetic. All patients had their underlying diagnosis confirmed from their debulking surgery. Twelve patients were found to have benign pathology and 18 had malignant airway obstruction. There were no laser-associated complications. One patient required conversion to emergency tracheostomy, during their debulking surgery. Endoscopic laser assisted debulking surgery has successfully been used to establish a safe airway. It allows obtaining tissue specimens, to confirm the underlying diagnosis, thus avoiding the need for further biopsies under anaesthetic. For all malignant cases, patients were subsequently able to proceed to definitive treatment. It has obviated the need for emergency tracheostomy in almost all of the cases in our patient cohort.

The somatizing patient.

The authors discuss the significance of identifying primary care patients with dramatic and persistent unexplained physical (medical) symptoms, especially given the concerns about containing health care costs. Such patients are a cause of frustration to the clinician, because the clinician may experience a sense of failure after using the state of the art and still being eluded by a diagnosis. We focus on the methods for understanding somatic worry or preoccupation, which is the essential process in a variety of somatoform disorders. The second half of the article focuses on evaluation and treatment considerations and includes a discussion of both psychotherapeutic and psychopharmacologic treatment strategies for the somatizing patient.

Expression of a soluble functional form of the integrin alpha4beta1 in mammalian cells.

The integrin alpha4beta1(VLA4) has been expressed as a soluble, active, heterodimeric immunoglobulin fusion protein. cDNAs encoding the extracellular domains of the human alpha4 and beta1 subunits were fused to the genomic DNA encoding the human gamma1 immunoglobulin Fc domain and functional integrin fusion protein was expressed as a secreted, soluble molecule from a range of mammalian cell lines. Specific mutations were introduced into the Fc region of the molecules to promote alpha4beta1 heterodimer formation. The soluble alpha4beta1-Fc fusion protein exhibited divalent cation dependent binding to VCAM-1, which was blocked by the appropriate function blocking antibodies. The apparent Kd for VCAM-1 binding were similar for both the soluble and native forms of alpha4beta1. In addition, the integrin-Fc fusion was shown to stain cells expressing VCAM-1 on their surface by FACs analysis. This approach for expressing soluble alpha4beta1 should be generally applicable to a range of integrins.

Genomic organization of the mouse gene for lung surfactant protein D.

Lung surfactant protein (SP)-D belongs to the family of soluble collagenous C-type lectins, named collectins. SP-D participates in the local innate immune defense of the lung, eliciting various effector functions by acting as a pattern recognition receptor for the carbohydrate structures on inhaled microorganisms and particulate matter. This work describes the isolation and characterization of the mouse SP-D gene (Sftpd), which spans 8 exons over 14 kb of sequence and shows an overall organization similar to other collectin genes. The complete 5' untranslated region of the messenger RNA, absent from the published complementary DNA for mouse SP-D, was also cloned and is shown to be encoded by a single exon. Analysis of 3.5 kb of 5' flanking nucleotide sequence for Sftpd is described and reveals positional conservation of a number of transcription factor binding sites on comparison of Sftpd with the human SP-D gene and the bovine conglutinin gene. In addition, a single copy SP-D-like gene has been shown to be present in mammals, birds, and amphibians but is absent in fish. An atypical, rodent-specific, long terminal repeat of retroviral origin containing a minisatellite that has become inserted in Sftpd is described. Three new polymorphic microsatellites are also described, one of which is just 160 base pairs upstream of Sftpd. This microsatellite was used to map the gene to the central region of chromosome 14; fine-scale mapping indicates that it lies in a 5. 64-centimorgan area between D14Mit45 and D14Mit60. This will allow the easy identification of the collectin gene cluster and aid in the construction of a physical map over this region.