Long-term pharyngeal dysphagia after esophagectomy for esophageal cancer-an investigation using videofluoroscopic swallow studies.

Dysphagia is a common symptom of esophageal cancer (EC). Esophagectomy should relieve the presenting dysphagia as the mechanical obstruction caused by the tumor is removed. However, the new onset oropharyngeal dysphagia develops after esophagectomy and the deficit may persist increasing the risk of aspiration pneumonia and mortality as well as adversely affecting quality of life (QOL). This study investigates the persistent swallowing deficits in long-term postesophagectomy patients and explores the factors associated with dysphagia severity, penetration, and aspiration. A better understanding of the swallowing function can aid future management of the condition. A total of 29 patients who were more than six months postesophagectomy for EC, had no history of disease that would likely affect swallowing function or vocal cord palsy underwent detailed videofluoroscopic swallow studies and completed the European Organisation for Research and Treatment of Cancer QLQ-C30 and OES18 QOL questionnaires. Swallowing deficits were analyzed and rated using the videofluoroscopic dysphagia scale (VDS) and the penetration-aspiration scale (PAS). These variables were correlated with the clinical and QOL parameters to determine which factors would affect swallowing function. Our cohort consisted of 27 males and 2 females. The mean duration after esophagectomy when the swallowing study was performed was 3.2 years (range: 0.5-18.4 years). Swallowing deficits were mainly found in the pharyngeal phase of swallowing. The mean total VDS score was 36.1 (SD = 15.2, range: 11.0-69.5) out of a possible 100. The mean PAS score was 4.1 (SD = 2.5, range: 1-8) and 1.5 (SD = 0.9, range: 1-4) for thin and semisolids, respectively. Dysphagia was significantly more severe in males, those of more advanced age at esophagectomy and at swallowing assessment. Increasing pathological N stage significantly correlated with worse PAS score for thin fluid. Self-reports of more pain and less troubles with coughing were also associated with less penetration and aspiration. This study demonstrated that a mild to moderate pharyngeal dysphagia is present late after esophagectomy even in patients without VC palsy or anastomotic stricture. The long-term aspiration rate is comparable to the figures in the literature for those early after esophagectomy. It is suggested that damage to the intercostal nerves and the pulmonary vagus may affect oropharyngeal swallowing function in this population.

Appropriate timing for surgery after neoadjuvant chemoradiation for esophageal cancer.

Optimal interval between neoadjuvant chemoradiotherapy (CRT) and surgery is not elucidated for esophageal squamous carcinoma. The aim of this study is to evaluate the impact of this time interval on patient outcome. Patients treated with neoadjuvant CRT followed by surgery between 2002 and 2009 were analyzed. Patients were divided into two groups based on the median interval to surgery (64 days): A  64 days (n = 53). A second analysis was performed by re-classifying patients into three interval groups: A* ≤ 40 days (n = 16); B* 41-80 days (n = 60); C* > 80 days (n = 31). Operative outcome, pathological data, and long-term survival were analyzed. One hundred and seven (n = 107) patients were analyzed. Five patients (9.4%) in group B had an anastomotic leak compared with no leakage from group A (P < 0.021). The complete pathological response was comparable in groups A and B (35% vs. 24.5%, p = 0.23). R0 was significantly lower in group A* (A*: 56.3%, B*: 90%, C*: 74.2%, P = 0.006). In patients with R0 resection, 5-year survival was significantly better in group A than B (71.7% vs. 51%, P = 0.032) and in group A* (A* 100% vs. B* 60.2% & C* 48.3%; A* vs. B*, P = 0.036; A* vs. C*, P = 0.019). Complete pathological response was an independent predictor of survival. Early surgery with R0 resection following neoadjuvant CRT may lead to a better outcome. Further prospective studies are still necessary to provide better insight into the issue. At present, timing of surgery should be individualized and performed at the earliest opportunity.

Progressive outer retinal necrosis in a renal transplant recipient: a rare treatment success.

Renal transplant recipients (RTRs) are subject to a variety of opportunistic infections. We present a rare case of varicella zoster virus-derived progressive outer retinal necrosis in an RTR, who presented with painless visual blurring. This clinical entity heralds an extremely poor visual prognosis and is an important condition to consider in any immunocompromised host. Early diagnosis by aqueous fluid sampling and immediate institution of combined systemic and intravitreal antiviral therapy was successful in this individual.

Recurrent and consecutive non-arteritic optic neuropathy in a patient with protein S deficiency.

A 50-year-old man with a history of protein S deficiency treated by long-term warfarin presented with right non-arteritic optic neuropathy. Following successful augmentation of warfarin to minimise the effect of thrombophilia, he had a recurrence in the right eye and involvement of the left eye 11 days after the initial onset. Further investigation showed a marginal blood lipid profile, which was treated with lipid-lowering agents. A combination of aetiologies was seen in this patient. Other unique factors, such as the short duration to recurrence and involvement of the fellow eye, are discussed.

Relationship between age and peripapillary retinal nerve fibre layer thickness: an optical coherence tomography study.

OBJECTIVE: To evaluate the relationship between age and peripapillary retinal nerve fibre layer thickness in healthy Chinese subjects. DESIGN: Cross-sectional study. SETTING: Regional hospital, Hong Kong. PARTICIPANTS: Healthy volunteers (n=218) of Chinese ethnicity with spherical equivalent of -6 to +4 dioptres were recruited for study from October 2001 to March 2003. Ocular examination was carried out and measurements of peripapillary retinal nerve fibre layer thickness were performed using optical coherence tomography (Carl Zeiss Humphrey OCT 2 machine), in a circular pattern of 3.4 mm diameter, centred on the optic disc. MAIN OUTCOME MEASURES: Mean retinal nerve fibre layer thickness and age. RESULTS: The mean age was 40 (standard deviation, 17; range, 11-69) years. The mean peripapillary retinal nerve fibre layer thickness was 111.6 (standard deviation, 18.5; range, 52.0-155.0) micrometres. Age correlated significantly with peripapillary retinal nerve fibre layer thickness (r= -0.28, P<0.0001). CONCLUSION: Mean peripapillary retinal nerve fibre layer thickness (based on optical coherence tomography) correlates negatively with age, which can interfere with the assessment and monitoring of glaucoma patients. An age-adjusted normogram may be necessary to interpret results.

Use of physical restraints in rehabilitation settings: staff knowledge, attitudes and predictors.

AIM: This paper reports a study examining the knowledge, attitudes and practices of staff with regard to the use of restraints in rehabilitative settings, and quantifying the direct and indirect effects of the factors that influenced these practices. BACKGROUND: Nursing staff hold many misconceptions that support the continued use of physical restraints as a desirable technique in clinical settings to control clients. A number of previous studies measuring the knowledge, attitudes and/or practices of nursing staff towards the use of restraints have been conducted in acute, elder care, or psychiatric settings. However, not many have examined the predictors of staff practices when restraints are applied. In the study reported here, physical restraint was defined as any manual method or physical/mechanical device, material or equipment attached to a client's body so that their free movement was restricted. METHODS: A questionnaire was administered to 168 nursing staff in two rehabilitation centres in Hong Kong. The data were collected in 2002-2003 and the response rate was 80%. FINDINGS: Inadequate knowledge and negative attitudes on the use of restraints were found among staff. Most believed that good alternatives to restraints are not available, or they underestimated the physical and psychological impact of restraints on clients. Path analysis indicated that staff attitudes and their clinical experiences had positive direct effects on restraint use. In addition, level of knowledge and clinical experience had a positive indirect effect on practice by influencing attitudes. CONCLUSION: These data could serve as a basis for re-educating nursing staff on the subject. Staff with more clinical experience could give appropriate guidance to other members of staff on decisions to apply restraints. More effective alternative interventions to restraining clients should be explored. Once the gaps in knowledge are closed, more positive attitudes among staff towards the use of restraints can be cultivated, thus leading to a higher standard of nursing practice.

Microscopic structure and elasticity of weakly aggregated colloidal gels.

We directly probe the microscopic structure, connectivity, and elasticity of colloidal gels using confocal microscopy. We show that the gel is a random network of one-dimensional chains of particles. By measuring thermal fluctuations, we determine the effective spring constant between pairs of particles as a function of separation; this is in agreement with the theory for fractal chains. Long-range attractions between particles lead to freely rotating bonds, and the gel is stabilized by multiple connections among the chains. By contrast, short-range attractions lead to bonds that resist bending, with dramatically suppressed formation of loops of particles.

Anomalous diffusion probes microstructure dynamics of entangled F-actin networks.

We study the thermal motion of colloidal tracer particles in entangled actin filament (F-actin) networks, where the particle radius is comparable to the mesh size of the F-actin network. In this regime, the ensemble-averaged mean-squared displacement of the particles is proportional to tau(gamma), where 0

Craniofacial arteriovenous metameric syndrome (CAMS) 3--a transitional pattern between CAM 1 and 2 and spinal arteriovenous metameric syndromes.

We report a rare case of craniofacial arteriovenous metameric syndrome (CAMS) 3 arteriovenous malformations of the mandible, left VIII nerve and petrous bone. The patient, a 19-year-old girl, presented with profuse gingival bleeding during a dental procedure and we diagnosed CAMS 3 during a pre-embolisation angiogram. The distribution of the vascular lesions suggests that CAMS 3 is intermediate CAMS 1 and 2 and spinal arteriovenous metameric syndrome (SAMS).

Relaxing effects of Ligstrum purpurascens extract and purified acteoside in rat aortic rings.

The present study describes the effects of an extract obtained from the leaves of Ligstrum purpurascens and acteoside purified from the extract on the contractile response to various agonists in rat isolated aortic rings. L. purpurascens extract relaxed 9,11-dideoxy-11 alpha,9 alpha-epoxymethanoprostaglandin F2 alpha (U46619)-preconstricted rings in a concentration-dependent manner (IC50: 0.14 +/- 0.01 mg/ml with endothelium and 0.16 +/- 0.01 mg/ml without endothelium). The extract also reduced contraction induced by 35 mM K+ or by 1 microM phorbol 12,13-diacetate (PDA) in endothelium-intact rings. The extract (0.1-0.3 mg/ml) reduced the concentration-response to U46619 in normal Krebs solution or to CaCl2 in 35 mM K(+)-containing solution. Acteoside accounts for 2.05% of total L. purpurascens extract in weight. Acteoside induced relaxation of rings preconstricted by U46619 (IC50: 0.22 +/- 0.01 mg/ml) but it caused an increase in 35 mM K(+)-induced tone. Removal of endothelium enhanced the relaxing effect of acteoside. Besides, pretreatment with acteoside inhibited endothelium/nitric oxide-mediated relaxation induced by acetylcholine. These results indicate that acteoside is unlikely the major ingredient responsible for the vasodilator effect of L. purpurascens extract. The extract relaxed the preconstricted aortic rings probably through multiple mechanisms by acting on smooth muscle cells. The inhibitory effect on endothelial nitric oxide-mediated relaxation suggests that acteoside could also act on the endothelial cells to reduce nitric oxide release.

Antioxidative activities of phenylethanoid glycosides from Ligustrum purpurascens.

Tea and kudingcha (bitter tea) are the two most popular beverages consumed in China. Tea derived from the leaves of Camellia sinensis has been well studied for its various health benefits, but there are very limited data on the biological activities of bitter tea derived from the leaves of Ligustrum purpurascens (LP). The present study was carried out to characterize the antioxidants present in the bitter tea brewed from the leaves of LP. It was found that the crude glycoside fraction possessed strong protection against oxidation of human low-density lipoprotein (LDL). The column chromatographic separation led to the isolatation of five phenylethanoid glycosides, namely, acteoside, ligupurpuroside A, cis-ligupurpuroside B, trans-ligupurpuroside B, and osmanthuside B. When acteoside was heated in the boiling water, it was isomerized to form isoacteoside. Acteoside, isoacteoside, and ligupurpuroside A purified from LP were protective, whereas cis-ligupurpuroside B, trans-ligupurpuroside B, and osmanthuside B exhibited no protection to human LDL from Cu(2+)-medicated oxidation. Acteoside, isoacteoside, and ligupurpuroside A were also effective in preventing the peroxyl free radical-induced oxidation of alpha-tocopherol in human LDL. The antioxidant activities of acteoside, isoacteoside, and ligupurpuroside A were comparable to that observed for a green tea antioxidant, (-)-epicatechin gallate. The inhibitory effect of these three phenylethanoid glycosides on oxidation of human LDL and alpha-tocopherol was dose-dependent at concentrations of 5-40 microM. The present results suggest that the bitter tea beverage derived from LP contains effective antioxidants that may have an equal benefit as a green tea beverage.