Prognostic significance of total disease length in esophageal cancer.

BACKGROUND: This study tested the hypothesis that endoluminal ultrasound (EUS) defined total length of disease (including both the primary tumor and the position and number of proximal and distal lymph nodes-ELoD) and the associated EUS lymph node metastasis count (ELNMC) are better predictors of outcome than endoscopic esophageal cancer (OC) length and radiological tumor node metastasis stage in patients who undergo potentially curative treatment with surgery or definitive chemoradiotherapy (dCRT). METHODS: A total of 645 consecutive patients diagnosed with OC and managed by a multidisciplinary team were staged by CT and EUS. The primary outcome measure was survival from date of diagnosis. RESULTS: A total of 323 patients received surgery (208 neoadjuvant chemotherapy), and 322 who were deemed unsuitable for surgery received dCRT. Univariable analysis revealed that survival was related to EUS T (p < 0.0001), N (p < 0.0001), EUS primary tumor length (p = 0.037), ELoD (p = 0.011), ELNMC (p < 0.0001), and treatment type (p = 0.001). Multivariable analysis revealed two factors: ELoD (hazard ratio (HR), 0.961; 95 % confidence interval (CI), 0.925-0.998; p = 0.041) and ELNMC (HR, 1.08; 95 % CI, 1.015-1.15; p = 0.016) were independently associated with survival. CONCLUSIONS: ELoD and ELNMC should become part of routine OC radiological staging to optimize stage-directed therapeutic outcomes.

Pyopericardium secondary to achalasia-associated squamous cell carcinoma of the oesophagus.

Patients with achalasia of the oesophagus are known to be at increased risk of oesophageal squamous cell carcinoma. To our knowledge, this is the first report of an achalasia-associated oesophageal squamous cell carcinoma presenting with acute sepsis secondary to pyopericardium.

X-linked mental retardation associated with bilateral clasp thumb anomaly.

We report on a family in which mental retardation is associated with a bilateral clasp-thumb anomaly (absent extensor pollicis brevis tendons). Males over 3 generations were documented to have this combination of findings and pedigree analysis strongly suggests X-linked inheritance. We are not aware of previous reports of X-linked mental retardation (XLMR) associated with this anomaly. There was no evidence of a fragile X in the 2 brothers who were studied for this abnormality.

Psychobiological effects of carbohydrates.

The authors studied whether the fatiguing effects of eating lunch are greater for carbohydrate-rich meals than for other meals, and related the time course of behavioral change to plasma glucose, insulin, and amino acids. On different occasions, in counterbalanced order, normal women (N = 7) fasted overnight, ate a standard breakfast, and at lunch either continued to fast or ate a high-carbohydrate, low-protein meal; a hedonically similar meal containing both carbohydrate and protein; or a high-protein, low-carbohydrate meal. Meals were isocaloric and equated for fat content. Only the carbohydrate meal significantly increased fatigue, which could not be attributed to hypoglycemia because plasma glucose remained elevated. Fatigue began approximately, when the carbohydrate meal elevated the plasma tryptophan ratio but ended even though the ratio remained elevated. Fatigue after a high-carbohydrate lunch could not be explained by reactive hypoglycemia or sweet taste, and could partially be explained by the hypothesis that fatigue parallels an elevation of the tryptophan ratio.

Small-sample reproducibility estimates: an example using rebreathing measurements.

We developed a statistical technique to estimate the reproducibility of a parameter from a population in which only two repeated measurements can be made in a single individual. The following data were analyzed: acetylene cardiac output (Qc), lung tissue volume (Vti), and carbon monoxide diffusing capacity (DLCO) measured by rebreathing techniques in a population of 86 healthy subjects (51 men and 35 women). Each subject was measured twice with a computerized rebreathing system using a test gas of 10% He-0.3% C18O-0.7% C2H2-25% O2-balance N2 while sitting at rest. The estimated coefficients of variation for repeated measurements were 6.8, 10.3, and 5.7% for Qc, Vti, and DLCO, respectively. Chebyshev's inequality was used to estimate the imprecision for a single measurement of these parameters and for averages of two or more repeated values. A single measurement of Qc would be within 14.2% of a "true" mean 90% of the time, whereas an average of three consecutive measurements would be within 8.2% of the true mean 90% of the time. Single measurements of Vti and DLCO were found to be within 21.7 and 12.0%, respectively, of the true mean 90% of the time. When three consecutive measurements are averaged, Vti is within 12.6% and DLCO is within 6.9% of the true mean 90% of the time. We conclude that 1) rebreathing Qc is as reproducible as other measurements of cardiac output, 2) rebreathing measurements of DLCO are as reproducible as those made by the single-breath technique, and 3) an average of two to three measurements of Vti should be made to obtain values with a reasonable degree of precision.

Local immunoglobulin synthesis in juvenile periodontitis: initial findings.

An electro-immunoassay technique was used to determine simultaneously immunoglobulin G (IgG) and albumin concentrations in serum and extracts of gingival tissue comprising the pocket wall. Assays of samples obtained from seven patients with juvenile periodontitis (mean age, 18 years) indicated that local synthesis accounted for 72% of the IgG found in the gingiva.

Chitosan as a nasal delivery system: the effect of chitosan solutions on in vitro and in vivo mucociliary transport rates in human turbinates and volunteers.

In these studies, we examined the effect on mucociliary transport rates (MTR) of various 0.25% (w/v) chitosan solutions applied to human nasal tissue both ex vivo and in vivo. In the first study a range of chitosans with different molecular weights were applied to freshly amputated human nasal turbinates, and their effect on MTR was recorded. The transient inhibitory effect on turbinate MTR that was found for most of the chitosan preparations showed a marked dependence on the volume of chitosan solution applied and the molecular weight of the chitosan tested. The higher the molecular weight of the chitosan and the more chitosan applied, the longer the original MTR was depressed. A small scale human trial, investigating the effect of chitosan glutamate, on saccharin clearance times, was also undertaken. The study showed that a once daily application of a 0.25% solution of the chitosan for 7 days had no effect on either saccharin clearance times or nasal histology as examined by light microscopy.

Effect of facial burns on the nasal mucosa.

In this study the nasal mucosa of patients who had recently sustained facial burns was examined endoscopically. The saccharin clearance test was performed as a measure of nasal mucociliary transport. All the patients had singed nasal hairs, but none had inflammatory changes extending beyond the nasal valve. In only one patient was the saccharin clearance prolonged beyond 20 min, and only one patient developed nasal obstruction postburn. This study shows that the nasal mucosa is resistant to damage when the face is burned, suggesting the nose is an efficient heat exchanger, and the nasal mucosa should preserve its capacity to absorb drugs.

Neural networks for identification of nonlinear systems under random piecewise polynomial disturbances.

The problem of identification of a nonlinear dynamic system is considered. A two-layer neural network is used for the solution of the problem. Systems disturbed with unmeasurable noise are considered, although it is known that the disturbance is a random piecewise polynomial process. Absorption polynomials and nonquadratic loss functions are used to reduce the effect of this disturbance on the estimates of the optimal memory of the neural-network model.

The evaluation of acute abdominal pain in children.

The infant or child that presents with abdominal pain must be evaluated with a careful history, physical examination, and selective laboratory studies. There are a few diagnoses that the emergency physician should always consider as "life threatening." In the event of any uncertainty in the diagnosis of conditions like appendicitis, pyloric stenosis, or intussusception, the child or infant should be observed carefully over time with appropriate laboratory/radiologic studies ordered to further delineate pathology. Ultrasound evaluation of children with abdominal pain continues to be one of the most valuable tools to help diagnose different conditions.

Foetal warfarin syndrome--a complex airway problem. Case report and review of the literature.

Premature cartilaginous calcification and nasal hypoplasia following first trimester exposure to warfarin are known as the Foetal Warfarin Syndrome (FWS). There are over 40 cases reported in the literature, many of which describe breathing and feeding difficulties in the first few months of life. We report a case where a child had had difficulties breathing and feeding in the first months of life. These had been attributed to nasal hypoplasia. After proper ENT assessment the child benefitted from adenoidectomy. ENT surgeons should be aware of the syndrome as more women of child bearing age are taking warfarin following cardiac surgery and treatment of thromboembolic disease. ENT surgeons may be asked to review these children who often present with airway and feeding problems which have been attributed to nasal hypoplasia.

Alar haematoma.

We present two cases of alar haematoma. This is a very rare complication of nasal trauma, and only two cases have been described previously. One case presented late and did not undergo surgical drainage and has a persistent cosmetic deformity. We recommend early surgical drainage when possible.

Raised ABR threshold after suction aspiration of glue from the middle ear: three case studies.

Between 1991 and 1993, 13 children (25 hearing ears) underwent recordings of the auditory brain stem response (ABR) under a general anaesthetic. The anaesthetic technique was similar for each child. Fourteen of these ears had fluid aspirated after myringotomy with insertion of grommets prior to the auditory brain stem response investigation. On subsequent hearing assessment six of these 14 ears (43 per cent) showed clear evidence of a threshold shift of 15 dB or greater. Eleven ears had either dry myringotomies or did not have a myringotomy prior to ABR and none of these showed evidence of a temporary threshold shift. Using Fisher's Exact probability test this difference is significant (p = 0.034). We feel it is important to report these observations so that unexpected high ABR thresholds following aspiration of glue are interpreted with caution.

Interpretation of the dilated pupil during endoscopic sinus surgery.

This article describes the anatomy of the visual pathways and how they should be assessed under anaesthesia. The differential diagnosis of asymmetrical pupils is illustrated with clinical examples and a strategy as to how they should be examined.

Client centred hypnotherapy in the management of tinnitus--is it better than counselling?

The aim of this study was to assess whether client centred hypnotherapy (CCH) which required three sessions with a trained therapist was superior to a single counselling session in reducing the impact of tinnitus. Patients were randomly allocated to receive either counselling (n = 42) or CCH (n = 44). The outcome measures were: tinnitus loudness match, subjective tinnitus symptom severity score, trend of linear analogue scale, request for further therapy and whether the patient had an impression of improvement in their tinnitus after treatment. CCH was no better than counselling in reducing the impact of tinnitus using the three quantative measures of tinnitus, and requests for further follow up. The only significant difference between the two therapies was that 20 (45.5 per cent) of the CCH group reported a general sense of improvement compared to six (14.3 per cent) in the counselling group, this is significant p < 0.01. The study did not demonstrate whether this was a genuine hypnotic effect or simply a response to the additional attention from the therapist.

Measurement of small tissue volumes using Holden's apparatus.

A reproducible method for the estimation of volumes of small tissue samples was needed to allow comparison of the biological activity of tissue explants and to relate symptom improvement to procedures such as adenoidectomy or polypectomy. Holden's apparatus, which utilizes fluid displacement between two chambers, was compared to displacement in a 20 ml syringe. Two observers made four readings each on 20 tissue samples (range 0.37 to 4.70 ml) using both methods for comparison. A two-way analysis of variance for replicated data gave an F ratio of 0.6885 (df = 19; p > 0.8) for Holden's apparatus, and an F ratio of 1.4307 (df = 19; p > 0.1) for the 20 ml syringe. The standard error of the mean for repeated readings on the same sample by an observer was 0.001 ml for Holden's apparatus and 0.014 ml for the syringe method. For accurate estimation of small tissue volumes within 0.01 ml we recommend Holden's apparatus.

Epistaxis, von Willebrand's type bleeding diathesis and Wilms' tumour: a case report.

We report a case of persistent epistaxis in a seven-month-old child with Wilms' tumour who had an associated von Willebrand's type bleeding diathesis. Correction of the bleeding diathesis to control the epistaxis required treatment of the tumour with chemotherapy.

A systematic approach to the interpretation of computed tomography scans prior to endoscopic sinus surgery.

Computed tomography (CT) provides an excellent map for the sinus surgeon as well as providing information about the extent of disease and the presence of bony destruction. Surgeons need to be aware of the anatomical configuration of the sinuses and the presence of any structural changes such as a dehiscent lamina papyracea, asymmetric skull base, low level of posterior skull base or an Onodi cell, which place the patient at increased risk. Described here is a six-step guide to help the sinus surgeon avoid missing any of the radiologically important features.

Adaptive classifier integration for robust pattern recognition.

The integration of multiple classifiers promises higher classification accuracy and robustness than can be obtained with a single classifier. This paper proposes a new adaptive technique for classifier integration based on a linear combination model. The proposed technique is shown to exhibit robustness to a mismatch between test and training conditions. It often outperforms the most accurate of the fused information sources. A comparison between adaptive linear combination and non-adaptive Bayesian fusion shows that, under mismatched test and training conditions, the former is superior to the latter in terms of identification accuracy and insensitivity to information source distortion.