: Narrow band imaging (NBI), an endoscopic technique featuring an augmented definition of microvasculature and mucosal patterns. NBI is increasingly advocated as a tool to characterize neoplasia and ...intestinal metaplasia in endoscopic standards, such as for colorectal polyps and tumors. Recently NBI has also been studied in the detection of Nasopharyngeal Carcinoma (NPC). Here we aimed to assess the diagnostic utility of NBI for the diagnosis of NPC.
A meta-analysis of studies comparing narrow-band imaging and white light endoscopy in the diagnosis of primary nasopharyngeal carcinoma was performed. The review process involved two independent investigators. The databases used were MEDLINE, PubMed, the Cochrane library, Embase, and the Web of Science. Statistical analysis was performed with OpenMetaAnalyst, MetaDiSc version 1.4, and Medcalc version 17.9.7.
: Five studies including 2480 patients were included. The sensitivity and specificity for narrow-band imaging were 0.90 (0.73-0.97) and 0.95 (0.81-0.99) respectively. The positive likelihood ratio and negative likelihood ratio were 18.82 (0.31-82.1) and 0.08 (0.02-0.31). For white light endoscopy, the sensitivity and specificity were 0.77 (0.58-0.89) and 0.91 (0.79-0.96). The positive likelihood ratio was 7.61 (3.61-16.04), and the negative likelihood ratio was 0.21 (0.11-0.39). The odds ratio for detection rates between narrow-band imaging and white light endoscopy was 4.29 (0.56-33.03, p = 0.16). Area under the curve for narrow-band imaging was 0.98 (SE: 0.02), and for white light it was 0.93 (SE: 0.03). There was no significant difference in the receiver operating characteristic curves between the two modalities (p = 0.14).
: Narrow-band imaging showed a higher sensitivity and positive likelihood ratio for the diagnosis of nasopharyngeal carcinoma. However, there was no significant difference in detection rates compared to white light endoscopy. Further investigation with a uniform diagnostic criteria and terminology is needed for narrow-band imaging in the diagnosis of nasopharyngeal carcinoma.
Postoperative chylous fistula after neck dissection is an uncommon complicationassociated with significant patient morbidity. Octreotide acetate is asomatostatin analogue established in the treatment ...of chylothorax; however, itsutility in the management of cervical chylous fistulae has not been fullyevaluated. The investigators hypothesized that chylous fistula can be managed bya combination of octreotide and peripheral total parenteral nutrition (TPN). Aretrospective review of cases compiled at our institution from 2009 to 2015 wasconducted. Ten patients, all men, were identified as having a postoperativechylous fistula after a neck dissection. All patients were treated withperipheral TPN. and intravenous octreotide. Mean age of the patients was 63.0years (range 49 to 82). Five (50.0%) had a neck dissection for the management ofmetastatic nasopharyngeal carcinoma and had previous neck irradiation. In 8(80%) patients, chylous fistula occurred in the left neck. Seven (70.0%) of theleaks occurred within the first 2 postoperative days. Eight (80%) leaks werecontrolled using TPN and octreotide, with 2 (20%) patients requiring surgicalintervention. No factors were significant in the successful conservativemanagement of chylous fistulae. One patient with a chylous fistula of 1,800ml/day was managed successfully without surgical intervention. The results ofthis case series suggest that chylous fistulae may be managed conservativelywith octreotide and TPN. However, long-term evaluation is needed to define ifand when surgical intervention is required for control.
Abstract
Background
Insufficient or excessive respiratory effort during acute hypoxemic respiratory failure (AHRF) increases the risk of lung and diaphragm injury. We sought to establish whether ...respiratory effort can be optimized to achieve lung- and diaphragm-protective (LDP) targets (esophageal pressure swing − 3 to − 8 cm H
2
O; dynamic transpulmonary driving pressure ≤ 15 cm H
2
O) during AHRF.
Methods
In patients with early AHRF, spontaneous breathing was initiated as soon as passive ventilation was not deemed mandatory. Inspiratory pressure, sedation, positive end-expiratory pressure (PEEP), and sweep gas flow (in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO)) were systematically titrated to achieve LDP targets. Additionally, partial neuromuscular blockade (pNMBA) was administered in patients with refractory excessive respiratory effort.
Results
Of 30 patients enrolled, most had severe AHRF; 16 required VV-ECMO. Respiratory effort was absent in all at enrolment. After initiating spontaneous breathing, most exhibited high respiratory effort and only 6/30 met LDP targets. After titrating ventilation, sedation, and sweep gas flow, LDP targets were achieved in 20/30. LDP targets were more likely to be achieved in patients on VV-ECMO (median OR 10, 95% CrI 2, 81) and at the PEEP level associated with improved dynamic compliance (median OR 33, 95% CrI 5, 898). Administration of pNMBA to patients with refractory excessive effort was well-tolerated and effectively achieved LDP targets.
Conclusion
Respiratory effort is frequently absent under deep sedation but becomes excessive when spontaneous breathing is permitted in patients with moderate or severe AHRF. Systematically titrating ventilation and sedation can optimize respiratory effort for lung and diaphragm protection in most patients. VV-ECMO can greatly facilitate the delivery of a LDP strategy.
Trial registration
: This trial was registered in Clinicaltrials.gov in August 2018 (NCT03612583).
Objectives. This research investigated the prognostic significance of radtographically detectable coronary calcific deposits.
Background. Coronary calcific deposits are almost always associated with ...coronary atherosclerosis. We investigated the association between fluoroscopically determined coronary calcium and coronary heart disease end points at 1 year of follow-up.
Methods. This prospective population-based cohort study was conducted in the suburbs of Los Angeles. Fourteen hundred sixty-one asymptomatic adults with an estimated ≥10% risk of having a coronary heart disease event within 8 years underwent cardiac dnefluoroscopy for assessment of coronary calcium at initiation of the study. Clinical status including angina, documented myocardial infarction, myocardial revascularization and death from coronary heart disease were determined after 1 year.
Results. The prevalence of calcific deposits was high (47%). A follow-up examination at 1 year was successfully completed in 99.9% of subjects. Six subjects (0.4%) had died from coronary heart disease and 9 (0.6%) had had a nonfatal myocardial infarction. Thirty-seven subjects (2.5%) reported angina pectoris, and 13 (0.9%) had undergone myocardial revascularization. Fifty-three subjects had at least one event during the 1-year period. Radiographically detectable calcium was associated with the presence of at least one of these end points, with a risk ratio of 2.7 (confidence limits 1.4, 4.6). The presence of coronary calcium was an independent predictor of at least one end point when controlling for age, gender and risk factors. However, three deaths due to coronary heart disease and two nonfatal myocardial infarctions occurred in subjects without detectable coronary calcium.
Conclusions. The presence of coronary calcific deposits incurs an increased risk of coronary heart disease events in asymptomatic high risk subjects at 1 year. This increased risk is independent of that incurred by standard risk factors.
Coronary calcific deposits are always associated with coronary atherosclerosis. Sensitive radiographic technology can detect coronary calcium before atherosclerosis becomes symptomatic. A total of ...1461 asymptomatic high-risk adult subjects were studied with digital subtraction fluoroscopy to detect coronary calcium. Risk factor data were recorded including age, sex, family history, smoking history, diabetes history, body mass index, systolic blood pressure, left ventricular hypertrophy on ECG, total serum cholesterol level, high-density lipoprotein (HDL) cholesterol, and total cholesterol/HDL ratio. Digital subtraction fluoroscopy in the left anterior oblique projection was performed in all subjects. The prevalence of calcific deposits in at least one major coronary artery was high (58.3%). Eleven percent had coronary calcium in all three major arteries. Multivariate logistic regression analysis showed significant correlations (p < 0.05) between the prevalence of coronary calcium and age, smoking history (relative risk = 1.30), diabetes history (relative risk = 1.24), and family history (relative risk = 1.26). In older subjects (at least 65 years of age), smoking and serum lipoproteins assumed greater importance as contributors to coronary calcium, whereas in younger subjects a history of diabetes was more significant. Coronary calcific deposits are prevalent in high-risk asymptomatic subjects. Their occurrence is closely related to most known risk factors.
Split hand/split foot (ectrodactyly; SHSF) is a human developmental malformation characterized by missing digits and claw-like extremities. An autosomal dominant form of this disorder has been mapped ...to 7q21.3-q22.1; the locus has been designated SHFD1. We have constructed a physical map consisting of overlapping yeast artificial chromosome clones for the entire region. Somatic cell hybrid and fluorescent in situ hybridization analyses were used to define SHSF-associated chromosomal rearrangements in twelve patients. An SHFD1 critical interval of 1.5 Mb was established by analysis of five patients with deletions. Translocation or inversion breakpoints found in six patients were mapped within 700 kb of each other in the critical region. Of note is that eight of the patients analyzed (67%) are in fact classified as having syndromic ectrodactyly. Thus, these mapping data establish a relationship between simple split hand/split foot and this more complex group of human birth defects. Finally, we have mapped DLX5, a member of the Distal-less homeobox gene family, to the SHFD1 critical interval.
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