Deglutition in patients treated with reconstructive laryngectomy]

BACKGROUND: Chronic papilledema may lead to irreversible damage of optic nerve fibers. To preserve visual functions, a decompression of the optic nerve is recommended by means of a fenestration of the optic nerve sheath. In this study long-term results after optic nerve sheath fenestration in patients with idiopathic pseudotumor cerebri are reported. PATIENTS AND METHODS: 14 patients were re-examined 15 to 145 months (mean 62 months) after a fenestration of the retrobulbar optic nerve sheath on 23 eyes by a transconjunctival approach. Surgery was done to treat progressive visual loss or in severe obscurations. The patient's symptoms, visual acuity, visual fields, and ophthalmoscopic findings of the optic nerve head and the central fundus were compared to the preoperative status. RESULTS: Re-examination revealed improvement or stabilisation of objective and subjective findings in 17 eyes, one of them was operated on the more involved contralateral side only. Six eyes showed a recurrence of the papilledema without a functional change for the worse after an interval of 7 to 121 months. Three eyes of two patients ended up with optic atrophy and extensive visual loss. Preoperatively, these eyes had shown cotton wool spots in the optic nerve head and a rapid deterioration of vision. CONCLUSIONS: Fenestration of the retrobulbar optic nerve sheath can prevent further visual loss in most patients with pseudotumor cerebri, unless the eye has already become nearly blind. Postoperatively, ophthalmological controls are necessary at regular intervals because relapses after successful surgery can occur after months or years.     

Sleep disorders presenting as psychiatric disorders

In summary, disordered sleep can present in a complex and atypical fashion in which the primary sleep-related component may not be immediately apparent. A high index of suspicion serves the clinician well in these cases. A careful and systematic evaluation of sleep often proves to be rewarding in terms of diagnostic accuracy and improved treatment outcome.     

Wake disorders. I. Primary wake disorders

Primary wake disorders encompass various conditions of excessive daytime sleepiness and/or increased nighttime sleep, of unknown origin beginning most often in adolescence and of chronic or recurrent natural history. The best known of these conditions is narcolepsy associating two major clinical features, irresistible episodes of sleep, sleep onset REM periods and an almost constant association with HLA DR2-DQ1. The prevalence of the condition is close to the one of multiple sclerosis but positive diagnosis requires most often over 10 years to be made. The treatment of excessive daytime sleepiness has recently benefited from a new non-amphetamine awakening compound, modafinil, active in 60 to 70 p. 100 of the cases. The treatment of cataplexy still relies on antidepressants, tricyclics or selective serotonin reuptake blockers. Major advances in pathophysiology and pathogeny have been obtained through a natural model of the disease, canine narcolepsy. Pharmacological studies point to the importance of alpha-1 b adrenergic mechanisms in cataplexy, while dopaminergic systems seem more involved in excessive daytime sleepiness. As concerns genetics, the HLA DQB1*0602 gene predisposes to narcolepsy. In the canine model it is mirrored by an autosomal recessive gene showing a strong homology with the human immunoglobulin gene mu-switch. Familial studies have shown that besides typical phenotypes, attenuated forms of the condition characterized by isolated recurrent daytime naps and/or lapses into sleep do exist. In addition one or several other genes may be involved. Narcolepsy is multifactorial, including one or several genes as well as environmental factors. Idiopathic hypersomnia is noted for very long night sleep, difficulty waking up and more or less constant excessive daytime sleepiness. In contrast with narcolepsy sleep in not refreshing. There is no polysomnographic or immunogenetic special feature. Idiopathic hypersomnia is 10 times less frequent than narcolepsy. It is often overdiagnosed due to insufficient knowledge of other causes of excessive daytime sleepiness such as the upper airway resistance syndrome. Modafinil is also of great value in the treatment of idiopathic hypersomnia. In the absence of an animal model, pathophysiology and pathogeny are still poorly understood. Even rarer is the Kleine-Levin syndrome which is easily distinguishable through its recurrent character and its tendency to progressively disappear. It mainly occurs in early adolescent males. Its main features are episodes of sleep of a week duration recurring at a several months' interval along with disturbances of alimentary and sexual behavior. There is no satisfactory treatment of hypersomniac episodes. On the other hand a prophylactic treatment with carbamazepine or lithium may be active. Pathophysiology remains unsettled in spite of some evidence of a hypothalamic functional disturbance.     

Amphetamine-related disorders

This is a review paper in which the author looks at amphetamine, its origin, place in history, epidemiologic data, mechanism of action, detection methods, new approaches in withdrawal, its toxicity in laboratory animals, use, and clinically observed results.     

Adrenocortical disorders

Preoperative preparation for the patient with adrenal disorders is directed toward restoring the intravascular volume and the electrolyte concentrations to normal. Hypertension and hypokalemia may be controlled by restricting sodium intake and administration of the aldosterone antagonist spironolactone. Patients taking steroids preoperatively must be adequately replaced throughout the perioperative phase at times of maximum stress.     

Drug-induced disorders

Recent estimates suggest that each year more than 1 million patients are injured while in the hospital and approximately 180,000 die because of these injuries. Furthermore, drug-related morbidity and mortality are common and are estimated to cost more than $136 billion a year. The most common type of drug-induced disorder is dose-dependent and predictable. Many adverse drug events occur as a result of drug-drug, drug-disease or drug-food interactions and, therefore, are preventable. Clinicians' awareness of the agents that commonly cause drug-induced disorders and recognition of compromised organ function can significantly decrease the likelihood that an adverse event will occur. Patient assessment should include a thorough medication history, including an analysis of all prescribed and over-the-counter medications, vitamins, herbs and "health-food" products to identify drug-induced problems and potentially reversible conditions. An increased awareness among clinicians of drug-induced disorders should maximize their recognition and minimize their incidence.     

Mitochondrial disorders

The production of Prostaglandin E2 (PGE2) and Thromboxane B2 (TXB2) by turkey blood monocytes and a chicken mononuclear phagocytic cell line MQ-NCSU after exposure to vitamin E (VE) was examined. Turkey embryos were exposed in ovo to 0 and 10 international units (IU) of VE; blood monocytes were collected at 2 weeks of age and cultured. MQ-NCSU macrophage monolayers were exposed to 0, 0.1, 0.25, and 0.5 IU VE. The monocyte/macrophage cultures were exposed to 1 microgram/mL bacterial lipopolysaccharide (LPS). Non-stimulated parallel cultures were maintained as controls. The PGE2 and TXB2 levels were quantitated in culture supernatants by a competitive ELISA. Blood monocytes from the 10 IU VE poults produced lower PGE2 levels as compared with the 0 IU VE controls. Upon stimulation with LPS, monocytes from the 10 IU VE group exhibited levels of PGE2 that were higher than the 0 IU VE group. Levels of TXB2 were not quantitated in the poult blood monocyte culture supernatants. The PGE2 and TXB2 levels in the supernatant of the VE treated MQ-NCSU macrophage cultures were lower than the 0 IU VE controls. Stimulation with LPS resulted in increased PGE2 and TXB2 production by the VE-exposed macrophages. The results from this study suggest that in ovo or in vitro exposure with VE may either upregulate or downregulate PGE2 and TXB2 production by monocytes/macrophages, and that this production may be dependent upon the exposure to a variety of external stimuli and/or the state of macrophage activation.     

Voice disorders

Many other diagnoses and treatments are of particular importance in caring for voice patients. Those discussed in this article are among the most common. The exacting demands of a professional singer or actor, his or her acute ability to analyze the body's condition, and his or her professional athlete's need for a nearly perfect result provide special challenges and gratification for physicians. However, a great many of our non-singer/actor patients are also extremely dependent on voice quality and endurance. Consequently, every patient with a voice complaint should be treated as Pavaroti or Sutherland would be treated, and every voice evaluation should be carried out systematically until a diagnosis has been made on the basis of positive evidence. The emergence of interdisciplinary teams, advanced instrumentation, and voice laboratories has made dramatic improvements in the standard of voice care, and the rapid development of voice as a subspecialty promises continuing advances in the care of voice disorders.     

Throat disorders

In nonpolarized epithelial cells, microtubules originate from a broad perinuclear region coincident with the distribution of the Golgi complex and extend outward to the cell periphery (perinuclear [PN] organization). During development of epithelial cell polarity, microtubules reorganize to form long cortical filaments parallel to the lateral membrane, a meshwork of randomly oriented short filaments beneath the apical membrane, and short filaments at the base of the cell; the Golgi becomes localized above the nucleus in the subapical membrane cytoplasm (apiconuclear [AN] organization). The AN-type organization of microtubules is thought to be specialized in polarized epithelial cells to facilitate vesicle trafficking between the trans-Golgi Network (TGN) and the plasma membrane. We describe two clones of MDCK cells, which have different microtubule distributions: clone II/G cells, which gradually reorganize a PN-type distribution of microtubules and the Golgi complex to an AN-type during development of polarity, and clone II/J cells which maintain a PN-type organization. Both cell clones, however, exhibit identical steady-state polarity of apical and basolateral proteins. During development of cell surface polarity, both clones rapidly establish direct targeting pathways for newly synthesized gp80 and gp135/170, and E-cadherin between the TGN and apical and basolateral membrane, respectively; this occurs before development of the AN-type microtubule/Golgi organization in clone II/G cells. Exposure of both clone II/G and II/J cells to low temperature and nocodazole disrupts >99% of microtubules, resulting in: 1) 25-50% decrease in delivery of newly synthesized gp135/170 and E-cadherin to the apical and basolateral membrane, respectively, in both clone II/G and II/J cells, but with little or no missorting to the opposite membrane domain during all stages of polarity development; 2) approximately 40% decrease in delivery of newly synthesized gp80 to the apical membrane with significant missorting to the basolateral membrane in newly established cultures of clone II/G and II/J cells; and 3) variable and nonspecific delivery of newly synthesized gp80 to both membrane domains in fully polarized cultures. These results define several classes of proteins that differ in their dependence on intact microtubules for efficient and specific targeting between the Golgi and plasma membrane domains.     

Tic disorders

The picture that emerges is one of complex behavioral phenotypes that alter over the course of CNS development. While many cases are mild and may not come to medical attention, others are chronic and disabling. The aim of this article is to provide an overview of recent progress in understanding phenomenology, epidemiology, genetics, neurobiology, and treatment of tic disorders.     

Lifetime comorbidity among anxiety disorders and between anxiety disorders and other mental disorders in adolescents

We examine the lifetime comorbidity among anxiety disorders, and between anxiety disorders and other mental disorders, in a large (n = 1,507) community sample of high school students on whom extensive diagnostic data were available. Three diagnostic groups were formed: those with a lifetime anxiety disorder (n = 134); those with a nonanxiety disorder (n = 510); and those who had never met criteria for a mental disorder (n = 863). The intra-anxiety comorbidity rate was relatively low (18.7%), and was strongly associated with being female (92%). The lifetime comorbidity between anxiety and other mental disorders (primarily MDD) was substantial (73.1%) and was not associated with being female.     

Personality disorders in patients with eating disorders in Japan

The use of a mnemonic cueing system (NeuroPage) and a paper and pencil checklist in the rehabilitation of executive problems in a 50-year-old woman are described. Following a CVA 7 years earlier, the patient, despite intact general intellectual and memory functioning, had specific executive impairments of attention, planning, realizing intended actions, and also exhibited behavioral routines similar in form to obsessive-compulsive rituals. In a series of ABAB single-case experimental designs, the efficacy of 2 external cueing systems in prompting appropriately timed action is demonstrated. It is argued that the combination of external control and increased sustained attention to action were critical to the success of NeuroPage with this patient. Furthermore it is hypothesized that the checklist was effective in facilitating the patient's ability to foresee and recognize the consequences of her actions, which in turn had an impact on the probability of her changing those same actions.