Tympanoplasty in children: A review of 91 cases

OBJECTIVES: There is a marked diversity in the reported success rates for achieving an intact tympanic membrane following tympanoplasty. Controversy exists about the factors thought to influence surgical outcome. These facts have important implications for the selection of patients who would benefit the most. This study reviews the factors thought to determine the anatomical and functional success of tympanoplasty in children. MATERIALS AND METHODS: Retrospective study of the anatomical and functional results of 91 tympanoplasties performed in children. Age, gender, size and site of perforation, status of operated and contralateral ear, underlying cause of the perforations, surgical technique, pre-operative and post-operative hearing levels, post-operative follow-up time and post-operative complications were recorded. We divided our population into two groups according to the expected eustachian tube maturity (younger group (N=24): ≤10 years old, older group (N=67): >10 years old). All patients were evaluated in terms of anatomical and functional outcome and complications. RESULTS: Anatomical success was achieved in 85.7% and functional success was 76.9% after a mean follow-up of 25.6 ± 17.1 months. Anatomical success (intact tympanic membrane) was achieved in 83% of younger vs 87% of older patients (p=n.s.). Functional (air bone gap closure) success was 75% in the younger group vs 78% in the older group (p=n.s.). There were no significant differences in post-operative gain at different frequencies (500, 1000, 2000 and 3000 Hz) between the two groups. A previous adenoidectomy in children older than 10 years seems to be an independent predictor of functional success The incidence of minor and major complications were 29% in patients aged ≤10 and 21% in those older than 10 (p=n.s.). We report 12.9% minor post-operative complications in successful cases: injury to the chorda tympani nerve (5.7%), wound infection (2.9%), otitis externa (2.9%) and transient vertigo (1.4%). Among the 21 reperforations observed, 92.3% occurred before 1 year. CONCLUSIONS: This study shows that tympanoplasty is a valid treatment modality for tympanic membrane perforation in the pediatric population. A tympanic membrane perforation can be closed at any age. There is no age limit below which perforation should not be closed. A previous adenoidectomy in children older than 10 years seems to be an independent predictor of functional success

The neuroinflammatory hypothesis of delirium

Delirium is a neuropsychiatric syndrome characterized by a sudden and global impairment in consciousness, attention and cognition. It is particularly frequent in elderly subjects with medical or surgical conditions and is associated with short- and long-term adverse outcomes. The pathophysiology of delirium remains poorly understood as it involves complex multi-factorial dynamic interactions between a diversity of risk factors. Several conditions associated with delirium are characterized by activation of the inflammatory cascade with acute release of inflammatory mediators into the bloodstream. There is compelling evidence that acute peripheral inflammatory stimulation induces activation of brain parenchymal cells, expression of proinflammatory cytokines and inflammatory mediators in the central nervous system. These neuroinflammatory changes induce neuronal and synaptic dysfunction and subsequent neurobehavioural and cognitive symptoms. Furthermore, ageing and neurodegenerative disorders exaggerate microglial responses following stimulation by systemic immune stimuli such as peripheral inflammation and/or infection. In this review we explore the neuroinflammatory hypothesis of delirium based on recent evidence derived from animal and human studies

The Cholinergic System and Inflammation: Common Pathways in Delirium Pathophysiology

OBJECTIVES: To investigate whether delirium is associated with an unbalanced inflammatory response or a dysfunctional interaction between the cholinergic and immune systems. DESIGN: Cohort observational study. SETTING: General hospital orthopedic ward. PARTICIPANTS: One hundred one individuals aged 60 and older with no previous cognitive impairment undergoing elective arthroplasty. MEASUREMENTS: Incidence of postoperative delirium, plasma cholinesterase activity (acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE)) and inflammatory mediators (C-reactive protein (CRP), interleukin (IL)-1 beta, tumor necrosis factor alpha, IL-6, IL-8, IL-10) before and after surgery. RESULTS: Thirty-seven participants developed postoperative delirium and had greater production of CRP and proinflammatory to anti-inflammatory ratio after surgery. In participants with delirium, but not in controls, preoperative levels of plasma cholinesterase activity correlated with ΔCRP (AChE: ρ = 0.428, P = .008 and BuChE: ρ = 0.423, P = .009), ΔIL-6 (AChE: ρ = 0.339, P = .04), and ΔP/A ratio (AChE: ρ = 0.346, P = .04). CONCLUSION: Delirium was associated not only with an unbalanced inflammatory response, but also with a dysfunctional interaction between the cholinergic and immune systems. Comprehensive understanding of the relationship between the cholinergic and immune systems is crucial to developing new insights into delirium pathophysiology and novel therapeutic intervention

Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients.

BACKGROUND: delirium is a frequent neuropsychiatric syndrome affecting medical and surgical elderly patients. Cholinergic dysfunction has been implicated in delirium pathophysiology and plasmatic acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) activities are suppressed in patients with delirium. In this cohort study, we investigated whether these changes emerge during delirium or whether they are present before its onset. METHODS: plasma activities of AChE and BuChE were measured pre- and postoperatively in consecutive patients ≥60 years old undergoing elective total hip replacement surgery. In addition to a comprehensive clinical and demographic baseline evaluation, venous blood samples were collected from each subject in the morning of hospital admission's day and in the morning of the first postoperative day. Delirium was screened daily with confusion assessment method (confirmed with diagnostic and statistical manual of mental disorders (DSM-IV)-TR). RESULTS: preoperatively, plasma esterase activity was significantly lower in patients who developed delirium compared with the remaining subjects. Following surgery BuChE activity was lower in the delirium group but this difference disappeared after controlling for preoperative values. Plasma cholinesterase activity correlated positively with calcium and haemoglobin and negatively with total bilirubin and international normalised ratio. CONCLUSION: plasma cholinesterase activity can be a useful candidate biomarker to identify subjects at greater risk of developing postoperative delirium

Development of an FIA system with amperometric detection for determination of bentazone in estuarine waters

On the basis of its electrochemical behaviour a new flow-injection analysis (FIA) method with amperometric detection has been developed for quantification of the herbicide bentazone (BTZ) in estuarine waters. Standard solutions and samples (200 µL) were injected into a water carrier stream and both pH and ionic strength were automatically adjusted inside the manifold. Optimization of critical FIA conditions indicated that the best analytical results were obtained at an oxidation potential of 1.10 V, pH 4.5, and an overall flow-rate of 2.4 mL min–1. Analysis of real samples was performed by means of calibration curves over the concentration range 2.5x10–6 to 5.0x10–5 mol L–1, and results were compared with those obtained by use of an independent method (HPLC). The accuracy of the amperometric determinations was ascertained; errors relative to the comparison method were below 4% and sampling rates were approximately 100 samples h–1. The repeatability of the proposed method was calculated by assessing the relative standard deviation (%) of ten consecutive determinations of one sample; the value obtained was 2.1%

The Stress Response to Surgery and Postoperative Delirium: Evidence of Hypothalamic—Pituitary—Adrenal Axis Hyperresponsiveness and Decreased Suppression of the GH/IGF-1 Axis

Introduction: The aim of this study is to determine whether postoperative delirium is associated with dysregulation of hypothalamic—pituitary—adrenal and growth hormone/insulin-like growth factor 1 (GH/IGF-1) responses following acute systemic inflammation. Methods: Plasma levels of cortisol, IGF-1, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 were measured before and after surgery in 101 patients 60 years without dementia undergoing elective hip arthroplasty. Participants were assessed with confusion assessment method and Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision; DSM-IV-TR) postoperatively and 37 patients fulfilled the DSM-IV-TR criteria for delirium. Results: Preoperative plasma cortisol levels were similar in delirium and nondelirium groups (405.37+189.04 vs 461.83+219.39; P ¼ .22). Participants with delirium had higher postoperative cortisol levels (821.67 + 367.17 vs 599.58 + 214.94; P ¼ .002) with enhanced postoperative elevation in relation to baseline (1.9- vs 1.5-fold; P ¼ .004). The plasma levels of IGF1 did not differ in delirium and nondelirium groups before (18.12 + 7.58 vs 16.8 + 7.86; P ¼ .477) and following surgery (13.39 + 5.94 vs 11.12 + 6.2; P ¼ .639), but the levels increased in relation to baseline more frequently in patients who developed delirium (24.3% vs 7.8%; P ¼ .034). The magnitude of postoperative cortisol elevation correlated with DIL-6 (P ¼ .485; P ¼ .002), DIL-8 (P ¼ .429; P ¼ .008), and DIL-10 (P ¼ .544; P < .001) only in patients with delirium. Conclusions: Hypothalamic—pituitary—adrenal axis hyperresponsiveness and a less frequent suppression of the GH/IGF-1 axis in response to acute stress are possibly involved in delirium pathophysiology

A leg ulcer with hard, yellow projections

Gout is a multisystem disease that may present in different ways. We report an elderly man who presented with a large ulcer of the left leg with hard yellow projections evolving for one year. Analytical study revealed a normal uric acid level, but histopathology showed a focal basophilic acellular material compatible with a gouty tophus. This tophus represents the cardinal feature of advanced gout and may present several challenges to wound care professionals. In fact, the ulcer in our patient persisted after one-year follow-up. Our aim is to alert clinicians about a rare cutaneous presentation of gout that may be increasingly diagnosed

Estudo de requalificação pedonal: o caso do centro urbano de Guimarães

A cidade que herdamos é produto de condicionalismos históricos, geralmente contraditórios, bem como resultado de circunstâncias económicas e políticas. Exceptuando as situações de catástrofe, o crescimento da cidade é resultado do aumento e população, de novos interesses de utilização dos solos e dos seus edifícios. A imagem dos edifícios é o resultado visível do processo urbano imposto pelas circunstâncias sociais. O maior interesse de uma cidade reside no seu espaço, sobretudo, se tivermos em mente que é nele que se realizam diariamente as diversas actividades sócio- económicas. De modo que, para falar da qualidade de vida de uma cidade é necessário começar por se analisar a qualidade dos seus espaços exteriores e elementos estruturais. O objectivo deste trabalho é o de caracterizar a qualidade pedonal urbana existente e de propor acções de qualificação do ambiente pedonal urbano. Deste modo, nesse trabalho ir-se-á desenvolver uma avaliação prévia das dimensões físicas, ambientais e de acessibilidade de um projecto de requalificação urbanística da praça do Toural, Alameda de São Dâmaso e Rua de Santo António em Guimarães, e propor acções de requalificação pedonal. Este trabalho inclui igualmente a descrição da proposta de intervenção com uma análise comparada do projecto face à situação existente

Qualidade pedonal urbana: o caso de Guimarães

As novas preocupações, com a qualidade de vida urbana, revelaram a necessidade de renovação das comunidades de vivência humana em espaço urbano, aumentado, deste modo, o interesse relativo ao ambiente pedonal. Este interesse vai para além do estudo das dimensões físicas dos espaços urbanos ou das suas características geométricas, procurando alargar a avaliação do ambiente encontrado pelo homem enquanto caminha pela cidade. Este trabalho tem como objectivo apresentar uma metodologia que permita avaliar se o desenho urbano responde de uma forma positiva na perspectiva da pessoa que caminha. Pretende-se esclarecer se as dimensões físicas e o ambiente pedonal correspondem às necessidades emocionais nas rotinas do caminhar. Deste modo, foi implementado um modelo de avaliação, na cidade de Guimarães - região noroeste de Portugal, procurando verificar se os espaços são bem dimensionados, seguros, confortáveis, e preparados para o tipo de uso previsto

Detecting delirium superimposed on dementia: diagnostic accuracy of a simple combined arousal and attention testing procedure

Detecting delirium superimposed on dementia (DSD) can be challenging because assessment partly relies on cognitive tests that may be abnormal in both conditions. We hypothesized that a combined arousal and attention testing procedure would accurately detect DSD. Patients aged ≥70 years were recruited from five hospitals across Europe. Delirium was diagnosed by physicians using DSM-5 criteria using information from nurses, carers, and medical records. Dementia was ascertained by the Informant Questionnaire on Cognitive Decline in the Elderly. Arousal was measured using the Observational Scale of Level of Arousal (OSLA), which assesses eye opening, eye contact, posture, movement, and communication. Attention was measured by participants signaling each time an “A” was heard when “S-A-V-E-A-H-A-A-R-T” was read out. The sample included 114 persons (mean age 82 years (SD 7); 54% women). Dementia alone was present in 25% (n = 28), delirium alone in 18% (n = 21), DSD in 27% (n = 31), and neither in 30% (n = 34). Arousal and attention was assessed in n = 109 (96%). Using OSLA, 83% participants were correctly identified as having delirium (sensitivity 85%, specificity 82%, AUROC 0.92). The attention task correctly classified 76% of participants with delirium (sensitivity 90%, specificity 64%, AUROC 0.80). Combining scores correctly classified 91% of participants with delirium (sensitivity 84%, specificity 92%, AUROC 0.94). Diagnostic accuracy remained high in the subgroup with dementia (93% correctly classified, sensitivity 94%, specificity 92%, AUROC 0.98). This combined arousal–attention assessment to detect DSD was brief yet had high diagnostic accuracy. Such an approach could have clinical utility for diagnosing DSD