Objectives (1) To describe characteristics of pediatric patients undergoing tracheostomy for obstructive sleep apnea (OSA). (2) To highlight perioperative events and outcomes of the procedure. Study Design Case series with chart review. Setting Four tertiary care academic children's hospitals. Subjects and Methods Twenty-nine children aged <18 years from January 1, 2010, to December 31, 2015, who underwent tracheostomy for severe OSA, defined as an apnea-hypopnea index (AHI) >10, were included in the study. Data on patient characteristics, polysomnographic findings, comorbidities, and perioperative events and outcomes were collected and analyzed. Results Twenty-nine patients were included. Mean age at tracheostomy was 2.0 years (95% CI, -2.2 to 6.2). Mean body mass index z score was -1.2 (95% CI, -4.9 to -2.5). Mean preoperative AHI was 60.2 (95% CI, -15.7 to 136.1). Mean postoperative intensive care unit stay was 23.2 days (95% CI, 1.44-45.0). One procedure was complicated by bronchospasm. Thirteen patients had craniofacial abnormalities; 10 had a neurologic disorder resulting in hypotonia; and 5 had a diagnosis of laryngomalacia. Mean follow-up was 30.6 months (95% CI, -10.4 to 71.6). Six patients were decannulated, with a mean time to decannulation of 40.8 months (95% CI, 7.9-73.7). Five patients underwent capped sleep study prior to decannulation with a mean AHI of 6.6 (95% CI, -9.9 to 23.1) and a mean oxygen nadir of 90.0% (95% CI, 80%-100%). Conclusion OSA is an uncommon indication for tracheostomy in children. Patients who require the procedure usually have an associated syndromic diagnosis resulting in upper airway obstruction. The majority of children who undergo tracheostomy for OSA will remain dependent at 24 months.
Protein delivery vectors can be grouped into two classes, those with specific membrane receptors undergoing conventional endocytosis and cell penetrating peptides (CPP) that have the capacity to cross cell or endosomal membranes. For both forms of vectors, translocation across a membrane is usually an inefficient process. In the current study, a novel vector combining the widely used CPP, Tat and the non-toxic neuronal binding domain of tetanus toxin (fragment C or TTC) was assessed for its capacity to deliver GFP as a test cargo protein to human neural progenitor cells (NPCs). These two functional membrane interacting domains dramatically enhanced internalization of the conjugated cargo protein. Tat-TTC-GFP was found to be bound or internalized at least 83-fold more than Tat-GFP and 33-fold more than TTC-GFP in NPCs by direct fluorimetry, and showed enhanced internalization by quantitative microscopy of 18 - and 14-fold, respectively. This preferential internalization was observed to be specific to neuronal cell types. Photochemical internalization (PCI) was utilized to facilitate escape of the endosome-sequestered proteins. The combined use of the Tat-TTC delivery vector with PCI led to both enhancement of neural cell type specific delivery to an endosomal target, followed by the option of efficient release to the cytosol.
Purpose of review The aim of this study was to review the recent literature on the utilization of the lateral arm free flap use in head and neck reconstruction. Recent findings The lateral arm free flap provides a reliable fasciocutaneous free tissue transfer option ideally suited for reconstruction of the oral cavity, pharynx and parotid. Primary donor site closure, compartmentalized fat and excellent colour match make it an excellent option for head and neck reconstruction. Donor site morbidity is low, and the primary limitation is the short and narrow vascular pedicle. Summary The lateral arm free flap should be considered in cases of oral cavity and skin reconstruction, particularly in cases wherein pedicle length is not restrictive.
Objective: The purpose of this study is to determine the utility of radiographic swallow study following a total laryngectomy or total laryngopharyngectomy when evaluating for presence of pharyngocutaneous fistula. Methods: We performed a retrospective analysis of patients undergoing total laryngectomy and total laryngopharyngectomy at University of Maryland Medical Center between the years of 2009-2014. Patients underwent closure of surgical defect by a variety of methods including primary closure, regional muscle flap, and vascularized soft tissue transfer. The results of the swallow study were identified as being either positive or negative for a fistula. Medical records were reviewed to determine whether or not each patient went on to develop a clinically evident salivary leak. Results: Totally 48 patients were selected for inclusion into the study based on the presence of a swallow study performed at either 1 week, 2 weeks, or 3 weeks post-operatively. Sensitivity and positive predictive value (PPV) were optimized at 1 week, while specificity and negative predictive value (NPV) were optimized at 3 weeks. There was no significant difference between salivary leak rates in radiated versus non-radiated patients or with the various methods of closure. Overall sensitivity of swallow study was found to be 50.0%, specificity was 92.1%. PPV and NPV were 62.5% and 87.5% respectively. Conclusion:The utility of contrasted swallow studies is limited due to its poor sensitivity, independent of timing. High risk patients may benefit from an extended period of NPO (nil per os; "nothing by mouth") status, foregoing a contrasted study. Standardization of study protocols and randomized prospective trials will better investigate these issues.
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