- NED - "Not Expecting Death"
- NED - "New Experiences Desired"
I wonder if we could come up with alternates that are even more useful?
e.g.
Never Envisaged Dying
New Energy Discovered
Novel Expectations Delivered
Comments on this 'rare' but fast growing disease
A particular enzyme is significantly higher in cancer cells that have been exposed to acid, leading to the overproduction of hydrogen peroxide, and offering a possible explanation for how acid reflux may lead to cancer of the esophagus, according to a recent study in the Journal of Biological Chemistry.I don't know what you make of this, but from now on I am not going to read any more jokes about Blondes.
The study found that the enzyme NOX5-S is affected by exposure to acid and that it produces stress on cells, activating genes that lead to DNA damage. For the first time, researchers have outlined the signaling pathway from cells damaged by acid, to the progression of esophageal cancer. They believe the same process may happen in the body when cells are exposed to acid reflux.
Calcium supplements fail to prevent fractures: study
A healthy lifestyle and eating more fruit and vegetables could be better for preventing bone fractures than taking calcium supplements.
Researchers from the University of Tasmania's Menzies Research Institute have compared 19 international studies on calcium supplements for children and their effects on bone density.
They have found the wrist is the only area where supplements improved bone density, but not sufficiently to reduce the risk of fractures either in childhood or as an adult.
The study shows supplements have no impact on the common adult fracture zones of the hip and spine.
The study's spokeswoman, Tania Winzenberg, says more research needs to be done on whether more fruit and vegetables or vitamin D supplements could improve bone density in children.
"Maybe we should be starting to look at things like vitamin D supplementation in children or looking at the effect of increasing fruit and vegetable intake in children on bone health," she said.
Dr Winzenberg says in the meantime, having a healthy lifestyle is the best advice.
"Still maintain adequate calcium and a balanced diet, still maintain adequate physical activity and for bones, particularly weight-bearing physical activity, things like walking, jogging and playing sport, and avoid smoking," she said.
The research has been published in the British Medical Journal.
Taking vitamin D tablets could substantially reduce the risk of pancreatic cancer, research suggests.For the new study, which was led by Northwestern University in Illinois and features in Cancer Epidemiology Biomarkers & Prevention, researchers examined data on more than 120,000 people from two large, long-term health surveys.
Taking the US Recommended Daily Allowance (RDA) of vitamin D (400 IU/day) was found to reduce the risk of pancreatic cancer by 43%.
They said further work was necessary to determine if consuming vitamin D in the diet, or through sun exposure might have even more of an effect than taking supplements.
Lead researcher Dr Hal Skinner said: "I would make no specific recommendation for vitamin D supplementation to prevent pancreatic cancer until we can carry out a trial to determine definitively who might benefit from such an intervention."
Henry Scowcroft, science information officer at the charity Cancer Research UK, said: "The results of this study don't mean that people should take vitamin D supplements to ward off pancreatic cancer, especially as vitamin D can be harmful in large quantities.
"As the authors themselves point out, this is the very first study to find any association between the disease and vitamin D intake.
from http://www.nlm.nih.gov/medlineplus/ency/article/002405.htm
"Vitamin D is a fat-soluble vitamin that is used by the body in the absorption of calcium.
Vitamin D promotes the body's absorption of calcium, which is essential for the normal development and maintenance of healthy teeth and bones. Calcium is also important to nerve cells, including the brain.
Vitamin D also helps maintain adequate blood levels of calcium and phosphorus.
Vitamin D is found in the following foods:
- Dairy products
- Cheese
- Butter
- Cream
- Fortified milk (all milk in the U.S. is fortified with vitamin D)
- Fish
- Oysters
- Fortified cereals
- Margarine
A vitamin D deficiency can lead to osteoporosis in adults or rickets in children.
Excessive doses of vitamin D can result in increased calcium absorption from the intestinal tract. This may cause increased calcium resorption from the bones, leading to elevated levels of calcium in the blood. Elevated blood calcium may then cause calcium deposition in soft tissues such as the heart and lungs. This can reduce their ability to function.
Kidney stones, vomiting, and muscle weakness may also occur due to the ingestion of too much vitamin D.
The best way to get the daily requirement of essential vitamins is to eat a balanced diet that contains a variety of foods from the food guide pyramid.
Vitamin D is also known as the "sunshine vitamin" because the body manufactures the vitamin after being exposed to sunshine. Ten to 15 minutes of sunshine 3 times weekly is adequate to produce the body's requirement of vitamin D.
So as usual we are left with the best advice that has been around for millenia, namely "all things in moderation".
I sometimes wonder where all this research is going
Federal Health Minister Tony Abbott is continuing to push for public hospitals to be managed by the private sector.
You have to be kidding!
I am now certain that Australia is seeing the resurrection of the former comic duo, Abbott and Costello.
Business, Mr Abbott, is in the business of making money for its shareholders. It does not give a fig for the people to whom it sells its products, especially in a market where they have no choice about whether or not they will purchase the product.Cancer sufferers will soon be able to tell whether their chemotherapy course is going to rid them of the disease.
Research conducted at the Peter MacCallum Cancer Centre in East Melbourne will allow doctors to determine if patients are benefiting from a course of chemotherapy.
Unilateral Vocal Cord Paralysis: When one of the vocal cords is paralyzed, the cords are not able to meet in the midline to initiate the glottic attack. This prevents development of the subglottic pressure needed to initiate speech. Also with the cords at such a distance, the mucosal wave cannot be adequately maintained. Hoarseness and breathiness are the most common complaints but vocal abnormalities may also include easy fatigability and voice or pitch change. It is important not to assume that the immobile cords are necessarily paralyzed. Arytenoid fixation can lead to an immobile cord and direct palpation of the arytenoid cartilage and/or laryngeal EMG can rule out this possibility. Potential return of function of an immobile cord can be determined if the underlying cause is known and with the aid of LEMG. This contributes significantly to the choice of surgical procedure to correct the problem. It is also important to remember that the larynx has a number of functions in the human and dysphonia may not be the primary compliant. Patients may be suffering from dysphagia, coughing, or choking episodes, or stridor.
There are a number of different causes of unilateral vocal cord paralysis. Any entity affecting the vagus nerve along its course may result in decrease in function. The most common cause is non-laryngeal cancer which includes neoplasms of the head, neck, chest, and skull base. Neuritis associated with upper respiratory infection, syphilis, or other infectious sources may cause nerve dysfunction. Neurologic conditions such as CVA, multiple sclerosis and myasthenia gravis may also effect vocal cord functioning. General medical conditions such as diabetes mellitus may cause an isolated neuropathy giving rise to vocal paralysis. Lesions of the vagal nerve occurring higher in the brain and may present with multiple cranial nerve abnormalities.
Vocal Fold Bowing: The inability of the folds to approximate at the midline decreases the ability to produce proper speech. Though it may be a normal change in the aging patient, it is also seen with muscular atrophy secondary to nerve sectioning or central neurologic conditions. With aging, changes in the lamina propria include a loss of elastic fibers, atrophy of submucous glands, increased fibrosis, and muscle atrophy. These changes result in an increased glottic gap and a number of perceptual changes. Geriatric patients may present with hoarseness, low pitch, imprecise articulation, or breathiness.
PATIENT EVALUATION AND SELECTION:
-History:
GENERAL: As always, obtaining a pertinent history is of utmost importance. One should determine the onset, duration, and severity of the dysphonia. As previously mentioned, the larynx is also crucial in protecting the lower respiratory tract and is a conduit of the upper respiratory tract. Therefore the patient may present with coughing and choking episodes, aspiration, stridor, dyspnea, dysphagia, or odynophagia (2). Intubation history and previous head and neck trauma are crucial pieces of information. It is important to know if the patient has had any previous laryngeal surgery or other head and neck surgery.
VOCAL: A specific vocal history is also important. Many patients who present with vocal complaints have a disease entity that does not warrant surgical treatment. Aside from onset, duration, variability, and past vocal problems, history should include pertinent medical questions such as presence of seasonal allergies, history of reflux disease, life stress, diabetes, and medications. Many patients who present for an initial evaluation of voice complaints are unfamiliar with questions of vocal use and hygiene. It is important for the physician to explain these concepts to the patient during the questioning to facilitate accurate responses and educate the patient. Questions should include voice demands at home and at work, recreational singing, and episodes of abuse i.e. sporting events. Smoking, water intake, caffeine intake, and environmental irritants are important questions about vocal hygiene.
-Physical:
It is important to do an entire exam with emphasis on palpation of the neck to assess for any neck mass or goiter and cranial nerve testing. An indirect laryngeal exam, as well as a flexible laryngoscopy or videostrobe should be performed. The patient should phonate a high pitched /ee/ sound. This causes elongation of the vocal folds and causes the larynx to move superiorly. These movements aid in obtaining a complete view of the larynx. In addition to assessing vocal fold position and mobility, it is crucial to rule out carcinoma of the larynx in a patient presenting with hoarseness. A direct laryngoscopy with palpation of the arytenoids to ensure joint fixation is absent should be done prior to any surgical procedure.
The manual compression test is an easy non-invasive office procedure to help evaluate a number of voice disorders. The lateral manual compression test is particularly useful in determining whether a patient with a wide glottic gap from unilateral vocal cord paralysis or vocal bowing will benefit from a medialization thyroplasty. To perform the test, the neck should be palpated to find the superior notch and the inferior margin of the thyroid ala. The vocal cords are located along a horizontal line drawn at the midpoint of these two landmarks. The patient is asked to sustain an /a/ phonation and pressure is applied to the lateral aspects of the thyroid cartilage. The concept is to approximate the vocal folds and decrease the glottic gap. A subjective improvement in voice quality is sufficient to state that the patient would benefit from a medialization thyroplasty though acoustic, aerodynamic, and videostroboscopic studies can be done to quantify improvement. The limitations to this test are older patients who have calcification of the thyroid cartilage, patients with obese necks, and patients with scarring of the vocal folds.
-Vocal Assessment:
Despite the recent outburst of technology used to measure and quantitatively assess voice, there is no substitute for the trained ear. Taking a history gives ample time for the physician to make a qualitative assessment of the patient’s voice. Qualities such glottic fry, hard glottal attacks, breathiness, diplophonia, pitch breaks, phonation breaks, and tense phonation can be assessed.
Acoustic evaluation is the quantitative measurement of various voice characteristics. Having the patient sustain a single tone, the fundamental frequency (Fo), variations in amplitude (shimmer), and variations in pitch (jitter) can be measured. Fo may be decreased in patients with vocal abuse or poor approximation of the vocal folds. Shimmer alteration is due to decreased stability of the vocal folds. Abnormal jitter correlates with the subjective quality of hoarseness.
Videostrobolaryngoscopy (VSL) should be performed whenever possible. It allows for dynamic assessment of the vocal folds. With this view, the physician is able to differentiate between functional voice problems and those caused by subtle structural abnormalities. Pulses of light allow us to watch various parts of successive cycles to obtain a complete picture of vocal cord activity. The physician is able to evaluate symmetry of movement, aperiodicity, glottic closure configuration, and horizontal excursion amongst other variables. If the cords are functioning symmetrically, they should essentially be mirror images of each other. The lateral excursion and timing of opening/closing should be identical. Aperiodicity is a measure of irregularities in vocal fold movement. If the frequency of the strobe light is equal to the fundamental frequency, no vocal fold movement should be seen. If movement is observed followed by a static period, aperiodicity is present. The glottis may also be assessed for gap, shape, and appropriate closure (11). The shape of the glottis may be characterized as complete, anterior chink, irregular, bowed, posterior chink, hourglass, or incomplete. Horizontal excursion is a measurement of the amplitude of the cords. Measurement both pre and post-operatively can provide objective data for evaluating improvement. An additional benefit is reviewing the results with the patient immediately after performing the examination. Giving the patient a visual image of the problem helps considerably in motivation for behavioral treatment and development of goals for improvement.
Electromyography (EMG), though not routinely performed, is an excellent evaluation of specific muscle functioning. By placing electrodes into laryngeal muscles (thyroarytenoid, cricothyroid), EMGs help elucidate whether there is any re-innervation of muscles which are thought to be paralyzed. It can also help to differentiate paralysis from arytenoid joint fixation. EMGs are also used to identify excessive muscle activity prior to the use of BOTOX for spasmodic dysphonia.
-Diagnostic Tests:
If indirect or stroboscopic exam demonstrates a unilateral vocal cord paralysis with no known etiology, a specific battery of tests should be considered. A CT scan from skull base to the mediastinum should be done to evaluate the entire length of the vagus and recurrent laryngeal nerves. If the patient is a child, pregnant, or suspected to have a generalized neurologic problem, an MRI is advised instead. A barium swallow may be done to evaluate swallowing mechanism and associated dysphagia. Radioactive thyroid uptake scan or ultrasound may be done to evaluate for the presence of a nodule or tumor. Chest x-ray is performed to rule out the presence of a bronchogenic carcinoma, mediastinal adenopathy/mass, or less likely, the presence of an enlarged heart compressing the recurrent laryngeal nerve, particularly on the left side. A FTA-Abs test should be done to rule out syphilis as a cause of vocal cord paralysis.
TREATMENT OPTIONS:
The most important aspect of rehabilitating voice is defining the patient's goals.
--VOICE THERAPY :
Assessment of patients by a speech pathologist allows for maximal medical treatment to be implemented before consideration is given to surgical treatment. Some patients develop hyperfunctional compensatory mechanisms which lead to the common complaints of voice strain, neck discomfort, and fatigue (16). Speech pathologists can help eliminate these habits and educate the patient on proper compensation techniques. Relaxation exercises, aerobic conditioning, voice exercises and other methods are all practiced by the patient to improve voice quality. Once vocal therapy has been maximized and further voice improvement is desired, surgical options may be considered. Utilizing voice therapy in treatment of unilateral vocal cord paralysis is crucial to ensuring the greatest improvement in voice.
--CORD INJECTION:
Teflon
Gelfoam:
Gelfoam injection is a temporary measure for treatment of unilateral vocal cord immobility. The main indications for the use of Gelfoam are temporary paralysis with glottic incompetence, augmentation to a re-innervation procedure, contraindication to an open procedure, and as a test run before injecting a non-absorbable material.
The method involves mixing Gelfoam powder with saline immediately prior to vocal fold injection. Approximately 1g of powder can be mixed with 4cc of saline. The consistency is very important; the less viscous the solution, the quicker it will be reabsorbed. It is injected in the same manner as Teflon.
In a trial with Gelfoam, it was effective in decreasing aspiration and returning the ability to cough in all patients. Voice was improved in all patients and most patients were able to improve without the aid of speech therapy. The amount of Gelfoam present in the cord is constant for approximately one month and is fully absorbed in 8 to 10 weeks. The slow resorption allows for a gradual compensation in speech and swallowing. There is a mild mucosal edema and erythema that occurs in some patients and rare reported cases of airway compromise.
Collagen
Collagen injections are derived from bovine collagen which is modified to minimize host immune response. Collagen implants are assimilated into the surrounding tissues by an invasion of fibroblasts and deposition of new host collagen. Histologically, the collagen is similar to the deep layer of the lamina propria. Therefore, the collagen is placed within this layer of the vocal fold. Though there is some resorption of the collagen, this is offset by the deposition of host collagen thereby providing long term voice improvement. Resorption of the cartilage may be precipitated by an upper respiratory infection. There have been reports of hypersensitivity reactions with rare cases of airway compromise. Some authors still advocate the use of dermal skin tests to test for possible allergic reaction to the injections. In a series by Ford and Bless, 2 of 80 patients had a positive skin test which is consistent with the reported incidence of 3%. Recently, an increased used of Zyplast collagen ,a GAX collagen, has decreased the incidence of allergic reactions.
Autologous Fat
In 1987, Brandenburg et al. reported the first use of autologous fat injection for glottic insufficiency. Since then, fat injection for a variety of etiologies has become very popular.
Hsiung et al. (12) divided failure into two categories, early and late. With early failure, it was believed that it was due to 1) a large glottal gap or 2) a posterior defect not corrected with fat injection. Late failure was attributed to absorption of the fat supported by an initial improvement in voice quality.
There are still a few concerns and questions about fat injection. Knowing that there will be some reabsorption of the fat, the cord needs to be overinjected. This leads to the question of exactly how much fat results in an optimal change in voice. It is also not known whether improved vocal function is due to the amount of fat injected or softening of the vocal cords. Another uncertainty is the rate of fat absorption by the vocal tissue. If initially effective, the benefits of fat injection may last anywhere from three months to several years. Some studies have shown that despite absorption of the fat, lipocytes and fibrous connective tissue retain the contour of the vocal cord and provide long term benefit. The exact method of harvesting and preparation of the fat and its relation to absorption is still unknown. Effort should be made to minimize that amount of trauma to the fat during extraction.
--TYPE I THRYOPLASTY
-Variations/Controversies:
Removal of the cartilage window: Some authors feel that the cartilage, if left in place can migrate superiorly and medialize the false vocal cord or ventricle. If the cartilage migrates inferiorly, it may cause overmedialization of the cord resulting in a persistently strained voice quality.
Inner perichondrium: Some authors prefer to leave the inner perichondrium intact stating that it decreases the incidence of graft extrusion. Netterville states that the reason for increased implant extrusion is injury to the ventricle. This occurs more frequently if a paramedian incision is used near the anterior commissure where the ventricle is located very close to the inner perichondrium. He argues that incising the inner perichondrium does not increase implant extrusion secondary to the development of a fibrous capsule around the implant.
Implant material: Though some authors feel that a carved implant allows for precise results, Montgomery et al. (10) reports certain benefits to a pre-made implant. The inner aspect, which medializes the cord, is made of a softer plastic closer to the consistency of the surrounding tissue. The outer half is made of a harder plastic which locks into the thyroid cartilage. This prevents displacement of the cords and eases revision. Hydroxylapatite is a pre-made implant which has minimal tissue reactivity and good biocompatibility with the surrounding tissue. Gore-tex (ePTFE) is another material reported to be of benefit in medializing a paralyzed vocal cord. This material has excellent biocompatibility and can be used to medialize the cord in an incremental fashion. This technique does not require extreme precision in creating the thyroid window or shaping the implant.
--ARYTENOID ADDUCTION:
There are two major indications for an arytenoid adduction. The first reason is to close a posterior glottic gap. Given that the cricoid overlaps the thyroid posteriorly, a posterior window is not effective in medializing the posterior vocal cord. The traditional Type I thyroplasty has been shown to be ineffective in medializing the posterior cord. A simple way to assess if an arytenoid adduction is necessary is to see if the vocal processes of the arytenoid cartilages touch in the midline when the patient phonates. The second reason is if the vocal folds are not at the same caudal-rostral level. The vocal process of the arytenoid cartilage moves inferior with adduction and superior with abduction. This is due to the cylindrical shape of the cricoarytenoid joint. Some surgeons advocate an intra-operative assessment of the vocal cord medialization. If after the silastic implant has been placed, there is a persistent posterior gap, an arytenoid adduction is performed.
The procedure is described as it is performed by Isshiki. Using a horizontal neck incision at the level of the vocal cords, the posterior border of the thyroid cartilage is exposed by transecting the strap muscles and detaching the inferior constrictor from the thyroid. It is important to identify the recurrent laryngeal nerve in this area to avoid any damage. The cricothyroid joint is then opened to allow access to the muscular process of the arytenoid cartilage. The piriform sinus mucosa is then elevated with great care to violating the piriform recess. Cricoarytenoid joint is then opened allow exposure of the muscular process. The posterior cricoarytenoid muscle is identified and ligated from the muscular process. Two 3-0 nylon sutures are placed around the muscular process and the surrounding soft tissue. The sutures are then pulled anteriorly through the thyroid ala. The patient is asked to phonate and the appropriate force is determined to provide optimum voice results.
The only significant variation is whether or not to open the thyroarytenoid joint. Some authors believe that opening the joint results in prolapse of the arytenoid cartilage into the laryngeal lumen with overadduction of the posterior commissure.
Arytenoid adduction can be used in conjunction with medialization thyroplasty and re-innervation surgery. Currently, no other procedure corrects for a discrepancy in vocal cord level and few other procedures effectively address a wide posterior chink.
--REINNERVATION SURGERY WITH ANSA CERVICALIS:
A universal criticism of reinnervation is the 4 to 6 month period required for the procedure to be effective. Many authors advocate the concurrent use of a medialization procedure, either Gelfoam injection or thyroplasty. Tucker has described removing the posterior inferior aspect of the implant in order to allow room for the muscle-pedicle implant to be placed.
When comparing the two methods of reinnervation, it is currently unclear which procedure produces the best results. Preliminary work by Hall et al. indicates that the muscle pedicle allows for more rapid innervation and stronger contractile force. Current research is directed toward understanding the role of cell adhesion markers in the role of nerve regrowth. This research will likely have a significant impact on the methods of reinnervation surgery.
Recently a modification has been proposed to the recurrent laryngeal nerve – ansa recurrent laryngeal anastomosis procedure. Paniello (16) has proposed a recurrent laryngeal – hypoglossal nerve anastomosis. The theoretical advantage is that these are the only two nerves involved in swallowing and phonation. Other advantages are an abundance of axons in the hypoglossal nerve, use in patients in which ansa is unavailable, and low donor site morbidity. Initial work with the procedure suggests that it results in a stronger reinnervation and sphincter-like action on swallowing. Though there is denervation of the ipsilateral tongue, no increase in aspiration has been shown.
As there was a committee that was looking at management information pertaining to the LINAC (linear accellerators) and in need of a consumer representative I thought I would make further inquiries to see whether what I had to offer might meet some of the needs.
As you would expect from any community organisation I was immediately told that there was a process by means of which I could apply and that this would be considered in due course by the relevant committees that undertook such work. I was also advised that there was a series of training days that I would be required to attend and presumably pass in order to be even considered suitable for being a consumer representative.
I was impressed.
I undertook to apply for membership, pay my membership fees and lodge an application to become a member of this committee looking at LINAC related matters.
So far I have had the pleasure of meeting with three of the main movers and shakers in this organistion and some of the staff who have been more than cordial and welcoming.
In return for their generosity in putting up with someone who still is unable to talk I have also joined their discussion group on Yahoo and tried as hard as I could to be of some assistance with their web site and with looking at their computer related services.
I hope to be able to be even more useful over time. Meanwhile I have placed a number of issues on to the discussion group and have taken the liberty of posting a few files on to the site so that Oesophageal Cancer actually is given a heads up opportunity among all of the more well known cancers in the community.
Among other things I have suggested that perhaps a support group for people suffering from this form of cancer could be useful and have urged people who are members of the list to let me know if there was any interest in starting such a group.
It's early days so I am not too disappointed by the fact that so far I have not had a response to this matter.
I have however had some very positive responses to some suggestions I have made about paid parking at the hospital.
If there are others out there who are readers of my blog that want to know more about the HCCA either because they themselves are comsumers of health services in the ACT or are carers for someone who is a consumer, then I would be happy to assist them to make a call to the HCCA and consider becming a member. It seems to me that the more people in the ACT who join an organisation like this the more powerful its voice can become in providing feedback from a consumer perspective to the ACT government and to the management of the various health providers in this community.
If you want to know more just drop me a line or better yet look up:
http://www.hcca.org.au/
Because of the perceived high risk of esophagectomy and the assumed poor long-term
results, the role of surgical resection as the mainstay of treatment for localized esophageal
cancer is currently being challenged. Early tumors are increasingly approached by
endoscopic mucosectomy or mucosal ablation techniques, whereas combined
radiochemotherapy without surgery has become the treatment of choice for locally advanced
tumors at many institutions. Several recent reports and our experience, however, indicate
that surgical resection of esophageal cancer has become a safe procedure and long-term
survival rates after surgical resection have improved markedly during the past two decades.
A number of factors have been associated with the marked reduction in postoperative
mortality and improved long-term survival after surgical resection. They include changes in
the epidemiology with an increased rate of adenocarcinoma mostly located distally, patient
selection for surgery, improvements in surgical technique and perioperative management,
and the use of neoadjuvant treatment protocols. The treatment strategy and extent of the
surgical procedure can now be tailored based on histologic tumor type, tumor location,
tumor stage, and the general condition of the patient. With an individualized approach,
surgical resection of esophageal cancer can predictably offer cure. Surgical resection thus
remains the major pillar in the successful treatment of esophageal cancer.