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Posterior laryngeal granuloma is an infrequent pathology of multidisciplinary interest. Actually, its real prevalence is difficult to quantify because in some cases it is asymptomatic and in other instances it may either be reabsorbed or eliminated spontaneously. It is located at the vocal apophysis of the arytenoid or, less frequently, above it or on the laryngeal side of the arytenoid. The many etiologic factors (laryngeal intubation, gastro-esophageal refluxes, blunt trauma of the larynx, vocal dysfunction), sometimes concomitant and with the possible addition of enhancing circumstances (upper aerodigestive tract inflammation, naso-gastric tube, smoking and alcohol abuse), converge to a single pathogenetic mechanism: an ulceration of the mucosa and the pericondrium, sometimes complicated by an infection, which does not heal but instead produces a typical granulation tissue with capillaries oriented radially from the center of the lesion. Post intubation granulomas, extremely rare in children, are more frequent in females. It appears that there is no correlation with duration of intubation in that granulomas, can also occur after short general anesthesia. Idiopathic or contact granulomas are more frequent in the males. They are the result of vocal laryngeal hyperfunction, habitual throat clearing or cough-like throat clearing. Gastro-esophageal reflux of gastric juice, coughing or throat clearing may injure the mucosa. A blunt trauma of the larynx may cause a granuloma if the cartilage of the vocal process is exposed. Symptoms, when present, are dysphonia, tiredness during or after voicing, bolus, laryngeal unilateral pain, sensation of something in the throat which is mobile during breathing and swallowing, traces of blood in the expectoration. Therapeutic options are surgical, medical or logopedic. Surgery, although followed by frequent recurrences, is mandatory when the granuloma causes dispnea or if a pathologic essay is needed. Medical treatment aims at solving gastroesophageal reflux and/or inflammations of the district. Logopedic rehabilitation is the most successful therapy. Since January 1992 the Authors have been adopting the rehabilitation protocol planned by the French phoniatrician Brigitte Arnoux-Sindt for post-intubation granulomas, which, moreover, is utilyzed for all type of granulomas, including those arising during the early postoperative period after cordectomy. This protocol is analytically presented and discussed. In the cases of contact granulomas, and when there is concomitant vocal dysfunction, logopedic treatment is prolonged after granuloma dissapearance with some sessions aiming at restoring correct vocal behaviour. In all the ten patients rehabilitated up to now, granulomas disappeared after a mean of 16.3 sessions held twice a week. After several months of follow-up we had no recurrences. This clinical experience, while limited in number, seems to confirm the good results already reported in French Literature.
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PMID:[Logopedic rehabilitation of laryngeal granulomas]. 872 28

The authors prospectively assessed symptoms induced by the interruption of antidepressants in 16 patients (11 women and 5 men), aged from 33 to 85 years (mean = 52.4 +/- 16.4), treated with antidepressants since at least two weeks. All patients were free of alcohol abuse or dependence disorder and of other dependence to psychoactive substances. None of them presented medical illness. Diagnosis were made by separate evaluations by two authors and confirmed with a semistructered assessment instrument: the Schedule for Affective Disorders and Schizophrenia (Lifetime Version). All patients were submitted to a brutal discontinuation of their antidepressant agent. Patients were assessed twice, before the interruption of the antidepressant, and 72 hours later. Effects of antidepressant interruption were assessed by several means. Modification of anxiety and depression were evaluated using the Montgomery Asberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Scale. Symptoms of withdrawal were assessed with Cassano and al.'s scale SESSH including an evaluation of anxiety, agitation, irritability, anergy, difficulty on concentrating, depersonalization, sleep and appetite disorders, muscle pains, nausea, tremor, sweating, altered taste, hyperosmia, paresthesias, photophobia, motor incoordination, dizziness, hyperacousia pain, delirium. Fourteen of the 16 patients (87.5%) presented modifications of their somatic or psychic state 3 days after the interruption of the antidepressant treatment. Most frequent symptoms were: increase in anxiety (31%), increase in irritability (25%), sleep disorders (19%), decrease of anergia and fatigue (19%). Mean scores of anxiety and depression were not significantly modified by the withdrawal. Following TCAs interruption (7 patients) most frequent symptoms were sleep disorders; increase in anxiety, nausea. Among patients withdrawn from SSRIs (6 patients), most frequent symptoms were increase in anxiety, increase in irritability, headache. Patients also presented a decrease of nausea, and of anorexia.
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PMID:[Prospective evaluation of antidepressant discontinuation]. 969 14

(+/-)3,4-Methylene-dioxymethamphetamine (MDMA, or 'Ecstasy') effects on serotonin system function and behaviour in humans are unclear. Fifteen MDMA users, who did not have other drug dependencies or alcohol abuse, and had not used other drugs for prolonged periods, and 15 control individuals were included in a study to assess the biological and psychological changes after chronic use of MDMA. Prolactin and cortisol responses to D-fenfluramine challenge, clinical psychobehavioural changes, personality characteristics, including mood, aggressiveness and temperamental aspects, were evaluated 3 weeks after MDMA discontinuation. MDMA users had significantly reduced prolactin and cortisol responses in comparison with control individuals (p < 0.001 and p < 0.005, respectively). Dysphoria and mood changes were exhibited in seven individuals, tiredness in five and sensation-seeking behaviour in twelve at the clinical evaluation. Significantly higher scores were found in MDMA individuals than in control individuals for Minnesota Multiphasic Personality Inventory subscale for Depression, for Buss Durkee Hostility Inventory direct and guilt subscales, for Hamilton Depression Rating Scale and for novelty-seeking Tridimensional Personality Questionnaire subscale. Prolactin responses to D-fenfluramine stimulation area under the curve among MDMA users were negatively correlated with direct aggressiveness scores for Buss Durkee Hostility Inventory; a negative correlation between prolactin responses and novelty-seeking scores was also evidenced among MDMA users. These data suggest an association between serotonin system impairment and MDMA use in humans; in interpretation of these results, the possibility that serotonin deficit in MDMA individuals was partially related to a premorbid condition, in relationship with novelty-seeking behaviour and mood disorders, can not be excluded.
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PMID:Serotonergic function after (+/-)3,4-methylene-dioxymethamphetamine ('Ecstasy') in humans. 998 61

Nonalcoholic steatohepatitis (NASH) is a histological diagnosis applied to a constellation of liver biopsy findings that develop in the absence of alcohol abuse. Steatosis, a mixed cellular inflammatory infiltrate across the lobule, evidence of hepatocyte injury and fibrosis are the findings that can be seen. This entity is often identified during evaluation of elevated aminotransferases after exclusion of viral, metabolic and other causes of liver disease. Obesity is a major risk factor for NASH. The role of diabetes is less certain, although evidence is accumulating that hyperinsulinism may play an important pathophysiological role. Patients sometimes suffer from right upper quadrant abdominal pain and fatigue; examination may reveal centripetal obesity and hepatomegaly. Although patients are often discovered because of persistent aminotransferase elevations, these enzymes can be normal in NASH. When they are elevated, the alanine aminotransferase level is typically significantly greater than the aspartate aminotransferase level. This can be particularly helpful for excluding occult alcohol abuse. Imaging studies identify hepatic steatosis when the amount of fat in the liver is significant; however, imaging does not distinguish benign steatosis from NASH. Ultimately a liver biopsy is needed to diagnose NASH. The biopsy may be useful for establishing prognosis based on the presence or absence of fibrosis and for excluding other unexpected causes of liver enzyme elevations. Weight loss is the mainstay of treatment for obese patients. About 15% to 40% of NASH patients develop fibrosis; how many of these cases progress to cirrhosis is unknown, but about 1% of liver transplants are performed with a pretransplant diagnosis of NASH.
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PMID:Nonalcoholic steatohepatitis: an evolving diagnosis. 1079 85

We report a case with spontaneous regurgitation of portal blood flow (SRPBF) that was normalized by meal intake. A 41-year-old man with long-term alcohol abuse was admitted with a chief complaint of general fatigue. He was diagnosed as having alcoholic liver cirrhosis since his laboratory tests showed the abnormal liver function. Dynamic computed tomography detected numerous portosystemic shunts. Hepatic arterial portography showed the portal vein was narrow and irregular. Color Doppler imaging portrayed the direction of the blood flows in the branches of the portal vein to be retrograde. However, 30 min after meal intake on the same day, color Doppler study showed the direction of the blood flow in the first branch of right and left portal vein became normal. Color Doppler imaging is a useful technique to detect SRPBF and hemodynamic change in portal venous system after meal intake in patient under a completely physiologic condition.
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PMID:Spontaneous regurgitation of portal blood flow normalized by meal intake in a patient with alcoholic liver cirrhosis. 1264 50

The term 'non-alcoholic fatty liver disease' (NAFLD) includes cases with steatosis alone and those with non-alcoholic steatohepatitis (NASH). Usually there are no signs or symptoms, sometimes fatigue or pain, and apart from hepatomegaly the condition is revealed by abnormal liver biochemistry or by abdominal ultrasound. Most cases are associated with overweight or diabetes. Liver enzymes are usually elevated, especially GGT, ASAT and ALAT. Other conditions, including alcohol abuse and autoimmune hepatitis, have to be excluded. The diagnosis of steatosis can be made with ultrasound or CT scan. A liver biopsy is often needed to exclude other disease and to assess inflammation and fibrosis. Cirrhosis can develop. NAFLD is usually caused by two 'hits': the 'first hit' is peripheral insulin resistance, causing steatosis. The 'second hit' is caused by reactive oxygen species, inducing vicious cycles leading to inflammation. Weight loss, metformin or thiazolidinediones can improve NAFLD by increasing insulin sensitivity. Radical scavengers such as vitamin E, betaine and perhaps also urodeoxycholic acid may improve the hepatitis component. Further studies on treatment are needed.
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PMID:Non-alcoholic fatty liver disease: a brief review. 1569 51

Farm mechanization has resulted in extensive use of wheat threshers on Indian farms. It has also increased agricultural injuries. A prospective study was undertaken for analysis of wheat thresher agricultural injuries and their remedial measures. Fifty two patients presenting with thresher injuries during the wheat harvesting season of March to June, 2003 were studied. A study-specific 14-point proforma was prepared to gather all possible information from site of injury to hospital records. Injuries were mostly of the upper limb and amputations accounted for most of these. Poor light arrangements, unskilled workers, drug / alcohol abuse, fatigue, poor designing and lack of orientation to work on these machines were the contributory factors to such injuries. The analysis emphasizes that the need of the hour is to decrease wheat thresher injuries through specific preventive approaches like improved designing, education, legislation, compensation and surveillance programmes.
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PMID:Wheat thresher agricultural injuries: a by-product of mechanised farming. 1604 31

60-90% of patients with intravenous drug abuse are chronically infected with the hepatitis C virus (HCV). Antiviral treatment with pegylated interferon-alfa (IFN-alpha) plus ribavirin is often complicated by psychiatric adverse events, significantly affecting patients adherence. Depression, anxiety, fatigue and irritability as typical IFN-alpha associated side effects occur in 30-80% during antiviral treatment of hepatitis C. Patients with drug addiction were shown to have an increased risk to discontinue HCV-treatment early in the first three treatment months, where most neuropsychiatric side effects appear. Especially vegetative side effects in the first few weeks ("flu-like syndrome") can be misunderstood as withdrawal symptoms, followed by a relapse in drug or alcohol abuse. As a consequence methadone substitution treatment was found to be the best therapeutic setting. In addition side effect management should be intensified during first three months of HCV-treatment. Most data for the management of specific IFN-alpha associated side effects are available for depressive syndromes. Antidepressants (especially serotonin-reuptake-inhibitors) such as citalopram were shown to significantly reduce IFN-alpha associated depressive symptoms. A pre-emptive treatment with antidepressants should be considered at least for patients with additional psychiatric risk factors before interferon-based therapy is started. Because data from prospective controlled trials are lacking, management of other side effects such as sleep disturbances, irritability, psychotic syndromes, mania, suicidal thoughts and delirious syndromes should follow general psychiatric treatment recommendations. Overall, the psychiatric adverse event profile of interferon-based therapy for HCV-infected patients with drug addiction is considerable and requires active management and knowledge about psychiatric medical therapy.
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PMID:Hepatitis C treatment in patients with drug addiction: clinical management of interferon-alpha-associated psychiatric side effects. 1963 Jul 16

It is estimated, that symptoms of obstructive sleep apnea syndrome (OSAS) affect 2 to 4% of the middle-aged population and their prevalence increases with age (over 50% people aged 65 and older suffer from OSAS). Among risk factors of OSAS we can distinguish: the male sex, race, overweight and obesity, thyroid hypofunction, age and alcohol abuse. Obstructive sleep apnea results in the absence (apnea) or reduction (hypopnea) of airflow lasting at least 10 s despite normal respiratory exertion. The apnea and hypopnea result in decreased oxygen saturation levels in the blood (hypoxemia). A number of consequences of OSAS can appear including: disruption of the sleep cycle, fragmentation of the sleep cycle, sleepiness, fatigue, headaches, cognitive impairments, irritability and mood disturbance, the higher risk of accidents at work and car accidents, the decrease of the quality of life and the higher risk of cardiovascular diseases. Besides various psychiatric and psychological complications presented in this review can occur in obstructive sleep apnea syndrome.
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PMID:[Psychiatric and psychological complications in obstructive sleep apnea syndrome]. 2119 Jan 50

The definition of burn-out the most often cited and proposed by Maslach and Jackson, clarifies the three cardinal symptoms affecting doctors, namely, emotional exhaustion, with depersonalization of their patients and reduction of the feeling of personal accomplishment. The causes of this phenomenon are relatively well-known: individual psychological factors, stressful factors intrinsic to the medical practice and finally extrinsic factors related to the professional environment and its organization. The purpose of this review is to estimate the prevalence of burnout within the population of Belgian family physicians and to understand both individual and societal consequences. About the method. This is a literature review using databases Medline, Cochrane Library, and the American Psychological Association from 2000 to 2011 with the keywords: primary health care, family practice, burnout, emotional exhaustion, psychological stressors, distress, fatigue, depersonalization, substance and alcohol abuse, depression, well-being, quality of life, job satisfaction, professional efficiency, patient care, physician-patient relations, medical errors, quality of health care, pharmaceutical/health expenditure/statistics-numerical data, obstacles to prevention, health system assessment, medical demography. Selecting of the most relevant articles through the reading of abstracts and then full text reading of 49 selected articles. In conclusion, the exact prevalence of burn-out amongst Belgian general practitioners is not known. From some works, it is estimated that about half of them would be achieved at least in terms of emotional exhaustion. The symptoms related to burn-out are potentially serious: ea depression, alcohol and tobacco abuse and cardiovascular complications. There are also arguments demonstrating the fact that this disorder amongst general practitioners influences negatively the quality of care, their cost, but also medical demography of primary care with as a corollary a questioning of the viability of the health care system as we know it. At the time of writing this article, the Belgian Health Care Knowledge Centre (KCE) is completing, at the request of the Belgian Ministry (SPF) of Health a study entitled "Burn Out of General Practitioners: which prevention, which solutions" whose goal is to make recommendations for the prevention and support of this issue. To measure the real impact of the solutions eventually implemented, we need to create a tool for a regular assessment of the prevalence of this problem in our country.
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PMID:[Burnout of general practitioners in Belgium: societal consequences and paths to solutions]. 2203 74


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