Enlarged tracheoesophageal puncture: A systematic review and retrospective analysis

Background. An enlarged tracheoesophageal puncture (TEP) results in aspiration around the voice prosthesis (VP) and may lead to pneumonia. The aims of this research were: (1) to conduct a systematic review and meta-analysis on enlarged TEP; (2) to analyze preoperative, perioperative, and postoperative risk factors for enlarged TEP; and (3) to evaluate control of leakage around the VP using conservative treatments and adverse events in patients with enlarged TEP.^ Methods. A systematic review was conducted (1978-2008). A summary risk estimate was calculated using a random-effects meta-analysis model. A retrospective cohort study was completed. Patients who underwent total laryngectomy and TEP at The University of Texas M. D. Anderson Cancer Center (MDACC) were included. Multiple logistic regression methods were used to assess risk factors for enlargement. Descriptive and bivariate statistics were calculated to evaluate outcomes and adverse events. Results: Twenty-seven manuscripts were included in the systematic review. The summary risk estimate of enlarged TEP/leakage around the VP was 7.2% (95% CI: 4.8%-9.6%). Temporary VP removal and TEP-site injections were the most commonly reported treatments. Neither prosthetic diameter (p=0.076) nor timing of TEP (p=0.297) significantly increased risk of enlargement per stratified analyses of published outcomes. The cumulative incidence of enlarged TEP was 18.6% (36/194, 95% CI: 13.0%-24.1%) in the MDACC cohort. Enlarged TEP occurred exclusively in irradiated patients. Adjusting for length of follow-up and timing of TEP, advanced nodal disease (ORadjusted: 4.3, 95% CI: 1.0-19.1), stricture (ORadjusted : 3.2, 95% CI: 1.2-8.6), and locoregional recurrence/distant metastasis after laryngectomy (ORadjusted: 6.2, 95% CI: 2.3-16.4) increased risk of enlarged TEP. At last follow-up, conservative methods controlled leakage around the VP in 81% (29/36) of patients. Unresolved leakage was associated with recurrent cancer (p=0.081) and TEP-site irregularity (p=0.003). Relative to those without enlargement, enlarged TEP patients had significantly higher risk of pneumonia (RR: 3.4, 95% CI: 1.9-6.2).^ Conclusions. These data establish that enlarged TEP poses serious health risks, and provide insight into medical and oncologic factors that may contribute to development of this complication. In addition, this research supports the use of conservative treatments to address leakage after enlarged TEP in lieu of complete TEP closure.^

Ozone and fine particulate matter association with CVD and COPD emergency room visits in Harris County, Texas: Spatiotemporal analysis

This study represents a secondary analysis of the merging of emergency room visits and daily ozone and PM2.5. Although the adverse health effects of ozone and fine particulate matter have been documented in the literature, evidence regarding the health risks of these two pollutants in Harris County, Texas, is limited. Harris County (Houston) has sufficiently unique characteristics that analysis of these relationships in this setting and with the ozone and industry issues in Houston is informative. The objective of this study was to investigate the association between the joint exposure to ozone and fine particulate matter, and emergency room diagnoses of chronic obstructive pulmonary disease and cardiovascular disease in Harris County, Texas, from 2004 to 2009, with zero and one day lags. ^ The study variables were daily emergency room visits for Harris County, Texas, from 2004 to 2009, temperature, relative humidity, east wind component, north wind component, ozone, and fine particulate matter. Information about each patient's age, race, and gender was also included. The two dichotomous outcomes were emergency room visits diagnoses for chronic obstructive pulmonary disease and cardiovascular disease. Estimates of ozone and PM2.5 were interpolated using kriging, in which estimates of the two pollutants were predicted from monitoring data for every case residence zip code for every day of the six years, over 3 million estimates (one of each pollutant for each case in the database). ^ Logistic regressions were conducted to estimate odds ratios of the two outcomes. Three analyses were conducted: one for all records, another for visits during the four months of April and September of 2005 and 2009, and a third one for visits from zip codes that are close to PM2.5 monitoring stations (east area of Harris County). The last two analyses were designed to investigate special temporal and spatial characteristics of the associations. ^ The dataset included all ER visits surveyed by Safety Net from 2004 to 2009, exceeding 3 million visits for all causes. There were 95,765 COPD and 96,596 CVD cases during this six year period. A 1-μg/m3 increase in PM2.5 on the same day was associated with a 1.0% increase in the odds of chronic obstructive pulmonary disease emergency room diagnoses, a 0.4% increase in the odds of cardiovascular disease emergency room diagnoses, and a 0.2% increase in the odds of cardiovascular disease emergency room diagnoses on the following day. A 1-ppb increase in ozone was associated with a 0.1% increase in the odds of chronic obstructive pulmonary disease emergency room diagnoses on the same day. These four percentages add up to 1.7% of ER visits. That is, over the period of six years, one unit increase for both ozone and PM2.5 (joint increase), resulted in about 55,286 (3,252,102 * 0.017) extra ER visits for CVD or COPD, or 9,214 extra ER visits per year. ^ After adjustment for age, race, gender, day of the week, temperature, relative humidity, east wind component, north wind component, and wind speed, there were statistically significant associations between emergency room chronic obstructive pulmonary disease diagnosis in Harris County, Texas, with joint exposure to ozone and fine particulate matter for the same day; and between emergency room cardiovascular disease diagnosis and exposure to PM2.5 of the same day and the previous day. ^ Despite the small association between the two air pollutants and the health outcomes, this study points to important findings. Namely, the need to identify reasons for the increase of CVD and COPD ER visits over the course of the project, the statistical association between humidity (or whatever other variables for which it may serve as a surrogate) and CVD and COPD cases, and the confirmatory finding that males and blacks have higher odds for the two outcomes, as consistent with other studies. ^ An important finding of this research suggests that the number and distribution of PM2.5 monitors in Harris County - although not evenly spaced geographically—are adequate to detect significant association between exposure and the two outcomes. In addition, this study points to other potential factors that contribute to the rising incidence rates of CVD and COPD ER visits in Harris County such as population increases, patient history, life style, and other pollutants. Finally, results of validation, using a subset of the data demonstrate the robustness of the models.^

Geochemistry of Cretaceous sills and lava flows of ODP Holes 129-800A and 129-802A

On the basis of their respective eruptive environments and chemical characteristics, alkalic dolerite sills from the northern Pigafetta Basin (Site 800) and tholeiitic pillow lavas from the Mariana Basin (Site 802) sampled during Ocean Drilling Program Leg 129 are considered to represent examples of the widespread mid-Cretaceous volcanic event in the western Pacific. Both groups of basic rocks feature mild, low-grade, anoxic smectite-celadonite-carbonate-pyrite alteration; late-stage oxidation is very limited in extent, with the exception of the uppermost sill unit at Site 800. The aphyric and nonvesicular Site 800 alkalic dolerite sills are all well-evolved mineralogically and chemically, being mainly of hawaiite composition, and are similar to ocean island basalts. They are characterized by high contents of incompatible elements (for example, 300-400 ppm Zr), well-fractionated rare earth element patterns ([La/Yb]N 18-21) and HIMU isotopic characters. They probably represent deep-sea, lateral, intrusive off-shoots from nearby seamounts of similar age. The olivine-plagioclase +/- clinopyroxene phyric tholeiitic pillow lavas and thin flows of Site 802 are nonvesicular and quench-textured throughout. Relative to normal-type mid-ocean ridge basalt, they are enriched in large-ion-lithophile elements, exhibit flat (unfractionated) rare earth element patterns and have distinctive (lower) Zr/Nb, Zr/Ta, La/Ta, and Hf/Th ratios. Overall they are compositionally and isotopically similar to the mid-Cretaceous tholeiites of the Nauru basin and the Ontong-Java and Manihiki plateaus. The Site 802 tholeiites differ from the thickened crustal segments of the oceanic plateaus, however, in apparently representing only a thin veneer over the local basement in an off-axis environment.

Mineralogy at DSDP Legs 58-60

Sediments recovered by drilling during Legs 58, 59, and 60 in the North and South Philippine Sea have been analyzed by X-ray diffractometry. The CaCO3 content was measured separately. The sites encompass several volcanic ridges and intervening inter-arc basin troughs as well as sites on the Mariana arc fore-arc sediment prism and the Mariana Trench. The sediments at all sites received major volcanogenic input from the various arcs; they tend to be rich in volcanic glass, with associated quartz, feldspar, pyroxenes and amphibole. Carbonate is a major component only at Site 445 at the southern end of the Daito Ridge, and at Site 448 on the Palau-Kyushu Ridge. All other sites were either deep relative to the carbonate compensation depth or had very high non-carbonate sedimentation rates. Clay minerals are mainly smectite and illite with lesser variable proportions of chlorite and kaolinite. Smectite predominates over illite except at sites in the Shikoku Basin and the Daito Ridge, and at one site in the Mariana Trench. At several sites, smectite increases and illite decreases with depth. Principal zeolites are phillipsite and clinoptilolite. Analcime occurs in some samples.

Total organic carbon content and isorenieratene concentrations from three holes of ODP Leg 160

Carotenoids were analysed in ca. 1-cm thick subsamples of three laterally time-equivalent sapropels from a west-east transect of the eastern Mediterranean Basin to study euxinic periods during Pliocene sapropel formation. The amount of intact isorenieratene (summed all-trans and cis isomers), ranged from non-detectable at the base and top of a sapropel up to 140 µg/g sediment in the central parts. Isorenieratene accumulation rates at the central and western site are remarkably similar and increase sharply to levels of up to 3.0 mg/m**2/ yr in the central part of the sapropel and then drop to low levels. This pattern indicates an expansion of euxinic conditions reaching into the photic zone, followed by deepening of the chemocline during deposition of this Pliocene sapropel. The sapropel from the easternmost site of the basin, which contains less organic carbon, shows much lower isorenieratene accumulation rates and even absence of isorenieratene in the central part of the sapropel. Ba/Al ratios indicate enhanced palaeoproductivity during sapropel formation, supporting previously proposed models, according to which increased productivity is the driving force for the generation of euxinic conditions.

Physical properties at DSDP Holes 77-535 and 77-540

Tables 1 and 2 contain the data for the physical properties of the material from Sites 535 and 540, respectively. These data are summarized for Site 535 in Table 23 and Figure 31 in the site chapter, Sites 535, 539, and 540. Site 540 data summaries can be found in Table 25 and Figure 37 of the site chapter, Sites 535, 539, and 540.

Late Pliocene stratigraphic distribution of Globoconella taxa in the North Atlantic

Quantitative records of Globorotalia puncticulata and Globorotalia inflata, the last two members of the Globorotalia (Globoconella) lineage, obtained from North Atlantic sediments collected at DSDP Site 552, ODP Site 659 and ODP Site 665, are used to examine fluctuations in the biogeographic distribution of these species in the Late Pliocene between 3 and 2 Ma. Abundance data indicate that prior to the expansion of Northern Hemisphere glaciation at about 2.5 Ma, Gr. puncticulata was an important component of the planktonic foraminiferal fauna and had a geographic distribution ranging from 2°N to at least 56°N in the North Atlantic. A previously undescribed 6 chambered variant of Gr. puncticulata is found at both Sites 659 and 665. The stratigraphic distribution of this morphotype is restricted, first occurring at 2.9 Ma and then disappearing when glacial intensity increased at 2.75 Ma (isotope stage 110). Similar declines in Gr. puncticulata abundances occurred during glacial isotope stages 102, 100, and 98 immediately prior to the extinction of Gr. puncticulata during glacial isotope stage 96. It appears that this extinction event was latitudinally diachronous within the North Atlantic, occurring earliest in the north at Site 552 (2.453 Ma), then at Site 659 (2.443 Ma) and later still in the Site 665 equatorial record (2.438 Ma). At Site 665 the first record of Gr. inflata occurs during glacial isotope stage 94 (2.416 Ma), shortly after the extinction of Gr. puncticulata. In the mid latitude North Atlantic there was a 340,000 year period following the disappearance of Gr. puncticulata when the Globoconella lineage was absent (the Gr. inflata gap). The Gr. inflata population found in the equatorial Atlantic must therefore have been introduced from the South Atlantic, probably by the South Equatorial Current. Faunal records from Sites 552 and 659 show that it was not until glacial isotope stage 78 (2.10 Ma) that Gr. inflata became widely established in the North Atlantic. Prior to this large-scale migration event, there were two limited colonisation events during glacial isotope stages 86 and 82 when Gr. inflata populations reached as far as Site 659 in the eastern North Atlantic. These incursions are believed to be reflect the entrainment of Gr. inflata within South Atlantic Central Water and the northward subsurface transport of individuals to the coastal upwelling zone off northwest Africa. It seems likely that the same mechanism was responsible for the re-establishment of the Globoconella lineage in the North Atlantic at 2.10 Ma, but in this instance additional factors, such as enhanced glacial circulation patterns and ecological changes within planktonic foraminiferal faunas, resulted in the successful expansion of Gr. inflata across the North Atlantic and the Mediterranean.

Isotope geochemistry of Ninetyeast Ridge basalts

The Ninetyeast Ridge lavas have Sr and Nd isotopic ratios intermediate between those of Indian Ocean MORBs and those of the very enriched Kerguelen hot spot. In an Nd-Sr isotope diagram, they also plot close to the fields of St. Paul Island lavas and of the early magmatism on Kerguelen Archipelago. The Ninetyeast Ridge lavas were generated by mixing among at least three components: a depleted, MORB-type component, such as the one erupted today on the Southeast Indian Ridge; a very enriched, high- Sr/ Sr, low-epsilon-Nd, OIB-type component (the Kerguelen hot spot); and an OIB-type component comparable to that sampled from the St. Paul (and Amsterdam) lavas. The Ninetyeast Ridge lavas show a typical Dupal anomaly signature and Pb, Sr, and Nd isotopic systematics indicate that the Kerguelen hot spot was involved in the ridge's formation as the Indian plate moved northward. The different sites cored during ODP Leg 121 show a trend in their isotopic compositions, from less radiogenic Pb/ Pb ratios and intermediate 87Sr/86Sr and 143Nd/**Nd ratios in the oldest lavas (Site 758) toward more radiogenic 206Pb/204Pb, higher epsilon-Nd, and lower 87Sr/86Sr values in the youngest lavas (Site 756). The lavas from Site 757 have 206Pb/204Pb ratios intermediate between those of the lavas from Sites 756 and 758 and higher 87Sr/86Sr and lower epsilon-Nd values. The relative proportions of the hot spot(s) and MORB component have evolved with time, reflecting differences of tectonic setting: the relative proportion of the Kerguelen hot spot component appears lower in the younger Site 756 lavas than in the older lavas from Sites 757 and 758. Site 756 coincides with the beginning of rifting at the Southeast Indian Ridge, about 43 Ma ago. The formation of the early Kerguelen Archipelago lavas may have drained most of the plume-derived material toward the Antarctic plate. Alternatively, the proximity of the spreading-ridge axis may account for the isotopic similarity of the Site 756 lavas to young lavas erupted on the Southeast Indian Ridge, from 33? to 37?S. The older lavas of Ninetyeast Ridge may have formed when the hot spot and ridge axis did not exactly coincide. The involvement of the third component, a St. Paul hot spot, in the genesis of the Ninetyeast Ridge lavas, especially for the Site 756 lavas, is clearly indicated by Sr, Pb, and Nd isotope systematics and also by trace element ratios. These data, together with those from the Kerguelen Plateau, indicate that the Kerguelen hot spot has been active more or less continuously in the South Indian Ocean for at least 115 Ma. This could indicate that the plume, and by inference the Dupal anomaly, is deep seated in origin.

Calcareous nannofossils of ODP Hole 123-765C and DSDP Hole 27-261

Sediments from the Argo Abyssal Plain (AAP), northwest of Australia, are the oldest known from the Indian Ocean and were recovered from ODP Site 765 and DSDP Site 261. New biostratigraphic and sedimentologic data from these sites, as well as reinterpretations of earlier findings, indicate that basal sediments at both localities are of Late Jurassic age and delineate a history of starved sedimentation punctuated by periodic influx of calcareous pelagic turbidites. Biostratigraphy and correlation of Upper Jurassic-Lower Cretaceous sediments is based largely on calcareous nannofossils. Both sites yielded variably preserved nannofossil successions ranging from Tithonian to Hauterivian at Site 765 and Kimmeridgian to Hauterivian at Site 261. The nannofloras are comparable to those present in the European and Atlantic Boreal and Tethyan areas, but display important differences that reflect biogeographic differentiation. The Argo region is thought to have occupied a position at the southern limit of the Tethyan nannofloral realm, thus yielding both Tethyan and Austral biogeographic features. Sedimentary successions at the two sites are grossly similar, and differences largely reflect Site 765's greater proximity to the continental margin. Jurassic sediments were deposited at rates of about 2 m/m.y. near the carbonate compensation depth (CCD) and contain winnowed concentrations of inoceramid prisms and nannofossils, redeposited layers rich in calcispheres and calcisphere debris, manganese nodules, and volcanic detritus. Lower Cretaceous and all younger sediments accumulated below the CCD at rates that were highest (about 20 m/m.y.) during mid-Cretaceous and Neogene time. Background sediment in this interval is noncalcareous claystone; turbidites dominate the sequence and are thicker and coarser grained at Site 765. AAP turbidites consist mostly of calcareous and siliceous biogenic components and volcanogenic smectite clay; they were derived from relatively deep parts of the continental margin that lay below the photic zone, but above the CCD. The Jurassic-Lower Cretaceous section is about the same thickness across the AAP; turbidites in this interval appear to have had multiple sources along the Australian margin. The Upper Cretaceous-Cenozoic section, however, is three times thicker at Site 765 than at Site 261; turbidites in this interval were derived predominantly from the south. Patterns of sedimentation across the AAP have been influenced by shifts in sea level, the CCD, and configuration of the continental margin. Major pulses of calcareous turbidite deposition occurred during Valanginian, Aptian, and Neogene time-all periods of eustatic lowstands and depressed CCD levels. Sediment redeposited on the AAP has come largely from the Australian outer shelf, continental slope, or rise, rather than the continent itself. Most terrigenous detritus was trapped in epicontinental basins that have flanked northwestern Australia since the early Mesozoic.

Chemical and isotope compositions of bottom sediments from ODP Leg 168, Eastern Flank of the Juan de Fuca Ridge

Ten sites were drilled in the eastern flank of the Juan de Fuca Ridge (North East Pacific) along a 100 km-long east-west transect during Leg ODP 168. This study focuses on the mineralogical and chemical study of sediments that overly basaltic basement through which seawater circulates. Silicate authigenesis was observed in the sediment layer just above basement at sites located more than 30 km from the ridge axis. This sediment alteration is particularly abundant at ODP Sites 1031 and 1029 where authigenic formation of Fe-Mg rich smectite and zeolite and the dissolution of biogenic calcite are observed. Comparison of the distribution of the alteration in the basal sediment collected along this transect suggests that diffusional transport of aqueous solutes from the basement into the overlying sediment cannot produce the mineralogical and chemical changes in the basal sediments at Sites 1031 located on a basement topographic high, and at Site 1029 located at about 50 km from the ridge axis on a buried basement area. Vertical advection of basement fluid though the sediment section is required to produce this alteration. These processes are still active at Site 1031, based on systematic variations in pore-water profiles and temperatures obtained from stable isotopic data on calcium carbonates and the nature of authigenic minerals. At Site 1029, there is no present-day advection of basement fluids though the sediment section, suggesting that this is a relic site for fluid flow.

Stable oxygen and carbon isotope composition of Miocene planktonic foraminifers from the tropical Indian Ocean

Oxygen and carbon isotope records are presented for the planktonic foraminifers Dentoglobigerina altispira and Globigerinoides sacculifer (shallow-dwelling species) and Globoquadrina venezuelana (deep-dwelling species) from Miocene sediments at two Ocean Drilling Program sites, located at depths of near 3000 m, in the western (Site 709) and eastern (Site 758) tropical Indian Ocean. The planktonic isotope record at Site 709 is compared with the benthic isotope record obtained at this site by Woodruff et al. (1990, doi:10.2973/odp.proc.sr.115.147.1990). The isotope stratigraphy is related to the biostratigraphy and the available magnetostratigraphy at the sites. Despite varying sampling density, incompleteness of isotopic records, and the condensed (or even disturbed) nature of parts of the sequences, a number of chronostratigraphic isotopic signals previously recognized in the equatorial Pacific and at other tropical Indian Ocean sites are identified.

Nd and Pb isotope signatures of the clay-size fraction of sediment core MD99-2227

Nd and Pb isotopes were measured on the fine fraction of one sediment core drilled off southern Greenland. This work aims to reconstruct the evolution of deep circulation patterns in the North Atlantic during the Holocene on the basis of sediment supply variations. For the last 12 kyr, three sources have contributed to the sediment mixture: the North American Shield, the Pan-African and Variscan crusts, and the Mid-Atlantic Ridge. Clay isotope signatures indicate two mixtures of sediment sources. The first mixture (12.2-6.5 ka) is composed of material derived from the North American shield and from a "young" crustal source. From 6.5 ka onward the mixture is characterized by a young crustal component and by a volcanic component characteristic of the Mid-Atlantic Ridge. Since the significant decrease in proximal deglacial supplies, the evolution of the relative contributions of the sediment sources suggests major changes in the relative contributions of the deep water masses carried by the Western Boundary Undercurrent over the past 8.4 kyr. The progressive intensification of the Western Boundary Undercurrent was initially associated mainly with the transport of the Northeast Atlantic Deep Water mass until 6.5 ka and with the Denmark Strait Overflow Water thereafter. The establishment of the modern circulation at 3 ka suggests a reduced influence of the Denmark Strait Overflow Water, synchronous with the full appearance of the Labrador Seawater mass. Our isotopic data set emphasizes several changes in the relative contribution of the two major components of North Atlantic Deep Water throughout the Holocene.

Isotopic and trace element composition of basalts from DSDP Leg 82 Holes

Sr and Nd isotopic composition of 23 basalts from Sites 556-559 and 561-564. are reported. The 87Sr/86Sr ratios in fresh glasses and leached whole rocks range from 0.7025 to 0.7034 and are negatively correlated with the initial 143Nd/ 144Nd compositions, which range from 0.51315 to 0.51289. The Sr and Nd isotopic compositions (in glasses or leached samples) lie within the fields of mid-ocean ridge basalts (MORB) and ocean island basalts (OIB) from the Azores on the Nd-Sr mantle array/fan plot. In general, there is a correlation between the trace element characteristics and the 143Nd/144Nd composition (i.e., samples with Hf/Ta>7 and (Ce/Sm)N<1 [normal-MORB] have initial 143Nd/144Nd>0.51307, whereas samples with Hf/Ta<7 and (Ce/Sm)N>1 (enriched-MORB) have initial 143Nd/144Nd compositions <0.51300). A significant deviation from this general rule is found in Hole 558, where the N-MORB can have, within experimental limits, identical isotopic compositions to those found in associated E-MORB. The plume-depleted asthenosphere mixing hypothesis of Schilling (1975), White and Schilling (1978) and Schilling et al. (1977) provides a framework within which the present data can be evaluated. Given the distribution and possible origins of the chemical and isotopic heterogeneity observed in Leg 82 basalts, and some other basalts in the area, it would appear that the Schilling et al. model is not entirely satisfactory. In particular, it can be shown that trace element data may incorrectly estimate the plume component and more localized mantle heterogeneity (both chemical and isotopic) may be important.