1. Laryngoscope. 2019 Jun 28. doi: 10.1002/lary.28160. [Epub ahead of print]
Pediatric tracheostomy: A large single-center experience.
Roberts J(1)(2), Powell J(1)(2), Begbie J(2), Siou G(2), McLarnon C(2), Welch
A(2), McKean M(3), Thomas M(1)(3), Ebdon AM(3), Moss S(3), Agbeko RS(1)(4), Smith
JH(5), Brodlie M(1)(3), O'Brien C(3), Powell S(2).
(1)Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne,
(2)Department of Paediatric Otolaryngology, Great North Children's Hospital,
Newcastle upon Tyne, United Kingdom.
(3)Department of Paediatric Respiratory Medicine, Great North Children's
Hospital, Newcastle upon Tyne, United Kingdom.
(4)Department of Paediatric Anaesthesia and Intensive Care, Great North
Children's Hospital, Newcastle upon Tyne, United Kingdom.
(5)Department of Paediatric Cardiothoracic Anaesthesia and Intensive Care,
Freeman Hospital, Newcastle upon Tyne, United Kingdom.
OBJECTIVES: To describe the epidemiology, specifically the indications,
complications, and outcomes, of pediatric tracheostomies performed in one
tertiary referral unit.
METHODS: Single-center retrospective cohort study of pediatric patients
undergoing tracheostomy between May 2010 and May 2018 at the Newcastle upon Tyne
Hospitals, United Kingdom.
RESULTS: One hundred seventy-two pediatric tracheostomies were performed during
the study period with a median age of 141 (interquartile range [IQR] 51-484)
days. The most common primary indication was long-term ventilation (38.4%, 66 of
172), followed by weaning from ventilation in cardiac patients (22.1%, 38 of
172). Only 5.2% (9 of 172) of our cohort underwent tracheostomy for subglottic
stenosis. The vast majority of tracheostomies were performed electively, with
just 6.4% (11 of 172) performed as an emergency procedure. Early and late
complication rates were 9.8% (15 of 153) and 40.0% (61 of 153), respectively.
Tracheostomy decannulation was successful in 44.4% of children (68 of 153). The
median duration the tracheostomy was in situ was 397 (IQR 106-708) days.
All-cause mortality was 22.1% (38 of 172), with tracheostomy-related mortality at
1.2% (2 of 172).
CONCLUSION: We report one of the largest contemporary case series of pediatric
tracheostomies. Present-day pediatric tracheostomy is primarily performed as an
elective procedure in ventilated children under the age of 1 year. Pediatric
tracheostomy should be considered as a long-term intervention in many children.
Nevertheless, a large proportion of children are ultimately decannulated. It is
important to acknowledge the significant morbidity associated with this
intervention and the small-but-present risk of tracheostomy-related mortality.
LEVEL OF EVIDENCE: 4 Laryngoscope, 2019.
© 2019 The American Laryngological, Rhinological and Otological Society, Inc.
2. Anaesthesia. 2019 Jun 27. doi: 10.1111/anae.14747. [Epub ahead of print]
From smartphone to bed-side: exploring the use of social media to disseminate
recommendations from the National Tracheostomy Safety Project to front-line
Ng FK(1), Wallace S(1), Coe B(1), Owen A(2), Lynch J(3), Bonvento B(3), Firn
M(4), McGrath BA(3)(5).
(1)Burns Intensive Care Unit, Manchester University NHS Foundation Trust,
(2)Acute Intensive Care Unit, Manchester University NHS Foundation Trust,
(3)Manchester University NHS Foundation Trust, Manchester, UK.
(4)South West London and St George's Mental Health NHS Trust, London, UK.
(5)Manchester Academic Critical Care, Division of Infection, Immunity &
Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of
Traditional methods used to disseminate educational resources to front-line
healthcare staff have several limitations. Social media may increase the
visibility of these resources among targeted groups and communities. Our project
aimed to disseminate key clinical messages from the National Tracheostomy Safety
Project to those caring for patients with tracheostomies or laryngectomies. We
commissioned an external media company to design educational material and devise
a marketing strategy. We developed videos to communicate recommendations from the
safety project and used Facebook, Twitter, YouTube and LinkedIn to deliver these
to our target users. We recorded 629,270 impressions over a paid 12-week
campaign. Our YouTube channel registered more than a five-fold increase in views
and watch time during the campaign as compared with the previous year. Around
two-thirds of views across all platforms were from peer-to-peer sharing. We spent
£4140 on social media advertising, with each view and click costing £0.02 and
£0.67, respectively. This intelligence-led approach using social media is an
effective and efficient method to disseminate knowledge on the principles of safe
tracheostomy care to front-line clinical staff. Similar strategies may be
effective for other patient safety topics, especially when targeting groups that
do not use medical journals or other traditional means of dissemination.
© 2019 Association of Anaesthetists.
3. Head Neck Pathol. 2019 Jun 27. doi: 10.1007/s12105-019-01043-z. [Epub ahead of
Bradykinin Receptor B1 and C-Reactive Protein as Prognostic Factors for
Pharyngocutaneous Fistula Development After Laryngectomy.
Koob I(1), Pickhard A(2), Buchberger M(1), Boxberg M(3), Reiter R(4), Piontek
G(1), Straßen U(1).
(1)Department for Ear- Nose- and Throat, Head and Neck Surgery, University
Hospital Klinikum rechts der Isar, Technical University of Munich, Ismaninger
Str. 22, 81675, Munich, Germany.
(2)Department for Ear- Nose- and Throat, Head and Neck Surgery, University
Hospital Klinikum rechts der Isar, Technical University of Munich, Ismaninger
Str. 22, 81675, Munich, Germany. email@example.com.
(3)Institute of Pathology, Technical University of Munich, Trogerstraße 18,
81675, Munich, Germany.
(4)Department of Otolaryngology Head and Neck Surgery, Section of Phoniatrics and
Pedaudiology, University of Ulm, Ulm, Germany.
Pharyngocutaneous fistulae (PCF) are one of the most common complications after
laryngectomy. Predisposing risk factors have been studied, yet knowledge to
determine which patients are prone to developing a fistula remains scarce. This
study aims to establish prognostic parameters to identify individual patients at
risk for PCF development. As PCF and inflammation seem to be interwoven, this
work focuses on markers able to detect an inflammatory response. We
retrospectively analyzed all patients who had undergone a laryngectomy at our
clinic in the years 2007 to 2017 (n = 182). Immunohistochemical expression of
bradykinin type 1 and 2 receptor and vascular endothelial growth factor receptor
2 was studied in all available tumor samples. Additionally, the clinical
inflammation parameters 'body temperature', 'pain', 'c-reactive protein (CRP)',
and 'leucocytes' were postoperatively tracked in all patients. The times between
fistula diagnosis, therapeutic approach, and hospital discharge were recorded. We
found a strong correlation between inflammation and the formation of a fistula.
High bradykinin 1 receptor expression in the tumor samples correlated with
postoperative PCF development. Persistently elevated CRP and leukocyte levels
beyond the 6th postoperative day were also risk factors. A decreased time lapse
between PCF diagnosis and surgical revision clearly correlated with a shorter
hospital stay. In this study, we identified a bradykinin 1 receptor positive
patient group at high risk for development of PCF. We recommend close monitoring
for fistula formation in these patients to ensure timely intervention.
4. Pediatr Crit Care Med. 2019 Jun 19. doi: 10.1097/PCC.0000000000002046. [Epub
ahead of print]
Factors Impacting Physician Recommendation for Tracheostomy Placement in
Pediatric Prolonged Mechanical Ventilation: A Cross-Sectional Survey on Stated
Meyer-Macaulay CB(1), Dayre McNally J(2), O'Hearn K(3), Lynne Katz S(2)(3),
Thébaud B(2)(3), Vaccani JP(4), Barrowman N(2)(3), Harrison MA(3), Jouvet P(5).
(1)Division of Pediatric Critical Care Medicine, Faculty of Medicine, University
of Ottawa, Ottawa, ON, Canada.
(2)Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada.
(3)Division of Pediatric Critical Care Medicine, University of Ottawa, Children's
Hospital of Eastern Ontario, Ottawa, ON, Canada.
(4)Department of Otolaryngology-Head & Neck Surgery, University of Ottawa,
Ottawa, ON, Canada.
(5)Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.
OBJECTIVES: To characterize the stated practices of qualified Canadian physicians
toward tracheostomy for pediatric prolonged mechanical ventilation and whether
subspecialty and comorbid conditions impact attitudes toward tracheostomy.
DESIGN: Cross sectional web-based survey.
SUBJECTS: Pediatric intensivists, neonatologists, respirologists, and
otolaryngology-head and neck surgeons practicing at 16 tertiary academic Canadian
INTERVENTIONS: Respondents answered a survey based on three cases (Case 1:
neonate with bronchopulmonary dysplasia; Cases 2 and 3: children 1 and 10 years
old with pediatric acute respiratory distress syndrome, respectively) including a
series of alterations in relevant clinical variables.
MEASUREMENTS AND MAIN RESULTS: We compared respondents' likelihood of
recommending tracheostomy at 3 weeks of mechanical ventilation and evaluated the
effects of various clinical changes on physician willingness to recommend
tracheostomy and their impact on preferred timing (≤ 3 wk or > 3 wk of mechanical
ventilation). Response rate was 165 of 396 (42%). Of those respondents who
indicated they had the expertise, 47 of 121 (38.8%), 23 of 93 (24.7%), and 40 of
87 (46.0%) would recommend tracheostomy at less than or equal to 3 weeks of
mechanical ventilation for cases 1, 2, and 3, respectively (p < 0.05 Case 2 vs
3). Upper airway obstruction was associated with increased willingness to
recommend earlier tracheostomy. Life-limiting condition, severe neurologic
injury, unrepaired congenital heart disease, multiple organ system failure, and
noninvasive ventilation were associated with a decreased willingness to recommend
CONCLUSION: This survey provides insight in to the stated practice patterns of
Canadian physicians who care for children requiring prolonged mechanical
ventilation. Physicians remain reluctant to recommend tracheostomy for children
requiring prolonged mechanical ventilation due to lung disease alone at 3 weeks
of mechanical ventilation. Prospective studies characterizing actual physician
practice toward tracheostomy for pediatric prolonged mechanical ventilation and
evaluating the impact of tracheostomy timing on clinically important outcomes are
needed as the next step toward harmonizing care delivery for such patients.
5. Pol Przegl Chir. 2018 Aug 6;91(3):30-37. doi: 10.5604/01.3001.0012.2307.
Total Laryngectomy for Treatment of T4 Laryngeal Cancer: Trends and Survival
(1)Apollo Cancer Institute, Jubilee Hills, Hyderabad, India, Cachar Caner
Hospital & Research Centre, Assam, India.
INTRODUCTION: Management of advanced laryngeal cancer has shown fluctuating
trends during the last few decades. Though many extensive reports are available
in the literature regarding survival outcomes for advanced laryngeal cancer,
there is a paucity of elaborate systematic reviews giving a complete picture of
facts and figures. The present analysis brings to attention the most relevant
data in a focused and up to date format, for simpler interpretation of
OBJECTIVE: To present the trends in the treatment of T4 laryngeal cancer over the
past few decades and analyze survival outcomes for different treatment modalities
in the management of T4 laryngeal cancer by way of systematic review.
METHODS: An electronic search was conducted using the terms "total laryngectomy",
"T4 laryngeal cancer", "survival outcomes" in combination with the following
search strategy : Search block Laryngeal cancer - "Laryngeal
Neoplasms"[Mesh] OR ((Laryngeal[tiab] OR larynx[tiab] OR
"Larynx"[Mesh]) AND ("Neoplasms"[Mesh] OR neoplasm* [tiab] OR tumor*
[tiab] OR tumour* [tiab] OR cancer* [tiab] OR malignancy* [tiab] OR carcinoma*
[tiab] OR neoplasm* [tiab] OR oncology* [tiab])); Search block Total laryngectomy
- "Laryngectomy"[Mesh] OR total laryngectomy*[tiab] OR total
laryngopharyngectomy*[tiab] OR total pharyngolaryngectomy*[tiab]; Search block T4
- t4[tiab]. Clinical studies were retrieved from the electronic databases of
PubMed, EMBASE, SCOPUS and Cochrane Library. 304 articles had been published till
June 2017, which included prospective studies, randomized controlled trials,
retrospective studies, and smaller descriptive studies. References of the
selected studies were further searched for relevant articles. Apart from this, a
search was conducted on Google Scholar to obtain related articles.
RESULTS: Numerous studies, as mentioned in this review, provide authentic
evidence in relation to the efficacy and outcome of surgical treatment for T4
laryngeal cancer. To address the problem of heterogeneity with regards to patient
selection, numerous reports pertaining to T4 patients exclusively have been
CONCLUSION: Total laryngectomy remains the gold standard for management of T4a
laryngeal cancer. After the unparalleled oncological outcomes of more than a
century, the technique has stood the test of time. An exhaustive review of the
literature has been presented, discussing the trends in the treatment of advanced
laryngeal cancer across different continents. However, it must be specified that
the purpose of the study is not to prove one treatment protocol to be superior to
the other but to bring out patterns of adherence to protocols and guidelines as
suggested by multidisciplinary consensus reports and the consequent outcomes.
6. Acta Otolaryngol. 2019 Jun 26:1-7. doi: 10.1080/00016489.2019.1616820. [Epub
ahead of print]
Long-term clinical outcomes of supracricoid partial laryngectomy with
cricohyoidoepiglottopexy for glottic carcinoma.
Gong H(1), Zhou L(1), Wu H(1), Tao L(1), Chen X(1), Li X(1), Li C(1), Zhou J(1).
(1)a Shanghai Key Clinical Disciplines of Otorhinolaryngology, Department of
Otorhinolaryngology, Eye, Ear, Nose, and Throat Hospital , Fudan University ,
Shanghai , China.
Background: Laryngeal carcinoma should be treated with the intent of
organ-sparing, and supracricoid partial laryngectomy with
cricohyoidoepiglottopexy (CHEP) might be an important option. Aims/objectives:
The purpose of this study was to evaluate the clinical outcomes of glottic
carcinoma patients treated with CHEP. Materials and methods: A series of 164
cases with glottic carcinoma undergoing CHEP from 2006 to 2010 was
retrospectively analyzed. Results: The 10-year overall survival (OS) rate,
disease-specific survival (DSS) rate, and disease-free survival (DFS) rate were
77.6%, 78.8%, 74.1%, respectively. The OS, DSS, and DFS of patients with stage T1
were higher than patients with stages T2 and T3. Patients with locoregional
recurrence and distant metastases had lower OS and DFS than patients with neither
recurrence nor metastasis. The DFS of patients with advanced laryngeal carcinoma
was worse than that of patients with early-stage carcinoma. T2 and T3 stages,
locoregional recurrence, and distant metastases had predictive value regarding
patient survival. Additionally, the decannulation rate of postoperative patients
was 95.1%, and the nasogastric feeding tube removal rate was 100%. Conclusions
and Significance: CHEP provided reliable oncologic and functional outcomes, and
it should be considered as a standard function-sparing option for glottic T1b,
T2, and selected T3 carcinoma patients.
7. OTO Open. 2019 Mar 22;3(1):2473974X19836432. doi: 10.1177/2473974X19836432.
eCollection 2019 Jan-Mar.
Use of a Silicon Stoma Stent as an Interim Step in High-Risk Tracheostomy
Ross J(1)(2), McMurray K(1)(3)(4), Cameron T(1)(5), Lanteri C(6)(7).
(1)Tracheostomy Review and Management Service, Australia.
(2)Victorian Spinal Cord Service, Melbourne, Australia.
(3)Ventilator Accommodation Support Service, Melbourne, Australia.
(4)Australian Nursing Federation, Melbourne, Australia.
(5)Department of Speech Pathology, Austin Health, Melbourne, Australia.
(6)Department of Respiratory Medicine, Austin Health, Melbourne, Australia.
(7)Institute of Breathing and Sleep, Austin Health, Melbourne, Australia.
Objective: To describe use of a stoma stent to facilitate high-risk
Methods: Retrospective chart review of 14 consecutive patients who received a
stent from March 2013 to December 2016 at a quaternary health care service.
Primary outcome measures were decannulation outcome and adverse events.
Results: Decannulation outcome: 12 of 14 patients had their tracheostomy tube
(TT) removal facilitated by stent use. Patients had the stent for a median of 6
days (interquartile range, 49). Reasons for use included medical instability,
risk of sputum retention, uncertain airway patency, and the need for ongoing
airway access. All patients survived to discharge. One patient residing in the
community has retained a stoma stent. Adverse events: One patient removed the
stent on the day of insertion, necessitating reinsertion of the TT. Granulation
tissue at the stoma site was seen in 2 patients.
Discussion: A tracheostoma will normally close within 48 hours following
decannulation, which is problematic if TT reinsertion is required. By using the
stent, reversal of decannulation becomes a simple ward-based procedure. In
comparison to a TT, which is secured with ties, the stoma stent proved unsuitable
for use in an agitated patient.
Implications for Practice: Decreasing total cannulation time is of benefit as
patients with tracheostomy are subject to high rates of complications and adverse
events. A stoma stent poses little risk and a low morbidity burden to the patient
in comparison to alternative management.
8. Laryngoscope Investig Otolaryngol. 2019 May 7;4(3):307-309. doi:
10.1002/lio2.263. eCollection 2019 Jun.
Aberrant innominate artery: A possible hazard during total laryngectomy.
Nijkamp J(1), Jaafar RBJ(1), Postma L(2), Snoeijs M(3), Qiu Shao SS(4), Tan B(1).
(1)ENT Department Maastricht University Medical Center Maastricht The
(2)Radiology Department Maastricht University Medical Center Maastricht The
(3)Vascular Surgery Department Maastricht University Medical Center Maastricht
(4)Plastic Surgery Department Maastricht University Medical Center Maastricht The
Background: Surgical management in laryngeal carcinoma remains a challenge with
countless unexpected complications. Great vessel anomalies such as anomaly of the
innominate artery carry high risk of morbidity and mortality if not managed
Methods: We present our first experience with an aberrant innominate artery
during total laryngectomy which complicated the whole surgical procedure and
Results: We decided to place a pectoralis major muscle flap to separate and cover
up the aberrant vessel from the trachea and end-stoma which ultimately did not
lead to major complications postoperatively and postradiation therapy.
Conclusion: Aberrant innominate artery is an extremely rare entity and failure of
recognizance can lead to hazardous complications. Preoperative angiography needs
to be done if there are high suspicions of aberrant vessels in the operative
field. Careful dissection of the head and neck region, and prompt decision making
are mandatory to manage such cases.
Levels of Evidence: Case Report.
9. Laryngoscope Investig Otolaryngol. 2019 Apr 22;4(3):292-299. doi:
10.1002/lio2.265. eCollection 2019 Jun.
Effect of early tracheostomy in mechanically ventilated patients.
Dochi H(1), Nojima M(2), Matsumura M(1), Cammack I(3), Furuta Y(1).
(1)Department of Otolaryngology-Head and Neck Surgery Teine-Keijinkai Hospital
(2)Center for Translational Research The Institute of Medical Science Hospital,
The University of Tokyo Tokyo Japan.
(3)Clinical Residency Department Teine-Keijinkai Hospital Sapporo Japan.
Objective: To investigate the effect of the timing of tracheostomy in patients
who required prolonged mechanical ventilation using two methods: analysis of
early versus late tracheostomy and landmark analysis.
Study Design: Retrospective cohort study.
Methods: Patients who were emergently intubated and admitted into the intensive
care unit or high dependency unit between January 2011 and August 2016, with or
without tracheostomy, were included. In the early and late tracheostomy analysis,
all patients were divided into early (≤10 days, n = 88) and late (>10 days,
n = 132) groups. In the landmark analysis, 198 patients requiring ventilation for
more than 10 days were divided into early tracheostomy (≤10 days, n = 57) and
nonearly tracheostomy (>10 days, n = 141) groups. We compared 60-day ventilation
withdrawal rate and 60-day mortality.
Results: Early tracheostomy was a significant factor for early ventilation
withdrawal, as shown by log-rank test results (early and late tracheostomy: P
= .001, landmark: P = .021). Multivariable analysis showed that the early group
was also associated with a higher chance of ventilation withdrawal in each
analysis (early and late tracheostomy: adjusted hazard ratio [aHR] = 1.69, 95%
confidence interval [CI] = 1.20-2.39, P = .003; landmark: aHR = 1.61, 95%
CI = 1.06-2.38, P = .027). Early tracheostomy, however, was not associated with
improved 60-day mortality (early and late tracheostomy: aHR = 0.88, 95%
CI = 0.46-1.69, P = .71; landmark: aHR = 1.46; 95% CI = 0.58-3.66; P = .42).
Conclusion: For patients requiring ventilation, performing tracheostomy within
10 days of admission was independently associated with shortened duration of
mechanical ventilation; 60-day mortality was not associated with the timing of
Level of Evidence: 2b.
10. Pulmonology. 2019 Jun 21. pii: S2531-0437(19)30120-5. doi:
10.1016/j.pulmoe.2019.05.011. [Epub ahead of print]
Tracheostomy prevalence at Skilled Nursing Facilities.
Pereira F(1), Silva AM(2), Vaz IM(3), Viamonte S(3), Winck JC(3).
(1)Hospital Senhora da Oliveira - Guimarães, Portugal. Electronic address:
(2)Hospital Senhora da Oliveira - Guimarães, Portugal.
(3)Centro de Reabilitaçao do Norte, Portugal.
The incidence of chronically ill subjects with prolonged mechanical ventilation
has significantly increased over the last decade. Many patients get discharge to
Skilled Nursing Facilities with an artificial airway, which do not have the means
to properly progress on weaning. In Portugal this prevalence is unknown. Our aim
was to establish the prevalence of tracheostomized patients at SNF in the North
of Portugal, characterizing these units and its population, in a cross-sectional
study, through an online questionnaire answered on the same day. Of the 75 SNF,
30 answered: 13 long-term, 2 medium-term, 2 short-term, 12 had beds of both
medium and long-term and 1 had the three typologies. 33 had tracheostomy
ventilation (prevalence 3.36%), all admitted at long-term units, the majority
transferred from previous hospital admission (n=27, 90%). Only one was under
mechanical ventilation. The most frequent reason for tracheostomy placement was
acute respiratory failure (n=10, 33.3%). The most commonly presented cannula was
the fenestrated non-cuffed (n=17, 59%). Only 4 were performing occlusion
training, 21 needed frequent secretion suctioning and 1 used the mechanical
in-exsufflation. Regarding motor function, 16 (53.3%) were unable to achieve
sitting balance and 20 (66.7%) had no orthostatic balance or walking ability. 14
(46.7%) had percutaneous endoscopic gastrostomy. Although low response rate may
induce some bias, this study revealed a significant prevalence of tracheostomized
patients at SNF. These facilities do not have the resources to safely and
effectively progress on ventilatory weaning. It is essential to establish new
referral criteria and create specialized weaning units.
Copyright © 2019 Sociedade Portuguesa de Pneumologia. Published by Elsevier
España, S.L.U. All rights reserved.
11. J Craniofac Surg. 2019 Jun 20. doi: 10.1097/SCS.0000000000005615. [Epub ahead of
Chimeric Lateral Arm Free Flap to Treat Pharyngocutaneous Fistula After Total
Fodor L(1), Chirila M(2)(3), Sobec R(1), Sita L(1), Fodor M(4).
(1)Emergency District Hospital, Plastic and Reconstructive Surgery Department.
(2)Emergency District Hospital.
(3)Iuliu Hatieganu University of Medicine and Pharmacy, Ear Nose and Throat
(4)Emergency District Hospital, Vascular Surgery Department, Cluj-Napoca,
Pharyngocutaneous fistula is a major complication after total laryngectomy,
leading to a severe adverse impact for the patient and social activity. The
reported incidence ranges from 9% to 25% in the last decade. In this paper, the
authors present our experience using chimeric lateral arm free flap for
reconstruction of the pharyngo-esophageal segment. Eight patients with
pharyngocutaneous fistula were treated with this technique. The flap has 2 skin
islands, each one supplied by a perforator coming from the main pedicle. One skin
island is used as a patch for pharynx closure and the other is used for anterior
soft tissue coverage. The follow-up period ranged from 8 months to 3 years. All
flaps survived. There was 1 small fistula that was sutured. External skin wound
dehiscence was present in 1 case and it was secondary closed by itself. All
patients were able to eat by mouth and there were no signs of stricture. The
authors preferred this type of flap because both defects are simultaneously
closed and each skin paddle is supplied by a perforator coming from the main
pedicle. It has a better color match than other free flaps. The skin island is
thin and remains thin even after the patients gain weight.