Tinnitus as a prognostic sign in idiopathic sudden sensorineural hearing loss

Idiopathic sudden sensorineural hearing loss remains a controversial problem with respect to etiology and the factors that might predict a favorable prognosis. This study evaluated the possible prognostic factors of recovery in 67 patients with idiopathic sensorineural hearing loss treated with steroids (prednisone), plasma expanders (intravenous dextran), and vasodilators (papaverine). Clinical recovery was estimated by contrasting the audiometric results on admission and those at discharge 10 days later. The correlation between various potential prognostic factors and audiological improvement was calculated. Only two factors were found to be associated significantly with hearing improvement: tinnitus (p < .04) and the slope of audiogram on admission (p < .045). Tinnitus and the presence of an ascending audiogram were found to be correlated with a favorable outcome in idiopathic sensorineural hearing loss.

The Combitube in elective surgery: a report of 200 cases

BACKGROUND

The Combitube has proved to be a valuable device for securing the airway in cases of difficult intubation. This study investigated the effectiveness of the Combitube in elective surgery during both mechanical and spontaneous ventilation.

METHODS

Two hundred patients classified as American Society of Anesthesiologists physical status I and II, with normal airways, scheduled for elective surgery were randomly allocated into two groups: nonparalyzed, spontaneously breathing (n = 100); or paralyzed, mechanically ventilated (n = 100). After induction of general anesthesia and insertion of the Combitube, oxygen saturation, end-tidal carbon dioxide and isoflurane concentration, systolic and diastolic blood pressure and heart rate, as well as breath-by-breath spirometry data were obtained every 5 min.

RESULTS

In 97% of patients, it was possible to maintain oxygenation, ventilation, and respiratory mechanics, as well as hemodynamic stability during either mechanical or spontaneous ventilation for the entire duration of surgery. The duration of surgery was between 15 and 155 min.

CONCLUSIONS

The results of this study suggest that the Combitube is an effective and safe airway device for continued management of the airway in 97% of elective surgery cases.

Tumour necrosis factor alpha in the diagnostic assessment of pleural effusion

We investigated the role of tumour necrosis factor-alpha (TNF) in the evaluation of pleural effusion aetiology. Using a commercially-available ELISA kit, concentrations of TNF were measured in the serum and pleural fluid of patients with malignant effusions (n=19), uncomplicated parapneumonic effusions (n=13), and exudative (n=13) and transudative (n=13) effusions due to congestive heart failure (CHFex and CHFtr, respectively). Serum TNF did not differ significantly between the four groups (p>0.05). In the group with malignancy, pleural fluid TNF was significantly higher than in the other groups (p<0.001), which were not significant different from each other (p>0.05). However, a considerable overlap between all four groups was found. Pleural fluid TNF was significantly higher than serum TNF in the malignant and the uncomplicated parapneumonic groups (p<0.001), and there was a significant positive correlation between serum TNF and pleural fluid TNF in the group with uncomplicated parapneumonic effusion (r=0.7, p<0.005), in the group with CHFex (r=0.54, p<0.01), and in the group with CHFtr (r=0. 8, p<0.005), but not in the group with malignancy. Pleural fluid TNF:serum TNF (TNF ratio) was significantly higher in the malignancy group than in the other groups (p<0.001); no significant difference was found between the other three groups (p>0.05). At an optimal cut-off point of 2.0 for TNF ratio, determined by ROC analysis for discrimination between malignant and non-malignant groups, sensitivity was 84%, specificity 90%, and total accuracy 88% (p<0. 0001). TNF ratio might be helpful in the diagnostic assessment of exudative pleural effusion.

Relationship between prostate size and percent free prostate-specific antigen in patients with operable prostate cancer

BACKGROUND

The free-to-total prostate-specific antigen ratio is the best marker for optimizing prostate cancer detection. The main problem with studies of percent free PSA is the variability of reported cutoff values.

OBJECTIVES

To evaluate the influence of prostate size on the ratio of free to total PSA.

METHODS

The study group included 58 patients (mean age 66.4 years) with clinically localized prostate cancer treated surgically at our institution. Total PSA and free PSA levels were measured by a solid phase enzyme immunoassay test (Hoffman-La Roche, Basel, Switzerland). The percent free PSA was compared with prostate size as determined from the surgical specimen.

RESULTS

A direct relation was noted between prostate size and the percent free PSA value (r = 0.49, P = 0.0001). Mean percentage free PSA was 9% +/- 0.004 in men with normal-sized gland while in men with large prostate (> 60 g) the average percent free PSA was 15.9 +/- 0.09 (P = 0.001).

CONCLUSIONS

In patients with prostate cancer the percent free PSA level is influenced by the gland size. The larger the prostate the higher the proportion of the free PSA. Such information may have influence on the recommendation for prostate biopsy in screening programs for early detection of prostate cancer.

Enterocyte apoptosis and proliferation are increased in microvillous inclusion disease (familial microvillous atrophy)

Microvillous inclusion disease (MID) is characterized by diffuse villous atrophy without inflammatory changes. While increased apoptosis has been related to mucosal flattening in celiac disease, the role of apoptosis in the pathogenesis of MID is unknown. The aim of this study was to assess the rates of apoptosis and cell proliferation in MID and to compare them with those of normal controls and celiac disease. Small intestinal biopsies from 5 infants with MID, 10 children with normal villous architecture, and 10 children with untreated celiac disease were stained with the terminal uridine deoxynucleotidyl nick end labeling (TUNEL) method to assess apoptotic activity, and with Ki-67 immunohistochemistry to assess cellular proliferation. TUNEL and Ki-67 positive enterocytes were counted in a minimum of 20 well oriented half crypts per section. The percentage of apoptotic cells per crypt (apoptotic index) in normal, MID, and celiac biopsies was 0.03 +/- 0.01%, 0.08 +/- 0.08%, and 0.16 +/- 0.3%, respectively. Significant differences were found between normal and MID, and between normal and celiac cases. The percentage of Ki-67 positive cells per crypt (proliferation index) in normal, MID, and celiac cases was 14 +/- 2.5%, 28 +/- 9.2%, and 56 +/- 14%. Significant differences were found between the 3 groups. In conclusion, (1) enterocyte apoptosis and proliferation are increased in MID; (2) apoptosis appears to be an important factor of cell loss and may be, at least in part, responsible for villous atrophy in MID; and (3) crypts in MID are hyperplastic and not hypoplastic. HUM PATHOL 31:1404-1410.

Superresolution optical system with two fixed generalized Damman gratings

We present a system that exceeds the Rayleigh limit of resolution, by placing two fixed gratings in predetermined positions. Lukosz suggested a setup that managed to exceed the Rayleigh limit of resolution [J. Opt. Soc. Am. 56, 1463 (1966); 57, 932 (1967)]. However, Lukosz's technique had some drawbacks that the new suggested system attempts to resolve. Similar to Lukosz's technique, the proposed system works without any moving elements and with no time- or wavelength-restricting conditions. It is suitable for coherent or incoherent two-dimensional imaging. However, the new system contains some important modifications. Although the system uses only two gratings, it is capable of producing superresolution without using an additional imaging lens at the output plane. The generalized Damman gratings allow for obtaining undistorted spectral restoration of information. To achieve superresolution, the input object is duplicated. The trade-off for higher resolution is a smaller field of view. Experimental results validate the theoretical analysis.

Value of nuclear morphometry for differentiating localized from metastatic renal cell carcinoma

OBJECTIVE

To evaluate the feasibility of using nuclear morphometry of primary renal cell carcinoma to differentiate cases with localized tumors from those with metastases.

METHODS

Using an interactive image analysis system, nuclear morphometry was performed on hematoxylin- and eosin-stained slides of 40 primary renal tumors. There were 18 cases with organ-confined disease and 22 with advanced stage.

RESULTS

The most significant shape descriptor to differentiate between the two groups was mean nuclear regularity factor (889.5 +/- 24.4 vs. 701.1 +/- 157.3, p = 0.00015). The combination of mean nuclear area and mean nuclear regularity factor enabled accurate prediction of metastatic potential in 36 (85%) cases.

CONCLUSION

Nuclear morphometry measured by image analysis provides prognostic information on patients with renal cell carcinoma.

The capnography head-up tilt test for evaluation of chronic fatigue syndrome

OBJECTIVES

To compare the hemodynamic and ventilatory responses to autonomic challenge evoked by upright tilt table testing in patients with chronic fatigue syndrome (CFS) to healthy individuals.

METHODS

Thirty-two consecutive patients with CFS and 32 healthy volunteers were evaluated with the aid of the recently introduced capnography head-up tilt test (CHUTT). The main outcome measures were values of blood pressure (BP), heart rate (HR), respiratory rate (RR), and end-tidal pressure of co2 (ETPco2) recorded during recumbence and tilt. In addition, the end points of vasodepressor and cardioinhibitory reactions, hyperventilation (defined by ETPco2 <25 mm Hg) and the postural tachycardia syndrome, were recorded.

RESULTS

The BP, HR, RR, and ETPco2 recorded during recumbence were similar in both groups. During tilt, patients with CFS developed significantly lower systolic BP, diastolic BP, and ETPco2, and a significant rise in HR and RR (P<.01). In CFS patients, the postural tachycardia syndrome occurred in 44%, vasodepressor reaction in 41%, cardioinhibitory reaction in 13%, and hyperventilation in 31% of cases. One or more end points of the CHUTT were reached in 78% of patients with CFS but in none of the controls (P<.0001).

CONCLUSIONS

In most patients with CFS, a spectrum of abnormal homeostatic reactions is diagnosed with the aid of the CHUTT. Data provided by the CHUTT may reinforce the clinical diagnosis by adding objective and unbiased criteria to the subjective assessment of CFS.

Immune aberrations in B and T lymphocytes derived from chronic urticaria patients

To investigate the pathophysiology of chronic urticaria (CU) in light of the abundant evidences that it is an autoimmune disease and to define some cellular markers in B/T lymphocytes that could be of pathogenic significance, we investigated 14 patients suffering from CU, compared to 7 contact dermatitis patients and 10 normal control individuals. We tested the expression of CD5, B7.1 (CD80), CD23, and CD25 on B cells and of CD(40L)) and CD25 on T cells from all studied individuals. We also tested B cell proliferation upon their activation followed by dexamethazone induced inhibition of proliferation. The expression of bcl-2 protein in activated lymphocytes from normal individuals was compared to that of contact dermatitis and CU patients. CD(40L) expression was found significantly higher on in (vitro activated CD3 [with phorbol myristate acetate (PMA) and ionomycine Ca2+ at 12 hr of culture] from CU patients compared to that of contact dermatitis and normal individuals. Whereas the proliferation of activated B cells from CU patients was higher, dexamethazone-induced inhibition of B cell proliferation was found statistically similar in both groups yet lower in B cells from most severe CU patients. We demonstrate a higher bcl-2 expression in activated B and T lymphocytes of severe CU patients compared to that of moderate CU and both contact dermatitis and normal individuals. The increased expression of CD(40L) on activated T cells might play a role in the polyclonal increased B cell proliferation of CU patients. This increased proliferation accompanies the finding that activated B and T lymphocytes from these patients demonstrate increased bcl-2 expression. The resistance of some B cells to dexamethazone-induced inhibition of proliferation encourages us to investigate the possibility that B cells from some CU patients might develop rescue mechanisms from activated cell death. These findings provide further evidence that CU is indeed an autoimmune disease, although its precise nature has yet to be fully elucidated.

Treatment of refractory, symptomatic, hepatitis C virus related mixed cryoglobulinemia with ribavirin and interferon-alpha

OBJECTIVE

To assess the benefit of interferon-alpha/ribavirin combination therapy in hepatitis C virus (HCV) infected patients with symptomatic mixed cryoglobulinemia (MC) who failed to respond to treatment with interferon-alpha (IFN-alpha).

METHODS

Nine patients (mean age 57 +/- 14 yrs) with type II symptomatic MC who failed to respond to IFN-alpha monotherapy were re-treated with combination treatment of IFN-alpha 3 times weekly and ribavirin 15 mg/kg daily for 6 months. Five of 9 patients had previously received additional treatment during IFN-alpha monotherapy. Clinical and laboratory evaluations (including cryocrit level) were performed weekly for the first month and monthly thereafter.

RESULTS

Baseline mean alanine aminotransferase (ALT) and cryocrit levels were 119 +/- 97 IU/l and 7.9% +/- 10%, respectively. All patients were HCV-RNA positive and 5 had cirrhosis. At the end of therapy, mean ALT level was 84 +/- 79 IU/l (p = 0.02), while normal ALT levels were observed in 4 of 9 patients (44%). However, complete virological response was achieved in only 2 patients (22%). Cryoglobulin became undetectable within 6 weeks of therapy in 7 patients (78%) and decreased significantly in 2 others (p = 0.008). A substantial improvement in MC related symptoms (arthralgia/arthritis, proteinuria, skin vasculitis) was achieved in all patients within 10 weeks of combination therapy, although polyneuropathy related symptoms were relatively resistant to treatment.

CONCLUSION

Symptomatic, refractory HCV related MC should be considered as an indication for combination therapy with IFN-alpha and ribavirin. Improvement in MC related symptoms can be achieved even without complete biochemical or virological response.

The influence of preemptive spinal anesthesia on postoperative pain

STUDY OBJECTIVE

To examine the influence of spinal anesthesia on postoperative pain and postoperative opioid requirements.

DESIGN

Prospective randomized study.

SETTING

Bnai-Zion Medical Center, Haifa, Israel-a government hospital.

MEASUREMENTS AND MAIN RESULTS

30 ASA physical status I and II unpremedicated women undergoing elective total abdominal hysterectomy were randomly allocated into two groups of 15 patients each using a sealed envelope technique. Patients in Group 1 were given a subarachnoid injection of 12 mg hyperbaric bupivacaine and after 10 minutes general anesthesia was induced. Patients in Group 2 received only general anesthesia. Anesthesia was induced with midazolam and maintained with oxygen, N2O, isoflurane, and pancuronium. No opioids were given intraoperatively. Postoperatively patient-controlled analgesia (PCA) with morphine was initiated in both groups (1 mg x mL(-1), bolus dose 1 mg, lockout interval 10 minutes, and background infusion 1 mg x mL(-1)) at patient first request for analgesic. Pain was assessed over 24 hours by cumulative morphine dose and visual analog score (VAS). Postoperative PCA morphine consumption at 2, 6, and 24 hours following patient first request for analgesic for Groups 1 and 2 were: 3.1 +/- 1 mg versus 7.2 +/- 3 mg (p = 0.04), 13.4 +/- 2 mg versus 17.2 +/- 4 mg (p = 0.03) and 35.9 +/- 8 mg versus 47.7 +/- 8 mg in Group 2 (p = 0.04). VAS scores at 4, 6, 12, and 24 hours postoperatively were not significantly different between the two groups.

CONCLUSIONS

Preoperative neural blockade may reduce postoperative analgesic requirements.

Laparoscopic cholecystectomy for acute cholecystitis: can the need for conversion and the probability of complications be predicted? A prospective study

BACKGROUND

Laparoscopic cholecystectomy (LC) in acute cholecystitis is associated with a relatively high rate of conversion to an open procedure as well as a high rate of complications. The aim of this study was to analyze prospectively whether the need to convert and the probability of complications is predictable.

METHODS

A total of 215 patients undergoing LC for acute cholecystitis were studied prospectively by analyzing the data accumulated in the process of investigation and treatment. Factors associated with conversion and complications were assessed to determine their predictive power.

RESULTS

Conversion was indicated in 44 patients (20.5%), and complications occurred in 36 patients (17%). Male gender and age >60 years were associated with conversion, but these factors had no sensitivity and no positive predictive value. The same factors, together with a disease duration of >96 h, a nonpalpable gallbladder, a white blood count (WBC) of >18,000/cc(3), and advanced cholecystitis, predicted conversion with a sensitivity of 74%, a specificity of 86%, a positive predictive value of approximately 40%, and a negative predictive value of 96%. However, these data became available only when LC was underway. Male gender and a temperature of >38 degrees C were associated with complications, but these factors had no sensitivity and no positive predictive value. Progression along the stages of admission and therapy did not add predictive factors or improve the predictive characteristics. Male gender, abdominal scar, bilirubin >1 mg%, advanced cholecystitis, and conversion to open cholecystectomy were associated with infectious complications. Their sensitivity and positive predictive value remained 0 despite progression along the stages of admission and therapy.

CONCLUSION

Although certain preoperative factors are associated with the need to convert a LC for acute cholecystitis, they have limited predictive power. Factors with higher predictive power are obtained only during LC. The need to convert can only be established during an attempt at LC. Preoperative and operative factors associated with total and infectious complications have no predictive power.

Using rate-based events to improve clinical practice

This article describes the implementation and utilization of a continuous quality improvement (CQI) program in the identification, analysis, and correction of a rate-based event in anesthesia, in this case, intraoperative hypertension. A CQI program was implemented based on voluntary, handwritten, anonymous reports of intraoperative and postanesthesia care unit events. This CQI program detected a high incidence of intraoperative hypertension, indicated major causal factors, suggested a set of corrective measures, and allowed for measurement of their efficacy.

Immunohistochemical staining of GLUT1 in benign, hyperplastic, and malignant endometrial epithelia

BACKGROUND

Aberrant expression of the facilitative glucose transporter, GLUT1, is found in a wide spectrum of epithelial malignancies. The current study describes an immunohistochemical study of GLUT1 expression in benign, hyperplastic, and malignant endometrial epithelia.

METHODS

One hundred sixteen formalin fixed, paraffin embedded sections of benign, hyperplastic, and malignant endometrial epithelium were immunostained with rabbit anti-GLUT1 antibody using the streptavidin-biotin method.

RESULTS

Proliferative, secretory, and atrophic endometrium were not stained with GLUT1 antiserum. Rare, minute foci of tubal metaplasia stained positively. Simple and complex endometrial hyperplasias were consistently GLUT1 negative. All specimens of atypical hyperplasia had foci that were positive for GLUT1. All endometrial adenocarcinomas were GLUT1 positive.

CONCLUSIONS

The results of the current study appear to indicate that 1) aberrant overexpression of GLUT1 is a consistent feature of endometrioid adenocarcinoma; 2) GLUT1 immunostaining may be useful in distinguishing benign hyperplasias from hyperplasias that are associated strongly with malignancy; and 3) some or all cases of atypical hyperplasia may be neoplastic rather than hyperplastic, given the existence of a molecular defect common to this hyperplastic subtype and endometrioid adenocarcinoma.

Does the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children?

We evaluated the effect of adding fentanyl to bupivacaine, compared with bupivacaine alone, on the stress response. The effect was evaluated by determining blood levels of epinephrine (E) and norepinephrine (NE) in pediatric patients receiving caudal epidural blocks. Sixty children, 1-8 yr of age, scheduled for elective herniorrhaphy, were randomly allocated to two groups of 30 patients each. Group A received inhaled anesthesia and caudal epidural block with bupivacaine 0.25% alone, 1.0 mL/kg. Group B received identical anesthesia; however, fentanyl 1 microg/kg was added to the bupivacaine in the caudal block. Blood samples for E and NE plasma levels were drawn at induction time (H(0)), at the end of surgery (H(1)), and in the postanesthesia care unit (H(2)). In both groups, there was a significant decrease in the E and NE plasma levels, when comparing H(1) and H(2) with H(0) within the same group (P < 0.001). There were no significant differences in the E and NE plasma levels between the two groups at H(0), H(1), and H(2) (P = 0.5, P = 0.12, P = 0.5, respectively). Pain scores (modified Children's Hospital of Eastern Ontario Pain Score) were also similar in both groups (P = 0. 19). This study suggests that adding fentanyl 1 microg/kg to bupivacaine in the caudal epidural block in children does not influence plasma levels of E and NE, nor does it improve the analgesic intensity of the caudal block.

Computer-assisted image analysis can aid the prognostication of advanced-stage neuroblastomas

PURPOSE

The aim of this work was to detect nuclear parameters related to the prognosis of patients with stage III, IV or DS neuroblastomas.

METHODS

Histological sections of 25 operation specimens obtained from children with advanced-stage neuroblastomas were subjected to computer-assisted image analysis. Statistical relationships between nuclear descriptors of the tumor cells and patients' clinical outcome were determined.

RESULTS

The coefficient of variability of the mean nuclear area the mean nuclear elongation factor, and the mean nuclear averaged Feret diameter of the neuroblastoma cells were ascertained to be discriminators separating high-grade from low-grade tumors.

CONCLUSIONS

The histomorphometrically gauged nuclear parameters may help oncologists to assess the prognosis of patients with advanced-stage neuroblastoma.

Role of tumor necrosis factor-alpha in the differential diagnosis of parapneumonic effusion

OBJECTIVE

This study was undertaken to investigate the role of tumor necrosis factor-a (TNF-a) in discriminating between uncomplicated parapneumonic effusion (UCPPE) and complicated parapneumonic effusion (CPPE).

METHOD

Using a commercially available high sensitivity enzyme-linked immunosorbent assay (ELISA) kit, concentrations of TNF were measured in the serum (TNFs) and pleural fluid (TNFpf) of 21 patients with parapneumonic effusion (PPE), 13 patients with UCPPE, and 8 patients with nonempyemic CPPE.

RESULTS

No significant difference in values of TNF concentration was found between the group with UCPPE and that with CPPE (P > 0.05). Concentration levels of TNFpf were significantly higher in the group with CPPE than in that with UCPPE (P = 0.0008). Levels of TNF in pleural fluid were significantly higher than in serum in both groups (P < 0.001). The ratio of TNF in pleural fluid to that in serum (TNFr) was significantly higher in the CPPE group than in the UCPPE group (P = 0.0002). At an optimal cutoff point of 10.7 pg/mL for TNFpf, the sensitivity was 87.5%, specificity was 92.3%, positive predictive value was 87.5%, negative predictive value was 93.3%, and total accuracy was 90.5% (P < 0.001). At an optimal cutoff point of 3.0 for TNFr, all values were 100% (P < 0.00001).

CONCLUSIONS

The results of this study indicate that TNFpf, and particularly TNFr, may be helpful in discriminating between UCPPE and CPPE. However, further studies are needed in a larger population to confirm these findings.

Laparoscopic cholecystectomy for acute cholecystitis: how do fever and leucocytosis relate to conversion and complications?

OBJECTIVE

To find out whether fever and raised white cell count (WCC) are associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis, and whether their presence could help in deciding the place of laparoscopic procedures.

DESIGN

Prospective study.

SETTING

Teaching hospital, Israel.

SUBJECTS

256 patients who were treated for clinical acute cholecystitis between January 1994 and November 1997.

INTERVENTIONS

Emergency laparoscopic cholecystectomy.

MAIN OUTCOME MEASURES

Raised temperature and WCC; incidence of conversion and complications.

RESULTS

Raised temperature (>38 degrees C) was independently associated with advanced cholecystitis (p = 0.002, odds ratio [OR] 2.7) and a palpable gallbladder preoperatively (p = 0.02, OR 2.1). Total complications correlated with a temperature of >38 degrees C. Raised WCC (>15 x 10(9)/L) was independently associated with age >45 years (p = 0.02, OR 2.4), a palpable gallbladder preoperatively (p = 0.001, OR 2.9), and a raised temperature (>38 degrees C) (p < 0.0001, OR 6.2). Conversion was associated with a WCC >18 x 10(9)/L (p = 0.0, OR 3.2).

CONCLUSION

A WCC of >18 x 10(9)/L may assist in predicting conversion, and fever of >38 degrees C may assist in predicting the development of complications.

Sonovestibular symptoms evaluated by computed dynamic posturography

The investigation of stability under bilateral acoustic stimulation was undertaken in an attempt to mimic the real-life conditions of noisy environment (e.g., industry, aviation). The Tullio phenomenon evaluated by computed dynamic posturography (CDP) under acoustic stimulation is reflected in postural unsteadiness, rather than in the classic nystagmus. With such a method, the dangerous effects of noise-induced instability can be assessed and prevented. Three groups of subjects were submitted. The first (group A) included 20 patients who complained of sonovestibular symptoms (i.e., Tullio phenomenon) on the background of an inner-ear disease. The second group (B) included 20 neurootological patients without a history of Tullio phenomenon. Group C consisted of 20 patients with normal hearing, as controls. A pure-tone stimulus of 1,000 Hz at 110 dB was delivered binaurally for 20 seconds during condition 5 and condition 6 of the CDP sensory organization test. The sequence of six sensory organization conditions was performed three times with two intermissions of 15-20 minutes between the trials. The first was performed in the regular mode (quiet stance). This was followed 20 minutes by a trial carried out in quiet stance in sensory organizations tests (SOTs) 1 through 4, and with acoustic stimulation in SOT 5 and SOT 6. The last test was performed in quiet stance throughout (identical to the first trial). A significant drop in the composite equilibrium score was witnessed in group A patients upon acoustic stimulation (p < .0001). This imbalance did not disappear completely until 20 minutes later when the third sensory organization trial was performed. In fact, the composite score obtained on the last SOT was still significantly worse than the baseline. Group B and the normal subjects (group C) showed no significant change in composite score. As regards the vestibular ratio score, again, group A marked a drop on stimulation with sound (p < .004). This decrease contrasted once more with the other two groups. The leading sensory organization pattern was vestibular dysfunction (i.e., 40%, 10%, and 0% before acoustic stimulation in groups A, B, and C, respectively). The initial proportion of vestibular dysfunction increased on acoustic stimulation to 55% in group A, but this subsequently decreased in the third trial. The percentages of vestibular dysfunction remained constant during repeated trials in the other two groups. The positive medical history of sonovestibular symptoms was confirmed objectively by CDP with sound stimulation with a high statistical significance. This establishes the described method as a sensitive testing technique for validating the existence of the Tullio phenomenon in patients with a variety of disorders of the inner ear, especially chronic noise-induced hearing loss and acute acoustic trauma. All patients who suffered phonic trauma, chronic exposure to noise (e.g., aviation employees, industry and army personnel), or other neurootological disorders and who complain of sonovestibular symptoms should be tested for the presence of the Tullio phenomenon. This should be carried out preferably by means of CDP with acoustic stimulation for an objective corroboration of their complaint before continuing activity in a noisy environment, thus preventing dangerous loss of balance when exposed to noise.

Treatment of experimental avascular necrosis of the femoral head with hyperbaric oxygen in rats: histological evaluation of the femoral heads during the early phase of the reparative process

The healing of vascular deprivation-induced necrosis of the femoral head of rats exposed to hyperbaric oxygen was compared with that in untreated rats. The amount of necrotic bone, extent of osteoneogenesis, degree of remodeling, and changes of the articular cartilage were histologically graded on a semiquantitative scale of 0 to 3+. On the 2nd, 7th, and 21st postoperative days, there were no differences between the two groups. Newly formed appositional and intramembranous bone was more abundant and remodeling was more advanced in the femoral heads of the hyperbaric oxygen-treated than untreated rats sacrificed on the 42nd postoperative day; also there was less necrotic debris in the femoral heads of the treated rats. There were no differences in the severity of the degenerative changes of the articular cartilage of the treated and untreated rats. Exposure of rats to hyperbaric oxygen does not preserve tissue viability after all arteries supplying the femoral head are severed. Yet, resulting in an increased oxygen tension of the tissues, it seems to provide the optimal settings for reparative processes. The results suggest that hyperoxygenation-mediated relief of ischemia enhances the fibroblastic, angioblastic, osteoblastic, and osteoclastic activities such that healing of the rats' necrotic femoral heads is expedited.

The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy is now used in the management of acute cholecystitis. Under these circumstances unfavorable conditions may result in conversion and complications. Information about these conditions may help in planning the laparoscopic approach or in proceeding directly to open cholecystectomy. This study was initiated to evaluate perioperative factors associated with conversion and complications of laparoscopic cholecystectomy in acute cholecystitis. Special attention was paid to the duration of complaints until surgery, to the delay on the part of the patient, and to the delay on the part of the physician.

METHODS

Between January 1994 and December 1997, we attempted to perform laparoscopic cholecystectomy on 348 patients with acute cholecystitis. All perioperative data were collected on standardized forms.

RESULTS

There were 182 cases (52%) of acute uncomplicated cholecystitis, 90 (26%) of gangrenous cholecystitis, 33 of hydrops (9.5%), and 43 of empyema of the gallbladder (12.5%). Seventy six patients (22%) needed conversion to open cholecystectomy and complications occurred in 57 cases. Advanced cholecystitis was associated with significant patient delay (P = 0.01), and it had a significantly higher conversion rate (39%) compared with early cholecystitis (14.5%); (P <0.00001). Conversion rates were also associated with male gender (P = 0.0017), a history of biliary disease (P = 0.0085), and a patient delay of >48 hours (P = 0.028). The total and infectious complication rates were associated with an age older than 60 years (P = 0.023 and 0.007, respectively) and male gender (P = 0.026 and 0.014, respectively).

CONCLUSIONS

In acute cholecystitis, patient delay is associated with a high conversion rate. Early timing of laparoscopic cholecystectomy tends to reduce the conversion rate, as well as the total and the infectious complication rates. Male gender, a history of biliary disease, and advanced cholecystitis are associated with conversion. Male and older patients are associated with a high total and infectious complication rates.

The possible impact of a myomatous uterus on the accuracy of fetal biometric measurements

OBJECTIVE

The propagation speed of ultrasound beams changes in different media. The aim of the study was to assess the possible measurement error of fetal biometry performed in cases of a myomatous uterus.

DESIGN

Three iron phantoms of 30 mm, 50 mm and 70 mm were measured by ultrasound. Each phantom was measured by three different transducers of 3.5 MHz, 6.5 MHz and 7.5 MHz. Measurements were performed in a water bath and the intraobserver variability was assessed. Thereafter phantoms were measured with one of their edges covered by a specimen of a myomatous uterus while their other edge was covered with water.

RESULTS

Artifactual lengthening of the phantoms' size was observed in measurements performed with the uterine myoma. The measurement errors were inversely related to the length of the phantoms and became statistically significant in the phantoms of 30 mm (13.15 +/- 3.16% without the myoma vs. 17.38 +/- 4.39% with the myoma; p < 0.0001). Measurement errors were independent of the transducer type (p = 0.001, p = 0.01 and p = 0.014 for the 3.5-MHz, 6.5-MHz and 7.5-MHz transducers, respectively).

CONCLUSIONS

Ultrasound measurement errors are expected while examining small fetal organs which are partially overshadowed by a myoma.

Evaluation of muscle capillary basement membrane in inflammatory myopathy. A morphometric ultrastructural study

The capillary basement membranes from 16 skeletal muscle biopsies from patients with a clinical and histological diagnosis of inflammatory myopathy and from six controls were analysed ultrastructurally and morphometrically. Resin sections from 244 endomysial capillaries were examined by light microscope, and the results were correlated with findings seen in electron micrographs of these capillaries. The ultrastructural morphometric measurements and the statistical analysis showed that the capillary basement membrane was thick and multilaminated in 87% specimens affected by inflammatory myopathy. No thick or multilaminated basement membrane was observed in controls. In inflammatory myopathy the endomysial space next to the capillaries contained an increased amount of collagen fibrils and showed signs of a chronic reparative process. It is suggested that the thick multilaminated basement membrane in inflammatory myopathy represents an advanced stage of vascular regeneration.