[Fainting during ingestion. Deglutition syncope ]

MEDICAL HISTORY

A 49-year-old woman was referred to the ENT department with a 1.5-year history of dysphagia accompanied by globus sensation and regurgitation as well as recurrent syncopal attacks associated with swallowing solid foods.

CLINICAL FINDINGS

Endoscopic examination revealed hyperplasia of the tongue base and redness of the aryepiglottic region. An axial hiatal hernia (> 3 cm) was seen on esophago-gastro-duodenoscopy. Esophageal manometry showed a diffuse esophageal spasm. Holter monitoring (24 h) revealed a third-degree atrioventricular block.

THERAPY

The patient’s symptoms resolved following placement of a permanent cardiac pacemaker. Globus sensation and regurgitation persisted. Treatment with proton pump inhibitors was successful. The final functional endoscopic evaluation of swallowing revealed no relevant findings.

CONCLUSION

We describe a case of a rare and extreme form of a vagal reflex. Deglutition syncope can be successfully treated by a multidisciplinary team consisting of otorhinolaryngologists, neurologists and cardiologists.

Atomistic magnetization dynamics in nanostructures based on first principles calculations: application to Co nanoislands on Cu(111)

The magnetization dynamics of Co nanoislands on Cu(111) is studied on the atomic scale by means of the stochastic Landau-Lifshitz-Gilbert equation. The exchange and anisotropy constants of the spin Hamiltonian are computed from first principles. We focus on hysteresis loops and magnetic switching in dependence on temperature, island size, and strength of an external magnetic field. The magnetic switching of nanoislands whose magnetization is reversed on the sub-nanosecond time scale is found consistent with the Stoner-Wohlfarth theory. We separate the superparamagnetic from the ferromagnetic regime and provide evidence that nanodomains can exist at least on a sub-picosecond time scale.

Cochlear implantation in patients with chronic otitis: indications for subtotal petrosectomy and obliteration of the middle ear

Normally, active chronic suppurative otitis media is regarded as a contraindication for cochlear implantation. In case of a radical cavity after surgical treatment for cholesteatoma, the electrode covered by the epithelial lining of the mastoid will likely become exposed or extruded. Under these circumstances we suggest the subtotal petrosectomy, obliteration of the middle ear cleft with abdominal fat, and the blindsac closure of the external ear canal before cochlear implantation.Fourteen patients with chronic otitis media were successfully implanted with an intracochlear multichannel cochlear implant. After an average follow-up of 28 months a temporary facial palsy in one patient and an insufficient closure of a retroauricular fistula over the mastoid cavity in two cases were observed as postoperative complications. One patient with a tumefactive inflammatory pseudotumor developed a massive inflammation in the implanted ear 2 months after surgery which could not be controlled by conservative treatment. The implant had to be removed and after administration of cyclophosphamide she could be successfully reimplanted 7 months later.Implantation of a foreign body in a potentially infected space which communicates with the endocranium means a surgical challenge which can be managed by obliteration of the middle ear. In case of massive inflammation we prefer a two-stage procedure.

Cochlear implantation after burn injury of the head

The loss of an auricle as a side-effect of burn injuries is a rare clinical event. If the patient also suffers fromsensorineural deafness, it is necessary, in planning management, to consider the aesthetic effects ofreconstructing or replacing the auricle as well as restoring the hearing. In this case report of a 17-year-oldboy who suffered a third-degree burn injury to his head we describe the surgical approach for cochlearimplantation combined with placement of a bone-anchored auricular prosthesis. Hearing restoration forone ear was successfully combined with an adequate aesthetic rehabilitation of both external ears.

Endobronchial ultrasound-guided lymph node biopsy with transbronchial needle forceps: a pilot study

One limitation of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the size of the available needles, frequently yielding only cells for cytological examination. The aim of this pilot study was to evaluate the efficacy and safety of newly developed needle forceps to obtain tissue for the histological diagnosis of enlarged mediastinal lymph nodes. Patients with enlarged, positron emission tomography (PET)-positive lymph nodes were included. The transbronchial needle forceps (TBNF), a sampling instrument combining the characteristics of a needle (bevelled tip for penetrating through the bronchial wall) with forceps (two serrated jaws for grasping tissue) was used through the working channel of the EBUS-TBNA scope. Efficacy and safety was assessed. 50 patients (36 males and 14 females; mean age 51 yrs) with enlarged or PET-positive lymph nodes were included in this pilot study. In 48 (96%) patients penetration of the bronchial wall was possible and in 45 patients tissue for histological diagnosis was obtained. In three patients TBNF provided inadequate material. For patients in whom the material was adequate for a histological examination, a specific diagnosis was established in 43 (86%) out of 50 patients (nonsmall cell lung cancer: n=24; small cell lung cancer: n=7; sarcoidosis: n=4; Hodgkin's lymphoma: n=4; tuberculosis: n=2; and non-Hodgkin's lymphoma: n=2).No clinically significant procedure-related complications were encountered. This study demonstrated that EBUS-TBNF is a safe procedure and provides diagnostic histological specimens of mediastinal lymph nodes.

[Perspectives in neurotology]

Vestibular diagnostics and therapy is the mirror of technological, scientific and socio-economics trends as are other fields of clinical medicine. These trends have led to a substantial diversification of the field of neurotology. The improvements in diagnostics have been characterized by the introduction of new receptor testing tools (e. g., VEMPs), progress in imaging (e. g., the endolymphatic hydrops) and in the description of central-vestibular neuroplasticity. The etiopathology of vestibular disorders has been updated by geneticists (e. g., the description of the COCH gene mutations), the detection of structural abnormalities (e. g., dehiscence syndromes) and related disorders (e. g. migraine-associated vertigo). The therapeutic options were extended by re-evaluation of techniques known a long time ago (e. g., saccus exposure), the development of new approaches (e. g., dehiscence repair) and the introduction of new drug therapy concepts (e. g., local drug delivery). Implantable, neuroprosthetic solutions have not yet reached experimental safety and validity and are still far away. However, externally worn neuroprosthetic solution were introduced in the rehab of vestibular disorders (e. g., VertiGuard system). These and related trends point into a medical future which is characterized by presbyvertigo as classical sign of the demographic changes ahead, by shortage of financial resources and a medico-legally over-regulated, even hostile environment for physicians in clinical medicine.

Anterior pituitary axis hormones and outcome in acute ischaemic stroke

BACKGROUND

Early and accurate prediction of outcome in acute stroke is important and influences risk-optimized therapeutic strategies. Endocrine alterations of the hypothalamic-pituitary axis are amongst the first measurable alterations after cerebral ischaemia. We therefore evaluated the prognostic value of cortisol, triiodothyronine (T3), free thyroxine (fT4), thyroid-stimulating hormone (TSH) and growth hormone (GH) in patients with an acute ischaemic stroke.

METHODS

In an observational study including 281 patients with ischaemic stroke, anterior pituitary axis hormones (i.e. cortisol, T3, fT4, TSH and GH) were simultaneously assessed to determine their value to predict functional outcome and mortality within 90 days and 1 year.

RESULTS

In receiver operating characteristic curve analysis, the prognostic accuracy of cortisol was higher compared to all measured hormones and was in the range of the National Institutes of Health Stroke Scale (NIHSS). Cortisol was an independent prognostic marker of functional outcome and death [odds ratio (OR) 1.0 (1.0-1.01) and 1.62 (1.37-1.92), respectively, P<0.0002 for both, adjusted for age and the NIHSS] in patients with ischaemic stroke, but added no significant additional predictive value to the clinical NIHSS score.

CONCLUSION

Cortisol is an independent prognostic marker for death and functional outcome within 90 days and 1 year in patients with ischaemic stroke. By contrast, other anterior pituitary axis hormones such as peripheral thyroid hormones and GH are only of minor value to predict outcome in stroke.

Tilting, bending, and nonterminal sites in CO/Cu(001)

Using scanning tunneling microscopy experiments in combination with first-principles calculations we have studied the geometric structure of the compressed c(7sqrt(2) × sqrt(2)) antiphase domain structure of CO on Cu(001). We find direct evidence for structural relaxations involving an inhomogeneous CO environment characterized by molecular tilting, bending, and nonterminal sites. Our analysis solves the long-standing problem of the adsorption structure of the compressed phase and is important for understanding the physical properties of this fundamental adsorption system.

Structural secrets of multiferroic interfaces

We present an experimental and theoretical study of the geometric structure of ultrathin BaTiO(3) films grown on Fe(001). Surface x-ray diffraction reveals that the films are terminated by a BaO layer, while the TiO(2) layer is next to the top Fe layer. Cations in termination layers have incomplete oxygen shells inducing strong vertical relaxations. Onset of polarization is observed at a minimum thickness of two unit cells. Our findings are supported by first-principles calculations providing a quantitative insight into the multiferroic properties on the atomic scale.

Treatment of advanced emphysema with emphysematous lung sealant (AeriSeal®)

BACKGROUND

This report summarizes initial tests of an emphysematous lung synthetic polymer sealant (ELS) designed to reduce lung volume in patients with advanced emphysema.

OBJECTIVES

The primary study objective was to define a therapeutic strategy to optimize treatment safety and effectiveness.

METHODS

ELS therapy was administered bronchoscopically to 25 patients with heterogeneous emphysema in an open-label, noncontrolled study at 6 centers in Germany. Treatment was performed initially at 2-4 subsegments. After 12 weeks, patients were eligible for repeat therapy to a total of 6 sites. Safety and efficacy were assessed after 6 months. Responses were evaluated in terms of changes from baseline in lung physiology, functional capacity, and health-related quality of life. Follow-up is available for 21 of 25 patients.

RESULTS

Treatment was well tolerated. There were no treatment-related deaths (i.e., within 90 days of treatment), and an acceptable short- and long-term safety profile. Physiological and clinical benefits were observed at 24 weeks. Efficacy responses were better among Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage III patients [n = 14; change in residual volume/total lung capacity (ΔRV/TLC) = -7.4 ± 10.3%; Δ forced expiratory volume in 1 s (ΔFEV(1)) = +15.9 ± 22.6%; change in forced vital capacity (ΔFVC) = +24.1 ± 22.7%; change in carbon monoxide lung diffusion capacity (ΔDLCO) = +19.3 ± 34.8%; change in 6-min walk test (Δ6MWD) = +28.7 ± 59.6 m; change in Medical Research Council Dyspnea (ΔMRCD) score = -1.0 ± 1.04 units; change in St. George's Respiratory Questionnaire (ΔSGRQ) score = -9.9 ± 15.3 units] than for GOLD stage IV patients (n = 7; ΔRV/TLC = -0.5 ± 6.4%; ΔFEV(1) = +2.3 ± 12.3%; ΔFVC = +2.6 ± 21.1%; ΔDLCO = -2.8 ± 17.2%; Δ6MWD = +28.3 ± 58.4 m; ΔMRCD = 0.3 ± 0.81 units; ΔSGRQ = -6.7 ± 7.0 units).

CONCLUSIONS

ELS therapy shows promise for treating patients with advanced heterogeneous emphysema. Additional studies to assess responses in a larger cohort with a longer follow-up are warranted.

Ultrafast magnon generation in an Fe film on Cu(100)

We report on a combined experimental and theoretical study of the spin-dependent relaxation processes in the electron system of an iron film on Cu(100). Spin-, time-, energy- and angle-resolved two-photon photoemission shows a strong characteristic dependence of the lifetime of photoexcited electrons on their spin and energy. Ab initio calculations as well as a many-body treatment corroborate that the observed properties are determined by relaxation processes involving magnon emission. Thereby we demonstrate that magnon emission by hot electrons occurs on the femtosecond time scale and thus provides a significant source of ultrafast spin-flip processes. Furthermore, engineering of the magnon spectrum paves the way for tuning the dynamic properties of magnetic materials.

Magnetic effects of defect pair formation in ZnO

In order to gain insight into the so-called d(0)-magnetic properties of defective ZnO we have carried out first principles calculations on various types of defects formed by intrinsic defects and doped atoms as well as pairs of them. The doped atoms include N and H. In agreement with previous works we find several possibilities to create magnetic defects especially by hole formation. Our results also show that two defects which are in the vicinity of each other and that are magnetic when isolated, in general become non-magnetic if one of them is acceptor-like and the other one donor-like. Furthermore, we have investigated the magnetic interaction of different defect pairs via total energy calculations, the results of which show in all cases the stability of ferromagnetic configurations. In order to reproduce the experimentally found localization of the magnetic hole states we have investigated the effect of applying correlation corrections on the p orbitals containing these holes.

Magnetoelectric coupling at metal surfaces

Magnetoelectric coupling allows the magnetic state of a material to be changed by an applied electric field. To date, this phenomenon has mainly been observed in insulating materials such as complex multiferroic oxides. Bulk metallic systems do not exhibit magnetoelectric coupling, because applied electric fields are screened by conduction electrons. We demonstrate strong magnetoelectric coupling at the surface of thin iron films using the electric field from a scanning tunnelling microscope, and are able to write, store and read information to areas with sides of a few nanometres. Our work demonstrates that high-density, non-volatile information storage is possible in metals.

Tuning independently the Fermi energy and spin splitting in Rashba systems: ternary surface alloys on Ag(111)

By detailed first-principles calculations we show that the Fermi energy and the Rashba splitting in disordered ternary surface alloys Bi(x)Pb(y)Sb(1 - x - y)/Ag(111) can be independently tuned by choosing the concentrations x and y of Bi and Pb, respectively. The findings are explained by three fundamental mechanisms, namely the relaxation of the adatoms, the strength of the atomic spin-orbit coupling, and band filling. By mapping the Rashba characteristics, i.e. the splitting k(R) and the Rashba energy E(R), and the Fermi energy of the surface states in the complete range of concentrations, we find that these quantities depend monotonically on x and y, with a very few exceptions. Our results suggest that we should investigate experimentally effects which rely on the Rashba spin-orbit coupling depending on spin-orbit splitting and band filling.

[A prospective comparison of video colonoscopy and CT colonography in asymptomatic patients screened for colorectal cancer]

BACKGROUND AND OBJECTIVE

It was the aim of this study to compare the sensitivity and specificity of low-dose CT colonography (CTC) with that of optical colonoscopy (OC) in asymptomatic patients undergoing these tests in a screening program for colonic cancer.

PATIENTS AND METHODS

58 patients (mean age 62.6 years) were included. They underwent low dose CTC and, immediately afterwards, colonoscopy. The colonoscopists were unaware of the CTC findings. A "second look" was performed if a lesion seen in CTC had been missed in the first colonoscopy.

RESULTS

A total of 150 lesions were detected and histologically confirmed. 136 were found to be polypoid lesions, classified as either hyperplastic polyps (n = 66) or polyps with intraepithelial neoplasia (n = 70). In the per-patient analysis only 22.4 % of patients had no polypoid lesion, 27.6 % had at least one hyperplastic and 50.0 % had at least one adenomatous lesion. Sensitivity for adenomas of all size categories was calculated 55.7 % for CTC and 92.9 % for OC. This marked difference (both for the detection of individual lesions and the per-patient analyses) does not reach significance in the two-sided McNemar test.

CONCLUSIONS

There was a high prevalence of lesions with intraepithelial neoplasia in this screening group. OC had a higher sensitivity than CTC in the detection of lesions smaller than 10 mm.