Kidney disease in trials of perioperative tranexamic acid

STUDY OBJECTIVE

To assess how kidney disease is handled in randomized trials evaluating the safety and efficacy of perioperative tranexamic acid, and to evaluate its effects across levels of kidney function.

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

SETTING

We screened studies from a previous comprehensive systematic review, and updated its search of PubMed, Embase, and Cochrane CENTRAL to July 31, 2023.

PATIENTS

Patients undergoing non-obstetric surgery.

INTERVENTIONS

Intravenous tranexamic acid compared to placebo or usual care without tranexamic acid.

MEASUREMENT

We summarized the handling of kidney disease in eligibility criteria, dose adjustments for kidney function, and effects of tranexamic acid on thrombotic events, seizures, and bleeding by subgroups of kidney function.

MAIN RESULTS

We evaluated 300 trials with 53,085 participants; 45,958 participants (86.6%) were enrolled in 228 trials (76.0%) that explicitly excluded patients with kidney disease. Definitions of kidney diseased used for exclusion varied widely. Most were non-specific and some corresponded to mild disease. Only 5 trials adjusted dosing for kidney function. Meta-analysis of two large trials found tranexamic acid unlikely to substantially increase or decrease the occurrence of thrombotic events in patients with eGFR <60 mL/min/1.73m2 (RR, 0.95; 95% CI: 0.83 to 1.07) or ≥ 60 mL/min/1.73m2 (RR, 1.00; 95% CI, 0.91 to 1.11; P for subgroup difference = 0.47), but both trials excluded patients with severe kidney disease. No analysis could be performed regarding seizure risk. One large trial in noncardiac surgery reported similar reduction in bleeding across subgroups of kidney function but excluded patients with creatinine clearance <30 mL/min.

CONCLUSIONS

The large evidence base supporting perioperative tranexamic acid suffers from broad and unjustified exclusion of patients with kidney disease. Typical perioperative dosing of tranexamic acid is likely safe and effective in patients with creatinine clearance >30 mL/min, but effects in more severe kidney disease are unknown.

Cellular blue nevus tumor presenting as a submandibular lymph node in a 16-year-old

The cellular blue nevus tumor is a type of dendritic melanocytic nevus that is typically benign and exceedingly rare. The incidence of all blue nevi is about 1%, usually affecting the adult population and appearing on the extremities, sacrococcygeal or gluteal regions. There have only been a handful of case reports cited in the literature where cellular blue nevi present in the head and neck region, usually affecting the scalp and young adult population (7, 8). As such, it is exceedingly rare to encounter a cellular blue nevus tumor in the neck or infiltrating into neck lymph nodes. Here we report a rare case of a cellular blue nevus tumor presenting as a right neck mass in a pediatric 16-year-old patient, shown to invade into the submandibular lymph node and surrounding soft tissue. It is important to be aware of the cellular blue nevus tumor as a differential diagnosis in pediatric neck masses. Histological evaluation is necessary to determine tumor aggression and malignant potential which can guide further treatment in pediatric patients.

External carotid artery pseudoaneurysm following upper respiratory infection masquerading as a pharyngeal abscess in an 8-month-old

Pseudoaneurysms are very rare with an incidence of less than 0.1% in the pediatric population. Approximately 30 cases of carotid artery aneurysms in children have been published in the literature, usually affecting children over one year of age. We present one of the youngest cases in the literature; the patient is an 8-month old female with a strep throat infection complicated by pseudoaneurysm development of the external carotid artery. Because of the rarity of these lesions, there is little known regarding the types of clinical presentation and management. They are commonly the result of direct arterial trauma; however, they can also occur secondary to infection, connective tissue disease or arteritis. We are presenting a case with a highly atypical presentation. When present, pseudoaneurysms harbor the potential risk of life-threatening hemorrhage and warrant immediate management. It is important to be aware of cases and the treatment modalities used to guide future diagnosis and planning.

Investigating the Knowledge, Attitudes and Behaviours of Parents Regarding Vaccine Rejection

Background

With an escalating prevalence, vaccine rejection is one of the ten threats to global health as identified by the World Health Organization in 2019. Vaccine rejection and hesitancy can be defined as the hesitancy of individuals to get vaccinated against diseases that can be prevented by vaccination. This study aimed to investigate the knowledge, attitudes and behaviours of parents who use primary healthcare services.

Methods

Conducted between August and September 2019, this study adopted a descriptive cross-sectional design. The sample size of the study was calculated to be 378, considering a 95% confidence interval and 80% power. The survey form, the data collection tool of the study, included questions concerning sociodemographic characteristics of individuals and their knowledge, attitudes and behaviours regarding vaccination. The data were analysed on SPSS 22.0. Chi-square test was used in statistical analyses, and the significance level was set as p &lt; 0.05.

Results

In the study group, 15.5% of the parents stated that they were hesitant about vaccines in childhood, 81.3% stated that their source of information on vaccines was healthcare staff and 28% stated that it was the internet. The hesitancy level was significantly high among those who believed that vaccines led to autism and infertility and those who did not trust pharmaceutical companies (p &lt; 0.05). The hesitancy level regarding vaccines was significantly lower among those whose source of information was healthcare staff, whereas it was significantly higher among those whose source of information was the internet (p &lt; 0.05).

Conclusions

Parents' beliefs that vaccines led to autism and infertility increased their hesitancy levels. The inaccurate information on the internet and social media increased their hesitancy levels. Hesitancy levels were lower among the parents who received information from healthcare staff.

Key messages

Healthcare staff should organise public trainings on vaccines to reduce the hesitancy levels of parents. Anti-vaccination statements on the internet and social media influence individuals’ vaccination behaviours.

Duplication of the pituitary gland and basilar artery, with multiple midline fusion defects and craniofacial anomalies

Duplication of the pituitary gland (DPG) is a phenomenon with no clear syndromic association. This case adds to the literature as a DPG-plus syndrome patient with multiple fusion defects of unknown etiology, fetal risk factors of first trimester tobacco usage and intrauterine drug exposure. An 8-month old female presented with noisy breathing, poor feeding, cleft palate, seizures and failure to thrive. MRI scan revealed duplicate pituitary gland, tubomammillary fusion, absent cleavage of brainstem and superior cerebellar peduncles, and cervical spinal malformations. We performed an airway evaluation, with a glossomandibulopexy for glossoptosis, and a primary palate repair.

Effect of chitosan on sealer penetration into the dentinal tubules

Objective

The objective of this study is to compare the effectiveness of final irrigation with chitosan, ethylenediaminetetraacetic acid (EDTA), and citric acid (CA) on a resin-based sealer (AH plus sealer [Dentsply DeTrey, Konstanz, Germany]) penetration into dentinal tubules using confocal laser scanning microscopy.

Materials and Methods

Seventy recently extracted human mandibular premolars were instrumented and irrigated with sodium hypochlorite (NaOCl), then divided into four groups according to the final irrigation regimen used: (1) the EDTA group: 17% EDTA + 2.5% NaOCl, (2) the CA group: 10% CA + 2.5% NaOCl, (3) the chitosan group: 0.2% chitosan + 2.5% NaOCl, and (4) the control group: 2.5% NaOCl. All teeth were obturated using the cold lateral condensation technique with gutta-percha and AH Plus sealer labeled with fluorescent dye. The apical 2 mm of specimen was discarded, and slices were obtained for apical, middle, and coronal thirds of the root with 1 mm intervals. Maximum, mean, and percentage of sealer penetration (SP) inside tubules were measured using confocal laser scanning microscopy.

Results

The percentage of SP was significantly higher in chitosan, EDTA, and CA group than control group for coronal thirds (P < 0.05), whereas there was no significant difference among all groups for middle and apical thirds. Chitosan and EDTA showed increased mean values of SP depth for middle thirds (P < 0.05). In all sections, the maximum depth of SP was significantly lower in EDTA group than other groups (P < 0.05).

Conclusions

Chitosan, EDTA, and CA significantly improved the percentage of SP for coronal thirds.

Traumatic Rupture of Giant Pulmonary Hydatid Cyst in a Child

Introduction

Trauma as a cause of hydatid cyst rupture leads to various clinical conditions, especially in children. Current literatures regarding the clinical presentation and management of such patients are rare.

Case report

A 14-year-old child was admitted with chest pain and dyspnoea due to blunt thoracic trauma after falling off a bicycle. Chest computed tomography showed right hydropneumothorax and cystic cavity. After chest tube insertion, massive air leak was observed from the tube. Cystotomy and capitonnage were performed on the right lower lobe via a posterolateral thoracotomy. He was discharged from the hospital in good condition.

Conclusion

Ruptured hydatid cysts into the pleura are difficult to diagnose radiologically. It can be misdiagnosed radiologically as empyema or hydrothorax. In undetermined cases, all the findings may be suggestive but not diagnostic. Operation must be performed early for exploration when the condition is suspected. High complication rate has been found in children who were operated late.

Diffuse, encasing lymphangioma of the supraglottis

BACKGROUND

Lymphangioma of the head and neck is considered a rare congenital tumor with the vast majority presenting before two years of age. Surgical excision and sclerosing therapy using OK-432 are recognized as effective treatment options for the majority of these lesions; however, treatment options of laryngeal lesions are less straightforward due to the risk of airway compromise and the desire to maintain the integrity of a functional larynx. We present the case of a four month old male who presented with chief complaint of inspiratory stridor after a single episode of pneumonia. His clinical presentation, flexible fiberoptic laryngoscopic examination, and operative evaluation were consistent with a lymphangioma completely encasing the epiglottis and arytenoids and isolated to the supraglottis. This report outlines our approach to workup and treatment of this rare lesion.

METHOD

Case report of presentation, diagnosis and treatment is presented.

RESULTS

A four-month old male presented to ENT clinic with inspiratory stridor, worsened with crying, without frank respiratory distress. History and initial examination was consistent with airway obstruction. Flexible fiberoptic laryngoscopy showed laryngomalacia as well as diffuse and symmetric supraglottic edema. Surgical evaluation identified edema limited to the supraglottis, notably along the ventral surface of the epiglottis and dorsal surface of bilateral arytenoids. Biopsies were taken and immunohistochemical staining was performed with strong positivity for D2-40 and CD31, supporting the diagnosis of isolated lymphangioma of the supraglottis. Treatment was performed through multiple point spot welding with a fiber equipped CO2 LASER (OmniGuide TM) at 5 watt continuous power.

CONCLUSION

Isolated supraglottic lymphangioma was diagnosed via direct laryngoscopy, with pathologic and immunohistochemical confirmation. Carbon dioxide laser spot welding technique was used with excellent clinical improvement in stridor. Clinical improvement is sustained after 6 months follow-up.

Bullous skin reaction seen after extravasation of calcium gluconate

Intravenous (IV) calcium is usually given to temporarily treat the effects of hyperkalaemia on muscle and heart. When extravasation of a calcium gluconate infusion occurs, there may be rapid and marked swelling and erythema, with signs of soft-tissue necrosis or infection, and ensuing extensive local calcification, called calcinosis cutis. We report a 26-year-old woman who was hospitalized for exacerbation of acute intermittent porphyria. She had a history of hypertension and chronic renal failure. On the second day of her hospitalization, she developed hyperpotassaemia (6.7 mEq/L potassium; normal range 3.5-5 mEq/L). She was given an IV infusion of 10 mL calcium gluconate into the left dorsal pedal vein. Bullous skin reactions occurred in the infusion area nearly 2 h after administration. The patient's leg was elevated and the lesions cleaned with 0.9% saline. By day 9 of hospitalization, the lesions had markedly regressed. Several drugs have been associated with dermoepidermal blistering as an adverse drug reaction, but there is only one existing report in the literature about this side-effect associated with calcium gluconate. Clinicians should be alert to the possibility of bullous skin reactions, which may be a predictor of extravasation and necrosis, when treating patients with IV calcium gluconate.

The association of oxidative stress and nasal polyposis

Many diseases are linked to damage from reactive oxygen species that occurs from an imbalance between reactive oxygen species and antioxidants, a condition called oxidative stress. Nasal polyposis is considered to be an inflammatory condition in nasal and paranasal sinus cavities and its aetiology is still unclear. There are very few data on epithelial changes in nasal polyposis and their relationship with free radical damage. Malondialdehyde as a major end-product of lipid peroxidation, and superoxide dismutase and nitric oxide as antioxidants play important roles in oxidative stress. In this study, the concentrations of malondialdehyde, superoxide dismutase and nitric oxide were compared in normal and nasal polyposis-affected tissue samples. Malondialdehyde levels were significantly higher, and superoxide dismutase and nitric oxide levels were significantly lower in patients with nasal polyposis compared with the control group. This study demonstrates that there is a strong relationship between oxidative stress and the pathogenesis of nasal polyposis.

Effectiveness of transmeatal low power laser irradiation for chronic tinnitus

Objective:

To evaluate effectiveness of 5 mW laser irradiation in the treatment of chronic tinnitus.

Study design:

Prospective, randomised, double-blind study.

Methods:

This investigation included 66 ears in 45 patients with chronic unilateral or bilateral tinnitus. A 5 mW laser with a wavelength of 650 nm, or placebo laser, was applied transmeatally for 15 minutes, once daily for a week. A questionnaire was administered which asked patients to score their symptoms on a five-point scale, before and two weeks after laser irradiation. A decrease of one scale point, regarding the loudness, duration and degree of annoyance of tinnitus, was accepted to represent an improvement.

Results:

The loudness, duration and degree of annoyance of tinnitus were improved, respectively, in up to 48.8, 57.7 and 55.5 per cent of the patients in the active laser group. No significant improvement was observed in the placebo laser group.

Conclusion:

Transmeatal, low power (5 mW) laser irradiation was found to be useful for the treatment of chronic tinnitus.

Iloprost-induced sudden hearing loss

We report a patient who developed sudden, bilateral, sensorineural hearing loss during therapeutic use of iloprost for Raynaud's phenomenon. The sudden hearing loss was attributed to iloprost use and completely reversed in eight days with conservative therapy. Iloprost may be a potentially ototoxic drug, causing sudden hearing loss.

Human papilloma virus prevalence in laryngeal squamous cell carcinoma

PURPOSE

To determine the prevalence and type of human papilloma virus deoxyribonucleic acid (DNA) in cases of laryngeal squamous cell carcinoma.

METHODS

We analysed the prevalence of human papilloma virus infection in archived paraffin block specimens taken from 99 cases of laryngeal squamous cell carcinoma between 1990 and 2005, using polymerase chain reaction techniques. Biopsy specimens from five proven verrucous skin lesions were used as positive controls, and peripheral blood samples from five healthy volunteers were used as negative controls.

RESULTS

Four test samples were found to have inadequate deoxyribonucleic acid purity and were therefore excluded from the study. Human papilloma virus deoxyribonucleic acid was detected in seven of 95 cases of laryngeal squamous cell carcinoma (7.36 per cent). Human papilloma virus genotyping revealed double human papilloma virus infection in three cases and single human papilloma virus infection in the remaining four cases. The human papilloma virus genotypes detected were 6, 11 and 16 (the latter detected in only one case).

CONCLUSION

In our series, a very low human papilloma virus prevalence was found among laryngeal squamous cell carcinoma cases. The human papilloma virus genotypes detected were mostly 6 and/or 11, and 16 in only one case. To the best of our knowledge, this is the first report of human papilloma virus prevalence in laryngeal squamous cell carcinoma, based on polymerase chain reaction genotyping in a Turkish population.

Evaluation of the outcomes of short bowel syndrome and indications for intestinal transplantation

Long-term parenteral nutrition (PN) and intestinal transplantation (IT) are life-saving therapies for patients with short bowel syndrome (SBS). However, indications and timing of these therapies are controversial. In this study we aimed to evaluate the indications for IT. Forty-two patients, each with <100 cm of small bowel, were divided into three groups according to the length of remnant: group I patients (n = 18): colon plus 50 to 100 cm of small bowel (SB); group II patients (n = 14): colon plus <50 cm of SB; and group III patients (n = 10): <50 cm of SB without colon. One-year mortality rates for groups I, II, and III were 50%, 72%, and 100%, respectively. All group I survivors developed intestinal adaptation, returning to regular oral feedings at 1 year. Interestingly, three of four surviving patients in group II developed adaptation and were fed an oral short bowel diet (SBD) at 1 year. None of the group III patients survived >1 year, dying due to multiorgan failure in the early postoperative period or from sepsis within 1 year. We conclude that patients with a very short bowel are candidates for IT when stable. If the colon is intact, however, regardless of small bowel remnant length, the patient should be given a chance to develop intestinal adaptation before making the decision for permanent PN or IT.

Significance of p53 and bcl-2 immunoexpression in the prognosis of laryngeal squamous cell carcinoma

This study was undertaken to determine whether p53 or bcl-2 immunoexpression has any significance in the prognosis of laryngeal squamous cell carcinoma. Eighty-four cases of laryngeal squamous cell carcinoma at different pathological stages and locations were studied. All patients were treated surgically first, and followed up for 6-96 months (mean, 35 months). p53 and bcl-2 immunoexpression in tumour cells, evaluated by image analysis and histoscore, were found in 71.4% and 46.4% of tumours, respectively. Glottic location was correlated with significantly longer survival than tumours at other locations. Pathological stage and histological grade of tumour were also significant predictors of survival. Neither p53 nor bcl-2 immunoexpression was found to be predictive of post-operative survival. Only transglottic tumours expressed significantly high levels of bcl-2. Both methods used to evaluate p53 and bcl-2 immunoexpression correlated well with each other. This study suggests that immunoexpression of p53 and bcl-2 is not a significant prognostic predictor in laryngeal squamous cell carcinoma.

Single-photon tunneling via localized surface plasmons

Strong evidence of a single-photon tunneling effect, a direct analog of single-electron tunneling, has been obtained in the measurements of light tunneling through individual subwavelength pinholes in a gold film covered with a layer of polydiacetylene. The transmission of some pinholes reached saturation because of the optical nonlinearity of polydiacetylene at a very low light intensity of a few thousand photons per second. This result is explained theoretically in terms of a "photon blockade," similar to the Coulomb blockade phenomenon observed in single-electron tunneling experiments. Single-photon tunneling may find applications in the fields of quantum communication and information processing.

Antibiotic theory in otitis media

Otitis media is currently the most common diagnosis made by clinicians, which has a major impact on managed care. The emergence of resistant bacterial pathogens has caused controversy over the use of antibiotics when acute otitis media (AOM) is diagnosed. All infants with AOM and all older children with severe AOM should be treated with antibiotics, despite concerns about rising rates of resistant bacterial pathogens. Some older children with nonsevere AOM may be candidates for initial observation, although this is not confirmed by clinical trials. Antimicrobial agents are not required for otitis media with effusion of recent onset but may be considered if this effusion becomes chronic; in these cases, tympanostomy tube placement may be indicated. Antimicrobial prophylaxis for prevention of recurrent AOM should be reserved for selected patients because of the possible emergence of resistant organisms. Tympanostomy tube placement is a more reasonable option today.

Location and gross morphology of the nasopalatine duct in human adults

OBJECTIVE

To characterize the nasal opening of the human nasopalatine duct (NPD; a major duct of the vomeronasal system used in animals for chemical communication) by identifying its location, categorizing variations in physical characteristics, and assessing frequency of detection.

DESIGN

Two studies: (1) general study incorporating endoscopic examinations documented by videotapes and photographs, and an investigation of detection bias in terms of method of visualization and defining criteria for NPD identification; and (2) cadaver dissections examining NPD gross anatomy and proximity to the putative vomeronasal organ (VNO), the second major duct of the vomeronasal system.

SETTING

Department of Otolaryngology, University of Chicago Hospitals, Chicago, Ill.

SUBJECTS

A total of 125 university community volunteers, with a mean age of 23 years.

RESULTS

(1) General study: NPD was located 1.9+/-0.02 cm (mean+/-SEM) dorsal to the columella nasi, and 0.2+/-0.01 cm above the nasal floor/septum junction, in both nostrils (90% bilateral), and was symmetrical in shape. An NPD was detected in 94% of 221 nostrils unobstructed in the region of interest. Fossa shapes were oval (57%), round (18%), spindle-shaped (18%), and tubular (7%). A small, round aperture was visualized in 30% of fossae. Among 3 observers, NPD detection frequency ranged from 94% to 40%, with the disparity due to inclusion of different defining characteristics. (2) Cadaver dissection study: bilateral nasal NPD fossae were found in every specimen probed to maximum approximate depth of 8 mm. No buccal pits associated with patent NPD were detected. Putative VNOs superior and just anterior to NPD fossae were detected in fewer than half the specimens.

CONCLUSIONS

The nasal opening of the NPD is bilateral and symmetrical, located at the base of the nasal septum. Unusually contradictory anatomical descriptions in the human putative VNO literature may be attributable to inexact descriptions or misidentification of structures. The function of NPD remains controversial.

Loratadine/pseudoephedrine for nasal symptoms in seasonal allergic rhinitis: a double-blind, placebo-controlled study

In this double-blind, placebo-controlled, crossover, parallel study, we treated 20 adults who had seasonal allergic rhinitis with once-daily fixed-combination loratadine/pseudoephedrine sulfate to observe its effect on relieving symptoms, primarily nasal congestion. Acoustic rhinometry detected a trend toward improvement in nasal patency, although the difference between pre- and post-treatment measures was not statistically significant. Endoscopic inferior turbinate photography documented that treatment led to statistically significant reductions in the amount of nasal edema and nasal secretions. The results of a quality-of-life questionnaire suggested that treatment alleviated nasal and ocular symptoms of rhinoconjunctivitis. An analysis of subjective visual analog scale scores showed a trend toward improvement in most but not all nasal symptoms. We conclude that once-a-day fixed-combination loratadine/pseudoephedrine is effective in relieving nasal congestion in patients with seasonal allergic rhinitis.

Pediatric obstructive sleep apnea syndrome

Pediatric obstructive sleep apnea occurs in about 2% of children, and manifests as snoring, difficulty breathing, and witnessed apneic spells. Daytime symptoms include excessive sleepiness with poor performance and behavior problems. Severe forms may be associated with failure-to-thrive or death. The gold standard diagnostic procedure is overnight polysomnography and is indicated in high-risk patients. While most pediatric patients with obstructive sleep apnea can be treated with tonsillectomy and adenoidectomy; uvulopalatopharyngoplasty, tracheotomy, or other procedures are sometimes indicated. Nonsurgical treatment with continuous positive airway pressure is used in some children. Postoperative management in high-risk children includes careful perioperative monitoring and postoperative polysomnography.

ImmunoCAP and HY*TEC enzyme immunoassays in the detection of allergen-specific IgE compared with serial skin end-point titration by receiver operating characteristic analysis

OBJECTIVES

In this study, we compared 2 different immunoassays, HY*TEC enzyme immunoassay (Hycor Biomedical Inc, Garden Grove, CA) and Pharmacia Upjohn ImmunoCAP (Pharmacia and Upjohn, Kalamazoo, MI) using skin end-point titration as a gold standard by receiver operating characteristic analysis.

MATERIALS

One hundred patients were enrolled in this study and were tested with the above 3 modalities. The results were analyzed by receiver operating characteristic analysis, in which the curves give a decision criterion for any diagnostic test relative to its sensitivity and specificity against an accepted gold standard test. Only inhalant allergens (Dermatophagoides pteronyssinus, Dermatophagoides farina, cat dander, giant ragweed, English plantain weed, timothy grass, Alternaria tenuis, Aspergillus fumigatus, meadow fescue, oak tree, white ash tree, and lamb's-quarter weed) were studied.

RESULTS

The results obtained with both ImmunoCAP and HY*TEC showed a good correlation with skin end-point titration for D pteronyssinus, D farina, cat dander, giant ragweed, timothy grass, A tenuis, and meadow fescue, with sensitivities ranging from 71% to 88%. However, the sensitivity of both tests to English plantain weed, lamb's-quarter weed, oak tree, and white ash tree was lower (66% down to 39%). Additionally, HY*TEC results were not satisfactory for detecting specific IgE to A fumigatus (30% sensitivity). The overall sensitivity for each test was 65.67% for the HY*TEC and 71.25% for the ImmunoCAP.

CONCLUSION

The 2 in vitro testing systems are comparable for most of the allergens, except for A fumigatus, English plantain, lamb's-quarter, and white ash tree; ImmunoCAP and HY*TEC would benefit from improved technology for detecting these specific IgE antibodies. The HY*TEC assay did not give acceptable results for A fumigatus. The overall assay characteristics were good to excellent for each system tested.

Effect of nasal surgery on the nasal cavity as determined by acoustic rhinometry

Acoustic rhinometry (AR) was used to objectively measure the success of septoplasty in relieving nasal obstruction caused by septal deviation. In addition, the patients were given a questionnaire to subjectively assess symptoms of congestion, rhinorrhea, and sneezing. Patients diagnosed with a septal deviation requiring surgery to eliminate obstruction were enrolled in this study. A septal deviation often results in concomitant sinonasal or respiratory problems that require septoplasty plus other surgeries to treat the patient effectively. AR measurements for patients who underwent septoplasty or septoplasty plus other surgeries were taken before and after surgery. To avoid confounding results caused by different levels of congestion, we used only postdecongestant values to analyze the data and only the side of the nose with the smaller volume for analysis. Patients in the septoplasty-only group showed a statistically significant (P < 0.01) increase in volume as measured by AR, a decrease in the symptom of congestion, and a decrease in the symptom of rhinorrhea. Patients who had septoplasty plus other sinonasal procedures showed significant increases in volume and cross-sectional area (CSA) 3, whereas CSAs 1 and 2 increased also, but not significantly.

Decreased neuropeptide release may play a role in the pathogenesis of nasal polyps

In this in vivo prospective, controlled study, we have examined the capsaicin-induced levels and secretion patterns of the colocalized neuropeptides substance P, calcitonin gene-related peptide (CGRP), and neurokinin A in nasal secretions of subjects with nasal polyps, and we compared these with secretion patterns from healthy subjects and from subjects with allergic rhinitis. Capsaicin was used to elicit neuropeptide release. The neuropeptide levels were measured by an ELISA technique. For substance P, subjects with nasal polyps responded very poorly to capsaicin stimulation. The atopic group was more reactive to capsaicin stimulation than control subjects. For CGRP the increase was immediate in all groups. Atopic subjects and subjects with polyps had a less pronounced but sustained response to capsaicin stimulation. CGRP levels in atopic subjects and those with polyps were restored rapidly. Atopic subjects had higher neurokinin A levels with an immediate and sustained response to capsaicin. Control subjects had higher levels than those with polyps, but both groups were nonresponsive to capsaicin stimulation.

Comparison of the response to histamine challenge of the nose and the maxillary sinus: effect of loratadine

To study the response of the maxillary sinus to histamine provocation, we performed a double-blind, randomized, crossover trial during which nonallergic subjects without symptoms of rhinitis (n = 25) received either 10 mg loratadine or placebo once daily for a week and then underwent nasal challenge with histamine (3, 10, and 30 mg/ml) followed, 24 h later, by a maxillary sinus challenge while still receiving the medication. Nasal challenge with histamine led to significant increases in vascular permeability, reflex nasal secretions, sneezing, and other nasal symptoms. Sinus challenge resulted in significant increases in vascular permeability within the sinus cavity (P < 0.01) and some nasal symptoms but no significant change in reflex nasal secretions. The response of the sinus mucosa to histamine was lower in magnitude than that of the nose. Treatment with loratadine resulted in a significant inhibition of the histamine-induced changes in both nasal and sinus cavities. Our data suggest the lack of a sinonasal reflex response to histamine provocation of the maxillary sinus of nonallergic individuals.

Detection of the nasal cycle with acoustic rhinometry: techniques and applications

Acoustic rhinometry is an appropriate method for detecting and recording the nasal cycle in normal subjects in terms of the cross-sectional areas and volume of the nasal cavity. In this study, we tried to detect and to define the nasal cycle in normal subjects so that we might develop a reliable and reproducible technique to be used in conjunction with studies on the physiology and pathology of nasal disease. We used normal volunteer adult subjects and performed bilateral acoustic rhinometry measurements every 15 minutes over 4 hours, along with the use of a visual analog scale for assessment of the subjective feeling of congestion (or patency) just before each acoustic rhinometry measurement. Volume and cross-sectional area changes were observed along with subjective patency-score changes in each subject. The subjective feeling of patency was not related to the volume and cross-sectional area changes measured simultaneously. The technique of recording the nasal cycle with acoustic rhinometry in nasal research is presented.

Normative standards for nasal cross-sectional areas by race as measured by acoustic rhinometry

Acoustic rhinometry evaluates the geometry of the nasal cavity with acoustic reflections and provides information about nasal cross-sectional area and nasal volume within a given distance. Variations in internal nasal diameters have attracted increased interest since the advent of endoscopic surgical techniques. Race is known to be one of the most important factors affecting the nasal structure. In this study, we evaluated 106 healthy adult volunteers with acoustic rhinometry to determine internal nasal diameters and volumes and obtained normative data for four racial/ethnic groups. The data were analyzed with regard to race, sex, height, and weight. All measurements were made before and after the application of a topical nasal decongestant so that the effects of the nasal cycle were eliminated by decongestion.

Fungal sinusitis: progression of disease in immunosuppression--a case report

Fungal sinusitis is a disease which can be grouped into invasive and noninvasive forms. The invasive entities include the acute/fulminant and chronic/indolent forms. The noninvasive entities include the fungus ball and allergic forms. The noninvasive forms, however, can develop into invasive disease under certain immunosuppressive states. The patient in this case report had the fungus ball form of fungal sinusitis which evolved into chronic, and then the acute/fulminant form approximately two weeks after undergoing cadaver-donor kidney transplantation. Due to the patient's immunosuppressed state, the fungus spread beyond the sinus region and eventually lead to fulminant disseminated disease. The severity of the fungal disease corresponded directly to the severity of the patient's immunosuppression.

Allergy for the laryngologist

Allergic disease can affect any portion of the respiratory tract, including the larynx, trachea, bronchial tree, nasal cavity, paranasal sinuses, nasopharynx, and pharynx. This review evaluates laryngeal manifestations of allergic disease and the impact of allergic mechanisms in disorders, within the scope of laryngology.

Prevalence of Mold-Specific Immunoglobulins in a Midwestern Allergy Practice

Mold allergy surveys are an important part of the correct identification and treatment of mold allergies. This study included 100 patients who were referred to a Midwestern allergy clinic for the evaluation of rhinitis, suspected to be of allergic origin. An in vitro screening test for allergen-specific IgE (ImmunoCAP) comprised of 10 allergens, including Candida, Aspergillus, Helminthosporium, and Alternaria, was used. To assess the seasonal distribution of mold allergies, we randomly selected 8 patients out of the 100 from each season during which the clinical contact occurred, and we tested them for 14 varieties of mold. The overall incidence of mold allergy in atopic subjects was 44%. The most common molds were (in descending order of frequency) Alternaria, Helminthosporium, Aspergillus, Candida, and Curvularia. Mold allergy was diagnosed most frequently in the winter; the second highest period was the fall. Population surveys of IgE antibody sensitization by in vitro techniques can provide useful information about fungal allergy.

Prevalence of mold-specific immunoglobulins in a Midwestern allergy practice

Mold allergy surveys are an important part of the correct identification and treatment of mold allergies. This study included 100 patients who were referred to a Midwestern allergy clinic for the evaluation of rhinitis, suspected to be of allergic origin. An in vitro screening test for allergen-specific IgE (ImmunoCAP) comprised of 10 allergens, including Candida, Aspergillus, Helminthosporium, and Alternaria, was used. To assess the seasonal distribution of mold allergies, we randomly selected 8 patients out of the 100 from each season during which the clinical contact occurred, and we tested them for 14 varieties of mold. The overall incidence of mold allergy in atopic subjects was 44%. The most common molds were (in descending order of frequency) Alternaria, Helminthosporium, Aspergillus, Candida, and Curvularia. Mold allergy was diagnosed most frequently in the winter; the second highest period was the fall. Population surveys of IgE antibody sensitization by in vitro techniques can provide useful information about fungal allergy.

A comparison of the nasal cross-sectional areas and volumes obtained with acoustic rhinometry and magnetic resonance imaging

Acoustic rhinometry (AR) evaluates the geometry of the nasal cavity with acoustic reflections and provides information about nasal cross-sectional areas (CSA) and nasal volume within a given distance. The accuracy of the information obtained by AR was compared with that of magnetic resonance imaging (MRI) of the nasal cavity. Five healthy subjects were evaluated with AR and the MRI before and after the application of a long-acting nasal decongestant spray, to eliminate possible interference of the nasal cycle with both measurement techniques. The MRI images of 2 mm coronal sections of the nasal cavity were traced by three independent observers and the CSAs were calculated by computer-aided imaging digitization, to be compared with the calculated CSAs obtained with the AR at the corresponding distance from the nasal tip. Digitized data from the MRI images were also used to calculate the nasal volume within the first 6 cm from the nasal tip and compared with the AR volume measurements. The interobserver variation of digitized MRI data predecongestant and postdecongestant was not significant. The correlations of CSA and volume measurements between the AR and MRI were high (0.969) after the application of the decongestant. The correlation between the AR and MRI measurements before the decongestant was low (0.345). This may have been the result of interference of the nasal cycle during the long MRI measurements (1 hour) or other unknown factors. We conclude that AR measurements of nasal CSAs and volumes provide accurate information when compared with the MRI of the decongested nasal airway.

Evaluation of the nasal cavity by acoustic rhinometry in normal and allergic subjects

With acoustic rhinometry, one can detect a difference in response to a topical decongestant between normal and allergic subjects at the minimal cross-sectional area. The minimal cross-sectional area corresponds in most cases to the anterior end of the inferior turbinate or the first valley, which occurs after the nose piece of the acoustic rhinometer on the acoustic rhinometry graph. Allergic patients typically have an increase in nasal mucosal swelling, which leads to a decrease in the nasal volume and area and, subsequently, to an increase in congestion. In this study acoustic rhinometry was used to test normal and allergic subjects before and after the application of a topical decongestant (1% phenylephrine (Neo-Synephrine)). Symptoms were measured by a five-point scale. Results showed that increasing symptom scores demonstrated a trend toward being related to decreasing area as measured at the minimal cross-sectional area or nasal valve. The average total percent change at the minimal cross-sectional area was calculated for both groups and compared. The normal subjects had an average total percent area change at the minimal cross-sectional area of 15.6% ± 14.8%, and the allergic subjects had a percent change of 24.6% ± 20.8%. This represents a significant difference between the normal and allergic subjects in response to the topical decongestant at the minimal cross-sectional area ( p = 0.04). However, the average total percent change was not significantly different between the two groups at the second and third valleys. At the second valley, the normal subjects had a percent change of 40% ± 17.5%, and the allergic subjects had a percent change of 36% ± 18.5%. At the third valley, the normal subjects had a percent change of 35% ± 15.4%, and the allergic subjects had a percent change of 32% ± 20.6% ( p = 0.4 and 0.5, respectively). The total area was calculated by adding measurements from both right and left nasal cavities for each subject in an attempt to control the effect of the nasal cycle. Acoustic rhinometry makes it possible to detect a trend in the relationship between either a decrease in area at the minimal cross-sectional area or a decrease in the total volume from 0 to 7 cm into the nasal cavity and congestion. A statistically significant difference between normal and allergic subjects in their response to a topical decongestant at the minimal cross-sectional area was detected by acoustic rhinometry at the nasal valve.

Evaluation of the nasal cavity by acoustic rhinometry in normal and allergic subjects

With acoustic rhinometry, one can detect a difference in response to a topical decongestant between normal and allergic subjects at the minimal cross-sectional area. The minimal cross-sectional area corresponds in most cases to the anterior end of the inferior turbinate or the first valley, which occurs after the nose piece of the acoustic rhinometer on the acoustic rhinometry graph. Allergic patients typically have an increase in nasal mucosal swelling, which leads to a decrease in the nasal volume and area and, subsequently, to an increase in congestion. In this study acoustic rhinometry was used to test normal and allergic subjects before and after the application of a topical decongestant (1% phenylephrine (Neo-Synephrine)). Symptoms were measured by a five-point scale. Results showed that increasing symptom scores demonstrated a trend toward being related to decreasing area as measured at the minimal cross-sectional area or nasal valve. The average total percent change at the minimal cross-sectional area was calculated for both groups and compared. The normal subjects had an average total percent area change at the minimal cross-sectional area of 15.6% +/- 14.8%, and the allergic subjects had a percent change of 24.6% +/- 20.8%. This represents a significant difference between the normal and allergic subjects in response to the topical decongestant at the minimal cross-sectional area (p = 0.04). However, the average total percent change was not significantly different between the two groups at the second and third valleys. At the second valley, the normal subjects had a percent change of 40% +/- 17.5%, and the allergic subjects had a percent change of 36% +/- 18.5%. At the third valley, the normal subjects had a percent change of 35% +/- 15.4%, and the allergic subjects had a percent change of 32% +/- 20.6% (p = 0.4 and 0.5, respectively). The total area was calculated by adding measurements from both right and left nasal cavities for each subject in an attempt to control the effect of the nasal cycle. Acoustic rhinometry makes it possible to detect a trend in the relationship between either a decrease in area at the minimal cross-sectional area or a decrease in the total volume from 0 to 7 cm into the nasal cavity and congestion. A statistically significant difference between normal and allergic subjects in their response to a topical decongestant at the minimal cross-sectional area was detected by acoustic rhinometry at the nasal valve.

Pediatric sinusitis: a literature review with emphasis on the role of allergy

Evaluation and treatment of pediatric sinusitis is a challenging area that has been subject to many different opinions and options during the past decade. Sinusitis is among the most commonly encountered diseases of childhood and has been the major area of interest for many otolaryngologists, allergists, and pediatricians. We have searched the medical literature to review the many aspects of the problem and the opinions of various authors. The increasing importance of allergic diseases and their relationship to sinus disease have been evaluated through a review of relevant literature. The poorly understood variations of the presentation of sinusitis and its signs and symptoms in the pediatric age group have been reviewed. Recommendations concerning the method, duration, and timing of the therapeutic intervention or interventions are summarized. The natural course of pediatric sinusitis in association with related respiratory tract diseases is discussed. Allergies and viral upper respiratory infections are among the most common predisposing factors of sinus disease. Every child with sinusitis is a candidate for an allergy evaluation.

Pediatric Sinusitis: A Literature Review with Emphasis on the Role of Allergy

Evaluation and treatment of pediatric sinusitis is a challenging area that has been subject to many different opinions and options during the past decade. Sinusitis is among the most commonly encountered diseases of childhood and has been the major area of interest for many otolaryngologists, allergists, and pediatricians. We have searched the medical literature to review the many aspects of the problem and the opinions of various authors. The increasing importance of allergic diseases and their relationship to sinus disease have been evaluated through a review of relevant literature. The poorly understood variations of the presentation of sinusitis and its signs and symptoms in the pediatric age group have been reviewed. Recommendations concerning the method, duration, and timing of the therapeutic intervention or interventions are summarized. The natural course of pediatric sinusitis in association with related respiratory tract diseases is discussed. Allergies and viral upper respiratory infections are among the most common predisposing factors of sinus disease. Every child with sinusitis is a candidate for an allergy evaluation.

In vitro testing for immunoglobulin E-mediated food allergies

The role of immunoglobulin E-mediated food allergy in subjects with allergic disorders, especially in patients with rhinitis and sinusitis, is underestimated by clinicians because of the initial attribution of these disorders to immediate-type hypersensitivity reactions. The difficulties of diagnosing food-related reactions have caused further delay in their recognition and incorporation into the daily practice of diagnosing food allergy. Two of the diagnostic methods for food allergy are the in vitro assay of total immunoglobulin E and the measurement of food-specific immunoglobulin E levels in serum with the radioallergosorbent test. Measurement of specific immunoglobulin E level is the most commonly used but also one of the most controversial techniques. We examined 123 patients with rhinitis who were referred to our otolaryngology/allergy clinic between January and April 1995. All patients received an initial radioallergosorbent test screen, which included milk. We determined the positive predictive value of this positive screen and, in particular, of a positive test for milk in the diagnosis of immunoglobulin E-mediated food allergies in these patients. Conclusions were based on comparison with the result of an additional radioallergosorbent test food panel consisting of eight common and two investigational food allergens.

Slime production by coagulase-negative staphylococci in the infected pulps

In this study; slime factor which is produced by coagulase negative Staphylococci was investigated in infected pulps of 145 primary and permanent teeth. Staphylococci were isolated in 27% of the cultures and all of the isolated Staphylococci were coagulase negative (CNS) in permanent teeth whereas 75% of isolated Staphylococci were coagulase negative in primary teeth. Slime production rate was the same for both groups and 22% of CNS were found slime positive. It is thought that slime production is important not only in endodontic microbiology, but also in other fields of dentistry for the explanation of the pathogenesis of infection.