Reconstructive ossiculoplasty options in primary cholesteatoma surgeries with an intact stapes

PURPOSE

In primary cholesteatoma patients, incus destruction with an intact and mobile stapes is a frequent finding. Different techniques have been described to restore the ossicular chain, including incus interposition, stapes augmentation and type III tympanoplasty. Controversy about postoperative hearing results in open versus closed surgical techniques exist.

METHODS

We performed a retrospective analysis of clinical, surgical and audiometric data of patients with primary cholesteatoma surgery operated between 2010 and 2020, and a mobile stapes and one-stage ossicular reconstruction. Pre- and post-operative audiograms were compared for the different surgical groups, mainly focusing on postoperative air-bone gap. Mastoid pneumatization and ventilation was also considered.

RESULTS

The mean postoperative air-bone gap (0.5-4 kHz) of the 126 included patients was 20 dB. Hearing after type III tympanoplasty (26 dB) was worse than incus interposition (19 dB) and stapes augmentation (20 dB). Hearing after an open (23 dB) versus closed (19 dB) surgical technique was significantly different. No improvement in air-bone gap was observed for the higher frequencies.

CONCLUSION

A residual postoperative air-bone gap should be considered after primary cholesteatoma surgery with intact and mobile stapes. Incus interposition in closed cavity operation is the optimal situation, but open cavity surgery should not be avoided because of hearing. Extent of the disease is prioritized and poorer ventilation before and after surgery may affect postoperative hearing.

Antibody-mediated procoagulant platelets in SARS-CoV-2-vaccination associated immune thrombotic thrombocytopenia

The COVID-19 pandemic has resulted in significant morbidity and mortality worldwide. To prevent severe infection, mass COVID-19 vaccination campaigns with several vaccine types are currently underway. We report pathological and immunological findings in 8 patients who developed vaccine-induced immune thrombotic thrombocytopenia (VITT) after administration of SARS-CoV-2 vaccine ChAdOx1 nCoV-19. We analyzed patient material using enzyme immune assays, flow cytometry and heparin-induced platelet aggregation assay and performed autopsies on two fatal cases. Eight patients (5 female, 3 male) with a median age of 41.5 years (range, 24 to 53) were referred to us with suspected thrombotic complications 6 to 20 days after ChAdOx1 nCoV-19 vaccination. All patients had thrombocytopenia at admission. Patients had a median platelet count of 46.5 x109/L (range, 8 to 92). Three had a fatal outcome and 5 were successfully treated. Autopsies showed arterial and venous thromboses in various organs and the occlusion of glomerular capillaries by hyaline thrombi. Sera from VITT patients contain high titer antibodies against platelet factor 4 (PF4) (OD 2.59±0.64). PF4 antibodies in VITT patients induced significant increase in procoagulant markers (P-selectin and phosphatidylserine externalization) compared to healthy volunteers and healthy vaccinated volunteers. The generation of procoagulant platelets was PF4 and heparin dependent. We demonstrate the contribution of antibody-mediated platelet activation in the pathogenesis of VITT.

Preoperative risk assessment for ambulatory sinonasal surgery

OBJECTIVES

An increasing proportion of patients who are candidates for endoscopic sinus surgery can be treated as an outpatient. A preoperative risk assessment is needed to evaluate eligibility for day surgery. This study analyses the effectiveness of a risk assessment scoring system which examines medical, procedure-related, and socioeconomic factors.

DESIGN

Prospective multicenter study.

SETTING

Three center study including Klinik Hirslanden, Zurich, Switzerland, Luzerner Kantonsspital, Lucerne, Switzerland and HNO-Klinik München-Bogenhausen, Munich, Germany.

PARTICIPANTS

Patients with endoscopic sinus procedures between January 1st, 2017 and December 31st, 2018.

MAIN OUTCOME MEASURES

The "day surgery risk score" consisted of three subgroups with medical, procedure-related and socioeconomic risk factors were assessed to determine if these predicted the severity of postoperative complications.

RESULTS

Three-hundred and one patients who underwent endoscopic sinus surgery were included. The score resulted in a median value of 5 [5, 5]. In the Receiver-Operating Curve (ROC-the true-positive rate against the false-positive rate), the Area Under the Curve (AUC) was 0.59 with 95% confidence interval from 0.49 to 0.69, indicating that the "day surgery risk score" may be no better at predicting the likelihood of a complication than a random classification model.

CONCLUSIONS

The "day surgery risk score" is a straightforward risk assessment which combines medical, procedure-related, and socioeconomic factors. The score is easy to use but in trying to decide whether a patient is eligible for ambulatory endoscopic sinus surgery it did not predict whether a complication was more likely to occur.

[The comparison of malleostapedotomy in primary and revision stapes surgery for otosclerosis]

Objective: To compare the effectiveness of primary malleostapedotomy with revision malleostapedotomy for otosclerosis. Methods: From April 2002 to December 2017, 70 consecutive patients with otosclerosis who underwent malleostapedotomy were reviewed. Depending on the primary malleostapedotomy (P-MS) or revision malleostapedotomy (R-MS), the patients were divided into P-MS group or R-MS group.The intraoperative findings and hearing results before and after surgery were compared between the two groups. ALL data were analyzed using SPSS 23. Results: Totally 73 malleostapedotomy were performed in 73 ears of 70 patients, including 38 P-MS and 35 R-MS. There was no significant difference between the two groups in sex ratio, age and operated ears (P>0.05 for all). The most common finding at P-MS was incus fixation (50.0%, 19/38) versus prosthesis displacement for R-MS (60.0%, 21/35) . Overall, the air-bone gap (ABG) improvement in P-MS were (18.1±8.2) dB in 0.5-3 kHz and (18.3±8.5) dB in 0.5-4 kHz, without significant difference to those in R-MS (P>0.05) . 31.4% of R-MS in 0.5-3 kHz and 22.9% R-MS in 0.5-4 kHz achieved an ABG<10 dB, significantly lower than those of P-MS (65.8% in 0.5-3 kHz and 57.9% in 0.5-4kHz; P<0.05). Failure (postoperative ABG>30 dB) occurred in 11.4% in R-MS and 0 in P-MS (for 0.5-3 kHz and 0.5-4 kHz). The incidence of postoperative sensorineural hearing loss (>10 dB increase in bone conduct) in R-MS group was 8.6% in 0.5-3 kHz and 0.5-4 kHz, without significant difference to those in P-MS (P>0.05) . 80.0% (20/25) of first R-MS achieved ABG<20 dB, compared to 37.5% (3/8) of second R-MS with ABG<20 dB. Conclusions: Although both P-MS and R-MS can significantly improve hearing, with similar risk of inner ear damage, R-MS is less effective and poses a higher risk of failure than P-MS. For patients with insufficient hearing improvement after first R-MS, conventional hearing aids or implantable hearing devices may be considered as an alternative.

A cluster of two human cases of tick-borne encephalitis (TBE) transmitted by unpasteurised goat milk and cheese in Germany, May 2016

In May 2016, two cases of tick-borne encephalitis (TBE) were confirmed by serology (positive IgM and IgG antibodies against TBE virus (TBEV) in serum), with a possible link to raw milk and cheese from a goat farm in a region in Baden-Württemberg, Germany not previously known as TBE-endemic. The outbreak investigation identified 32 consumers of goat dairy products (29 consumers, one farm employee, two owners) of whom none had IgM antibodies against TBEV 3–8 weeks after consumption. Of the 27 notified TBE cases in the State, none reported consumption of raw goat milk or cheese from the suspected farm. Five of 22 cheese samples from 18 different batches were RT-qPCR-positive for TBEV -genome, and two of the five samples were confirmed by virus isolation, indicating viability of TBEV in the cheese. Nine of the 45 goats had neutralising TBEV antibodies, two of them with a high titre indicating recent infection. One of 412 Ixodes ricinus was RT-qPCR-positive, and sequencing of the E gene from nucleic acid extracted from the tick confirmed TBEV. Phylogenetic analyses of tick and cheese isolates showed 100% amino acid homology in the E gene and a close relation to TBEV strains from Switzerland and Austria.

Values and value in simulated participant methodology: A global perspective on contemporary practices

This article has been written for the 40th year of the publication of Medical Teacher. While we celebrate the contribution of simulated participants (SPs) to health professions education through values and value-based learning, we also offer critical reflection on elements of our practice, commencing with language. We argue for the use of the term simulated rather than standardized and acknowledge the dominant role of the SP as patient and the origins of the methodology. These shifts in terms and their implications in practice reflect changes in the conceptualization of SP-based methodology. Recently published standards for those who work with SPs (SP practitioners) are noted as an important milestone in our community's development. We consider contemporary practices addressing the complex notions of values and value in SP-based learning. We simultaneously refer to the work of SPs and SP practitioners. Phases of educational design including identifying learning objectives, scenario design, implementation, feedback and debriefing are used to illustrate methodological shifts. Within each of these phases, there are relational issues that have to date often gone unchecked and are under reported in literature. Finally, using the metaphor of a murmuration, we celebrate contemporary practices of the global SP practitioner community.

Closure of nasal septal perforations with a polydioxanone plate and temporoparietal fascia in a closed approach

BACKGROUND

Septal perforation closure is still often invasive and complex, with relatively low closure rates.

OBJECTIVES

We aimed to provide the first results of a case series of 20 patients with nasal septal perforations who underwent septal perforation repair by both an open and a minimally invasive technique by using a graft that consisted of temporoparietal fascia and a polydioxanone (PDS) plate without mucosal flaps. Between 2014 and 2016, we tested, for the first time, the feasibility of the insertion of this graft via a hemitransfixion incision at our institution. The rationale for the closed approach was to avoid any visible nasal scars. We reported our results of both approaches.

METHODS

The septal perforations were closed by insertion of a graft, which consisted of a 0.25-mm PDS flexible plate enveloped by temporoparietal fascia, into the perforation. The insertion of the graft was performed either via a columellar incision (open approach) or via a cosmetically advantageous hemitransfixion incision (closed approach) in an underlay technique. No attempts were made to close the perforation by mucosal flap rotation and/or advancement. Protective silastic sheeting to both sides of the perforation provided fixation to the graft while natural mucosal healing occurred over the perforation in the course of 3 to 8 weeks.

RESULTS

Eighteen of 20 perforations were closed by mucosa at the last follow-up. The mean follow-up was 8.7 months. Thirteen patients had surgery via the closed approach.

CONCLUSION

We showed, for the first time, that the insertion of a graft that consisted of a PDS flexible plate enveloped in temporoparietal fascia via a hemitransfixion incision was feasible and resulted in complete mucosal closure of nasal septal perforations in most patients. By performing the hemitransfixion incision, we avoided any visible nasal scars.

Long-term results after restoring nasal tip support using auricular cartilage as an intercrural columellar strut graft: the “I-Beam” technique

BACKGROUND

The lack of nasal tip support resulting in poor protection and projection of the nose is a common cause of nasal obstruction and cosmetic impairment. Although septal cartilage is preferred for restoration of nasal tip support, there is often not enough septal cartilage available. We describe an intercrural columellar strut graft in a circumferential soft tissue pocket: the I-Beam technique.

METHODOLOGY

In this cohort study over an 8-year period the clinical and biometrical long-term results after restoration of nasal tip support with an autologous auricular cartilage graft, the I-Beam technique, is evaluated.

RESULTS

Out of the 72 consecutive septorhinoplasties with the I-Beam technique, we studied 66 patients in the median long-term follow-up of 89 months. In all patients a significant improvement in nasal tip projection was found. A functional improvement in nasal breathing was achieved in 86%. The overall satisfaction with the I-Beam graft was of 83%. No deterioration in smell perception was found after surgery.

CONCLUSIONS

The I-Beam technique using back-to-back sutured autologous auricular cartilage is a safe and effective technique and gives long-term structural support and enhances tip projection.

Titanium incus interposition ossiculoplasty: audiological outcomes and extrusion rates

This study aimed to evaluate the benefit but also the extrusions, dislocations, and failures of a titanium incus prosthesis along with the long-term audiological outcomes. We prospectively collected data from 139 patients undergoing ossiculoplasty using the Fisch titanium incus prosthesis between 2001 and 2016. Overall, 126 patients with at least 6 months of follow-up (mean 4.5 years, range 6-155 months) were analyzed. Patients were grouped as "extrusion" (n = 9, 7%) if the prosthesis extruded, "failure" (n = 22, 18%) if a reoperation was needed concerning the prosthesis, and "stable" (n = 95, 75%) if the prosthesis remained functional in the middle ear. Mean postoperative air bone gaps (ABG) for 0.5-3 kHz for the overall group and the stable group were 19.8 (±11.9) and 15.3 (±7.5), respectively. Long-term results of stable group revealed an ABG (0.5-3 kHz) below 10 dB in 25% and below 20 dB in 81% of the patients. Atelectasis was the most frequent cause of extrusion, which occurred after a mean time of 28.7 months (range 15-48 months). Mean timing for reoperation was 30.7 months (range 5-131 months) in the failure group. There was no significant difference in mean postoperative ABG among patients with or without cholesteatoma, primary or staged ossiculoplasty in cholesteatoma, presence or absence of malleus head at the time of ossiculoplasty, open or closed cavity surgeries, or the degree of pneumatization of the temporal bone. The Fisch titanium incus prosthesis is a reliable alternative to using autologous incus for interposition ossiculoplasty, with similar hearing outcomes. Using this prosthesis, a 15 dB ABG should be expected.

Traceable dynamic measurement of mechanical quantities: objectives and first results of this european project

Nine european national metrology institutes (NMIs) are collaborating in a new project funded by the european metrology research programme (EMRP) to establish traceable dynamic measurement of the mechanical quantities force, pressure, and torque. The aim of this joint research project (JRP) is to develop appropriate calibration methods, mathematical models, and uncertainty evaluation. The duration of the project is 3 years for a global amount of €3.6 million. It began in September 2011.

Release of ANP and fat oxidation in overweight persons during aerobic exercise in water

Exercise in water compared to land-based exercise (LE) results in a higher release of natriuretic peptides, which are involved in the regulation of exercise-induced adipose tissue lipolysis. The present study was performed to compare the release of atrial natriuretic peptide (ANP) and free fatty acids (FFA) during prolonged aerobic water-based exercise (WE) with the release after an identical LE. 14 untrained overweight subjects performed 2 steady state workload tests on the same ergometer in water and on land. Before and after exercise, venous blood samples were collected for measuring ANP, FFA, epinephrine, norepinephrine, insulin and glucose. The respiratory exchange ratio (RER) was determined for fat oxidation.The exercises resulted in a significant increase in ANP in LE (61%) and in WE (177%), and FFA increased about 3-fold in LE and WE with no significant difference between the groups. Epinephrine increased, while insulin decreased similarly in both groups. The RER values decreased during the exercises, but there was no significant difference between LE and WE. In conclusion, the higher ANP concentrations in WE had no additional effect on lipid mobilization, FFA release and fat oxidation. Moderate-intensity exercises in water offer no benefit regarding adipose tissue lipolysis in comparison to LE.

Gd-based single-ion magnets with tunable magnetic anisotropy: molecular design of spin qubits

We report ac susceptibility and continuous wave and pulsed EPR experiments performed on GdW10 and GdW30 polyoxometalate clusters, in which a Gd3+ ion is coordinated to different polyoxometalate moieties. Despite the isotropic character of gadolinium as a free ion, these molecules show slow magnetic relaxation at very low temperatures, characteristic of single molecule magnets. For T≲200  mK, the spin-lattice relaxation becomes dominated by pure quantum tunneling events, with rates that agree quantitatively with those predicted by the Prokof'ev and Stamp model [Phys. Rev. Lett. 80, 5794 (1998)]. The sign of the magnetic anisotropy, the energy level splittings, and the tunneling rates strongly depend on the molecular structure. We argue that GdW30 molecules are also promising spin qubits with a coherence figure of merit Q(M)≳50.

High-frequency and -field EPR and FDMRS study of the [Fe(H2O)6]2+ ion in ferrous fluorosilicate

The complex [Fe(H2O)6]SiF6 is one of the most stable and best characterized high-spin Fe(II) salts and as such, is a paradigm for the study of this important transition metal ion. We describe high-frequency and -field electron paramagnetic resonance studies of both pure [Fe(H2O)6]SiF6 and [Zn(H2O)6]SiF6 doped with 8% of Fe(II). In addition, frequency domain magnetic resonance spectroscopy was applied to these samples. High signal-to-noise, high resolution spectra were recorded which allowed an accurate determination of spin Hamiltonian parameters for Fe(II) in each of these two, related, environments. For pure [Fe(H2O)6]SiF6, the following parameters were obtained: D=+11.95(1) cm(-1), E=0.658(4) cm(-1), g=[2.099(4),2.151(5),1.997(3)], along with fourth-order zero-field splitting parameters: B4(0)=17(1)×10(-4) cm(-1) and B4(4)=18(4)×10(-4) cm(-1), which are rarely obtainable by any technique. For the doped complex, D=+13.42(1) cm(-1), E=0.05(1) cm(-1), g=[2.25(1),2.22(1),2.23(1)]. These parameters are in good agreement with those obtained using other techniques. Ligand-field theory was used to analyze the electronic absorption data for [Fe(H2O)6]SiF6 and suggests that the ground state is 5A1, which allows successful use of a spin Hamiltonian model. Density functional theory and unrestricted Hartree-Fock calculations were performed which, in the case of latter, reproduced the spin Hamiltonian parameters very well for the doped complex.

Broadband electron spin resonance at 4-40 GHz and magnetic fields up to 10 T

A broadband electron spin resonance spectrometer is described which operates at frequencies between 4 and 40 GHz and can be used in superconducting magnets. A tunable cylindrical cavity is connected to a vector network analyzer via coaxial cables, and the radiation is fed into the cavity by a coupling loop. No field modulation is employed. Resonance frequencies below 14 GHz are obtained by inserting dielectrics with different permittivities into the cavity. The setup allows for measurements with the microwave magnetic field either parallel or perpendicular to the external field.

Direct observation of quantum coherence in single-molecule magnets

Direct evidence of quantum coherence in a single-molecule magnet in a frozen solution is reported with coherence times as long as T{2}=630+/-30 ns. We can strongly increase the coherence time by modifying the matrix in which the single-molecule magnets are embedded. The electron spins are coupled to the proton nuclear spins of both the molecule itself and, interestingly, also to those of the solvent. The clear observation of Rabi oscillations indicates that we can manipulate the spin coherently, an essential prerequisite for performing quantum computations.

Two families with nonsyndromic low-frequency hearing loss harbor novel mutations in Wolfram syndrome gene 1

Although hereditary hearing loss is highly heterogeneous, only a few loci have been implicated with low-frequency hearing loss. Mutations in one single gene, Wolfram syndrome 1 (WFS1), have been reported to account for most familial cases with this type of hearing impairment. This study was conducted to determine the cause of nonsyndromic low-frequency hereditary hearing impairment in two large families. Two large families from Switzerland and United States with low-frequency hearing loss were identified. Genomewide linkage analysis was performed followed by mutation screening in the candidate gene WFS1 with direct DNA sequencing and restriction fragment analysis. Both families were linked to DFNA6/14/38 with lod scores>3. Two novel heterozygous missense mutations in WFS1 were identified: c.2311G>C leading to p.D771H in the Swiss family and c.2576G>C leading to p.R859P in the US family. The sequence alteration was absent in 100 control chromosomes. Nonsyndromic low-frequency hereditary hearing impairment seems to be predominantly a monogenic disorder due to WFS1. We confirm that most mutations in WFS1 associated with isolated low-frequency hearing loss are clustered in the C-terminal protein domain coded by exon 8.

Krankheitskosten von COPD in Deutschland

The present cost-of-illness study is focused on the costs of COPD in Germany. In a pre-study, data on 814 randomly selected patients were collected to achieve reliable figures for the distribution of COPD severity grades and the frequencies of exacerbations. The main study was performed on 321 randomly selected patients from the pre-study. Data on resource use were collected in a face-to-face interview with the respective physicians using the patient records as a basis. Costs associated with resource consumption were weighted with the frequencies of COPD severity grades as assessed in the pre-study to determine the costs of COPD. Annual COPD-related costs per patient were 3,027 from the societal perspective. Main cost components were hospitalisations (26 %), medication (23 %) and early retirement (17 %). Annual COPD-related costs from the perspective of the German health insurance system (GKV) were 1,944 euros per patient.

DFNA54, a third locus for low-frequency hearing loss

Nonsyndromic hereditary hearing impairment (NSHHI) is a highly heterogeneous disorder with more than 90 loci mapped, of which nearly one-half of the responsible genes are identified. In dominant NSSHI hearing loss is typically biased towards the high frequencies while low-frequency hearing loss is unusual. Only two NSHHI loci, DFNA1 and DFNA6/14/38, are associated with predominantly low-frequency loss. We mapped the loci harboring the gene responsible for autosomal dominant low-frequency hearing loss in a multigenerational family. The pedigree of a Swiss family with low-frequency hearing loss was established. Using genomic DNA, DFNA1 and DFNA6/14/38 were excluded by linkage analysis or by direct sequencing of the responsible gene. Genome-wide linkage analysis was performed using commercially available microsatellite markers. Two-point linkage analysis demonstrated linkage to chromosome 5q31, the locus for DFNA15, with a lod score of 6.32 at recombination fraction theta=0 for marker D5S436. Critical recombinations were seen at markers D5S1972 and D5S410. Sequencing of the corresponding gene POU4F3 yielded no pathogenic mutation segregating with the affected members. In addition to Wolfram syndrome gene 1 (DFNA6/14/38) and diaphanous (DFNA1) there is evidence for a third gene involved in low-frequency hearing loss located at DFNA15. Because of the differences in auditory phenotype and the absence of pathogenic mutation in the coding region of POU4F3 it is likely that there is a second gene in 5q31, designated DFNA54, associated with NSHHI.

Diagnosis and initial management of laryngotracheal injuries associated with facial fractures

INTRODUCTION

Laryngotracheal injuries are uncommon with an estimated incidence of 1 per thousand (1-6 patients per 15000-42500 trauma victims). They may be associated with fractures of the facial skeleton. Their symptoms are variable ranging from obvious airway obstruction to minor or almost missing symptoms. Early diagnosis and proper initial management may sometimes be difficult or delayed.

PATIENTS

Three patients with maxillofacial fractures and concomitant laryngotracheal injuries are presented. The diagnostic procedures used and the management of these injuries are reported.

DISCUSSION AND CONCLUSION

Due to their low incidence and their hidden nature laryngotracheal injuries may pose diagnostic problems, especially in polytraumatized or intubated patients. Subcutaneous emphysema is the chief clinical sign. Fibreoptic endoscopy is the most important and informative diagnostic examination. Radiographic evaluation by CT scan provides additional information about the extent of the injury and the indication for surgery. A coordinated team approach is necessary for proper management of these injuries.

Phase II trial of intralesional therapy with interleukin-2 in soft-tissue melanoma metastases

The objective of the present study was to validate the use of intralesional injection of interleukin-2 (IL-2) in patients with skin and soft-tissue melanoma metastases. A total of 24 patients with AJCC stage III or IV melanoma and single or multiple skin and soft-tissue metastases were included. Interleukin-2 injections were administered intralesionally into the total number of cutaneous and soft-tissue metastases accessible from the skin, 2-3 times weekly, over 1-57 weeks. Single doses varied from 0.6 to 6 x 10(6) IU, depending on lesion size. The clinical response was monitored by sonography and confirmed by histopathology; response evaluation was confined to the intralesionally treated tumours. Complete response (CR) of the treated metastases was achieved in 15 patients (62.5%), the longest remission lasting 38 months to date. In five patients, partial response (PR) was achieved (21%) and in another three patients, progressive disease was observed (one patient not assessable). A total of 245 metastases were treated with CR in 209 (85%), and PR in 21 (6%). The therapy was generally well tolerated; the observed adverse events were mainly of grade 1-2 severity. Immunohistochemical studies showed the tumour cells undergoing apoptosis and revealed a mixed character of the inflammatory infiltrate. The unusual high CR rate in metastatic melanoma of 62.5% and the limited toxicity suggest that treatment of skin and soft-tissue melanoma metastases with intralesional injection of IL-2 may be a safe and effective alternative to conventional therapies. The optimal dosage and duration of this therapy still remain to be defined in larger prospective multicentre trials.

Congenital laryngotracheo-oesophageal cleft: successful ventilation with the Laryngeal Mask Airway

A congenital laryngotracheo-oesophageal cleft is a rare airway malformation which results from incomplete separation of the larynx and trachea from the hypopharynx and oesophagus. Patients usually present with stridor, aspiration and cyanosis associated with feeding. For early diagnosis, a high index of suspicion is needed. Unless an appropriate diagnostic approach is taken, the diagnosis can be missed. The successful ventilation of a neonate with the Laryngeal Mask Airway is described.

Localization of functional calcitonin gene-related peptide binding sites in a subpopulation of cultured dorsal root ganglion neurons

In this study we investigated whether cultured dorsal root ganglion (DRG) neurons from the adult rat express binding sites for calcitonin gene-related peptide (CGRP). These were identified on fixed cells by using CGRP labeled at the N-terminal site with 1.4-nm gold particles. After 1 day in culture, about 20% of small to medium-sized DRG neurons showed CGRP-gold binding. Binding of CGRP-gold was dose-dependently reduced by coadministration of CGRP. The calcium imaging technique in living cells revealed that the bath administration of CGRP evoked an increase of the intracellular calcium in up to 30% of the DRG neurons tested. Both depletion of intracellular calcium stores by thapsigargin or using a calcium-free medium blocked the CGRP-mediated increase of cytosolic calcium in most neurons. Thus intracellular and extracellular sources of calcium are relevant for the CGRP response. Using the whole-cell patch-clamp technique, about 30% of the neurons were found to exhibit an inward current and a depolarization upon administration of CGRP close to the neurons. Immunocytochemical double-labeling techniques showed that most of the CGRP-gold binding sites were expressed in unmyelinated (neurofilament 200-negative) DRG neurons. Most of the neurons with CGRP-gold binding sites also expressed the tyrosine kinase A receptor, and all of them showed CGRP-like immunoreactivity. This study shows, therefore, that a subpopulation of unmyelinated, peptidergic primary afferent neurons express CGRP binding sites that can be activated by CGRP in an excitatory direction. The binding sites may serve as autoreceptors because all of these neurons also synthesize CGRP. The activation of CGRP binding sites may sensitize primary afferent neurons and influence the release of mediators.

Photoneutron cross sections for unstable neutron-rich oxygen isotopes

The dipole response of stable and unstable neutron-rich oxygen nuclei of masses A = 17 to A = 22 has been investigated experimentally utilizing electromagnetic excitation in heavy-ion collisions at beam energies about 600 MeV/nucleon. A kinematically complete measurement of the neutron decay channel in inelastic scattering of the secondary beam projectiles from a Pb target was performed. Differential electromagnetic excitation cross sections d sigma/dE were derived up to 30 MeV excitation energy. In contrast to stable nuclei, the deduced dipole strength distribution appears to be strongly fragmented and systematically exhibits a considerable fraction of low-lying strength.

[Infectious aspects of Wegener's granulomatosis]

INTRODUCTION

Because of manifestation of Wegener's granulomatosis in the upper respiratory tract the ENT-specialist is often initially involved in diagnosis. Recent research results suppose the chronic nasal carriage of Staphylococcus aureus triggering relapse rate in Wegener's granulomatosis. The adequate therapy of this bacteria as chronic nasal carriage may reduce the number of relapses in patients with Wegener's granulomatosis in remission.

PATIENT

An illustrative case report shows the positive effect of prolonged treatment with cotrimoxazole in a 49-year-old male with a second relapse of Wegener's granulomatosis.

RESULTS

The prolonged treatment of cotrimoxazole reduced the dose of cyclophosphamid and glucocorticoids which show long-term side effects.

DISCUSSION

15 years ago a positive effect of cotrimoxazole to Wegener's granulomatosis was discussed. Later immunological and clinical studies confirmed this fact. Prolonged treatment with cotrimoxazole seems to reduce the number of relapses in patients with this chronic disease. Corresponding with our case reduction of the systemic therapy with cyclophosphamid and glucocorticoids is possible.

[Results after shock wave lithotripsy for salivary gland stones]

INTRODUCTION

Extracorporeal shock wave lithotripsy for salivary gland stones was not introduced until 1989 as a new treatment modality. Follow-up studies years after treatment are lacking.

METHODS

Follow-up study from February to March 2000 of 71 (91%) of all 78 patients who had extracorporeal shock wave lithotripsy for salivary gland stones at our clinic between March 1996 and November 1998.

RESULTS

Over 2 years after treatment (mean 27 months, range 12-48 months), 13 (48%) of 27 patients with parotid stones are free of stones and symptoms and 17 (63%) are free of symptoms. In 44 patients with submandibular stones, 13 (29%) are free of stones and symptoms and 23 (52%) are free of symptoms. For residual symptoms, 9 (20%) patients had submandibulectomy whereas no parotidectomy had to be performed. 5 patients with residual stones after treatment showed increased stone size in sonography, and one patient with a stone-free interval for 3 years had a local recurrence.

DISCUSSION

Extracorporeal shock wave lithotripsy is often the treatment of choice for parotid stones and the recommended conservative treatment option for smaller submandibular stones. Limitation to the common, larger submandibular stones diminishes the general value of this modality, which needs to be established in comparison with endoscopic techniques in further studies. Residual stones after treatment may cause new symptoms over time, but only in one case was renewed stone formation observed.

Dielectric properties of skeletal muscle during ischemia in the frequency range from 50 Hz to 200 MHz

The complex dielectric properties of canine skeletal muscles were measured at 25 degrees C during ischemia in the frequency range from 50 Hz to 200 MHz. The dielectric spectrum of skeletal muscle shows an alpha-dispersion below 1 kHz and a beta-dispersion with a relaxation frequency of about 100 kHz. The alpha-dispersion disappears between 450 and 500 min of ischemia time, the same time during which mechanical contraction was observed, and was restored later. During ischemia, the beta-dispersion is shifted continuously to higher frequencies; and at frequencies above 50 MHz, a decrease of the real part of the dielectric permittivity was measured. The dielectric loss factor decreases during ischemia at frequencies below 500 kHz, only interrupted by a short increase, coinciding with the disappearance of the alpha-dispersion. The principal processes that happen during ischemia inside the skeletal muscle tissues were studied with the help of a model especially designed to simulate membrane effects on the dielectric spectrum. The disappearance of the alpha-dispersion is explained by an increase of conductivity in the membrane of the sarcoplasmic reticulum. Shifting beta-dispersion to higher frequencies is a result of metabolically produced ions and therefore increasing conductivity of the intracellular medium. Decreasing dielectric permittivity at frequencies above 50 MHz and decreasing dielectric loss factor at low frequencies are caused by the cell edema.

Escher-Hirt syndrome

A mother and her two daughters are reported with bilateral conductive deafness due to incudo-stapedial abnormalities, and microtia with thickened ear lobes. This pattern of abnormal findings, transmitted with an autosomal dominant mode of inheritance, is characteristic of the Escher-Hirt syndrome. One of the daughters died from an additional cardiac malformation (VSD). Anomalies of the middle ear were demonstrated in the surviving patients by computed tomography. Differential diagnosis with other genetic syndromes associated with deafness, and possible therapeutic approaches are discussed.

[Conservative therapy in thoracic outlet syndrome. Literature review and pathogenetic considerations]

Due to the broad clinical presentation and the lack of generally accepted diagnostic criteria, thoracic outlet syndrome (TOS) is a disputed diagnosis. Various surgical techniques have been described and investigated as treatment for TOS, whereas only a few studies have reported the outcome after a conservative approach. Based on the literature, the pathophysiology of TOS and the impact of conservative therapy are discussed. Our personal experience has shown that after early diagnosis and implementation this treatment is a safe and valuable therapeutical option in TOS based on the correction of a postural and functional disturbance of the upper thoracic aperture underlying the pathogenic process. Successful conservative treatment may also be considered as further diagnostic evidence for TOS.

[Lithotripsy in the conservative treatment of salivary stones]

Otolaryngologists and generalists as well are commonly involved in the evaluation and management of salivary gland stones. Most patients present with a history of recurrent swelling and pain in the gland, associated with eating. Up to date conservative therapy was limited to the treatment of the acute sialadenitis, which may develop as a consequence of the obstruction and often recurs until the function of the salivary gland ceases. Surgical treatment depends on the location of the calculus. Distal stones can be removed trans-orally by dilatation or incision of the duct, whereas those near the hilus and intraglandular stones required excision of the gland, including the disadvantage of a scar and the risk of injury to cranial nerves. Extracorporal shock wave lithotripsy is a new noninvasive method, which allows to destroy intra- and extraglandular salivary stones, mostly without the need of local or general anesthesia. Reported disintegration rates vary from 14% to 85%, depending on site and size of the calculus. About 80% of the patients remain symptomless Lithotripsy of salivary stones is a cost-effective, additional treatment modality to surgery and may be employed on an outpatient basis.

Morphological adaptations of human skeletal muscle to chronic hypoxia

Muscle structural changes during typical mountaineering expeditions to the Himalayas were assessed by taking muscle biopsies from 14 mountaineers before and after their sojourn at high altitude (greater than 5000 m for over 8 weeks). M. vastus lateralis samples were analyzed morphometrically from electron micrographs. A significant reduction (-10%) of muscle cross-sectional area was found on CT scans of the thigh. Morphologically this loss in muscle mass appeared as a decrease in muscle fiber size mainly due to a loss of myofibrillar proteins. A loss of muscle oxidative capacity was also evident, as indicated by a decrease in the volume of muscle mitochondria (-25%). In contrast, the capillary network was mostly spared from catabolism. It is therefore concluded that oxygen availability to muscle mitochondria after prolonged high-altitude exposure in humans is improved due to an unchanged capillary network, supplying a reduced muscle oxidative capacity.

[Course and prognosis of pregnancy, delivery and childbirth in patients with congenital heart defects]

On the conditions of an optimal therapy and with reference to certain contraindications the prognosis of patients with congenital heart diseases and their children scarcely differs from that of the normal population during gestation. The rate of decompensation in pregnancy was 4.1%, with 3.9% the rate of gestosis was significantly below that of the other patients. The perinatal mortality of the children of patients with congenital vitium cordis os 2.23%, the rate of newborn of 11.2% and the proportion of hypotrophic children of 8.38% were also not increased compared with the totality. By changed diagnostic and therapeutic conditions the relation of the congenital to the acquired vitia cordis has much altered in favour of the congenital ones. With a high proportion of women who underwent an operation of the heart among our patients the results shows that, apart from the already generally accepted absolute contraindications for a pregnancy, the prognosis for patients with stenoses of the outlet is clearly worse than that of the patients with other congenital heart diseases.