[Chronic rhinosinusitis in people with cystic fibrosis-an up-to-date review from the perspective of otorhinolaryngology]

BACKGROUND

Cystic fibrosis (CF) is a complex systemic disease involving numerous organ systems. With improved treatment options and increasing life expectancy of persons with CF (PwCF), extrapulmonary manifestations are coming increasingly into the focus. From birth, almost all PwCF have radiologically detectable pathologies in the upper airways attributable to CF-associated chronic rhinosinusitis (CF-CRS).

OBJECTIVE

The aim of this work is to provide an up-to-date overview of CF-CRS from the otorhinolaryngology perspective and to provide the reader with background knowledge and current developments.

PATHOPHYSIOLOGY

The cystic fibrosis transmembrane conductance regulator (CFTR) gene defect leads to increased viscosity of sinonasal secretions and reduced mucociliary clearance, causing chronic infection and inflammation in the upper airway segment and, consequently, to CF-CRS.

CLINICAL PICTURE AND DIAGNOSTICS

The clinical picture of CF-CRS comprises a wide spectrum from asymptomatic to symptomatic courses. CF-CRS is diagnosed clinically and radiologically.

THERAPY

Sinonasal saline irrigation is recommended as a conservative treatment measure. Topical corticosteroids are also commonly used. Surgical therapy is reserved for highly symptomatic treatment-refractory patients without a sufficient response to conservative treatment including CFTR modulator (CFTRm) therapies. Depending on the CFTR mutation, CFTRm therapies are the treatment of choice. They not only improve the pulmonary and gastrointestinal manifestations in PwCF, but also have positive effects on CF-CRS.

CONCLUSION

The ENT specialist is part of the interdisciplinary team caring for PwCF. Depending on symptom burden and treatment responsiveness, CF-CRS should be treated conservatively and/or surgically. Modern CFTRm have a positive effect on the clinical course of CF-CRS.

Qualification of the Low-pressure Cold Gas Spraying for the Additive Manufacturing of Copper-Nickel-Diamond Grinding Wheels

Grinding wheels are usually manufactured by powder metallurgical processes, i.e., by molding and sintering. Since this requires the production of special molds and the sintering is typically carried out in a continuous furnace, this process is time-consuming and cost-intensive. Therefore, it is only worthwhile for medium and large batches. Another influencing factor of the powder metallurgical process route is the high thermal load during the sintering process. Due to their high thermal sensitivity, superabrasives such as diamond or cubic boron nitride are very difficult to process in this way. In this study, a novel and innovative approach is presented, in which superabrasive grinding wheels are manufactured by thermal spraying. For this purpose, flat samples as well as grinding wheel bodies were coated by low-pressure (LP) cold gas spraying with a blend of a commercial Cu-Al2O3 cold gas spraying powder and nickel-coated diamonds. The coatings were examined metallographically in terms of their composition. A well-embedded superabrasive content of 12 % was achieved. After the spraying process, the grinding wheels were conditioned and tested for the grinding application of cemented carbides and the topographies of both the grinding wheel and the cemented carbide were evaluated. Surface qualities of the ground surface that are comparable to those of other finishing processes were reached. This novel process route offers great flexibility in the combination of binder and hard material as well as a cost-effective single-part and small-batch production.

Health status and labour force participation among older workers: a growth curve analysis

Objectives

We investigate how individual trajectories of health status and labor force participation among older workers in Switzerland are interrelated and how this relationship varies by occupation.

Methods

We use data from the Swiss Household Panel (SHP) to analyze the long-term trajectories of older workers, measured in terms of working hours and general health status. The sample includes more than 7,000 workers aged 50 to 65(men)/64(women). We run a bivariate response multilevel model for growth that allows examining between- and within-individual changes over time.

Results

All occupational groups become more heterogeneous in terms of health status with increasing age. At the same time, working hours decrease in all occupational groups with increasing age. A look at the individual level indicates that the working hours of manual workers seem to be more dependent on their health status compared to those of non-manual workers and that this dependence increases over time. This result confirms our hypothesis that the labor market participation of manual workers is more sensitive to their health status.

Conclusions

Our findings contribute to the debate about the importance of older workers' health in the context of working life extension.

Key messages

All occupational groups become more heterogenous in terms of health status with increasing age, however working hours of manual workers seem to be more dependent on their health status. Manual workers experience a stronger effect of health on working hours and that this effect increases over time, therefore prevention of ill health may be particularly beneficial in manual workers.

Clinical evolution, genetic landscape and trajectories of clonal hematopoiesis in SAMD9/SAMD9L syndromes

Germline SAMD9 and SAMD9L mutations (SAMD9/9L^mut) predispose to myelodysplastic syndromes (MDS) with propensity for somatic rescue. In this study, we investigated a clinically annotated pediatric MDS cohort (n = 669) to define the prevalence, genetic landscape, phenotype, therapy outcome and clonal architecture of SAMD9/9L syndromes. In consecutively diagnosed MDS, germline SAMD9/9L^mut accounted for 8% and were mutually exclusive with GATA2 mutations present in 7% of the cohort. Among SAMD9/9L^mut cases, refractory cytopenia was the most prevalent MDS subtype (90%); acquired monosomy 7 was present in 38%; constitutional abnormalities were noted in 57%; and immune dysfunction was present in 28%. The clinical outcome was independent of germline mutations. In total, 67 patients had 58 distinct germline SAMD9/9L^mut clustering to protein middle regions. Despite inconclusive in silico prediction, 94% of SAMD9/9L^mut suppressed HEK293 cell growth, and mutations expressed in CD34⁺ cells induced overt cell death. Furthermore, we found that 61% of SAMD9/9L^mut patients underwent somatic genetic rescue (SGR) resulting in clonal hematopoiesis, of which 95% was maladaptive (monosomy 7 ± cancer mutations), and 51% had adaptive nature (revertant UPD7q, somatic SAMD9/9L^mut). Finally, bone marrow single-cell DNA sequencing revealed multiple competing SGR events in individual patients. Our findings demonstrate that SGR is common in SAMD9/9L^mut MDS and exemplify the exceptional plasticity of hematopoiesis in children.

Loss of the Fanconi anemia-associated protein NIPA causes bone marrow failure

Inherited bone marrow failure syndromes (IBMFSs) are a heterogeneous group of disorders characterized by defective hematopoiesis, impaired stem cell function, and cancer susceptibility. Diagnosis of IBMFS presents a major challenge due to the large variety of associated phenotypes, and novel, clinically relevant biomarkers are urgently needed. Our study identified nuclear interaction partner of ALK (NIPA) as an IBMFS gene, as it is significantly downregulated in a distinct subset of myelodysplastic syndrome-type (MDS-type) refractory cytopenia in children. Mechanistically, we showed that NIPA is major player in the Fanconi anemia (FA) pathway, which binds FANCD2 and regulates its nuclear abundance, making it essential for a functional DNA repair/FA/BRCA pathway. In a knockout mouse model, Nipa deficiency led to major cell-intrinsic defects, including a premature aging phenotype, with accumulation of DNA damage in hematopoietic stem cells (HSCs). Induction of replication stress triggered a reduction in and functional decline of murine HSCs, resulting in complete bone marrow failure and death of the knockout mice with 100% penetrance. Taken together, the results of our study add NIPA to the short list of FA-associated proteins, thereby highlighting its potential as a diagnostic marker and/or possible target in diseases characterized by hematopoietic failure.

[Social reimbursement-the Spanish-German ENT Society's (SDGHNO) Latin America project]

Nowadays, social projects are usually oriented in such a way that after a given period of time, they can either support themselves independently or even allow a pecuniary reimbursement. In the latter case, experts speak of a profit-oriented reimbursement. On the other hand, there is so-called social reimbursement, which in contrast to the abovementioned form is not profit oriented, but, for example, considers its task fulfilled by the fact of successful knowledge transfer. The Spanish-German Society for ENT Medicine and Head and Neck Surgery (SDGHNO) launched the Latin America project in 2001 under the patronage of the then President Prof. Dr. Wolfgang Draf (Fulda). The goal of the SDGHNO was and is to create a professional as well as cultural platform for Spanish- and German-speaking ENT doctors. This platform can and should be used for professional purposes, e.g., for knowledge transfer. Since the beginning of its existence, the Latin America project has thus brought numerous scientific events into being and created specific contacts which have lasted until today or have even been continued and further developed. Particularly successful examples are Chile, Colombia, and Peru. This is a vivid example of social reimbursement, because the participating German-speaking members/speakers carried out their tasks on an entirely voluntary basis. Thus, the SDGHNO did not bear any travel, catering, or accommodation costs. The activities of the SDGHNO within the framework of the Latin America project are explained.

[State of the art of quality-of-life measurement in patients with chronic otitis media and conductive hearing loss]

The evaluation of results after middle ear reconstruction has been mainly based on functional parameters. In clinical practice as well as in otological research, the pure tone audiogram represents the gold standard in the assessment of the postoperative outcome. In order to assess the patient's subjective outcome, outcome analyzes focus increasingly on the health-related quality of life (HRQOL). However, the evaluation of HRQOL requires reliable and validated measuring instruments. A modest number of validated questionnaires for determination of the disease-specific HRQOL in patients with chronic otitis media and/or conductive hearing loss are currently available. Three of seven available questionnaires were developed and validated in the German-speaking countries, the Zurich Chronic Middle Ear Inventory 21 (ZCMEI-21), the Chronic Otitis Media Outcome Test 15 (COMOT-15) and the Stapesplasty Outcome Test 25 (SPOT-25). In this review, all seven available disease-specific measuring instruments as well as the generic questionnaires, which were used in previous clinical trials, are explained and current findings of quality-of-life research in patients with chronic otitis media and/or conductive hearing loss are presented.

[Development and validation of the Stapesplasty Outcome Test 25 (SPOT-25)]

BACKGROUND

Otosclerosis affects health-related quality of life (HRQOL). Until now, measurements have only been performed using audiometric data or non-validated quality of life questionnaires.

OBJECTIVE

The objective of this study was to develop the first validated disease-specific HRQOL measuring instrument to determine HRQOL in otosclerosis.

MATERIALS AND METHODS

After sequential analysis and item reduction of the initial Stapesplasty Outcome Test 47 (SPOT-47), the SPOT-25 was validated prospectively on 52 otosclerosis patients undergoing stapes surgery. In addition to the overall score, four subscores were defined (hearing function, tinnitus, social restrictions, mental condition).

RESULTS

The SPOT-25 showed a high internal consistency (Cronbach's α > 0.7), allowed discrimination between otosclerosis patients and healthy subjects, and demonstrated acceptable test-retest reliability (r = 0.85). After stapes surgery, the HRQOL improved significantly. The responsiveness was high.

CONCLUSION

The SPOT-25 is the first validated disease-specific instrument for HRQOL measurement in otosclerosis patients. It should be used routinely for quality control.

[Acupuncture in posttonsillectomy pain : A prospective double-blind randomized controlled trial. German version]

BACKGROUND

Postoperative swallowing pain is one of the most unpleasant after-effects of tonsillectomy. During recent years, the demand for alternatives to drug-based pain therapy has continued to grow, although the topic has received little research attention until now.

MATERIALS AND METHODS

A total of 46 patients were randomized into verum acupuncture, control acupuncture, and drug-based treatment groups. All patients received nonsteroidal antirheumatic drugs (NSAIDs). One hour after drug intake, the verum group also received acupuncture according to classical acupuncture rules (S34, S44 and PC5). The control group had acupuncture needles placed at nonspecific acupuncture points in the midaxillary line. Acupuncture was performed by a blinded acupuncturist, who had learnt exclusively these techniques in the run up to the study. Patients were asked to evaluate their pain before, and at intervals of 20 min, 1 h, 2 h, and 3 h after drug intake/acupuncture treatment using a visual analog scale (VAS).

RESULTS

The analgesic effect of acupuncture was significant up to 3 hours in the verum group (p < 0.05). The analgesic effect in the control acupuncture group was significant for up to 1 h after acupuncture (p < 0.05). With reference to the time point before acupuncture, the differences between both acupuncture groups and the drug group were significant (p < 0.01) over the whole time.

CONCLUSION

Acupuncture is an effective complement to NSAIDs in the treatment of posttonsillectomy pain. Particularly patients with allergies, drug intolerance, or reduced response to the commonly administered drugs may benefit from acupuncture.

Upfront azacitidine (AZA) in juvenile myelomonocytic leukemia (JMML): Interim analysis of the prospective AZA-JMML-001 study

10031

Background: Hematopoietic stem cell transplantation (HSCT) is the only curative therapy for JMML patients (pts). Novel therapies controlling the disorder prior to HSCT are urgently needed. A phase 2, multicenter, open-label study was conducted to evaluate safety and anti-leukemia activity of AZA monotherapy prior to HSCT in pts with newly diagnosed (ND) JMML. Methods: AZA (75 mg/m2 IV) was administered once daily on days 1–7 of each 28-day cycle (C). Primary endpoint was number of pts with clinical complete remission or clinical partial remission (cPR) at C3 day (D) 28 (C3D28). Results: 18 JMML pts (13 PTPN11-, 3 NRAS-, 1 KRAS-, 1 NF1-mutated) were enrolled from 09/2015 to 11/2017. Median (range) white blood cell and platelet (Plt) counts were 19.7 (4.3–59.0) × 109/L and 28 (7–85) × 109/L, respectively. DNA methylation class (MC) was high, intermediate (int), or low in 11, 5, and 2 pts, respectively. 16 pts completed C3 and 5 pts C6. 2 pts discontinued treatment (Tx) pre-C3D28 due to disease progression (PD). 6 pts (33%) had ≥ 1 grade (Gr) 3–4 manageable adverse event (AE) related to AZA. Most common Gr 3–4 AEs related to AZA were neutropenia (2) and anemia (2). 11 pts (61%) were in cPR at C3D28; 7 had PD at C3D28 or prior. All 7 pts of the int/low MC and 4/11 in high MC achieved cPR. 17 pts received HSCT at median of 58 days (37–518) from last AZA dose; 14 were leukemia-free at a median follow-up of 15.7 months (0.1–31.7) after HSCT. 2 pts (high MC) given HSCT relapsed after allograft. 16/18 pts were alive at a median follow-up of 19.8 months (2.6–37.3) from diagnosis. 1 pt discontinuing Tx prior to C3 died from PD; 1 non-responder died from transplant-related causes. Plt response in pts with cPR prompted retrospective comparison of Plt counts at time of HSCT with a historical registry control cohort. Pts with NF1-mutated JMML with higher Plt counts versus other genetic subtypes were excluded. While 7/16 (44%) study pts had Plt counts ≥ 100 × 109/L at HSCT, only 10/58 (17%) historical cohort pts reached this cutoff ( P < 0.01). Conclusions: This study shows that AZA monotherapy was well tolerated in pts with ND JMML. Although the long-term advantage of AZA Tx remains to be fully assessed, responses show it was effective in JMML and provided clinical benefit to pts in this study. Clinical trial information: NCT02447666.

Prolongation of working life and its effect on mortality and health in older adults: Propensity score matching

Many countries are raising the age of pension eligibility because of increases in life expectancy. Given the social gradient in life expectancy and health, it is important to understand the potential late-life health effects of prolonging working life and whether any effects differ by socioeconomic position. We examined the effect of prolonging working life beyond age 65 on mortality and a series of indicators of late-life physical health (the ability to climb stairs without difficulty, self-rated health, ADL limitations, and musculoskeletal pain) in a representative sample of the Swedish population. In addition to average effects, we also examined heterogeneous effects, for instance by occupational social class. To do this, we use propensity score matching, a method suitable for addressing causality in observational data. The data came from two linked Swedish longitudinal surveys based on nationally representative samples with repeated follow-ups; The Swedish Level of Living Survey and the Swedish Panel Study of Living conditions of the Oldest Old, and from national income and mortality registries. The analytical sample for the mortality outcome included 1852 people, and for late-life physical health outcomes 1461 people. We found no significant average treatment effect on the treated (ATT) of working to age 66 or above on the outcomes, measured an average of 12 years after retirement: mortality (ATT -0.039), the ability to climb stairs (ATT -0.023), self-rated health (ATT -0.009), ADL limitations (ATT -0.023), or musculoskeletal pain (ATT -0.009) in late life. Analyses of whether the results varied by occupational social class or the propensity to prolong working life were inconclusive but suggest a positive effect of prolonging working life on health outcomes. Accordingly, more detailed knowledge about the precise mechanisms underlying these results are needed. In conclusion, working to age 66 or above did not have effect on mortality or late-life physical health.

Quality of life after nasal cancer resection - surgical versus prosthetic rehabilitation

BACKGROUND

Nose reconstruction following resection of nasal carcinomas is controversial. The objective of this study is to investigate the effect of surgical reconstruction versus prosthetic rehabilitation on patient quality of life (QOL).

DESIGN

This was a monocentric prospective study of patients diagnosed with nasal carcinoma from 2003 to 2013. QOL was evaluated using two organ-specific questionnaires (Rhinoplasty Outcome Evaluation [ROE] and the Functional Rhinoplasty Outcome Inventory-17 [FROI-17]) and a generic questionnaire, the Short-Form 36 Health Survey (SF-36).

MATERIAL AND METHODS

Sixty-four patients were included. Patients completed the ROE, FROI-17, and SF-36 questionnaires after nasal reconstruction. Questionnaires were completed by 62.8% of the 51 alive patients.

RESULTS

Recurrence-free survival (RFS) was 89.9%, disease-specific survival was 94.5%, and overall survival was 75.5% after five years according to the Kaplan-Meier method. Considering initial tumor stage, early stage patients had a significantly higher self-confidence score in FROI-17 subgroup analysis. In contrast, advanced stage patients showed a significantly higher score for social functioning in SF-36. Prosthetically fitted patients scored highly on the ROE questionnaire showing a high degree of aesthetic satisfaction. Surgically reconstructed patients showed a high degree of self-confidence on the FROI-17 questionnaire. However, the organ-specific ROE and FROI-17 scores were not significantly different between patients who received surgical reconstruction and prosthetic rehabilitation after oncological resection. When comparing the rehabilitation method as a function of tumor stage, there was significantly better score for physical functioning in early stage surgically reconstructed patients in the SF-36, but no significant differences in organ-specific QOL.

CONCLUSION

Surgical reconstruction and prosthetic rehabilitation after nasal cancer resection have the same effect on organ- and non-organ-specific QOL.

Molecular profile of inflammatory and megakaryocytic factors in pediatric myelodysplastic syndrome with acute myelofibrosis

Pediatric fibrotic myelodysplastic syndromes (ped-MDS-MF) and pediatric primary myelofibrosis (ped-PMF) are rare, and the molecular changes which mediate fibrosis have never been investigated. Histology and gene expression profile of 119 fibrosis/angiogenesis/inflammation/megakaryopoiesis-related factors in bone marrow biopsies were performed (two ped-MDS-MF and one ped-PMF). In one progressive ped-MDS, comparison of MF grade 0 (no myelofibrosis) and MF grade 2 (dense network of reticulin fibres) after 4 months showed that expression of fibrosis-related transcripts increased and dysplastic megakaryocytes formed a dense net of CD42b⁺ proplatelets. These changes were not observed in another ped-MDS-MF, whereas ped-PMF showed a similar proplatelet pattern. These findings indicate that fibrotic changes in ped-MDS may involve proplatelet-related and unrelated pathways.

[CF Lung Disease - a German S3 Guideline: Module 2: Diagnostics and Treatment in Chronic Infection with Pseudomonas aeruginosa]

Cystic Fibrosis (CF) is the most common autosomal-recessive genetic disease affecting approximately 8000 people in Germany. The disease is caused by mutations in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene leading to dysfunction of CFTR, a transmembrane chloride channel. This defect causes insufficient hydration of the epithelial lining fluid which leads to chronic inflammation of the airways. Recurrent infections of the airways as well as pulmonary exacerbations aggravate chronic inflammation, lead to pulmonary fibrosis and tissue destruction up to global respiratory insufficiency, which is responsible for the mortality in over 90 % of patients. The main aim of pulmonary treatment in CF is to reduce pulmonary inflammation and chronic infection. Pseudomonas aeruginosa (Pa) is the most relevant pathogen in the course of CF lung disease. Colonization and chronic infection are leading to additional loss of pulmonary function. There are many possibilities to treat Pa-infection. This is a S3-clinical guideline which implements a definition for chronic Pa-infection and demonstrates evidence-based diagnostic methods and medical treatment for Pa-infection in order to give guidance for individual treatment options.

Constitutional SAMD9L mutations cause familial myelodysplastic syndrome and transient monosomy 7

Familial myelodysplastic syndromes arise from haploinsufficiency of genes involved in hematopoiesis and are primarily associated with early-onset disease. Here we describe a familial syndrome in seven patients from four unrelated pedigrees presenting with myelodysplastic syndrome and loss of chromosome 7/7q. Their median age at diagnosis was 2.1 years (range, 1-42). All patients presented with thrombocytopenia with or without additional cytopenias and a hypocellular marrow without an increase of blasts. Genomic studies identified constitutional mutations (p.H880Q, p.R986H, p.R986C and p.V1512M) in the SAMD9L gene on 7q21, with decreased allele frequency in hematopoiesis. The non-random loss of mutated SAMD9L alleles was attained via monosomy 7, deletion 7q, UPD7q, or acquired truncating SAMD9L variants p.R1188X and p.S1317RfsX21. Incomplete penetrance was noted in 30% (3/10) of mutation carriers. Long-term observation revealed divergent outcomes with either progression to leukemia and/or accumulation of driver mutations (n=2), persistent monosomy 7 (n=4), and transient monosomy 7 followed by spontaneous recovery with SAMD9L-wildtype UPD7q (n=2). Dysmorphic features or neurological symptoms were absent in our patients, pointing to the notion that myelodysplasia with monosomy 7 can be a sole manifestation of SAMD9L disease. Collectively, our results define a new subtype of familial myelodysplastic syndrome and provide an explanation for the phenomenon of transient monosomy 7. Registered at: www.clinicaltrials.gov; #NCT00047268.

Quality of life after primary septorhinoplasty in deviated- and non-deviated nose measured with ROE, FROI-17 and SF-36

BACKGROUND

Quality of life measurements are gaining in importance. The present study was conducted with the aim to compare patient satisfaction after septorhinoplasty according to their preoperative nasal deformity.

METHODS

The patients completed two disease-specific questionnaires before their surgery: the Functional Rhinoplasty Outcome Inventory (FROI-17), the Rhinoplasty Outcome Evaluation (ROE) and as a general instrument, the Short Form 36 Health Survey (SF-36). The second measurement was taken during an outpatient examination 12 months after their primary septorhinoplasty. Patients were grouped in nasal axis deviation (NAD), nasal hump deformity (NHD) and NAD plus NHD. Additionally the patients with preoperative NAD and NAD+NHD were combined as deviated nose and compared to the non-deviation group.

RESULTS

One hundred and two patients (51 male and 51 female) underwent primary septorhinoplasty. The ROE- and the FROI-17 overall score including all three subgroups showed significant postoperative improvements. Regarding the SF-36, the postoperative score improved significantly only in two scales (role-functioning physical and mental health). Looking at the the different QoL questionnaires, there were significant postoperative differences in regards to deviated versus non-deviated nose in the FROI-17 overall- and FROI-17 subscores (nasal and general symptoms) and in three scales of the SF-36 (vitality, social functioning, role-functioning emotional), showing a greater postoperative satisfaction in the deviated-nose patient.

CONCLUSION

Patients with and without nasal deviation showed improved QoL after their surgery, as measured with the ROE, the FROI-17 and the SF-36. The patients with a nasal deviation showed a significantly better outcome, as measured with the FROI-17, in comparison with the non-deviated group.

[Quality of life in patients with vestibular schwannoma]

BACKGROUND

Vestibular schwannoma (VS) is a disease which might affect health-related quality of life (HR-QOL) in a negative manner. For many years, only generic quality of life instruments such as SF-36 were available to measure HR-QOL. However, some years ago, the Penn Acoustic Neuroma Quality Of Life (PANQOL) tool, a disease-specific instrument, was developed and validated. It is expected that the application of this instrument will be able to better assess relevant aspects of the HR-QOL of VS patients in the future. A validated German version of the instrument does not exist yet. The disease-specific symptoms most frequently named by patients are headache and dizziness.

RESULTS AND DISCUSSION

The available literature shows that the therapeutic approaches affect HR-QOL differently. In particular, radiation therapy of small and medium-sized tumors has no pronounced negative effects on HR-QOL. However, restrictions after surgery become similar to those after radiotherapy over the course of several years. For large VS with a diameter >3 cm, no guiding data on this aspect are currently available. To clarify the outstanding issues, future prospective studies with long-term follow-up of 10 years and more are desirable.

Quality of life after primary septorhinoplasty in deviated- and non-deviated nose measured with ROE, FROI-17 and SF-36

BACKGROUND

Quality of life measurements are gaining in importance. The present study was conducted with the aim to compare patient satisfaction after septorhinoplasty according to their preoperative nasal deformity.

METHODS

The patients completed two disease-specific questionnaires before their surgery: the Functional Rhinoplasty Outcome Inventory (FROI-17), the Rhinoplasty Outcome Evaluation (ROE) and as a general instrument, the Short Form 36 Health Survey (SF-36). The second measurement was taken during an outpatient examination 12 months after their primary septorhinoplasty. Patients were grouped in nasal axis deviation (NAD), nasal hump deformity (NHD) and NAD plus NHD. Additionally the patients with preoperative NAD and NAD+NHD were combined as deviated nose and compared to the non-deviation group.

RESULTS

One hundred and two patients (51 male and 51 female) underwent primary septorhinoplasty. The ROE- and the FROI-17 overall score including all three subgroups showed significant postoperative improvements. Regarding the SF-36, the postoperative score improved significantly only in two scales (role-functioning physical and mental health). Looking at the the different QoL questionnaires, there were significant postoperative differences in regards to deviated versus non-deviated nose in the FROI-17 overall- and FROI-17 subscores (nasal and general symptoms) and in three scales of the SF-36 (vitality, social functioning, role-functioning emotional), showing a greater postoperative satisfaction in the deviated-nose patient.

CONCLUSION

Patients with and without nasal deviation showed improved QoL after their surgery, as measured with the ROE, the FROI-17 and the SF-36. The patients with a nasal deviation showed a significantly better outcome, as measured with the FROI-17, in comparison with the non-deviated group.

[Rhinosinusitis in cystic fibrosis]

In cystic fibrosis (CF) mucociliary clearance of the entire respiratory system is impaired. This allows pathogens, such as Pseudomonas aeruginosa to persist and proliferate, which by progressive pulmonary destruction causes 90 % of premature deaths due to this inherited disease. The dramatic improvement in life expectation of patients due to intensive therapy has resulted in the inevitable but variably expressed sinonasal involvement coming into the clinical and scientific focus. Thereby, almost all CF patients reveal sinonasal pathology and many suffer from chronic rhinosinusitis. Recently, the sinonasal niche has been recognized as a site of initial and persistent colonization by pathogens. This article presents the pathophysiological background of this multiorgan disease as well as general diagnostic and therapeutic standards. The focus of this article is on sinonasal involvement and conservative and surgical options for treatment. Prevention of pathogen acquisition is an essential issue in the otorhinolaryngological treatment of CF patients.

Butyric acid fermentation from pretreated and hydrolysed wheat straw by an adapted Clostridium tyrobutyricum strain

Butyric acid is a valuable building-block for the production of chemicals and materials and nowadays it is produced exclusively from petroleum. The aim of this study was to develop a suitable and robust strain of Clostridium tyrobutyricum that produces butyric acid at a high yield and selectivity from lignocellulosic biomasses. Pretreated (by wet explosion) and enzymatically hydrolysed wheat straw (PHWS), rich in C6 and C5 sugars (71.6 and 55.4 g l⁻¹ of glucose and xylose respectively), was used as substrate. After one year of serial selections, an adapted strain of C. tyrobutyricum was developed. The adapted strain was able to grow in 80% (v v⁻¹) PHWS without addition of yeast extract compared with an initial tolerance to less than 10% PHWS and was able to ferment both glucose and xylose. It is noticeable that the adapted C. tyrobutyricum strain was characterized by a high yield and selectivity to butyric acid. Specifically, the butyric acid yield at 60–80% PHWS lie between 0.37 and 0.46 g g⁻¹ of sugar, while the selectivity for butyric acid was as high as 0.9–1.0 g g⁻¹ of acid. Moreover, the strain exhibited a robust response in regards to growth and product profile at pH 6 and 7.

Outcomes of mismatched and unrelated donor hematopoietic stem cell transplantation in Fanconi anemia conditioned with chemotherapy only

Fanconi anemia (FA) is a genomic instability syndrome associated with bone marrow failure, myelodysplastic syndrome (MDS), and/or acute myeloid leukemia (AML) requiring hematopoietic stem cell transplantation (HSCT) to restore normal hematopoiesis. Although low-intensity fludarabine-based preparative regimens without radiation confer excellent outcomes in FA HSCTs with HLA-matched sibling donors, outcomes for FA patients with alternative donors are less encouraging, albeit improving. We present our experience with 17 FA patients who completed mismatched related or unrelated donor HSCT using a non-radiation fludarabine-based preparative regimen at Charité University Medicine Berlin. All patients engrafted; however, one patient had unstable chimerism in the setting of multi-viral infections that necessitated a stem cell boost to revert to full donor chimerism. Forty-seven percent of patients developed grade I acute graft-verus-host disease (aGVHD). No grade II-IV aGVHD or chronic graft-versus-host disease of any severity occurred. At a median follow-up of 30 months, 88 % of patients are alive with normal hematopoiesis. Two patients died of infections 4 months post-transplantation. These results demonstrate that short-term outcomes for FA patients with mismatched and unrelated donor HSCTs can be excellent using chemotherapy only conditioning. Viral reactivation, however, was a major treatment-related complication.

Bone marrow immunophenotyping by flow cytometry in refractory cytopenia of childhood

Refractory cytopenia of childhood is the most common type of childhood myelodysplastic syndrome. Because the majority of children with refractory cytopenia have a normal karyotype and a hypocellular bone marrow, differentiating refractory cytopenia from the immune-mediated bone marrow failure syndrome (very) severe aplastic anemia can be challenging. Flow cytometric immunophenotyping of bone marrow has been shown to be a valuable diagnostic tool in differentiating myelodysplastic syndrome from non-clonal cytopenias in adults. Here, we performed the first comprehensive flow cytometric analysis of immature myeloid, lymphoid cells and erythroid cells, and granulocytes, monocytes, and lymphoid cells in bone marrow obtained from a large prospective cohort of 81 children with refractory cytopenia. Children with refractory cyotopenia had a strongly reduced myeloid compartment, but not as severe as children with aplastic anemia. Furthermore, the number of flow cytometric abnormalities was significantly higher in children with refractory cytopenia than in healthy controls and in children with aplastic anemia, but lower than in advanced myelodysplastic syndrome. We conclude that flow cytometric immunophenotyping could be a relevant addition to histopathology in the diagnosis of refractory cytopenia of childhood. (The multi-center studies EWOG-MDS RC06 and EWOG-MDS 2006 are registered at clinicaltrials.gov identifiers 00499070 and 00662090, respectively).

Juvenile-like (inflammatory/hyperplastic) mucosal polyps of the gastrointestinal tract in neurofibromatosis type 1

AIMS

Diffuse neurofibromatosis/ganglioneuromatosis, solitary/plexiform neurofibroma, periampullary carcinoids and gastrointestinal stromal tumour (GIST) are the main gastrointestinal manifestations of neurofibromatosis type 1 (NF-1, von Recklinghausen disease). Inflammatory (juvenile-like) polyps have not been recognised to date as specific gastrointestinal (GI) manifestations of NF-1.

METHODS AND RESULTS

We describe four males aged 23-65 years with NF-1 and inflammatory (juvenile-like) gastrointestinal polyps, and review the literature for similar cases. Two patients had single polyps (sigmoid colon and antrum, respectively), one had two polyps (left colon), and one had three polyps (distal oesophagus and colon). Histological appearances were variable, ranging from juvenile-like to granulation tissue-rich, predominantly inflammatory and hyperplastic. Three lesions showed obliterative vasculopathic changes. None had neurofibromatous or ganglioneuromatous polyps. A review of the literature disclosed 11 similar cases. Most patients presented with severe gastrointestinal symptoms and/or anaemia.

CONCLUSIONS

NF-1-associated inflammatory polyps probably represent specific GI manifestations of this disorder, and should be considered, particularly in patients with GI symptoms. They should be distinguished from inflammatory fibroid polyps and from juvenile-like changes associated with ganglioneuroma/ganglioneuromatosis and neurofibroma/neurofibromatosis. Their aetiology remains obscure, but different mechanisms, including NF-1 inactivation, NF-1-associated vasculopathy, and localised mucosal prolapse/damage caused by motility disorders, might be involved.

Comparison of horse and rabbit antithymocyte globulin in immunosuppressive therapy for refractory cytopenia of childhood

Refractory cytopenia of childhood is the most common subtype of myelodysplastic syndrome in children. In this study, we compared the outcome of immunosuppressive therapy using horse antithymocyte globulin (n=46) with that using rabbit antithymocyte globulin (n=49) in 95 patients with refractory cytopenia of childhood and hypocellular bone marrow. The response rate at 6 months was 74% for horse antithymocyte globulin and 53% for rabbit antithymocyte globulin (P=0.04). The inferior response in the rabbit antithymocyte globulin group resulted in lower 4-year transplantation-free (69% versus 46%; P=0.003) and failure-free (58% versus 48%; P=0.04) survival rates in this group compared with those in the horse antithymocyte globulin group. However, because of successful second-line hematopoietic stem cell transplantation, overall survival was comparable between groups (91% versus 85%; P=ns). The cumulative incidence of relapse (15% versus 9%; P=ns) and clonal evolution (12% versus 4%; P=ns) at 4 years was comparable between groups. Our results suggest that the outcome of immunosuppressive therapy with rabbit antithymocyte globulin is inferior to that of horse antithymocyte globulin. Although immunosuppressive therapy is an effective therapy in selected patients with refractory cytopenia of childhood, the long-term risk of relapse or clonal evolution remains. (ClinicalTrial.gov identifiers: NCT00662090).

[Development and validation of the Tonsillectomy Outcome Inventory 14]

BACKGROUND

Until now, no validated instrument to measure disease-specific, health-related quality of life (HR-QOL) in adults with chronic tonsillitis (CTO) exists.

MATERIAL AND METHODS

After an item reduction of the alpha-version of the Tonsillectomy Outcome Inventory (TOI), the TOI-14 resulted. In addition to the total score, it includes the subscales throat problems, overall health, resources, and social-psychological restrictions. In phase 2, the TOI-14 was prospectively validated on 108 adults with CTO, who had undergone a tonsillectomy.

RESULTS

The TOI-14 had, on average, good reliability. It included all important aspects of the HR-QOL. Patients with CTO can be distinguished with high sensitivity from healthy subjects. All scores showed moderate to good correlation with the subjective limitation in quality of life. The sensitivity of the questionnaire demonstrated major effects postoperatively.

CONCLUSION

The TOI-14 constitutes the first worldwide-validated, disease-specific instrument to measure HR-QOL in adults with CTO. Due to its ease of use, it can be utilized both in the outcome research and in clinical routine.

Apoptotic cells and clonally expanded cytotoxic T cells in bone marrow trephines of patients with myelodysplastic syndrome

AIMS

There is increasing evidence that autoimmunity is involved in the pathogenesis of myelodysplastic syndromes (MDS). We examined the number of apoptotic cells, and analysed the T cells and the T cell receptor gene rearrangements in bone marrow trephines of patients with low-grade MDS [refractory anaemia (RA), refractory anaemia with ringed sideroblasts (RAS) and refractory cytopenia with multilineage dysplasia (RCMD)] to investigate the correlation between T cells and apoptosis.

METHODS AND RESULTS

Bone marrow trephines from 30 patients with RA, seven patients with RCMD, four patients with RAS and 11 normal bone marrow donors were stained for CD3 and for apoptotic cells using immunohistochemistry and terminal deoxynucleotidyl transferase 2'-deoxyuridine, 5'-triphosphate (dUTP) nick end labelling (TUNEL) technique, respectively. The positive cells were quantified by computer-assisted image analysis. In addition, CD 8 and T cell-restricted intracellular antigen-1 (TIA-1)-positive cells were analysed by single staining and evaluated semiquantitatively by light microscopy. Junctional diversity of the T cell receptor (TCR) α-, β- and γ-chains were analysed in 24 cases of RA and RCMD by reverse transcription-polymerase chain reaction (RT-PCR). In all cases of RA, RCMD and RAS an increase of apoptotic cells was accompanied by an increase of T cells, when compared to normal donors (P < 0.001). Expression of TIA-1 was found in 33 of 41 patients with low-grade MDS. In contrast, normal controls showed either no or only very weak expression. Furthermore, 14 of 24 cases with low-grade MDS showed clonal TCR gene rearrangement.

CONCLUSION

These findings provide evidence that increased apoptosis in low-grade MDS correlates with increased numbers of cytotoxic T cells. A considerable proportion of the MDS cases showed clonal TCR rearrangement suggesting an antigen-driven selection of the T cells. We therefore speculate that cases of MDS can be accompanied by a presumably autoreactive T cell-mediated apoptosis induction in bone marrow cells.

[Differential diagnosis of headaches in otorhinolaryngology]

Facial pain and headaches are heterogeneous, therefore, a differential diagnosis, interdisciplinary survey and mapping of the pain symptoms are essential for determination of treatment concepts. This requires an otorhinolaryngology (ENT) adapted zoning of the various pains in the head and neck in line with the classification of the International Headache Society (IHS). In this review, idiopathic, symptomatic and neuralgic facial pain and headaches will be differentiated and classified according to their location from the ENT medical point of view. This provides otolaryngologists with a simplified, targeted diagnosis and subsequent indication for therapy.

[Microsurgical middle ear operations : Variability of the audiometric results from frequency variations]

INTRODUCTION

The audiometric results after reconstructive tympanic surgery on 504 patients carried out between October 2005 and October 2007, including 190 cases of tympanoplasty type I and 314 cases of tympanoplasty type III according to Wullstein, were retrospectively analyzed at the Department of Otolaryngology, Ruprecht-Karls-University in Heidelberg.

PATIENTS AND METHODS

To investigate the influence of the frequencies used to compare the outcome, the pure tone average air-bone gaps (PTA-ABG) of the preoperative and postoperative audiograms of tympanoplasties type I and III were analyzed. The frequencies covered the ranges of 0.5 kHz, 1 kHz, 2 kHz, 4 kHz and 6 kHz. In each case the 3-frequency, 4-frequency and 5-frequency analyses were calculated for the different surgical groups.

RESULTS

The 3-frequency analysis (0.5 kHz, 1 kHz and 2 kHz) of the type 1tympanoplasties were 18.8 ± 11.8 dB preoperative and 12.3 ± 11.8 dB postoperative. In 58.9% of cases the PTA-ABG ≤ 10 dB and in 86.7% it was ≤ 20 dB. The 3-frequency analysis showed that the tympanoplasties type III had a PTA-ABG of 30.6 ± 15.3 dB preoperatively and 21.8 ± 15.1 dB postoperatively. In 30.4% of cases the PTA-ABG was ≤ 10 dB and ≤ 20 dB for 56%.

DISCUSSION

The detailed itemization of frequencies in this study and the consequent opportunity to modify the frequency range, allowed the impact of this selection on the PTA-ABG to be illustrated and various comparisons with other studies could be carried out. In this article, the exclusion criteria were dealt with liberally and risk patients were also included and data from patients who displayed prognostic risks regarding the successful surgery in terms of the audiometric reports were integrated. These prognostic risks were due to the poor aeration of the tympanum and recent (sometimes diverse), pre-surgery as well as chronic inflammatory processes. This study has proved that all surgery collectives showed significant improvements of the PTA-ABG. Therefore, all surgery collectives (measured against the audiometric evaluation) benefited from the surgery.