Audiological phenotyping evaluation in KBG syndrome: Description of a multicenter review

OBJECTIVES

Our objective was to reinforce clinical knowledge of hearing impairment in KBG syndrome. KBG syndrome is a rare genetic disorder due to monoallelic pathogenic variations of ANKRD11.The typical phenotype includes facial dysmorphism, costal and spinal malformation and developmental delay. Hearing loss in KBG patients has been reported for many years, but no study has evaluated audiological phenotyping from a clinical and an anatomical point of view.

METHODS

This French multicenter study included 32 KBG patients with retrospective collection of data on audiological features, ear imaging and genetic investigations.

RESULTS

We identified a typical audiological profil in KBG syndrome: conductive (71%), bilateral (81%), mild to moderate (84%) and stable (69%) hearing loss, with some audiological heterogeneity. Among patients with an abnormality on CT imaging (55%), ossicular chain impairment (67%), fixation of the stapes footplate (33%) and inner-ear malformations (33%) were the most common abnormalities.

CONCLUSION

We recommend a complete audiological and radiological evaluation and an ENT-follow up in all patients presenting with KBG Syndrome. Imaging evaluation is necessary to determine the nature of lesions in the middle and inner ear.

[Vocal cord dysfunction in athletes: Interest of rehabilitation to effort]

INTRODUCTION

Vocal Cord Dysfunction (VCD) is a syndrome characterized by paradoxical adduction of the vocal folds during breathing. Its non-specific clinical manifestations frequently lead to misdiagnosis and delay in its treatment. The treatment of VCD is not pharmacological but rehabilitative and remains poorly appreciated.

OBSERVATION

In this clinical case we describe a 16-year-old female judoka who presented with effort intolerance associated with occasional dyspnea, which had suddenly worsened over the preceding few months so that in now produced sudden respiratory difficulty, mainly during intense and sudden efforts. After a period where her symptoms were confused with asthma, she was diagnosed with exercise-induced VCD. Her treatment was aimed to: (a) rehabilitate respiratory mechanics in order to eliminate abdominal-thoracic asynchrony, (b) rehabilitate naso-nasal breathing, (c) train her to control abdominal-diaphragmatic breathing at rest and then during effort, (d) train her to use ventilatory control as soon as prodromal symptoms appear in order to prevent the development of stridor or complete closure of the vocal folds (at rest and then progressively during exercise).

CONCLUSION

Following the implementation of these rehabilitation strategies to correct her ventilatory and dyskinetic issues, the patient no longer develops respiratory discomfort during exercise, including during judo competitions.

Effect of liquid properties on swallowing and ventilation coordination in rats

BACKGROUND

One aspect of rehabilitation in swallowing disorders is to change liquid properties. The objective of our study was to test how liquid properties could improve oropharyngeal dysphagia and swallowing and ventilation coordination in an animal model.

METHODS

Forty-two healthy male rats were distributed in six groups, including a control group. Rats were deprived of water for 24 h and then each group was administered liquid with different properties: tap water, sugar water, sparkling water, salt water, cold water, and acidic water. Rats were studied without and with oropharyngeal dysphagia achieved by unilateral section of the hypoglossal nerve. Swallowing and ventilation were analyzed by barometric plethysmograph.

KEY RESULTS

In healthy rats, swallowing occurred during expiratory time for all liquid properties. Most deglutitions were during expiratory time for all liquid properties (88±12%) and were not modified. There was an increase in VT/TI during swallowing with sparkling water and cold water (P<.05). In the operated groups, rats had significantly fewer swallows with tap water (P<.05) and significantly more swallows with sparkling water (P<.001), sugar water (P<.001) and cold water (P<.001) during expiratory time. The mean inspiratory volume (VT/TI) increased with sparkling water (P<.05).

CONCLUSION AND INFERENCES

Sparkling water seemed to improve swallowing and ventilation coordination in an animal model, to be confirmed in a study including patients with oropharyngeal dysphagia.

Acremonium sclerotigenum-Acremonium egyptiacum: a multi-resistant fungal pathogen complicating the course of aplastic anaemia

A patient with aplastic anaemia, successively treated with caspofungin then liposomal amphotericin, developed a disseminated infection due to Acremonium, further confirmed as resistant in vitro to these drugs. Successful treatment was achieved with voriconazole. Multiple antifungal treatments may expose to the risk of breakthrough of multi-resistant pathogens in haematology patients.

Modification in swallowing and ventilation co-ordination during hypercapnia, hypoxia, and tachypnea in unrestrained animals

BACKGROUND

It has been demonstrated that aspirations could occur during respiratory failure, explained by a lack of co-ordination between swallowing and ventilation. To test this hypothesis, we examined the co-ordination of ventilation and swallowing in a completely unrestrained rat model during different level of hypercapnia, during hypoxia, and during tachypnea.

METHODS

A total of 50 male Wistar rats (250-350 g) were studied in a barometric plethysmograph to analyze swallowing and ventilation during swallowing, at different gas concentration [room air (G1), 10% of O2 and 0% of CO2 (G2), 21% of O2 and 5% of CO2 (G3), 21% of O2 and 10% of CO2 (G4), tachypnea (G5)].

KEY RESULTS

During hypoxia, there was no difference between G2 and G1 regarding the swallowing parameters and ventilatory parameters. During hypercapnia, there was an increase in swallowing during inspiration in G4 (16 ± 20%P < 0.01) compared with G1. The analysis of ventilatory parameters during swallowing showed an increase in tidal volume (VT) and mean inspiratory time (VT/TI) (P < 0.001) with no change in respiratory cycle duration (TTOT), inspiratory time (TI), and expiratory time (TE) when compared with G1. During tachypnea (G5), the VT decreased (P < 0.05) without any change in VT/TI.

CONCLUSIONS & INFERENCES

Our results on animal demonstrated that hypercapnia increased swallowing during inspiration, which was not the case for tachypnea or hypoxia, and could explain some aspirations during respiratory failure.

[Role of hypnotherapy in the treatment of debilitating tinnitus]

OBJECTIVE

Hypnotherapy is currently used for tinnitus therapy in our university hospital. The aim of this study was to evaluate its efficacy.

MATERIAL AND METHODS

This study was performed on 110 patients suffering from distressing tinnitus. They were treated during five sessions with hypnotherapy, supplemented by instruction on self-hypnotherapy. A subjective evaluation was done by the practitioner at the end of the sessions of hypnotherapy. Then a questionnaire on psychologic distress (Wilson 1991) was sent retrospectively to the patients.

RESULTS

We received 65 responses which were used for this study. Before treatment, the mean value of the Wilson score was 54 (28-104). After treatment, it was: 31 (0-86). 69% of the patients felt an improvement > or = 5 points Wilson score. These results were compared with the evaluation carried out by the practitioner at the end of the sessions of hypnosis. There was a "significant correlation" between the evaluation of the felt benefice, analyzed by the practitioner at the end of the sessions of hypnosis, and by the patient questioned long after the treatment. These results had significant correlation with the evaluation made by the therapist at the end of the five sessions of hypnotherapy. They show, how effective (68% improvement) this therapeutic approach can be.

CONCLUSION

Hypnotherapy can be regarded as an effective treatment against distressing tinnitus.

Multidrug Resistance (MDR) Gene Expression in Acute Non Lymphoblastic Leukemia: Sequential Analysis

Sequential evaluation of P-glycoprotein expression was performed in 29 patients with acute nonlymphoblastic leukemia using immunocytochemistry with the C219 antibody. At diagnosis, 32% of the patients exhibited more than 5% of the P-gp(+) leukemic cells. Under chemotherapy, 62% of the patients eventually expressed a subset of P-gp positive leukemic cells. After conventional doses of cytosine-arabinoside (Ara-C) and daunorubicin or mitoxantrone, positive P-gp cells were noted in 65% of the cases. This percentage was significantly higher (p = 0.002) than the proportion of positive cases (15%) observed after regimens containing either intermediate doses of Ara-C or cyclosporine A, a P-gp modulator.

Impact of swallowing and ventilation on oropharyngeal cortical representation

Our aim was to determine whether ventilation and swallowing tasks can modify oropharyngeal cortical motor organisation. Mylohyoid motor-evoked potentials (MEP) induced by non-focal (NF) and focal (F) magnetic stimulations were recorded in nine healthy volunteers four times, with 1 week between each recording. Baseline values were evaluated and their reproducibility was assessed 1 week later. Thereafter, the subjects were asked to perform swallowing and ventilation tasks in random order 15 min per day for 1 week. The NF MEP amplitudes after the swallowing and ventilation tasks increased after effortful swallows (p<0.001) and ventilation efforts (p<0.001). The F MEP amplitudes obtained after focal cortical stimulations increased after effortful swallows (p<0.01) and ventilation efforts (p<0.05). The cortical magnitude of the oropharyngeal muscle representation increased after swallowing practice (p<0.01). In conclusion, swallowing and ventilation tasks modified the motor cortex of oropharyngeal muscles and should be evaluated for use in rehabilitation strategies.

Quality of life in head and neck cancers patients: predictive factors, functional and psychosocial outcome

The principal endpoints in head and neck cancer are survival with improvement of quality of life (QoL) in cancer patients. Patients treated for head and neck cancer suffer from a number of symptom domains: physical symptoms linked to diet and feeding, communication disorders, pain and their general state of health; psychological symptoms including depression, irritability, loss of self-esteem (occasionally feelings of shame), and social symptoms including relationship difficulties with partner (sexual disorders) or with other family members, loss of work, reduction in salary, and sense of uselessness, resulting in a negative impact on their daily life. At present, most tools only partially evaluate patient QoL, concentrating on the global impact of disease and its treatment on patients' physical and psychological condition. The "sociability" of individual patients is rarely evaluated, and the development of qualitative studies in this domain will enable improved understanding of the social factors involved in each patient's adaptability to disease, its treatment and after-effects.

[Laryngeal schwannomas]

Laryngeal schwannoma is a rare benign tumour of the larynx. Schwannomas derive from the Schwann cells. The majority occurs in supraglottic area and may arise at any age. Magnetic resonance imaging (MRI) is the best imaging tool for suggesting the diagnosis in the appropriate clinical context. Conservative surgery is the treatment of choice. These tumors have to be distinguished from neurofibromas. We report 2 cases of laryngeal schwannoma. The first one concerned an 8-month-old baby with a laryngeal stridor history which seemed to be related to laryngomalacia. The second case was a 22-year-old man with a 5-year history of dysphonia. On nasofibroscopic examination, a sub mucosal mass enlarged the posterior part of the right false vocal cord in both cases. Both CT scan and MRI sequences showed a well margined lesion in the same place. Histological biopsies identified a schwannoma. External surgeries were subsequently and successfully performed. Diagnosis (imaging), specific treatment (endoscopic or external surgery), and possible association of laryngeal schwannomas are discussed.

Mylohyoid motor-evoked potentials relate to swallowing function after chronic stroke dysphagia

This work aimed to study mylohyoid motor-evoked potentials (MHMEPs) and examined if it is related to chronic stroke dysphagia. Conduction time (CT) and amplitudes of the right and left MHMEPs in response to focal cortical magnetic stimulations over affected and unaffected hemispheres were recorded in 16 stroke patients with aspiration (n = 9) or residue (n = 7) and compared with eight control patients. In control group, MHMEPs were present on ipsilateral and contralateral sides after stimulation of both hemispheres and permitted to determine a dominant hemisphere. In stroke patients, after stimulation of the affected hemisphere, ipsilateral MEPs had a longer CT and lower amplitudes in patients with aspiration compared with patients with residue or control patients (P < 0.05). Contralateral CT was not different between the three groups, but amplitudes were lower in patients with residue and aspiration than in control patients (P < 0.01). In the unaffected hemisphere, MHMEPs were present, and not different between the three groups for the ipsilateral side and amplitudes were decreased in contralateral side in patients with residue. In conclusion, MHMEP alterations of the affected hemisphere related to chronic stroke dysphagia severity and were closed to normal in the unaffected hemisphere.

Malignant hematopoietic cells induce an increased expression of VEGFR-1 and VEGFR-3 on bone marrow endothelial cells via AKT and mTOR signalling pathways

Angiogenesis plays a significant role in a variety of malignant hematologic diseases, and it is recognized that it has prognostic value. However, the cellular mechanisms by which malignant hematologic cells induce angiogenesis are not well understood. In order to investigate the role of cells from B-cell chronic lymphocytic leukemia (B-CLL) and multiple myeloma (MM) in angiogenesis on human bone marrow endothelial cells (HBMEC), we analyzed the impact of factors secreted by B-CLL cells and by MM cells on HBMEC capillary tube formation on matrigel. It was found that, in addition to the secretion of angiogenic factors VEGF and b-FGF by B-CLL and MM cells, MM cells (but not B-CLL cells) induced a dramatic increase in expression of VEGFR-1 and VEGFR-3 on human bone marrow endothelial cells (HBMEC). It would seem that this increase in VEGFR-3 occurred via the ERK and mTOR pathways, since their respective inhibitors U0126, LY294002 or rapamycin were responsible for a decrease of VEGFR-3. In response to MM cells-increased VEGF receptors on HBMEC, endothelial cell migration was enhanced in a wound artificially produced in a semi-confluent HBMEC culture, a phenomenon which was also down-regulated by the same inhibitors that reversed the increase in VEGF receptors. The present study suggests that, in addition to the classic angiogenic pathway, another mechanism related to an increased expression of VEGFRs on HBMEC might exist in malignant hematopoietic angiogenesis.

A phase I dose-finding and pharmacokinetic study of subcutaneous semisynthetic homoharringtonine (ssHHT) in patients with advanced acute myeloid leukaemia

To determine the maximum-tolerated dose (MTD), dose-limiting toxicities and pharmacokinetic of semisynthetic homoharringtonine (ssHHT), given as a twice daily subcutaneous (s.c.) injections for 9 days, in patients with advanced acute leukaemia, 18 patients with advanced acute myeloid leukaemia were included in this sequential Bayesian phase I dose-finding trial. A starting dose of 0.5 mg m⁻² day⁻¹ was explored with subsequent dose escalations of 1, 3, 5 and 6 mg m⁻² day⁻¹. Myelosuppression was constant. The MTD was estimated as the dose level of 5 mg m⁻² day⁻¹ for 9 consecutive days by s.c. route. Dose-limiting toxicities were hyperglycaemia with hyperosmolar coma at 3 mg m⁻², and (i) one anasarque and haematemesis, (ii) one life-threatening pulmonary aspergillosis, (iii) one skin rash and (iv) one scalp pain at dose level of 5 mg m⁻² day⁻¹. The mean half-life of ssHHT was 11.01±3.4 h, the volume of distribution at steady state was 2±1.4 l kg⁻¹ and the plasma clearance was 11.6±10.4 l h⁻¹. Eleven of the 12 patients with circulating leukaemic cells had blood blast clearance, two achieved complete remission and one with blast crisis of CMML returned in chronic phase. The recommended daily dose of ssHHT on the 9-day schedule is 5 mg m⁻² day⁻¹.

Common 4q24 deletion in four cases of hematopoietic malignancy: early stem cell involvement?

We determined bone marrow karyotype at diagnosis in four female acute myeloid leukemia (AML) or myelodysplasia patients, aged between 52 and 56 years. In each case, we observed chromosome rearrangement involving the same 4q24 band. Three patients had a balanced reciprocal translocation as the sole abnormality - t(3;4)(q26;q24), t(4;5)(q24;p16) and t(4;7)(q24;q21) - and the fourth had del(4)(q23q24), +4. We used a set of 4q BAC probes for fluorescent in situ hybridization (FISH) in these four cases. We found a 4q24 submicroscopic deletion in all three translocations, with a common deletion of approximately 0.5 Mb. In three cases, we concluded that rearrangement occurred in an early hematopoietic stem cell, as it was detected, in mosaic with a normal karyotype, in a fraction of remission bone marrow cells, peripheral T and B lymphocytes, malignant lymph node T-lymphoma cells in one case and B-lymphoblastoid cell lines established in two cases. Moreover, one of 10 additional AML patients tested by FISH had a normal karyotype and deletion of one of the commonly deleted probe sequences. A tumor suppressor gene may therefore be involved, especially as two patients developed malignant lymphoma at the same time as myeloid proliferation.

Hamartoma of the middle ear: a case study

Hamartomas and teratomas are rare tumors in children. Its location in head and neck is quite exceptional. An unusual case of hamartoma in the middle ear is reported in a 5-month-old child. The tumor was isolated without associated malformation. Definitive diagnosis was made after surgery and based on histological results. At 2 years follow-up, no recurrence was observed. CT-scan is useful in order to reach a final diagnosis. Although rare, this type of tumor should be considered in the differential diagnosis of a middle ear mass during childhood.

Implementation of the European Laryngological Society (ELS) basic protocol for assessing voice treatment effect

OBJECTIVES

93 patients with various kinds of organic benign voice pathology (vocal fold nodules, polyp, Reinke's oedema, unilateral paralysis, sulcus/scar) and/or with muscle tension dysphonia, were evaluated before and after their voice treatment (phonosurgery with voice therapy, antireflux medication, or voice therapy alone) in order to check the clinical relevance of a basic multidimensional protocol for assessing functional results of voice treatments, as developed by the Committee on Phoniatrics of the ELS.

MATERIAL AND METHOD

The protocol has been used in different university voice clinics. It comprises 5 dimensions: Perception: Grade, Breathiness and Roughness from the GRBAS-scale, rated by two experienced judges: a phoniatrician/laryngologist and a speech therapist. Acoustics: Jitter % and Shimmer % computed on a /a:/, at comfortable loudness and pitch. Also Fo-range and softest possible intensity. Videostroboscopy: Glottal closure, regularity, mucosal wave and symmetry, rated separately. Phonation quotient: computed by dividing the vital capacity (ml) by the maximum phonation time (s) (best value of 2x3 trials). Self rating by the patient: voice quality in itself and general social/occupational handicap due to the voice problem rated separately.

RESULTS

Results show that, at group level, the overall effects for each parameter indicate a significant improvement after treatment. However, the correlations between the pre/post changes for the different parameters are weak (low redundancy).

CONCLUSION

The assessment of voice pathology needs to be multidimensional, as these multidimensional informations about voice changes lead to a better understanding of the actual way in which a treatment works.

[Ewing's sarcoma of the head and neck: a case report]

We report a case of Ewing's sarcoma located in the ethmoid sinus. The patient complained of facial pain, anosmia and visual defect. Diagnosis was established at microscopic examination with histoimmunochemistry and molecular biology. Treatment combined chemotherapy and surgical resection with skull base reconstruction and post-operative ratio and chemotherapy.

[Therapeutic impact of streptococcal and enterococcal bacteremia in hematology patients]

From January 1999 to May 2000 (17 months), 21 strains of streptococci and four strains of enterococci have been isolated from 74 blood cultures in 25 infectious episodes in hematologic patients. They concerned 21 patients, of 21 to 77 years old. These patients suffered from acute leukaemia (14 cases), chronic lymphoid leukaemia (two cases), non-Hodgkin's lymphoma (two cases) or myeloma (three cases). Seventeen patients displayed a single streptococcal or enterococcal episode, two had two episodes in the course of a single stay in the hospital, two others in the course of two different stays. During 16 episodes (64%), the bacteremia occurred within 15 days after the onset of neutropenia consecutive to antimitotic chemotherapy, and in nine episodes (36%) it has occurred after a period exceeding 15 days. In six cases the patients had already received antibiotics with a large antibacterial activity (beta-lactam, fluoroquinolone and/or glycopeptide +/- aminoside) and in four cases a single antibiotic (synergistine or cotrimoxazole). Most streptococci (20/21) were oral streptococci (ten Streptococcus mitis, five S. oralis, two S. sanguis, three S. pneumoniae). A single strain of beta-hemolytic streptococci has been identified as S. dysgalactiae subsp. equisimilis. The enterococci were one strain of Enterococcus faecalis and three E. faecium. Ten streptococci were susceptible to 0.25 mg/L of penicillin G, ten were less susceptible (0.5 < or = MIC < 32 mg/L), and a strain was resistant (MIC = 32 mg/L). Eighteen strains were susceptible to amoxicillin and cefotaxime. For three strains, the MICs of amoxicillin and cefotaxime (8-16 mg/L and 8-32 mg/L, respectively) were higher. Levels of resistance of the enterococci to the beta-lactam (penicillin, amoxicillin, and piperacillin) were variable. All species were susceptible to glycopeptides. Three patients were transferred in intensive care unit for respiratory distress or shock syndrome. Their evolution has remained severe under antibiotherapy comprising beta-lactam or vancomycin associated with an aminoside. This results demonstrate the interest of species identification to adapt the antibiotic treatment and confirms the frequency of oral streptococci in severe bacteremia in neutropenic patients.

Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients

Upper airway (UA) anatomical abnormalities are frequently observed in obstructive sleep apnea syndrome (OSAS). The correspondence between UA anatomical modifications and UA resistance (UAR) had not been studied. We aimed to determine if cephalometric characteristics could be related to segmental UAR. In twenty-five patients (21 males) (15 OSAS patients, 10 snorers) and 10 control subjects (8 males), segmental UAR were measured in supine position and cephalometry was performed. Inspiratory and expiratory UAR were calculated at peak flow. Length of the soft palate (LP), posterior airway space (PAS), distance from hyoid bone to mandibular plane and to posterior pharyngeal wall were different between the groups (P<0.01). Inspiratory and expiratory, total and segmental, UAR were higher in OSAS (P<0.001). Segmental UAR were correlated with PAS and distance from hyoid bone to mandibular plane and to pharyngeal posterior wall (P<0.05). In conclusion, OSAS patients had higher UAR depending on anatomical variables, especially the place of the hyoid bone.

Drug resistance in hematologic malignancies

Drug resistance eventually occurs in most hematologic malignancies treated with chemotherapy. The mechanisms responsible for drug resistance include expression of transporters of xenobiotics of the adenosine triphosphate-binding cassette protein superfamily (P-glycoprotein, multidrug resistance associated proteins, breast cancer resistance protein), modifications of enzymes like deoxycytidine kinase, and defects in chemotherapy-induced apoptosis. The efforts to overcome this drug resistance have been focused, thus far, on modulation of P-glycoprotein. Several compounds were manufactured for this purpose, and phase III trials of PSC833, one of the most potent P-glycoprotein inhibitors, are completed. The emergence of modulators with several adenosine triphosphate-binding cassette protein targets, like GG120918 (inhibiting P-glycoprotein and breast cancer resistance protein) and VX710 (inhibiting P-glycoprotein and multidrug resistance associated protein 1), are of clinical interest in malignancies often expressing several efflux pumps simultaneously. Another approach is the use of "furtive" drugs like liposomal or nanoparticular anthracyclines.

[Wegener's granulomatosis involving head and neck: retrospective analysis of 16 patients]

Based on a retrospective analysis of patients with Wegener's granulomatosis (WG), the aim of our study was to compare our finding with those previously reported in the literature. We also reviewed the characteristic features of WG, particularly otorhinolaryngology features. Sixteen consecutive patients were followed over a period of 23 years. There were 8 men and 8 women, all Caucasians, aged between 13 and 74 years (mean 42 years). Initial ENT signs and symptoms were observed in 62.5% of the cases, and occurred in 94% during disease progression with predominant rhino-sinusal (75%) and otological (38%) or laryngotracheal (25%) localizations. Later, the disease primarily affected the lower respiratory tract (87.5%) and the kidneys (50%). Articular (40%), ocular (25%), cardiovascular (25%), neurological (25%), and cutaneous (19%) localizations were also observed. The mean delay to diagnosis was 40 months, more than 1 year in 7 patients. A definitive diagnosis could not be made for 5 patients because of lack of histological evidence, but clinical and biological arguments suggested diagnosis of WG. Antineutrophil cytoplasmic antibodies (ANCA) were assessed in 13 patients and were positive in all. The role of ENT biopsies was significant to our study (31%). The ENT specialist can play a very important role in the diagnosis of Wegener's granulomatosis.

[Cutaneous manifestations of B-CLL masked by florid epithelioid granulomatous response]

We report an unusual case of iterative cutaneous manifestations of B-cell chronic lymphocytic leukaemia, masked by a florid epithelioid granulomatous response. These cutaneous lesions appeared without blood hyperlymphocytosis or lymph node enlargement. The diagnosis of cutaneous tumorous infiltrates was morphologically very difficult and required immunohistochemistry as well as PCR. This observation stresses the diagnostic difficulties encountered in lymphoma, with intense stroma reaction and the need for complementary techniques to reach the right diagnosis and thus deliver appropriate therapy.

Post-intubation vocal cord paralysis: the viral hypothesis. A case report

After digestive surgery, a 20-year-old man presented dysphonia and fever. Indirect laryngoscopy revealed a left vocal cord paralysis with no structural lesion. IgM and IgG were positive for cytomegalovirus and negative for human immunodeficiency virus, herpes simplex virus, varicella zoster virus and Epstein-Barr virus. The patient recovered spontaneously with a normal voice, and the mobility of vocal cord recovered within 3 months. The aetiology of post-intubation vocal cord paralysis (VCP) remains controversial. Vocal cord paralysis with cytomegalovirus has been reported in two cases associated with acquired immunodeficiency syndrome. Vocal cord paralysis secondary to viral disease has also been described in other circumstances. panied by polyneuritis, especially in immunocompromised patients. We report the case of a patient with transitory unilateral post-intubation vocal cord paralysis which could have been related to a virus infection.

[Adenocarcinoma of the ethmoid sinuses: results of a retrospective study in Rouen]

Ethmoid adenocarcinoma is a rare tumour of the ethmoidal sinuses. The authors report on the clinical features, treatment and follow-up results in 19 cases. Risk factors were those regularly encountered. Delay to diagnosis was long due to the nonspecific clinical features and course. Nasal endoscopy was essential for follow-up. Computed tomography and magnetic resonance imaging were also required to assess tumour spread. Our results suggest that radiotherapy following surgery should be preferred. Survival rate is generally low for this type of tumor. We had 77% survival at 5 years.

Cell cycle regulatory protein expression in fresh acute myeloid leukemia cells and after drug exposure

Characteristics of treatment-induced cell cycle arrest are important for in vitro and in vivo sensitivity of acute myeloid leukemia (AML) cells to cytotoxic drugs. We analyzed the expression of the major G1 cell cycle regulators (p21Cip1, p27Kip1, cyclins D, cyclin E and pRb) in 41 fresh AML cell samples. The level of p27 expression was the only factor correlated with the response to chemotherapy, a high level of p27 expression being predictive of complete remission. There was a close relation between expression of pRb, cyclin D2 and FAB subtype, illustrated by the absence of both proteins in most samples having a monocytic component (M4, M5). We also assessed the expressions of pRb, cyclin E, p21 and p27 and the activity of cdk2, the major regulator of S-phase entry, after exposure to cytosine-arabinoside (AraC) and daunorubicin (DNR), and found these proteins could characterize time- and dose-dependent cellular response to each drug. We observed hyperphosphorylated pRb, increased levels of cyclin E and a high cdk2 activity, but no p21 induction, in AML cells exposed to 10(-6) M AraC. After exposure to 10(-5) M AraC, corresponding to the serum concentration reached in high-dose AraC regimens (HDAraC), a strong p21 induction was observed, associated with similarly overexpressed cyclin E and even higher cdk2 activity than after 10(-6) M AraC, while apoptosis was significantly increased. These data suggest that cdk2 activity is likely to play a role in AraC-induced apoptosis in AML cells. This mechanism may account for high efficacy of HDAraC in cells showing little sensitivity to conventional AraC doses.

Upper airway resistance during progressive hypercapnia and progressive hypoxia in normal awake subjects

Ventilatory motor output is known to influence the upper airway. Although inspiratory upper airway resistance decreases during progressive hypoxia or hypercapnia, the effects of hypoxia and hypercapnia on expiratory upper airway resistance remain unknown. In the present study, we attempted to examine whether the expiratory and the inspiratory upper airway resistances were modified in the same way by progressive hyperoxic hypercapnia or by progressive normocapnic hypoxia. Nine healthy subjects (five males, four females, 33+/-9 years) participated in the study. Inspiratory upper airway (iUAR) and expiratory upper airway resistances (eUAR) were calculated at flow 300 ml x s(-1). Both resistances were obtained during a baseline period and during progressive hyperoxic hypercapnia or progressive normocapnic hypoxia. In all subjects, iUAR and eUAR decreased significantly during hypercapnic or hypoxic challenge (P<0.05). eUAR was always lower than iUAR during hypercapnic challenge (P<0.0001) and during hypoxic challenge (P<0.0001). The authors conclude that expiratory upper airway resistance, as with inspiratory resistance, decreases during progressive hypercapnia or during progressive hypoxia. Pharyngeal dilator or constrictor muscle activities may be implicated.

JC-1: a very sensitive fluorescent probe to test Pgp activity in adult acute myeloid leukemia

One of the best-characterized resistance mechanisms in acute myeloid leukemia (AML) is the drug extrusion mediated by P-glycoprotein (Pgp). Recently the results of workshops organized by several groups concluded that accurate measurement of low activity of Pgp is a difficult goal in clinical samples. Therefore, highly sensitive and specific assays were developed to assess the functionality of Pgp using JC-1, a fluorescent molecule with the different emission wavelength (green and red fluorescence) according to its concentration in 129 AML samples. It was shown that JC-1 (green and red bands) may define 3 groups of patients: resistant (R) (29% of patients), intermediate (I) (36%), and sensitive (S) (35%). In contrast, rhodamine 123 assay detected only the R group defined by JC-1. Nevertheless, the I group has an intermediate expression of Pgp (0.39, 0.29, and 0.19 for the R, I, and S groups, respectively, P =.002), an intermediate biologic profile (percentage of CD34, 95%, 67%, and 44%, respectively, P <.0001; in vitro resistance to daunorubicin, 94 microM, 20 microM, and 12 microM, respectively, P =. 02), and an intermediate prognosis (achievement of complete remission, 55%, 65%, and 87%, P =.006; 3-year disease-free survival, 11%, 16%, and 36%, respectively, P =.005; and 3-year overall survival, 0%, 20%, and 51%, respectively, P <.0001). Therefore, JC-1 appeared to be a more convenient and simple way to detect a functional Pgp in clinical AML samples than rhodamine 123. (Blood. 2001;97:502-508)

Mantle cell lymphoma, in leukaemic phase with prominent splenomegaly. A report of eight cases with similar clinical presentation and aggressive outcome

Mantle cell lymphoma (MCL) is a well-defined peripheral B-cell lymphoma usually diagnosed upon peripheral lymph node biopsy. We report eight cases of peripheral B-cell leukaemia that demonstrate presumptive evidence of mantle cell characteristics. The patients had a median age of 68.5 years, and five were male. All presented with an enlarged spleen without any peripheral lymphadenopathies, and they were leukaemic at presentation (median lymphocytosis, 38x10(9)/l). Morphological diagnosis of MCL was very difficult in five cases but easier in three because we were able to analyse either pre- or post-mortem lymph nodes and spleen. The immunophenotype of blood lymphocytosis using flow cytometry, the presence of a t(11;14)(q13;q32) and a cyclin D1 expression by leukaemic cells all fit with the diagnosis of MCL. All patients progressed and died with a median overall survival of 8 months. Multifocal areas of transformation in blastoid or large cell variants were observed in the three autopsied patients. In summary, one should consider the diagnosis of MCL at presentation in leukaemic phase even in the absence of peripheral adenopathies.

Therapy-related acute myeloid leukaemia after successful therapy for acute promyelocytic leukaemia with t(15;17): a report of two cases and a review of the literature

We describe two patients with positive t(15;17) acute promyelocytic leukaemia (APL) that developed into a therapy-related myelodysplasia 2-2.5 years after complete remission (CR) and then evolved into therapy-related acute myeloid leukaemia (t-AML). Both patients received anthracyclines as potential leukaemogenic drugs. In both cases, cytogenetic changes usually occurring after use of alkylating agents were noticed: monosomy 7 associated with monosomy 5 or 5q- chromosome. A review of the literature on t-AML occurring after successful therapy for APL showed only one report similar to these two cases. These observations suggest that anthracyclines can cause t-AML similar to that induced by alkylating agents.

The immunophenotype of 177 adults with acute myeloid leukemia: proposal of a prognostic score

In acute myeloid leukemia (AML) patients, a variety of clinical and biologic parameters, including phenotype, have been examined for potential value in predicting treatment response and survival. The European Group for the Immunological Classification of Leukaemias (EGIL) has proposed that AML be defined immunologically by the expression of 2 or more of the following myeloid markers: myeloperoxidase, CD13, CD33, CDw65, and CD117. With regard to this classification, the prognostic significance of 21 antigens taken separately and with immunophenotypic subgroups were evaluated and compared with other clinical and biological variables in 177 adult AML patients. None of the antigens tested were associated with treatment outcome. In contrast, patients with blasts disclosing a full expression of panmyeloid phenotype (defined by the expression of all 5 myeloid markers) had a higher complete remission rate (P <. 0001) and differed significantly in disease-free survival (P =.02) and overall survival (P =.008) than patients whose cells expressed fewer than 5 of these markers. In multivariate analysis, only age, panmyeloid phenotype, performance status, and permeability glycoprotein activity influence treatment outcome. Cytogenetics was significant in univariate analysis but not in multivariate analysis, most likely because of the redundancy with panmyeloid phenotype and a higher sensitivity of immunophenotyping. Patients whose cells exhibit the panmyeloid phenotype appear to define a relatively homogeneous biological subset of AML. The 4 independent prognostic factors were used to create a prognostic score, defined by the number of factors present. This score permitted a stratification of patients with AML, thereby allowing for the consideration of innovative therapies to improve outcome in the poorer outcome groups.

Submicroscopic insertion of RARalpha gene into chromosome 15 in two cases of acute promyelocytic leukemia

Acute promyelocytic leukemia (APL) is characterized by a specific translocation (15;17)(q22;q21), resulting in the formation of PML/RARalpha chimeric transcripts. We report two female patients with PML/RARalpha-positive classical APL, whose leukemic cells expressed a variant translocation, t(5;15)(q13;q22) and t(15;17)(q22;p13), respectively. Both translocations were confirmed by whole chromosome painting which revealed no apparent involvement of 17q. A two-color fluorescence in situ hybridization with a 5' PML and a 3' RARalpha probe showed, in both cases, the presence of a PML-RARalpha fusion gene, on the der(15)t(5;15) long arm, and on the der(17)t(15;17) short arm, respectively. These two complex rearrangements resulted most probably from a two-step mechanism: (1) a submicroscopic insertion into 15q of a 17q segment including the 3' part of the RARalpha gene; (2) a reciprocal translocation between der(15) and a variable chromosome arm, with a breakpoint distal and proximal to RARalpha insertion in the case of t(5;15) and t(15;17), respectively. Molecular and prognosis significance of these variant translocations are discussed.

Current Awareness

In order to keep subscribers up-to-date with the latest developments in their field, John Wiley & Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of NMR in biomedicine. Each bibliography is divided into 9 sections: 1 Books, Reviews ' Symposia; 2 General; 3 Technology; 4 Brain and Nerves; 5 Neuropathology; 6 Cancer; 7 Cardiac, Vascular and Respiratory Systems; 8 Liver, Kidney and Other Organs; 9 Muscle and Orthopaedic. Within each section, articles are listed in alphabetical order with respect to author. If, in the preceding period, no publications are located relevant to any one of these headings, that section will be omitted.

Magnetic resonance spectroscopy of cellular lipid extracts from sensitive, resistant and reverting K562 cells and flow cytometry for investigating the P-glycoprotein function in resistance reversion

The proton NMR spectra of K562 cells contain resonances of lipids. When these cells acquire multidrug resistance phenotype, the NMR lipid signals are modified and partially recovered when the resistance is reversed. The goals of the present study are to elucidate the mechanism of the resistance phenotype reversion and to investigate the possible origin of lipid signals detected in whole cells with proton NMR spectroscopy. Therefore, the K562 drug-sensitive cell line, its adriamycin resistant counterpart and two reverting derivates, obtained by verapamil treatment and long term culture in drug-free medium, were used in this study. The P-glycoprotein (P-gp) pump function was measured by flow cytometry and lipids were extracted to be analysed by proton and phosphorus spectroscopy. The phenotype reversion is due to the decrease of the P-gp function and an increased entrance of anthracycline drug when compared with the resistant cells. The spectra obtained on extracts showed no modification of the fatty acid composition and of the ratio of total cholesterol to fatty acid content. A different phospholipid composition in sensitive and resistant cells was found, but the reversion of resistance did not produce a recovery of these lipids. Thus, the lipid NMR spectra of extracts could not explain the spectral modifications observed on whole cells, in relation to acquiring and reverting drug resistance. These results are in favour of a different lipid organization or of localization within the cell.

Has the prognosis of adult patients with acute myeloid leukemia improved over years? A single institution experience of 784 consecutive patients over a 16-year period

We reviewed the reports of 784 consecutive patients admitted to our department for newly diagnosed acute myeloid leukemia (AML) over a 16-year period. Median, 5-year and 10-year overall survivals were 9. 5 months, 17.3% and 11.7% respectively. Induction treatment (698 patients) resulted in 50% complete remissions (CR) (from 26.5% in secondary AML to 81.2% in patients <60 years with de novo AML). Period of diagnosis (1980-84/85-89/90-95) demonstrated a major significance for CR achievement and OS in multivariate analysis. In patients >/=60 years (372), CR rate increased (25% to 36.8%, P = 0. 03), and 5-year OS (3.7% to 10.6%, P = 0.022) improved, probably due to an increase in the proportion of patients administered conventional combined chemotherapy (54.5% to 83.8%, P < 0.0001). In younger patients CR rate continuously increased (61.5% to 74.8%, P = 0.028) with an associated improvement of 5-year OS (19.2% to 35.4%). No significant change in DFS and CR durations was observed. This large single center study on a large cohort of unselected AML patients reflects the improvement achieved in the management of AML patients, likely due to improvement of supportive care practices, administration of conventional induction to more elderly patients, and intensification of induction and post-remission treatments in patients <60 years.

Experimental reinnervation of a strap muscle with a few roots of the phrenic nerve in rabbits

In order to compare application of the roots of the phrenic nerve to the ansa hypoglossi for laryngeal muscle neurotization, 1 or more roots from the phrenic nerve were implanted into the right sternothyroid (RST) muscle of rabbits (n = 36). Controls were intact animals (in which RST innervation is provided by the ansa; n = 6) and denervated ones (n = 6). At 66 +/- 2 days (mean +/- SE) after neurotization, during quiet breathing, inspiratory electromyographic activity and isometric contraction force were observed in all reinnervated RST muscles (n = 24). During maximal inspiratory effort, electromyographic activity and force increased. In animals reinnervated by the C4 root alone, forces (46.22 +/- 7.8 g) were significantly higher than in intact animals (10.83 +/- 5.0 g). Retrograde labeling proved the phrenic origin of the neurotization. Electromyography of the diaphragm was recorded. We conclude that in rabbits, neurotization of a strap muscle by 1 or 2 roots of the phrenic nerve allows inspiratory contraction, even during quiet breathing. Such inspiratory activity is not observed in sternothyroid muscles of intact animals innervated by the ansa hypoglossi.

Both Pgp and MRP1 activities using calcein-AM contribute to drug resistance in AML

Thirteen cell lines with different levels of Pgp and MRP1 expression were used to assess the ability of calcein-AM uptake and calcein efflux to measure Pgp and MRP1 functions, respectively. There was a good correlation between MRP1 expression and the modulatory effect of probenecid (a specific modulator of MRP1) on the calcein efflux (r = 0.91, p = 0.0003) and between Pgp expression and the modulatory effect of CsA on calcein-AM uptake (r = 0.96, p < 0.0001). On light of the high correlations for both proteins, we tested calcein-AM uptake and efflux in fresh myeloid leukemic cells. In 53 AML patients, there was also a good correlation between MRP1 expression (measured by RT/PCR and by MRPm6 expression by flow cytometry) and the modulatory effect of probenecid on the calcein fluorescence (r = 0.92, p < 0.0001) and between Pgp expression as measured by UIC2 antibody binding on flow cytometry and the modulatory effect of CsA on calcein-AM uptake (r = 0.83, p < 0.0001). Pgp activity was higher in CD34+ leukemia than in CD34- leukemia (2.26 +/- 1.50 vs 1.46 +/- 1.21 respectively, p = 0.003) and MRP1 activity was higher in CD34- leukemia than in CD34+ leukemia (1.77 +/- 0.40 vs 1.4 +/- 0.29 respectively, p = 0.004). Pgp expression and activity (p = 0.004 and p = 0.01, respectively), MRP1 activity (p = 0.03) but not MRP1 expression were prognostic factors for achievement of CR. The effect of probenecid and CsA together were higher than the effect of either probenecid or CsA alone on calcein-AM uptake. These results suggest that functional testing (with calcein-AM +/- modulators) for the presence of both MRP1 and Pgp activities is of prognostic value and that MRP1 contributes to drug resistance in AML.

MDR1/P-GP expression as a prognostic factor in acute leukemias

P-glycoprotein (P-gp) is often expressed (40-50%) on leukemic cells at diagnosis in acute myelogenous leukemia (AML), and is even more frequently present after treatment failure. Several large cohorts of newly diagnosed AML patients treated with a classical anthracycline + standard doses of cytosine arabinoside were tested for the prognosis value of MDR1 phenotype, and demonstrated an high correlation between a significant increase of MDR1 gene expression and treatment failure (or, better, drug resistance). This P-gp(+) drug resistance could be due either to a particular phenotype of bad prognosis AML, as it is suggested by the association of myelodysplasia, complex karyotype and advanced age with MDR1 phenotype, or due primarily to the active efflux of anthracyclines and VP16 in P-gp(+) leukemic cells. Several observations tend to confirm the functional role of the P-gp in clinical drug resistance; (i) using multivariate analysis, MDR1 phenotype appears to be an independent variable, as potent (or higher) as karyotype and age for predicting in vivo drug resistance; (ii) the prognostic value is limited to the CD34(+)/P-gp(+) phenotype, wich is linked to a functional P-gp; (iii) the in vitro sensitivity to anthracyclines and VP16 is highly correlated with P-gp expression. All these data argue for an early use of P-gp modifier agents in the treatment of AML. The role of the MDR1 gene in ALL resistance is controversial and marginal compared to the sensitivity of ALL blasts to glucocorticoids, and the frequency of MDR1 phenotype is low at diagnosis, and is increasing only after repetitive chemotherapies.

Cyclin D1 overexpression allows identification of an aggressive subset of leukemic lymphoproliferative disorder

The conjunction of clinical features, cell morphology and immunological characteristics allows an accurate diagnosis in most cases of B cell chronic lymphoproliferative disorders (CLD). However, the diagnosis remains uncertain in a small percentage of cases, often referred as to unclassified B cell proliferation or atypical chronic lymphocytic leukemia (CLL). We have studied retrospectively the 192 cases of leukemic CLD seen in our institution over a 3-year period, for which both clinical and routine biological data at presentation were available. Forty cases (20%) did not fit into any of the well-identified categories according to the FAB criteria and remained unclassified. We assessed cyclin D1 expression in all of these cases and found that 10 of them expressed a high level of cyclin D1 protein. We compared the characteristics of these 10 cases with those of the 30 cyclin D1 negative CLD. Despite non-distinctive cytological and phenotypic features, the 10 cyclin D1 positive patients exhibited a strikingly uniform clinical presentation with elevated leukocytosis, massive spleen enlargement and no superficial lymphadenopathy. Their outcome was very poor with a median survival of 10 months, contrasting with the prolonged survival of the cyclin D1 negative patients. The cytological features of tumor cells from these 10 patients with cyclin D1 positive unclassified leukemic CLD were similar to those of the circulating lymphoid cells from 15 patients with histologically proven mantle cell lymphoma (MCL) and primary or secondary blood involvement. Therefore, cyclin D1 expression allowed identification among the unclassified CLD, a subset of aggressive disorders which represent a leukemic counterpart of MCL (mantle cell leukemia). We suggest that determination of cyclin D1 expression by any technique available should be systematically included when investigating atypical CLL.