Pharmacobezoar Formation From HPMC-AS-Containing Spray-Dried Formulations in Nonclinical Safety Studies in Rats

Changing the physical state from crystalline to amorphous is an elegant method to increase the bioavailability of poorly soluble new chemical entity (NCE) drug candidates. Subsequently, we report findings from repeat-dose toxicity studies of an NCE formulated as a spray-dried amorphous solid dispersion (SD-ASD) based on hydroxypropyl methylcellulose acetate succinate (HPMC-AS) in rats. At necropsy, agglomerates of SD-ASD were found in the stomach and small intestine, which in reference to literature were termed pharmacobezoars. We interpreted the pH-dependent insolubility of HPMC-AS in the acidic gastric environment to be a precondition for pharmacobezoar formation. Gastric pharmacobezoars were not associated with clinical signs or alterations of clinical pathology parameters. Pharmacobezoar-correlated histopathological findings were limited to the stomach and consisted of atrophy, erosion, ulcer, and inflammation, predominantly of the nonglandular mucosa. Pharmacobezoars in the small intestines induced obstructive ileus with overt clinical signs which required unscheduled euthanasia, prominent alterations of clinical pathology parameters indicative of hypotonic dehydration, degenerative and inflammatory processes in the gastrointestinal tract, and secondary renal findings. The incidence of pharmacobezoars increased with dose and duration of dosing. Besides the relevance of pharmacobezoars to animal welfare, they limit the non-observed adverse effect level in nonclinical testing programs and conclusively their informative value.

Assessment of Mitochondrial Protein Topology and Membrane Insertion

Analyzing the membrane integrity and topology of a mitochondrial protein is essential for truly understanding its function. In this chapter, we demonstrate how to analyze mitochondrial membrane proteins using both an immunological-based assay and an in vivo self-assembling GFP approach. First, immunological approaches to investigate the solubility or membrane association of a protein within mitochondria are described. With this method, we demonstrate how the topology of soluble domains of a membrane-integrated protein can be determined. Using protein-specific antibodies, the localization of the soluble domains of a protein are analyzed by a proteolytic-cleavage approach using proteinase K in mitochondria, outer membrane-ruptured mitochondria, and solubilized mitochondrial membranes. In a second approach, we determine the topology of plant mitochondrial proteins using an in vivo self-assembling GFP localization approach.

Predictors and prognosis of right ventricular function in pulmonary hypertension due to heart failure with reduced ejection fraction

Aims

Failure of right ventricular (RV) function worsens outcome in pulmonary hypertension (PH). The adaptation of RV contractility to afterload, the RV‐pulmonary artery (PA) coupling, is defined by the ratio of RV end‐systolic to PA elastances (Ees/Ea). Using pressure–volume loop (PV‐L) technique we aimed to identify an Ees/Ea cut‐off predictive for overall survival and to assess hemodynamic and morphologic conditions for adapted RV function in secondary PH due to heart failure with reduced ejection fraction (HFREF).

Methods and results

This post hoc analysis is based on 112 patients of the prospective Magdeburger Resynchronization Responder Trial. All patients underwent right and left heart echocardiography and a baseline PV‐L and RV catheter measurement. A subgroup of patients (n = 50) without a pre‐implanted cardiac device underwent magnetic resonance imaging at baseline. The analysis revealed that 0.68 is an optimal Ees/Ea cut‐off (area under the curve: 0.697, P < 0.001) predictive for overall survival (median follow up = 4.7 years, Ees/Ea ≥ 0.68 vs. <0.68, log‐rank 8.9, P = 0.003). In patients with PH (n = 76, 68%) multivariate Cox regression demonstrated the independent prognostic value of RV‐Ees/Ea in PH patients (hazard ratio 0.2, P < 0.038). Patients without PH (n = 36, 32%) and those with PH but RV‐Ees/Ea ≥ 0.68 showed comparable RV‐Ees/Ea ratios (0.88 vs. 0.9, P = 0.39), RV size/function, and survival. In contrast, secondary PH with RV‐PA coupling ratio Ees/Ea < 0.68 corresponded extremely close to cut‐off values that define RV dilatation/remodelling (RV end‐diastolic volume >160 mL, RV‐mass/volume‐ratio ≤0.37 g/mL) and dysfunction (right ventricular ejection fraction <38%, tricuspid annular plane systolic excursion <16 mm, fractional area change <42%, and stroke‐volume/end‐systolic volume ratio <0.59) and is associated with a dramatically increased short and medium‐term all‐cause mortality. Independent predictors of prognostically unfavourable RV‐PA coupling (Ees/Ea < 0.68) in secondary PH were a pre‐existent dilated RV [end‐diastolic volume >171 mL, odds ratio (OR) 0.96, P = 0.021], high pulsatile load (PA compliance <2.3 mL/mmHg, OR 8.6, P = 0.003), and advanced systolic left heart failure (left ventricular ejection fraction <30%, OR 1.23, P = 0.028).

Conclusions

The RV‐PA coupling ratio Ees/Ea predicts overall survival in PH due to HFREF and is mainly affected by pulsatile load, RV remodelling, and left ventricular dysfunction. Prognostically favourable coupling (RV‐Ees/Ea ≥ 0.68) in PH was associated with preserved RV size/function and mid‐term survival, comparable with HFREF without PH.

In vivo models and decision trees for formulation development in early drug development: A review of current practices and recommendations for biopharmaceutical development

The ability to predict new chemical entity performance using in vivo animal models has been under investigation for more than two decades. Pharmaceutical companies use their own strategies to make decisions on the most appropriate formulation starting early in development. In this paper the biopharmaceutical decision trees available in four EFPIA partners (Bayer, Boehringer Ingelheim, Bristol Meyers Squibb and Janssen) were discussed by 7 companies of which 4 had no decision tree currently defined. The strengths, weaknesses and opportunities for improvement are discussed for each decision tree. Both pharmacokineticists and preformulation scientists at the drug discovery & development interface responsible for lead optimization and candidate selection contributed to an overall picture of how formulation decisions are progressed. A small data set containing compound information from the database designed for the IMI funded OrBiTo project is examined for interrelationships between measured physicochemical, dissolution and relative bioavailability parameters. In vivo behavior of the drug substance and its formulation in First in human (FIH) studies cannot always be well predicted from in vitro and/or in silico tools alone at the time of selection of a new chemical entity (NCE). Early identification of the risks, challenges and strategies to prepare for formulations that provide sufficient preclinical exposure in animal toxicology studies and in FIH clinical trials is needed and represents an essential part of the IMI funded OrBiTo project. This article offers a perspective on the use of in vivo models and biopharmaceutical decision trees in the development of new oral drug products.

A practice-oriented method for the analysis of coplanar tetra- to heptachlorinated terphenyls

Polychlorinated terphenyls (PCT) were produced and used on industrial scale in the last century. Today, PCT are formed especially during combustion and some chemical conversion processes. As being persistent, low volatile chlorinated aromatics, they are continuously emitted into the environment from primary and secondary sources. Blatant knowledge gaps exist concerning environmental behavior, toxicology, and ecotoxicology of this presumably ubiquitously present substance group because of the non-availability of a generally accepted, practice-oriented, and validated analytical method for the PCT. Here, a novel and easy to conduct analytical method is presented that is applicable to environmental samples. This method is based on a thorough clean-up of the sample extracts, followed by a separation of 29 tetra- to heptachlorinated coplanar reference congeners and their quantification by means of gas chromatography coupled with mass spectrometry. For the validation of the analytical procedure, the parameters selectivity, detection limit, limit of decision, limit of quantification, measuring and method precision, linearity, specifity, and recovery rates were considered. By the method validation, it was demonstrated that this novel procedure for the analysis of PCT in environmental samples like soils/sediments, fats, and combustion residues is fit for purpose.

CD99L2 deficiency inhibits leukocyte entry into the central nervous system and ameliorates neuroinflammation

Leukocyte entry into the CNS is a crucial step in the development of multiple sclerosis and its animal model experimental autoimmune encephalomyelitis (EAE). Adhesion molecules mediating the docking of leukocytes to the endothelium of the blood-brain barrier (BBB) represent valuable targets for interference with the disease. However, little is known about the adhesion and signaling mechanisms in endothelial cells that mediate the diapedesis through the BBB. Here, we show that conditional Tie-2-Cre driven gene inactivation of CD99L2 inhibits leukocyte entry into the CNS during active MOG_35-55 -induced EAE and alleviates severity of the disease. No detrimental effect on the immune response was observed. The number of perivascular cuffs around vessels of the CNS was reduced, as was the number of inflammatory foci, sites of demyelination and expression levels of pro-inflammatory cytokines. Three-dimensional analysis of vibratome sections of the CNS revealed an accumulation of leukocytes between endothelial cells and the underlying basement membrane, whereas leukocyte docking to the luminal surface of the endothelium of the BBB was unaffected. Collectively, these results suggest that CD99L2 participates in the development of EAE by supporting diapedesis of leukocytes through the endothelial basement membrane of blood vessels of the BBB in the CNS.

[Analysis of cardiovascular diseases after the upload phase with intravitreal ranibizumab and bevacizumab in patients with exudative age-related macular degeneration]

BACKGROUND

The intravitreal administration of vascular endothelial growth factor (VEGF) inhibitors is the gold standard in the treatment of exudative age-related macular degeneration (AMD) but the possible risks of systemic, particularly cardiovascular side effects are still discussed.

PATIENTS AND METHODS

We prospectively followed 111 patients at the University Hospital in Göttingen with exudative AMD and intravitreal ocular treatment with bevacizumab and ranibizumab during the upload phase of 3 months using a questionnaire for documentation of possible cardiovascular events.

RESULTS

In 5 out of 111 patients angina pectoris was observed and in 6 patients the antihypertensive medication had to be increased. No differences were found between bevacizumab and ranibizumab. A patient with pre-existing cardiovascular diseases suffered a stroke in the upload phase but no thromboembolic events were observed in the other patients.

CONCLUSION

In this small but prospective clinical study no increased risk for cardiovascular events during the upload phase of the VEGF inhibitors ranibizumab and bevacizumab could be detected when taking the age and pre-existing cardiovascular diseases into consideration.

MST1-dependent vesicle trafficking regulates neutrophil transmigration through the vascular basement membrane

Neutrophils need to penetrate the perivascular basement membrane for successful extravasation into inflamed tissue, but this process is incompletely understood. Recent findings have associated mammalian sterile 20-like kinase 1 (MST1) loss of function with a human primary immunodeficiency disorder, suggesting that MST1 may be involved in immune cell migration. Here, we have shown that MST1 is a critical regulator of neutrophil extravasation during inflammation. Mst1-deficient (Mst1-/-) neutrophils were unable to migrate into inflamed murine cremaster muscle venules, instead persisting between the endothelium and the basement membrane. Mst1-/- neutrophils also failed to extravasate from gastric submucosal vessels in a murine model of Helicobacter pylori infection. Mechanistically, we observed defective translocation of VLA-3, VLA-6, and neutrophil elastase from intracellular vesicles to the surface of Mst1-/- neutrophils, indicating that MST1 is required for this crucial step in neutrophil transmigration. Furthermore, we found that MST1 associates with the Rab27 effector protein synaptotagmin-like protein 1 (JFC1, encoded by Sytl1 in mice), but not Munc13-4, thereby regulating the trafficking of Rab27-positive vesicles to the cellular membrane. Together, these findings highlight a role for MST1 in vesicle trafficking and extravasation in neutrophils, providing an additional mechanistic explanation for the severe immune defect observed in patients with MST1 deficiency.

Visual Acuity Testing: Feedback Affects Neither Outcome nor Reproducibility, but Leaves Participants Happier

Assessment of visual acuity is a well standardized procedure at least for expert opinions and clinical trials. It is often recommended not giving patients feedback on the correctness of their responses. As this viewpoint has not been quantitatively examined so far, we quantitatively assessed possible effects of feedback on visual acuity testing. In 40 normal participants we presented Landolt Cs in 8 orientations using the automated Freiburg Acuity Test (FrACT, <michaelbach.de/fract. Over a run comprising 24 trials, the acuity threshold was measured with an adaptive staircase procedure. In an ABCDDCBA scheme, trial-by-trial feedback was provided in 2 x 4 conditions: (A) no feedback, (B) acoustic signals indicating correctness, (C)visual indication of correct orientation, and (D) a combination of (B) and (C). After each run the participants judged comfort. Main outcome measures were absolute visual acuity (logMAR), its test-retest agreement (limits of agreement) and participants' comfort estimates on a 5-step symmetric Likert scale. Feedback influenced acuity outcome significantly (p = 0.02), but with a tiny effect size: 0.02 logMAR poorer acuity for (D) compared to (A), even weaker effects for (B) and (C). Test-retest agreement was high (limits of agreement: ± 1.0 lines) and did not depend on feedback (p>0.5). The comfort ranking clearly differed, by 2 steps on the Likert scale: the condition (A)-no feedback-was on average "slightly uncomfortable", the other three conditions were "slightly comfortable" (p<0.0001). Feedback affected neither reproducibility nor the acuity outcome to any relevant extent. The participants, however, reported markedly greater comfort with any kind of feedback. We conclude that systematic feedback (as implemented in FrACT) offers nothing but advantages for routine use.

Synthesis of coplanar PCT as reference substances for the residue analysis of polychlorinated terphenyls

In the course of the development of a new and reliable analytical method for the PCT, a group of environmental contaminants, six coplanar terphenyl congeners were synthesized and characterized by means of spectroscopic methods. These congeners are 3,3″,4,4″,5-pentachloro-p-terphenyl, 3,3″,4,5,5″-pentachloro-p-terphenyl, 3,3″,4,5″-tetrachloro-m-terphenyl, 3,3″,4,4″,5-pentachloro-m-terphenyl, 3,3″,5,5',5″-pentachloro-m-terphenyl, and 3,3″,4,4″,5,5″-hexachloro-m-terphenyl. A combination of silica gel column chromatography and preparative NP-HPLC was successfully applied for the first time for the isolation of especially the asymmetrically chlorinated target compounds from product mixtures of the syntheses. For the 29 coplanar, tetra- to heptachlorinated meta- and para-indicator congeners which are envisaged to be used within the analytical method, a simplified systematic nomenclature is suggested. Furthermore, calculation results for all torsion angles of the preferred conformations of the substances are given. The practical relevance of the calculated conformation optima is exemplarily demonstrated by the chromatographic behavior of the PCT compounds.

Impaired protein translation in Drosophila models for Charcot-Marie-Tooth neuropathy caused by mutant tRNA synthetases

Dominant mutations in five tRNA synthetases cause Charcot-Marie-Tooth (CMT) neuropathy, suggesting that altered aminoacylation function underlies the disease. However, previous studies showed that loss of aminoacylation activity is not required to cause CMT. Here we present a Drosophila model for CMT with mutations in glycyl-tRNA synthetase (GARS). Expression of three CMT-mutant GARS proteins induces defects in motor performance and motor and sensory neuron morphology, and shortens lifespan. Mutant GARS proteins display normal subcellular localization but markedly reduce global protein synthesis in motor and sensory neurons, or when ubiquitously expressed in adults, as revealed by FUNCAT and BONCAT. Translational slowdown is not attributable to altered tRNA(Gly) aminoacylation, and cannot be rescued by Drosophila Gars overexpression, indicating a gain-of-toxic-function mechanism. Expression of CMT-mutant tyrosyl-tRNA synthetase also impairs translation, suggesting a common pathogenic mechanism. Finally, genetic reduction of translation is sufficient to induce CMT-like phenotypes, indicating a causal contribution of translational slowdown to CMT.

Zwischenmolekulare Kräfte und die Temperaturabhängigkeit der Selbstdiffusion von CO2

Durch Beimengung von 14CO2 zu normalem CO2 wird mit Hilfe der radioaktiven Strahlung von 14C die Diffusion von 14CO2 gegen CO2 im Temperaturgebiet zwischen —40°C und +240°C untersucht. Die daraus ermittelten temperaturabhängigen Wirkungsquerschnitte, die als Mittelwerte über die Intensität anzusehen sind, mit der definierte Ablenkungswinkel beim Stoß zweier CO2-Molekeln auftreten, lassen sich mit nahezu der gleichen Potentialkurve beschreiben, mit der auch die Darstellung des zweiten Virialkoeffizienten von CO2 gelingt. Dabei erweist es sich bei Virialkoeffizienten und Wirkungsquerschnitten als notwendig, den durch die nicht-kugelförmige Gestalt der Molekeln und die relativ großen — sich freilich gegenseitig aufhebenden — partiellen CO-Dipolmomente bedingten Besonderheiten der zwischenmolekularen Kräfte der CO2-Molekel Rechnung zu tragen. Zum Schluß kann kurz gezeigt werden, daß auch der Temperaturgang des Wärmeleitvermögens im gleichen Temperaturgebiet mit den gleichen Wirkungsquerschnitten richtig erfaßt wird.

Increased proatherogenic monocyte-platelet cross-talk in monocyte subpopulations of patients with stable coronary artery disease

BACKGROUND

Monocytes and platelets are important cellular mediators of atherosclerosis. Human monocytes can be divided into CD14(++) CD16(-) , CD14(++) CD16(+) and CD14(+) CD16(++) cells, which differ in their functional properties. The aim of this study was to examine monocyte subset distribution, monocyte-platelet aggregate (MPA) formation and expression of CCR5, the receptor of the platelet-derived chemokine CCL5, and to determine whether these parameters are altered in individuals with coronary atherosclerosis.

METHODS

Peripheral blood cells from 64 healthy blood donors (HBDs) and 60 patients with stable coronary artery disease (CAD) were stained with antibodies against CD14, CD16, CD42b and CCR5 and analysed by flow cytometry. Circulating CCL5 levels were determined using an enzyme-linked immunosorbent assay.

RESULTS

In patients with CAD, the relative proportion of the CD14(++) CD16(-) monocyte subset was elevated (P < 0.05) and of the CD14(+) CD16(++) subset was reduced (P < 0.001) compared with the HBD group. Furthermore, MPA formation significantly increased in patients with CAD in all three monocyte subsets. In both study groups, the majority of CCR5(+) cells was detected in CD14(++) CD16(+) monocytes (P < 0.001 versus CD14(++) CD16(-) and CD14(+) CD16(++) ), although the CCR5(+) monocyte number was reduced in patients with CAD (CD14(++) CD16(-) /CD14(+) CD16(++) , P < 0.001; CD14(++) CD16(+) , P < 0.05) compared with the HBD group, particularly in those who were not taking statins. Ex vivo incubation of monocytes from HBDs with plasma from patients with CAD also decreased CCR5(+) expression (P < 0.05 versus plasma from HBDs). Serum CCL5 levels were similar in both groups.

CONCLUSIONS

The increased monocyte-platelet cross-talk in patients with CAD might have contributed to atherosclerosis progression. The decreased CCR5(+) monocyte numbers in patients with CAD could have resulted from CCR5(+) cell recruitment into atherosclerotic lesions or CCR5 downregulation in response to circulating factors.

[Fundus screening by medical technicians]

Ocular fundus photography allows detection of both ocular and systemic diseases. This study investigated the efficacy of a broad screening in a department of internal medicine using nonmydriatic digital fundus photography. For 8 weeks a medical technician was trained in using the camera as well as interpreting the photographs. The medical technician and an ophthalmologist evaluated the fundus photographs separately by using a self-developed questionnaire. The fundus camera was user-friendly and after several weeks of adjustment and practical application the medical technician was able to detect the majority of pathological fundus photographs. Out of 218 patients examined 148 (68%) were identified as pathological by the medical technician and 163 (75%) by the ophthalmologist (p = 0.0003). The medical technician missed 15 (7%) patients. Furthermore the diagnoses made by the medical technician were faulty. In summary an ophthalmological screening by a medical technician is feasible but the diagnosis still remains the responsibility of ophthalmologists. Such a compromise could facilitate the examination of a large number of patients and disclose previously unrecognized diseases.

Acceptance of hospital nurses toward sensor-based medication systems: a questionnaire survey

BACKGROUND

Sensor-based technologies offer numerous benefits in hospital environments as they can be used (1) to improve efficiency defined processes and (2) to monitor their conduction in order to prevent errors. However, the impact of these technologies on the stakeholders involved such as professional ward nurses is largely unexplored. The early assessment of technology acceptance and user resistance is crucial to anticipate potential conflicts and to improve future implementation success.

OBJECTIVES

To understand the attitudes and intentions of usage of professional ward nurses toward sensor-based medication systems based on an adjusted extended technology acceptance model (TAM2) in a pre-implementation stage.

DESIGN

A scenario-based research design was used in a nation-wide empirical study.

SETTINGS

Nurses of Australian associations/unions evaluated a scenario of a sensor-based medication support system.

PARTICIPANTS

A randomly selected sample of 579 professional ward nurses participated in this study.

METHODS

Data were collected using an online questionnaire and explored using hierarchical regression analysis.

RESULTS

The majority of nurses intend to use the system but 25% - not voluntarily. 8% reject the system entirely. In assessing the nurses' perceived usefulness, image, demonstrability, qualitative and quantitative overload as well as personal innovativeness were found to have a significant impact. Qualitative and quantitative overload also have a significant negative effect on personal innovativeness. Regarding the nurses' usage intention, we identified a significant negative influence of subjective norm, moderated by experience and a positive effect of perceived usefulness on intention to use the system. Image, qualitative and quantitative overload as well as personal innovativeness are significantly influenced by age.

CONCLUSIONS

Our findings support a successful implementation of medication support systems in hospitals by stating acceptance drivers and barriers. Nurses' adoption is promoted once a high degree of perceived usefulness is achieved by result demonstrability, a positive image of the technology and a high degree of personal innovativeness. Image and innovativeness are moderated by age, showing that an increase in age leads to an increase in user resistance toward the perceived usefulness of the envisioned medication support systems. Future studies should investigate these barriers in further stages of implementation to extend understanding of sensor-based medication system acceptance.

Detection of Clostridium perfringens type C in pig herds following disease outbreak and subsequent vaccination

Immunisation of sows using Clostridium perfringens type C toxoid vaccines is recommended to prevent necrotising enteritis (NE) on pig breeding farms. Absence of disease, however, oftentimes leads to the false assumption of pathogens being eradicated. The prevalence of C perfringens type C was determined by PCR in faecal samples of piglets and sows in three Swiss pig breeding farms two to four years after implementation of a vaccination programme following disease outbreaks. C perfringens type C could still be detected several years after an outbreak despite absence of NE. In-herd prevalence of the pathogens varied significantly between the farms and was also lower compared with a farm which experienced a recent outbreak. In conclusion, C perfringens type C can be detected on once-affected farms, even in the absence of NE for several years.

Serological analysis of xenogeneic anti-lymphoblastoid cell-line sera with specificity against HLA-B12

In view of the importance of potent anti-HLA sera with narrow reaction patterns against defined HLA antigens, two xenogeneic antisera were raised in rabbits following immunization with human lymphoblastoid cell lines from HLA-nonidentical donors homozygous for HLA-B12. After absorption with lymphoblastoid cell lines of an appropriate HLA phenotype, the antisera were purified over DEAE-cellulose ion exchange chromatography and reconcentrated. Both antisera recognized HLA-B12-positive peripheral blood cells of unrelated donors tested in the microcytotoxicity assay. The two rabbit antisera revealed a high degree of similarity in their anti-HLA-B12 antibody specificity. One antiserum showed some cross reactivity with HLA-B13 as has been reported in allo-anti-HLA-B12 sera. The other antiserum revealed some activity against HLA-DRw7-positive donors. Antibody activity could be removed completely from two further rabbit anti-HLA antisera by absorption with lymphoblastoid cell lines from related and unrelated HLA-identical donors. The advantages of using lymphoblastoid cell lines as immunogens and absorption material for the production of heterologous anti-HLA typing sera are discussed.

ENT manifestations in patients with primary ciliary dyskinesia: prevalence and significance of otorhinolaryngologic co-morbidities

Primary ciliary dyskinesia (PCD) is a rare inherited disease with a prevalence of about 1:20,000. The underlying pathogenesis is disrupted ciliary function, which results in delayed mucus transportation leading to chronic inflammation, mainly in the upper and lower respiratory tract. Although the pathogenesis of the disease and its clinical presentation is somewhat understood, data regarding the prevalence of accompanying symptoms is limited, especially in the field of otorhinolaryngology. A total of 44 patients diagnosed with PCD answered a questionnaire regarding the diagnosis and clinical presentation of the disease, their medical history and clinical manifestations, and medical treatment in the field of otorhinolaryngology. The majority of participants (70%) had seen a physician more than 50 times before the diagnosis was made at an average age of 10.9 ± 14.4 years. As much as 59% of all patients had recurring problems at the paranasal sinuses and 69% of these patients needed corresponding surgical intervention. Even more patients (81%) suffered from recurring otitis media and, as a result, 78% of these patients underwent paracentesis with temporary tympanostomy tubes at least once at an average age of 9.5 ± 13.0 years. Otorhinolaryngologic symptoms, especially chronic otitis media and chronic rhinosinusitis, are frequently associated with PCD. Surgical intervention to treat these symptoms is common. The awareness of this disease should be raised, especially among ENT physicians, and surgical intervention should be indicated carefully.