Vibration characteristics and function of atelectatic segments in the tympanic membrane in fresh human cadaveric temporal bones

Dimeric segments are commonly encountered in otological practice. They may be associated with a mild conductive hearing loss and often coexist with other tympanic membrane and middle ear abnormalities. Some otologists have advocated surgical management but the consequences of dimeric segment stiffening, shielding or excision and grafting on acoustic transfer to the stapes footplate has been poorly explored. In this study, laser Doppler vibrometry was used to measure vibrations at the tympanic membrane and the stapes footplate in the fresh cadaveric human temporal bone. The dimeric segment vibrates more than the adjacent, thicker normal tympanic membrane. Shielding or excision and grafting of the dimeric segment with thicker and stiffer materials has little effect on displacement at the stapes footplate.

"Bones of Contention". The donation of temporal bones for dissection after the organ-retention scandals

It is essential for the Otologist in training to become familiar with the anatomy of the temporal bone. Generations of trainees have acquired this knowledge, together with basic surgical skills and techniques by dissection of cadaver temporal bones. In recent years, however, the supply of temporal bones for dissection has become a contentious issue in many British hospitals. Media and public attention has recently focused on issues surrounding the retention of human tissues following post-mortem examinations. In response, the Chief Medical Officer, the Royal College of Pathologists in the UK, the Faculty of Pathology of the Royal College of Physicians in Ireland, the British Medical Association, and other bodies have issued new guidelines that are of relevance to the Otolaryngologist. This paper gives details of some of the UK guidelines and where they can be accessed. A copy of the Royal College of Pathologists preferred post-mortem consent form is presented. The authors' experience in Manchester is discussed and details of an information leaflet on the subject of temporal bone donation are given. It is concluded that, with knowledge of the existing guidelines and good communication with other hospital colleagues, as well as families of the deceased, it is still possible legally to obtain temporal bones for dissection.

Phosphorylation of RNA polymerase II CTD fragments results in tight binding to the WW domain from the yeast prolyl isomerase Ess1

The yeast prolyl isomerase, Ess1, has recently been shown to interact via its WW domain with the hyperphosphorylated form of the RNA polymerase II C-terminal domain (CTD). We have investigated folding of the Ess1 WW domain and its binding to peptides representing the CTD by circular dichroism and fluorescence. Ess1 WW folds and unfolds reversibly, but in the absence of ligand is only marginally stable with a melting temperature of 19 degrees C. The WW domain is stabilized by the addition of anionic ligands, namely, chloride, inorganic phosphate, phosphoserine, and phosphorylated CTD peptides. Dissociation constants were measured to be 70--100 microM for CTD peptides phosphorylated at one serine, and 16--21 microM for peptides with two or more phosphorylated serines. Weaker or no affinity was observed for nonphosphorylated CTD peptides. There is surprisingly little difference in the affinity for peptides phosphorylated at Ser 2 or Ser 5 of the consensus repeat, or for peptides with different patterns of multiple phosphorylation. The binding of Ess1 to phosphorylated CTD peptides is consistent with a model wherein the WW domain positions Ess1 to catalyze isomerization of the many pSer--Pro peptide bonds in the phosphorylated CTD. We suggest that cis/trans isomerization of prolyl peptide bonds plays a crucial role in CTD function during eukaryotic transcription.

Relapsing polychondritis associated with monoclonal gammopathy in a patient with myelodysplastic syndrome

Relapsing polychondritis is a rare condition characterized by inflammation and subsequent degeneration of cartilages. Deformity of the pinna, nasal saddling and stridor due to involvement of the cartilages of the respiratory tract may lead to patients being referred to the otolaryngologist for initial assessment and further management. Recent observations have suggested that relapsing polychondritis may occur as a paraneoplastic phenomenon in cases of myelodysplasia. The case of a patient with relapsing polychondritis, myelodysplastic syndrome and a monoclonal gammopathy is presented. The authors highlight the apparent existence of this association and encourage otolaryngologists to consider such possible links when cases of relapsing polychondritis present to the outpatients department.

Combined 'trache-stent': a useful option in the treatment of a complex case of subglottic stenosis

The authors describe the adaptation of a Montgomery T-tube laryngo-tracheal stent to incorporate an uncuffed fenestrated Shiley tracheostomy tube in the management of a complex case of subglottic stenosis. The combined 'trache-stent' provided a secure, unobstructed airway and optimal phonation. The presence of a removable inner tube facilitated cleaning and reduced patient anxiety regarding the perceived risks of stent obstruction with dried secretions. The combined 'trache-stent' was upsized at four weeks with minimal evidence of local granulation formation. The device was removed entirely six weeks later after direct laryngoscopy reconfirmed the above findings. Almost two years later the patient retains a good voice and airway using a simple fenestrated tracheostomy tube and speaking valve. The subglottic area is stable and the patient has returned to full-time employment.

The splicing factor, Prp40, binds the phosphorylated carboxyl-terminal domain of RNA polymerase II

We showed previously that the WW domain of the prolyl isomerase, Ess1, can bind the phosphorylated carboxyl-terminal domain (phospho-CTD) of the largest subunit of RNA Polymerase II. Analysis of phospho-CTD binding by four other WW domain-containing Saccharomyces cerevisiae proteins indicates the splicing factor, Prp40, and the RNA polymerase II ubiquitin ligase, Rsp5, can also bind the phospho-CTD. The identification of Prp40 as a phospho-CTD binding protein represents the first demonstration of direct interaction between a documented splicing factor and the phospho-CTD. Domain dissection studies reveal that phospho-CTD binding occurs at multiple locations in Prp40, including sites in both the WW and FF domain regions. Because the conserved repeats of the CTD make it an ideal ligand for multi-site binding events, the implications of multi-site binding are discussed. Our data suggest a mechanism by which the phospho-CTD of elongating RNA polymerase II facilitates commitment complex formation by juxtaposing the 5' and 3' splice sites.

The application of computer-enhanced imaging to improve preoperative counselling and informed consent in children considering bone anchored auricular prosthesis surgery

OBJECTIVES

Bone anchored auricular prostheses have become a valuable option in the treatment of congenital and acquired deformities of the pinna. However, preoperative counselling and informed consent remains a challenging issue. Until recently it has been difficult to provide the child with a realistic prediction of their own postoperative appearance. This is particularly relevant when a remnant pinna needs to be excised prior to the second stage. The potential for psychological repercussions and the possibility that remnant excision might compromise future autologous tissue reconstruction make it imperative that the decision to proceed with surgery is founded on the best possible information.

METHODS

The authors describe the use of computer enhanced images using the Adobe Photoshop (Apple Mac. Inc.) software package to provide such a preview. This technique is used in the outpatient clinic as an adjunct to counselling provided by clinic staff and is reinforced by meeting children who have already enrolled on to the implant programme. Children are encouraged to follow the stages of their planned operation on the computer screen, providing an accurate insight into the physical consequences of surgery.

RESULTS

Our experiences suggest that this approach has encouraged a better qualitative understanding of implant surgery which has helped to foster the on-going commitment that is required to maintain a long-lasting, trouble-free implant site.

CONCLUSIONS

This application of the Adobe Photoshop package has strengthened our basis for a personal informed consent and has provided an opportunity to lessen the adverse psychological consequences of such irreversible surgery. It is commended for its simplicity as it employs established software to enhance photographic prints or slides taken from the child's clinical records.

Amyloidosis of Waldeyer's ring and larynx

Amyloidosis of the upper aerodigestive tract is relatively rare. A case of localized amyloidosis involving all components of Waldeyer's ring with added laryngeal involvement is described. This has not been previously reported. A literature review of this conditions is presented.

Phospho-carboxyl-terminal domain binding and the role of a prolyl isomerase in pre-mRNA 3'-End formation

A phospho-carboxyl-terminal domain (CTD) affinity column created with yeast CTD kinase I and the CTD of RNA polymerase II was used to identify Ess1/Pin1 as a phospho-CTD-binding protein. Ess1/Pin1 is a peptidyl prolyl isomerase involved in both mitotic regulation and pre-mRNA 3'-end formation. Like native Ess1, a GSTEss1 fusion protein associates specifically with the phosphorylated but not with the unphosphorylated CTD. Further, hyperphosphorylated RNA polymerase II appears to be the dominant Ess1 binding protein in total yeast extracts. We demonstrate that phospho-CTD binding is mediated by the small WW domain of Ess1 rather than the isomerase domain. These findings suggest a mechanism in which the WW domain binds the phosphorylated CTD of elongating RNA polymerase II and the isomerase domain reconfigures the CTD though isomerization of proline residues perhaps by a processive mechanism. This process may be linked to a variety of pre-mRNA maturation events that use the phosphorylated CTD, including the coupled processes of pre-mRNA 3'-end formation and transcription termination.

The implant-site split-skin graft technique for the bone-anchored hearing aid

We describe the technique of implant-site split-skin grafting for the bone-anchored hearing aid (BAHA). Twenty-five patients have undergone this procedure (20 adults and five children) since 1993 with a minimum follow-up of 1 year. Fifteen adults were operated upon as single stage surgery, all other cases (including all children) were performed in two stages. In four patients (16%) significant early graft inflammation was encountered which settled with outpatient treatment. In one the abutment had to be temporarily removed to allow the graft to settle. All patients now have a stable graft site. This surgical technique is straightforward and a separate graft donor site is avoided. It would appear this technique results in a stable BAHA graft site with low associated morbidity.

Bones of contention. The supply of temporal bones for dissection: the legalities, problems and solutions

Temporal bone dissection is considered to be an important aspect of the otological training of the Specialist Registrar with dissection skills being formally assessed in the Intercollegiate Fellowship Examination. However the procurement of cadaveric specimens suitable for dissection may be fraught with difficulties. The authors take an historical perspective to clarify the existing legal issues and outline the means available to improve supply.

Protonation of the neutral repeats of the RNA polymerase II CTD

The CTD (carboxy-terminal repeat domain) of the largest subunit of RNA Polymerase II in most eukaryotes consists of from 26 to 52 seven amino acid repeats, the consensus sequence of which is YSPTSPS. Even though this consensus repeat does not contain residues that are normally protonated under the conditions used for positive ion electrospray mass spectrometry, we find that the CTD acquires about one proton per repeat when analyzed by this procedure. We have termed this phenomenon superprotonation. Superprotonation is apparently a property of the consensus sequence as the repeat peptide, (YSPTSPS)4, is superprotonated whereas other proteins and the repeat peptides (YSPTSPK)4, (YSPTSPR)4 and (YSPTAPR)4 are not. The highly conserved nature of the contiguous consensus repeats in organisms ranging from yeast to mammals implies that the functionally significant behavior of the domain is easily perturbed. We propose that CTD superprotonation is a manifestation of a unique biophysical property that will influence and could be the basis for consensus repeat function in vivo.

Assaying CTD kinases in vitro and phosphorylation-modulated properties of RNA polymerase II in vivo

The functional properties of RNA polymerase II are modulated by hyperphosphorylation of its unique C-terminal repeat domain (CTD). A number of enzymes with CTD kinase activity have been identified, and correlations between CTD phosphorylation and RNA polymerase II function have been made. Here we describe methods for assaying CTD kinases and for characterizing them enzymologically. In addition we present approaches for studying phosphorylation-mediated behavior of chromosome-associated RNA polymerase II by using CTD-directed, phosphorylation state-sensitive antibodies and in situ localization techniques. The methods described here should, in conjunction with genetic approaches, contribute to elucidating the physiological roles of CTD kinases.

Factor IX activation by factor XIa proceeds without release of a free intermediate

Factor IX activation by factor XIa is thought to proceed through the singly-cleaved free intermediate, factor IX alpha. However, we observed no intermediate development during factor IX activation by factor XIa when using a low substrate to enzyme ratio (44:1 mol/mol). This result can be explained by one of two mechanisms: (1) factor XIa-catalyzed activation proceeds via a singly-cleaved free intermediate with a much higher efficiency of cleavage than factor IX zymogen, or (2) the reaction occurs without free intermediate generation, whereby factor XIa makes both proteolytic cleavages in a single substrate molecule before releasing the final product (processive mechanism). We compared the factor XIa cleavage rates of free factor IX alpha and factor IXa alpha with that of factor IX zymogen. In contrast to the requirements of mechanism (1), the cleavage rate constants of factor IX zymogen, factor IX alpha, and factor IXa alpha were similar: 0.38 +/- 0.02 s(-1), 0.34 +/- 0.05 s(-1), and 0.27 +/- 0.01 s(-1), respectively. It seems likely that factor XIa-generated intermediates observed under some reaction conditions are produced through the occasional failure of a processive mechanism. Indeed, in reactions using a high substrate to enzyme ratio (1900:1 mol/mol), we observed some factor IX alpha development; however, the pattern of intermediate and product development over time was inconsistent with a mechanism involving an obligate intermediate. Rather, it corresponded to behavior expected from a processive mechanism undergoing a consistent low failure. We conclude that factor XIa-catalyzed activation of factor IX proceeds via a processive mechanism without release of a free intermediate.

Processive post-translational modification. Vitamin K-dependent carboxylation of a peptide substrate

Mass spectrometry has been used to demonstrate that vitamin K-dependent carboxylation is a processive post-translational modification (i.e. multiple carboxylations occur during a single association between enzyme and substrate). Purified vitamin K-dependent carboxylase can carboxylate as many as 12 glutamate residues in FIXQ/S, a peptide substrate based on amino acids -18 to 41 of the human blood clotting enzyme factor IX. Mass spectrometry was used to determine the number of gamma-carboxyl groups added to FIXQ/S by the carboxylase during an in vitro reaction. Despite the fact that most substrate molecules in a reaction were uncarboxylated, almost all carboxylated FIXQ/S molecules were carboxylated many times. This observation can only be explained by two types of mechanisms. In a processive mechanism, multiple carboxylations could occur during a single substrate binding event. Alternatively, a distributive mechanism could result in the observed behavior if the initial carboxylation event results in a substrate that is additionally carboxylated far more efficiently than the uncarboxylated FIXQ/S. Kinetic experiments and arguments were used to show that the vitamin K-dependent carboxylase is not distributive but rather is one of the first well documented examples of an enzyme that catalyzes a processive post-translation modification.

Practical aspects of acoustic rhinometry: problems and solutions

Acoustic rhinometry now has an established place in the rhinology laboratory as a measure of nasal geometry. We aimed to investigate several aspects of technique in order to offer some guidance on preferred procedures. We studied the effects of nosepiece seal quality, nosepiece aperture diameter, angle of inclination of the wave tube (in two planes), palate position and inter-observer variation on the nasal area-distance function. One hundred nasal cavities in adults and children were examined: 50 normal and 50 pathological. Each factor was examined intensively in 20 cavities, and reproducibility data obtained on all 100 cavities. The baseline mean coefficient of variation for nasal cavity volume (V1) was 6% and for minimum cross-sectional area (MCA) was 8%. Altering the angle of incidence of the wave tube in the axial and coronal planes caused considerable change in the traces from the anterior nasal cavity, including the I- and C-notches, and affected the MCA significantly (p < 0.01, Wilcoxon signed rank test). Using a small nosepiece aperture accentuated the I-notch, and the nosepiece in some cases became the site of the minimal area. Addition of a silicone-based sealant to the standard nosepiece caused a mean reduction of 14.3% in nasal volume, if the seal quality was suspected to be suboptimal. Nasopharyngeal volume decreased by a mean of 28.6% when the palate is raised by the modified Valsalva manoeuvre, and no difference was found between quiet oral respiration and cessation of nasal respiration. Acoustic rhinometry is sensitive to minor changes in the details of technique. We recommend using an intermediate range of angles in both planes, the addition of a sealant where the nosepiece seal is suspect, use of newer improved nosepieces and synchronizing readings with either cessation of nasal respiration or with quiet oral respiration. There is a pressing need for international agreement on such details if collaboration and clinical application of acoustic rhinometry is to flourish.

Thrombosed posterior-inferior cerebellar artery aneurysm: a rare cerebellopontine angle tumour

A case report of a thrombosed posterior-inferior cerebellar artery aneurysm is described. The tumour masqueraded as a vestibular schwannoma on imaging but the presenting features were unusual, the facial pain and weakness predominating despite well preserved hearing. This is an example of a rare cerebellopontine angle tumour and highlights the need for suspicion when lesions present atypically.

Experimental studies of the resolution of acoustic rhinometry in vivo

The ability of acoustic rhinometry to detect objects of defined size in nasal cavities has hitherto been investigated only in cadavers and models. We aimed to determine the resolution of the technique in the nose of living subjects. Silicone spheres of 3.0, 5.0, and 7.0 mm diameter were placed at two sites in the decongested and locally anaesthetised nasal cavities of 3 healthy adults. Acoustic rhinometry area-distance functions were obtained before and after insertion of the spheres, with further control data obtained after removal of the sphere from the nasal cavity. Six nasal cavities were studied in each test state on two separate occasions. The 3.0 mm sphere caused a statistically significant change in cavity volumes in only 17% of cases when placed in the middle meatus and in 8% at the nasal value (Mann-Whitney U-test; p < 0.05). The detection rates for the 5.0 mm sphere were 50% in the middle meatus and 50% at the nasal valve. When the control and test curves were compared by superimposition and the cross-sectional areas at the site of perturbations compared statistically (Mann-Whitney U-test) the detection rates in the middle meatus were: 33%-3.0 mm and 67%-5.0 mm sphere. The detection rate at the nasal valve region was 25%-3.0 mm sphere and 58%-5.0 mm. The 7.0 mm sphere was detected in 100% cases by volume changes, and 80% by area changes. Acoustic rhinometry can reliably detect changes of volume and area in the living nose resulting from the introduction of a 7 mm sphere into the nasal valve or middle meatal region in most cases. Smaller spheres are detected in only a fraction of cases. The resolution of the technique is therefore close to 7.0 mm (1.44 cm3). These findings are important when interpreting acoustic rhinometry data in monitoring patients with nasal pathology.

Reduction in junior doctors' hours in an otolaryngology unit: effects on the 'out of hours' working patterns of all grades

This study aimed to assess the effects of recent controls on juniors' duty hours (the 'New Deal') on the work performed by all grades of ENT medical staff 'out of hours'. For 100 days in 1993 the out of hours duties of all grades of doctor in the Otolaryngology Unit were monitored using daily logs. Three patterns of cover were run in parallel and subjected to comparison: Light: Senior House Officer (SHO)--Consultant (CON); Traditional: SHO-Intermediate (Registrar or Senior Registrar)--Consultant; Cross-cover--Pre-Registration House Officer (PRHO)--Intermediate-Consultant. The SHO 'out of hours' daily workload did not differ significantly between the traditional and light systems (median hours: 5.6 versus 5.0). There was an increase in working hours for the intermediate (registrar or senior registrar) grade of 84 per cent when the cross-cover system was in operation compared with the traditional system (median hours: 5.0 versus 2.8; p < 0.0001--Mann-Whitney U test). Consultant working hours increased by an average of 132 per cent as a result of removal of the intermediate tier (median hours: 1.7 versus 0.80; p < 0.0001). Reduction in on-call hours of junior staff resulted in a need for cross-cover and also in the frequent removal of an intermediate tier of staff. This has been shown to have a considerable effect on working patterns for intermediate and senior grades in an ENT unit of average size. Further reductions would be expected to have major effects on the working patterns of the consultant grade and considerably dilute the emergency experience of trainees.

Characterization of the purified vitamin K-dependent gamma-glutamyl carboxylase

Vitamin K-dependent carboxylase, purified from bovine liver, has properties similar to those reported for the carboxylase activity present in crude, solubilized microsomes. The purified carboxylase was found to possess the vitamin K epoxidase activity, believed to be essential for vitamin K-dependent carboxylation, but did not contain vitamin K epoxide reductase activity. Kinetic studies of the carboxylase done under defined conditions were complicated by the non-Michaelis-Menten kinetic behavior observed for reactions with two of the enzymes substrates, FLEEL and vitamin K1 hydroquinone. Initial rate experiments with the substrate FLEEL demonstrated behavior consistent with substrate inhibition and gave half-maximal activity at 1 mM FLEEL. Experiments with the substrate vitamin K1 hydroquinone also displayed non-Michaelis-Menten kinetics, as maximal activity was reached prematurely in relation to behavior at lower concentrations. Half-maximal activity was observed at 35 microM vitamin K1 hydroquinone. Initial rate experiments with varying NaH14CO3 concentration displayed Michaelis-Menten kinetics and gave a Km(app) of 0.29 mM. At cosubstrate concentrations chosen to obtain near-maximal activity, initial rate studies with varying NaH14CO3 concentration indicated a kcat near 1.0 s-1. Removal of the fourth substrate, oxygen, resulted in the loss of more than 99% of carboxylase activity. The sulfhydryl reagent N-ethylmaleimide inhibited carboxylase irreversibly, as did the anticoagulant warfarin.

Identification and purification to near homogeneity of the vitamin K-dependent carboxylase

Vitamin K-dependent carboxylase catalyzes the modification of specific glutamic acids to gamma-carboxyglutamic acid in several blood-coagulation proteins. This modification is required for the blood-clotting activity of these proteins and has thus been the subject of intense investigation. We have now identified the bovine vitamin K-dependent carboxylase and purified it to near homogeneity by an affinity procedure that uses the 59-amino acid peptide FIXQ/S (residues -18 to 41 of factor IX with mutations Arg----Gln at residue -4 and Arg----Ser at residue -1). The carboxylase as purified has a molecular weight of 94,000. It is also the major protein that can be cross-linked to iodinated FIXQ/S and is the only protein whose cross-linking is prevented by a synthetic factor IX propeptide. The degree of purification is about 7000-fold with reference to ammonium sulfate-fractionated microsomal protein from liver.

[3H]forskolin. Direct photoaffinity labeling of the erythrocyte D-glucose transporter

Irradiation of erythrocyte ghosts in the presence of [3H]forskolin resulted in a concentration-dependent, covalent incorporation of radiolabel into several of the major membrane protein bands. Most of the incorporation occurred in four regions of the gel. Peak 1 (216 kDa) was a sharp peak near the top of the gel in the region corresponding to spectrin. Peak 2 appeared to be associated with band 3 (89 kDa), while a third peak occurred around the position of band 4.2 (76 kDa). The fourth region of labeling was a broad area between 43-75 kDa which corresponds to the region of the glucose transporter. Forskolin labeling of this region was inhibited by cytochalasin B and D-glucose, but not L-glucose. Extraction of extrinsic membrane proteins resulted in a loss of radiolabeled protein from the 216- and 76-kDa regions. Treatment of membranes labeled with either cytochalasin B or forskolin with endo-beta-galactosidase resulted in identical shifts of the 43 to 75-kDa peaks to 42 kDa. Similarly, trypsinization of membranes photolabeled with either cytochalasin B or forskolin resulted in the generation of a 17-kDa radiolabeled fragment in both cases. Photoincorporation of [3H]cytochalasin B into the glucose transporter was blocked in a concentration-dependent manner by unlabeled forskolin.