How Do Patients and Otolaryngologists Define Dizziness?

OBJECTIVE

To assess for differences in how patients and otolaryngologists define the term dizziness.

METHODS

Between June 2020 and December 2022, otolaryngology clinicians and consecutive patients at 5 academic otolaryngology institutions across the United States were asked to define the term "dizziness" by completing a semantics-based questionnaire containing 20 common descriptors of the term within 5 symptom domains (imbalance-related, lightheadedness-related, motion-related, vision-related, and pain-related). The primary outcome was differences between patient and clinician perceptions of dizzy-related symptoms. Secondary outcomes included differences among patient populations by geographic location.

RESULTS

Responses were obtained from 271 patients and 31 otolaryngologists. Patients and otolaryngologists selected 7.7 ± 3.5 and 7.1 ± 4.3 symptoms, respectively. Most patients (266, 98.2%) selected from more than 1 domain and 17 (6.3%) patients identified symptoms from all 5 domains. Patients and clinicians were equally likely to define dizziness using terms from the imbalance (difference, -2.3%; 95% CI, -13.2%, 8.6%), lightheadedness (-14.1%; -29.2%, 1.0%), and motion-related (9.4; -0.3, 19.1) domains. Patients were more likely to include terms from the vision-related (23.6%; 10.5, 36.8) and pain-related (18.2%; 10.3%, 26.1%) domains. There were minor variations in how patients defined dizziness based on geographic location.

CONCLUSIONS

Patients and otolaryngologists commonly described dizziness using symptoms related to imbalance, lightheadedness, and motion. Patients were more likely to use vision or pain-related terms. Understanding of these semantic differences may enable more effective patient-clinician communication.

Impact of dupilumab on medical readiness in a military population

KEY POINTS

Military servicemembers reported high satisfaction rates of dupilumab treatment for CRSwNP. Some service members fear that dupilumab treatment may limit their career progression. Updated guidelines are needed for servicemembers to make decisions regarding dupilumab.

Unique clinical and prognostic behavior of patients diagnosed with combined exophytic and inverted papilloma histologic subtype

Objectives

To evaluate the clinical and prognostic behaviors of sinonasal papillomas.

Methods

Patients diagnosed with sinonasal papilloma were reviewed between 2001 and 2016 at a tertiary rhinology practice. Using pathology-specific electronic medical record software, patients diagnosed with sinonasal papilloma were identified. Four subcategories of this lesion were identified: inverting (IP), exophytic (EP) oncocytic (OP) and inverting + exophytic (IP + EP) papillomas.

Results

A total of 107 patients were identified with unique sinonasal papilloma diagnoses. Of these, the majority were diagnosed with IP (87, 81.3%). The subpopulation of patients co-diagnosed with IP and EP (IP + EP) was unique with respect to clinical presentation and prognosis relative to both the IP and EP alone populations. IP + EP patients (5, 4.7%) were older with an average age of 75.25 years compared to 45 (EP) and 55.26 (IP), p < .0001. IP + EP patients more often presented with epistaxis (60%) compared to 33.3% (EP) and 4.6% (IP). Finally, all IP + EP patients had at least one recurrence of their disease, compared to 33.3% (EP) and 28.5% (IP).

Conclusions

Each histopathologic subtype of sinonasal papilloma has unique clinical characteristics and recurrence rates after surgical resection. The subpopulation of patients diagnosed with IP + EP tends to be older, more likely to present with epistaxis, and more likely to recur. Additional investigation and analysis of this subpopulation is warranted.

Level of Evidence

4.

Are you congested? A comparison of definitions between otolaryngologists and their patients

OBJECTIVE

To assess for differences of intended meaning in the description of congestion-related symptoms among otolaryngology patients and clinicians.

MATERIALS AND METHODS

Between June 2020 and October 2022, a questionnaire consisting of 16 common descriptors of congestion-related symptoms within four domains (obstructive-related, pressure-related, mucus-related, and other symptoms) was completed by patients and otolaryngologists at five tertiary otolaryngology practices. The primary outcome was to assess differences in patient and clinician perceptions of congestion-related symptoms. Differences based on geographic location was a secondary outcome.

RESULTS

A total of 349 patients and 40 otolaryngologists participated. Patients selected a median of 6.8 (standard deviation [SD] 3.0) terms compared with 4.0 (SD 1.6) terms for otolaryngologists (p < 0.001). Otolaryngologists were more likely to select obstruction-related symptoms (difference 6.3%; 95% confidence interval [CI] 3.8%, 8.9%). Patients were more likely to describe congestion using pressure-related (-43.7%; -58.9%, -28.5%), mucus-related (-43.5%; -59.3%, -27.8%), and other symptoms (-44.2; -51.3%, -37.1%) compared with otolaryngologists. There were no significant differences identified based on geographic location with regard to symptom domains on multivariate analysis.

CONCLUSIONS

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of congestion. Clinicians tended to have a narrower interpretation of congestion that was limited to the obstruction-related symptom domain, while patients defined congestion more broadly. This has important counseling and communication implications for the clinician.

Anterior Cervical Pain Syndromes: Defining the Patient Population and Approach to Treatments

Objective This study aimed to evaluate patients with anterior cervical pain syndromes (ACPSs) by describing patient characteristics, therapeutic interventions, and response to treatments. Study Design This is a retrospective observational study. Methods Patients treated for diagnoses associated with ACPSs over a seven-year period in one laryngology practice at a tertiary care center were identified and evaluated via a review of clinical and surgical records. Patients identified to have undergone any treatment for ACPSs via medication, trigger-point injections of local anesthetics mixed with steroids, and/or surgical resection of the greater cornu of the hyoid bone and superior cornu of the thyroid cartilage were included. Participants subsequently underwent a medical record review and telephone interview to determine response to treatments. Results Twenty-seven patients met the inclusion criteria, including 12 patients (44.4%) with superior laryngeal neuralgia (SLN), seven patients (25.9%) with superior thyroid cornu syndrome (STCS), and eight patients (29.6%) with hyoid bone syndrome (HBS)/clicking larynx syndrome. The most common symptoms were neck/throat pain (27, 100%), globus sensation (20, 74.1%), and dysphagia (20, 74.1%). A total of 24 patients (93.3%) underwent point injections of bupivacaine and dexamethasone. Of these, 12 patients (52.2%) demonstrated a complete response that was permanent in six patients (26.1%). Seven patients (25.9%) underwent surgical intervention, with at least partial improvement noted in six patients (85.7%). Conclusion ACPSs constitute a number of complex diagnoses that remain poorly characterized in the literature. The use of point injections of local anesthetics with steroids appears efficacious with surgical options available for those with an incomplete response or return of symptoms.

Layperson Perception of Reflux-Related Symptoms

Objective

To assess for differences of intended meaning in the description of reflux-related symptoms among otolaryngology patients and clinicians.

Study Design

Cross-sectional survey-based study.

Setting

Five tertiary, academic otolaryngology practices.

Methods

Between June 2020 and July 2022, a questionnaire consisting of 20 common descriptors of reflux-related symptoms within four domains (throat-, chest-, stomach-, and sensory-related symptoms) was completed by patients. Attending otolaryngologists at five academic medical centers then completed the same survey. The primary outcome was to assess differences in patient and clinician perceptions of reflux-related symptoms. Differences based on geographic location was a secondary outcome.

Results

A total of 324 patients and 27 otolaryngologists participated. Patients selected a median of six terms compared with 10.5 for otolaryngologists (p < .001). Otolaryngologists were more likely to select sensory symptoms (difference: 35.8%; 95% confidence interval [CI]: 19.2%, 52.4%), throat-related symptoms (32.4%; 21.2, 43.6%), and chest-related symptoms (12.4%; 8.8, 15.9). Otolaryngologists and patients were equally likely to consider stomach symptoms as related to reflux (4.0%, -3.7%, 11.7%). No significant differences were identified based on geographic location.

Conclusion

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of reflux. Patients tended to have a narrower interpretation of reflux with symptoms primarily limited to classic stomach-related symptoms, while clinicians tended to have a broader definition of reflux that included extra-esophageal manifestations of disease. This has important counseling implications for the clinician, as patients presenting with reflux symptoms may not comprehend the relationship of those symptoms to reflux disease.

Sinonasal Complications Following the Sinus Lift Procedure

Background: Although the incidence of postoperative acute and chronic rhinosinusitis in patients undergoing a sinus lift procedure is relatively high, a paucity of rhinology literature examines the management of and outcomes for this patient population. The objective of this study was to review the management and postoperative care of sinonasal complications and identify possible risk factors that should be considered prior to and following sinus augmentation. Methods: We identified sequential patients who had undergone a sinus lift procedure and were referred to the senior author (AK) at a tertiary rhinology practice for intractable sinonasal complications and reviewed their charts for demographic data, history of illness including prereferral treatment, examination findings, imaging results, treatment modalities, and culture results. Results: Nine patients were initially treated medically without improvement and subsequently underwent endoscopic sinus surgery. The sinus lift graft material remained intact in 7 patients. Two patients had extrusion of the graft material into the facial soft tissues, resulting in facial cellulitis requiring graft removal and debridement. Seven of the 9 patients had predisposing factors that could have prompted referral to an otolaryngologist for optimization prior to sinus lifting. The mean follow-up was 10 months, and all patients had full resolution of symptoms. Conclusion: Acute and chronic rhinosinusitis is a complication of the sinus lift procedure and is more commonly seen in patients with preexisting sinus disease, anatomic sinonasal obstruction, and Schneiderian membrane perforation. Preoperative evaluation by an otolaryngologist may improve outcomes in patients at risk of sinonasal complications from sinus lift surgery.

The acoustic environment before and during the SARS-CoV-2 lockdown in a major German city as measured by ecoacoustic indices

The SARS-CoV-2 pandemic drastically changed daily life. Lockdown measures resulted in reduced traffic mobility and, subsequently, a changed acoustic environment. The exceptional lockdown was used to analyze its impact on the urban acoustic environment using ecoacoustic indices. Using data from 22 automated sound recording devices located in 9 land use categories (LUCs) in Bochum, Germany, the normalized difference soundscape index (NDSI) and Bioacoustics index (BIO) were explored. The NDSI quantifies the proportion of anthropophonic to biophonic sounds, and BIO quantifies the total sound activities of biological sources. The mean differences and standard deviation (SD) were calculated 5 weeks before and 5 weeks during the first lockdown. Pronounced peaks for the NDSI and BIO before lockdown that diminished markedly during lockdown were observed, however, with distinct differences in terms of the LUC. The mean NDSI increased from 0.00 (SD = 0.43) to 0.15 (SD = 0.50), the mean BIO decreased from 4.74 (SD = 2.64) to 4.03 (SD = 2.66). Using the NDSI and BIO together reveals that changes of the acoustic environment during lockdown are mainly driven by decreased anthropophonic sound sources. These results suggest that further studies are needed to tailor ecoacoustic indices more accurately to conditions of the urban environment.

The Draf III procedure: A review of indications and techniques

The Draf Ⅲ procedure involves the creation of a common frontal sinus cavity. The most common indication for the Draf Ⅲ procedure is chronic rhinosinusitis of the frontal sinuses despite the failure of more conservative interventions such as bilateral Draf Ⅱa procedures. Primary Draf Ⅲ may be indicated in patients with a high risk of failures such as those with severe polyposis and those with a frontal sinus opening less than 4 mm on computed tomography imaging. Other indications for the Draf Ⅲ include access for tumor removal and repair of traumatic fractures of the frontal sinus. The “inside‐out” Draf Ⅲ procedure is the standard approach when the frontal recess anterior–posterior diameter is wide enough for instrument access, usually larger than 4–5 mm. The “outside‐in” Draf Ⅲ procedure can be done when the frontal recess is too narrow to safely accommodate instruments. Regular follow‐up with debridement should be done to prevent neo‐ostium stenosis.

Cochlear Implantation in the Active Duty Military Population: A Survey Assessing Military Readiness and Satisfaction

OBJECTIVE

Evaluate the impact of cochlear implantation (CI) on retention for United States active duty (AD) service members.

STUDY DESIGN

Retrospective observational study.

SETTING

Tertiary military CI centers.

PATIENTS

AD service members who underwent CI and completed a telephonic survey.

MAIN OUTCOME MEASURES

The ability for military personnel to maintain AD status following CI as determined by the nonvolitional hearing-related AD separation rate and whether subjects would recommend CI to other qualified candidates.

RESULTS

Twenty AD service members who underwent CI between 2004 and 2020 completed a telephonic survey. Fifteen (75%) were single-sided deafness (SSD) and five were traditional CI candidates. The mean age was 40.3 years (range 27.5-64.3), 19 (95%) were male, and 12 (80%) were Caucasian. Ten (50%) were officers and 14 (70%) were noncombat support personnel. Idiopathic sudden sensorineural hearing loss was the most common cause of hearing loss (8, 40%) followed by occupational noise exposure (4, 20%). Sixteen (80%) maintained AD status yielding 46.15 person-years of AD service following CI. For SSD, 14 (93%) maintained AD status yielding 40.54 person-years of AD service. The nonvolitional hearing-related patient separation rate for CI recipients with bilateral hearing loss was 35.65 cases per 100 AD person-years and 0 cases per 100 person-years for SSD candidates. Nineteen (95%) stated they would recommend CI to other AD CI candidates.

CONCLUSIONS

The vast majority of AD CI recipients, and particularly those with SSD, are able to remain on AD after surgery and report a high degree of satisfaction with their implant.

Patient and Provider Satisfaction With Telemedicine in Otolaryngology

Objective

The objective of this study is to evaluate patient and provider satisfaction with telemedicine encounters across 3 otolaryngology practices.

Study Design

Cross-sectional survey.

Setting

A military community hospital, an academic military hospital, and a nonmilitary academic center.

Methods

A telephone-based survey of patients undergoing telemedicine encounters for routine otolaryngology appointments was performed between April and July 2020. Patients were asked about their satisfaction, the factors affecting care, and demographic information. A provider survey was emailed to staff otolaryngologists. The survey asked about satisfaction, concerns for reimbursement or liability, encounters best suited for telemedicine, and demographic information. The results were analyzed with descriptive statistics and a multivariable logistic linear regression model to determine odds ratios.

Results

A total of 325 patients were surveyed, demonstrating high satisfaction with telemedicine (average score, 4.49 of 5 [best possible answer]). Patients perceived “no negative impact” or “minor negative impact” on the encounter due to the lack of a physical examination or face-to-face interaction (1.86 and 1.95 of 5, respectively). High satisfaction was consistent across groups for distance to travel, age, and reason for referral. A total of 25 providers were surveyed, with an average satisfaction score of 3.44 of 5. Providers reported “slight” to “somewhat” concern about reimbursement (40%) and liability (32%).

Conclusion

Given patients’ and providers’ levels of satisfaction, there is likely a role for telemedicine in otolaryngology practice that may benefit patient care independent of the COVID-19 pandemic.

A Dizzying Complaint: Investigating the Intended Meaning of Dizziness Among Patients and Providers

OBJECTIVE/HYPOTHESIS

To assess for semantic differences regarding the definition of dizziness among otolaryngology patients, otolaryngologists, and non-otolaryngologist providers.

STUDY DESIGN

Cross-sectional survey.

METHODS

Between March and May 2020, a survey consisting of 20 common descriptors for dizziness within five domains (lightheadedness, motion sensitivity, imbalance, vision complaints, and pain) was completed by patients at two outpatient otolaryngology clinics. Surveys were subsequently obtained from otolaryngology and non-otolaryngology providers attending a multidisciplinary dizziness lecture. The primary outcome measure was to assess for differences in definition of dizziness between patients and providers. Secondary outcome measures included assessing differences between otolaryngologists and non-otolaryngologists.

RESULTS

About 221 patients and 100 providers participated. Patients selected a median of 7 terms compared to 8 for providers (P = .375), although providers had a larger overall distribution of number of terms selected (P = .038). Patients were more likely than providers to define dizziness according to the following domains: lightheadedness (difference 15.0%; 95% confidence interval [CI] 5.5%-25.3%), vision complaints (difference 21.6%, 95% CI 12.0%-29.6%), and pain (difference 11.5%, 95% CI 4.7%-17.1%). Providers were more likely to define dizziness according to the motion sensitivity domain (difference 13.8%, 95% CI 6.8%-19.6%). Otolaryngology and non-otolaryngology providers defined dizziness similarly across symptom domains.

CONCLUSION

Although patients and providers both view dizziness as imbalance, patients more commonly describe dizziness in the context of lightheadedness, vision complaints, and pain, whereas providers more frequently define dizziness according to motion sensitivity. These semantic differences create an additional barrier to effective patient-provider communication.

LEVEL OF EVIDENCE

4. Laryngoscope, 131:E1443-E1449, 2021.

Prevalence of Eustachian Tube Dysfunction in the US Elderly Population

Objective

To investigate the prevalence of eustachian tube dysfunction (ETD) in elderly adults in the United States and its association with other upper aerodigestive inflammatory processes.

Study Design

Cross-sectional study.

Setting

Population based.

Subjects and Methods

In total, 147,805 patients without malignancy were compared to 13,804 demographically matched patients with malignancy of the upper aerodigestive tract (UADT) by querying the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database for patients aged 66 to 99 years between 2003 and 2011. The prevalence of ETD and inflammatory diseases among these patients was compared. Association between ETD, other upper aerodigestive inflammatory processes, and UADT malignancies was evaluated.

Results

The prevalence of ETD was 5.44% among patients without malignancy and 9.08% in those with cancer (odds ratio [OR], 1.73; 95% CI, 1.63-1.84). Patients with ETD in the control population were more likely (OR, 95% CI) to be diagnosed with chronic rhinitis (5.00, 4.70-5.33), chronic sinusitis (4.20, 3.98-4.43), allergic rhinitis (4.27, 4.08-4.47), and gastroesophageal reflux disease (GERD) (2.42, 2.31-2.53). Patients with ETD and chronic rhinitis (1.43, 1.24-1.65), chronic sinusitis (1.57, 1.38-1.78), and acute otitis media (1.33, 1.08-1.65) were associated with higher rates of UADT malignancy.

Conclusion

Over 5% of patients older than 65 in the United States are diagnosed with ETD in the absence of UADT malignancy. Associations between ETD and chronic rhinitis, chronic sinusitis, allergic rhinitis, and GERD in the absence of UADT malignancy suggest that some patients may benefit from treatment of inflammatory disease as a cause of ETD.

Trace element concentrations from lichen transplants in Pretoria, South Africa

PURPOSE

The purpose of this study was to assess the level and possible sources of trace elements in Tshwane metropolis using transplanted lichen thallus of Parmelia sulcata with a view to evaluating the ability of this lichen species to monitor air pollutants from a perceived polluted environment.

METHODS

Samples of the lichen thalli were transplanted into ten different sites and covered with a net. Samples were exposed for 3 months. Concentrations of ten trace elements were determined with the use of inductively coupled plasma mass spectrometry.

RESULTS

A significant difference was observed in the values of elemental concentration in lichen from unpolluted area and those transplanted to all the sites (p < 0.01). Variations in values of trace elements recorded in lichen transplant from different sites were also statistically significant (p < 0.01). The high traffic sites showed significantly higher elemental concentrations, particularly for Pb, Zn, and Cu than the industrial and residential areas (p < 0.05).

CONCLUSION

Trends in the trace element values from different sites suggested that the elements might have come from anthropogenic sources.

Investigating Jacaranda mimosifolia tree as biomonitor of atmospheric trace metals

Studies on the use of tree bark as biomonitors for environmental pollutants are still very scarce. We evaluated the reliability of using Jacaranda mimosifolia, a common tree in Tshwane City of South Africa, as a suitable biomonitor of atmospheric trace metals. Bark samples were collected from ten different locations during two sampling periods. The concentrations of the metals were determined by inductively coupled plasma mass spectrometry. The concentrations of the metals were 33.2-1,795 microg/g (Pb), 21.4-210 microg/g (Cu), 68.4-490 microg/g (Zn), 30.6-2,916 microg/g (Cr), 0.12-1.34 microg/g (Cd), and 6.04-68.0 microg/g (V), respectively. The differences obtained for the results from different sites were significant (p < 0.05). A significant difference was also observed between the two sampling periods. The trace metals concentrations suggested that automobile emissions are a major source of these metals. The study also confirms the suitability of J. mimosifolia as a biomonitor of atmospheric deposition of these metals.

Family, personality, and social risk factors impacting the retention rates of first-year Hispanic and Anglo college students

This study investigated familial and behavioral differences between Hispanic and Anglo-American first-year college students. Analyses of variance and chi-square analyses were used to test for ethnic differences in (a) risk factors associated with family dysfunction, family addictions, personality factors, and social experiences, (b) student problem behaviors, namely alcohol use, drug use, and eating disorders, (c) a one-year follow-up of student retention, and (d) specific factors related to retention at the one-year follow-up. The Hispanic freshmen appeared to demonstrate resilience despite a lack of mentoring and greater paternal addiction. However, the one-year follow-up suggested that Hispanic females were at particular risk for leaving school. To improve college retention rates, social policy should focus on Hispanic students' vulnerabilities and strengths in making important developmental transitions.

Hispanic and Anglo college women's risk factors for substance use and eating disorders

This study investigated the role of temperament style (Novelty Seeking and Harm Avoidance) of Hispanic American and Anglo college women in moderating and mediating the relationship between family addiction/family functioning and offspring problem behaviors. The sample was comprised of 67 Hispanic American and 770 Anglo undergraduate women. Findings of this study indicate that the processes of risk that lead to substance use and eating disorders follow different routes for Hispanic American and Anglo women. Novelty Seeking and Harm Avoidance were found to be important factors in both moderating and mediating the effects of parental drinking and family dysfunction for both Hispanic and Anglo college women.

[The founding of the chair of comparative embryogeny at the Collège de France (1844)]

The first chair of embryology was founded in 1844 at the College de France. Yet the founding met with hostility. The first occupant Victor Coste (1807-1873) was imposed on the institution. The administrator-professors of the College de France criticized the governmental procedure. Some professors, such as Georges-Louis Duvernoy, made a stand against the appointment of the young embryologist. Duvenoy continued for several years to protest against Coste's teachings at the College of France. But Coste was tacked by De Blainville and eventually Flourens. Credit should be given to Coste for having introduced a scientific embryology in France. The history of the founding of the chair of comparative embryogeny at the College de France is here described by drawing mainly on an umpublished archival source.

[Progressive cardiomyopathic lentiginosis]

We report on a 30-year-old man with progressive cardiomyopathic lentiginosis. This syndrome is first described by Polani and Moynahan 1972. They distinguish between the earlier described multiple lentigines syndrome, the LEOPARD syndrome (L-entiginosis, E-lectrocardiographic conduction defects, O-cular hypertelorism, P-ulmonary stenosis, A-bnormalities of genitalia, R-etardation of growth, D-eafness) and the progressive cardiomyopathic syndrome. The progressive cardiomyopathic syndrome is characterised by multiple symmetrical lentigines, hypertrophic obstructive cardiomyopathy and retardation of growth. All characteristics were present in our patient with only mild right ventricular hypertrophic cardiomyopathy.

[High malignant B-cell non-Hodgkin lymphoma of the heart: intravital diagnosis by transesophageal echocardiography controlled biopsy]

We report about a 66-year old patient with Non-Q-wave infarction in coronary artery two-vessel disease. During an echo- and transesophageal multiplane echocardiography preoperatively before a coronary artery bypass surgery a right atrium septal tumor of unknown form was discovered. The computerized axial tomography (CAT) and nuclear magnetic resonance (NMR) scans did not demonstrate extracardiac pathologic findings. A transesophageal echocardiography-guided biopsy of the right atrial septum over the vena femoralis and the right atrium enabled intra vitam a very early diagnosis of high malignant B-cell Non-Hodgkin-lymphoma without the need for thoracotomy. The diagnosis was confirmed histopathologically and immunohistochemically and early treatment with cytostatic therapy could begin. To our knowledge the transesophageal echocardiography-guided biopsy has never been described in the worldwide literature.

Isolation of Thermus strains from hot composts (60 to 80 degrees C)

High numbers (10(7) to 10(10) cells per g [dry weight]) of heterotrophic, gram-negative, rod-shaped, non-sporeforming, aerobic, thermophilic bacteria related to the genus Thermus were isolated from thermogenic composts at temperatures between 65 and 82 degrees C. These bacteria were present in different types of wastes (garden and kitchen wastes and sewage sludge) and in all the industrial composting systems studied (open-air windows, boxes with automated turning and aeration, and closed bioreactors with aeration). Isolates grew fast on a rich complex medium at temperatures between 40 and 80 degrees C, with optimum growth between 65 and 75 degrees C. Nutritional characteristics, total protein profiles, DNA-DNA hybridization (except strain JT4), and restriction fragment length polymorphism profiles of the DNAs coding for the 16S rRNAs (16S rDNAs) showed that Thermus strains isolated from hot composts were closely related to Thermus thermophilus HB8. These newly isolated T. thermophilus strains have probably adapted to the conditions in the hot-compost ecosystem. Heterotrophic, ovalspore-forming, thermophilic bacilli were also isolated from hot composts, but none of the isolates was able to grow at temperatures above 70 degrees C. This is the first report of hot composts as habitats for a high number of thermophilic bacteria related to the genus Thermus. Our study suggests that Thermus strains play an important role in organic-matter degradation during the thermogenic phase (65 to 80 degrees C) of the composting process.

Comparison of Doppler echocardiographic methods with heart catheterisation in assessing aortic valve area in 100 patients with aortic stenosis

OBJECTIVE

To examine the practicability and accuracy of Doppler echocardiographic methods in determining aortic valve area.

METHODS

Aortic valve areas determined by three methods using Doppler echocardiography (applying the continuity equation and the modified Gorlin formula using data from Doppler echocardiography and right heart catheterisation) were compared with values obtained by heart catheterisation.

PATIENTS

100 consecutive patients with aortic stenosis aged between 34 and 83 years (mean (SD) 66 (10)).

RESULTS

Differences in individual patients' measurements of aortic valve area by the three Doppler techniques varied by up to 0.56 cm2 compared with values obtained by heart catheterisation. On average, values obtained from Doppler echocardiographic methods lay up to 51% below and 78% above those obtained by heart catheterisation.

CONCLUSIONS

All three Doppler echocardiographic methods were practicable in routine clinical practice for patients of all ages, but they were of limited accuracy when compared with the aortic valve areas found invasively using the invasive Gorlin equation. However, these deviations may not always be due to inadequacies of the Doppler methods: they could also be caused by limitations in the Gorlin formula. Doppler methods can be repeated if required, they allow examination of the morphology of the valve, and they subject the patient to considerably fewer risks than the invasive procedure. An adequate strategy in determining the severity of aortic valve stenosis would be to calculate the valve area by Doppler echocardiography as well as considering the valvar aortic pressure gradient. The valve area alone should not be relied on exclusively, as has been the increasing practice in the past few years.

A comparative analysis of results and morbidity in type I diabetics undergoing preemptive versus postdialysis combined pancreas-kidney transplantation

Although combined pancreas-kidney transplantation (PKT) has become a valid treatment option for selected type I diabetics, the timing of PKT relative to the degree of nephropathy remains controversial. We analyzed results and morbidity in 30 type I diabetics undergoing PKT after starting dialysis (PKT:D) versus 31 type I diabetics undergoing PKT prior to dialysis (PKT:ND). The two groups were similar with the respect to age, duration and severity of diabetes, gender, race, preservation time, retransplants, sensitization, HLA-matching, and CMV status. The mean preoperative serum creatinine was higher in the PKT:D group (9.9 +/- 3.4 vs. 3.9 +/- 1.9 mg/dl PKT:ND, P < 0.01). All patients were managed with quadruple immunosuppression with OKT3 induction. Actuarial patient survival is 100% (PKT:D) and 96.8% (PKT:ND). Renal and pancreas allograft survival are 97% and 93%, respectively, in both groups. The incidence of rejection, infection, operative complications, reflux pancreatitis, and total hospital days was similar in both groups. Long-term renal and pancreas allograft function and quality of life were like-wise comparable. No adverse coagulation or immunologic effects were noted in the PKT:ND group. Rehabilitation potential favored the PKT:ND group. PKT can be performed safely and effectively in the absence of uremia. In selected type I diabetics with significant nephropathy, we believe that PKT is the best treatment option and need not be considered as preemptive, especially in view of increasing waiting times and the variable progressive nature of diabetic complications.

Recipient selection and evaluation for vascularized pancreas transplantation

Vascularized pancreas transplantation (PT) is becoming an accepted therapy for selected type I diabetic patients. However, selection and evaluation criteria remain uncertain. In the last 3.5 years, we have interviewed 205 and evaluated 151 diabetic patients for PT. The degree of renal dysfunction (creatinine clearance below 45 ml/min) was used to select patients for combined pancreas-kidney transplantation (PKT) or solitary pancreas transplantation (PTA) (clearance above 70 ml/min). The cardiovascular evaluation (stress thallium study with liberal use of coronary angiography) was used to determine operative risk and provided the other major selection criterion. A total of 104 patients were selected as candidates for PT; 70 have undergone PKT with 98.6% patient survival (1 cardiovascular death), 97.1% kidney graft survival, and 94.2% pancreas graft survival. Thirty-three evaluated patients (24.1%) were not accepted as candidates for PT; 13 have undergone cadaveric kidney transplantation, 5 were placed on the kidney waiting list, and 9 have died. Criteria for PTA include 2 or more diabetic complications or hyperlabile diabetes. Patient (n = 12) and pancreas graft survival after PTA is 83.3 and 50%, respectively. Our conclusion is that a multidisciplinary approach was used for recipient selection for PT based on degree of nephropathy, cardiovascular risk, and presence of diabetic complications. Nearly 75% of diabetic patients evaluated were acceptable candidates for PT. Only 4 (3.8%) of these selected patients died while awaiting or undergoing PT, thus optimizing the use of scarce allograft resources and providing evidence for appropriate patient selection.

Hyperammonemic encephalopathy in urinary diversion with urea-splitting urinary tract infection

We present two cases of hyperammonemic encephalopathy secondary to urea-splitting urinary tract infection with urinary diversion. One patient had a ureterosigmoidostomy, the other an ileal loop diversion. Neither patient had significant underlying liver disease, but both had considerable muscle atrophy that may have predisposed them to develop hyperammonemia. Medical therapy did not provide long-term control of symptoms. In both cases, hyperammonemic encephalopathy resolved after revision of their urinary diversions. The probable mechanism of the metabolic derangements produced by urea-splitting urinary tract infections is reviewed. We suggest that patients with urinary diversion who develop hyperammonemic encephalopathy secondary to a urea-splitting urinary tract infection be treated with surgical revision of the urinary system to improve drainage and decrease bowel contact time.

[Rupture of the ventricular septum following posterior wall infarction: echo- and Doppler echocardiography diagnosis with pressure determination]

In the postinfarct ventricular septal rupture, an early surgical intervention improves prognosis. A rapid and accurate diagnosis is necessary. A 56-year-old patient was admitted to the hospital with a Q-wave posterior myocardial infarction. Auscultation suggested a ventricular septal defect. Neither M-mode nor the two-dimensional echocardiography with apical four- chamber view could confirm the ventricular septal defect. Only the subcostal view showed a basal ventricular septal defect, which was sometimes covered by the septal leaflet of the tricuspid valve. With the continuous wave Doppler, a left-to-right shunt on the ventricular septum could be registered and the pressure in the right ventricle could be measured. Catheterization confirmed the diagnosis of a basal ventricular septal defect with the associated pressure characteristic. The basal ventricular septal defect was successfully closed with a patch. The high accuracy of the continuous-wave Doppler, which is superior to M-mode and two-dimensional echocardiography, was confirmed by this report. Pressure measurement in the right ventricle by continuous wave Doppler also provides a non-invasive diagnostic method that can be used at the bedside.

Selectivity of basolateral anion exchange in the acidification pathway of turtle bladder

The turtle urinary bladder in vitro acidifies the solution bathing its luminal surface. Protons are actively extruded across the apical membrane by an H+-ATPase. Bicarbonate ion exits the cell across the basolateral membrane via a stilbene-sensitive, anion exchange for chloride. Chloride then exits the cell via a conductive pathway. The present studies were undertaken to define the specificity of the basolateral anion exchange mechanism for chloride. Turtle bladders were mounted on chambers in vitro, short-circuited, and treated with ouabain. The current remaining after inhibition of sodium transport was used to measure the acidification rate. Ion replacement studies with bromide, isethionate, sulfate, and nitrate indicated that only bromide supported acidification at rates comparable to chloride. In separate experiments, kinetic analysis of anion interaction with the exchanger indicates that maximal acidification rates decrease in the order: Cl greater than Br greater than SO4 greater than methyl sulfate = gluconate. The affinity of the exchanger decreases in the order: Cl greater than SO4 greater than Br greater than HCO3 greater than methylsulfate greater than gluconate. These selectivity sequences indicate "strong" interaction of the anions with the selectivity site. The differences in position of the polyatomic anions in the two sequences indicates that the "binding" site is accessible but that transport is limited by steric factors.

[Noninvasive assessment of an aortic bioprosthesis malfunction with Doppler echocardiography]

A 27-year-old patient with aortic stenosis received a Carpentier Edwards bioprosthesis and a reconstruction of the mitral valve, in 1978. With auscultation, M-mode and two-dimensional echocardiography, we diagnosed in 1985 a malfunction of the aortic prosthesis with restenosis, insufficiency and mitral insufficiency. A reliable qualitative and quantitative non-invasive assessment, however, was only possible with Doppler echocardiography. The velocity of blood flow over the aortic valve was measured with the continuous-wave Doppler technique; the aortic valve pressure gradient and the valve area were determined. The pulsed Doppler allowed a semi-quantitative evaluation of the severity of the aortic and mitral insufficiency. The intraoperative and pathological anatomical results confirmed the results from Doppler echocardiography: aortic valve prosthesis malfunction with restenosis and insufficiency and mild haemodynamically insignificant mitral valve insufficiency. The need for cardiac catheterization in patients with valvular heart disease and prosthesis is discussed.

Compliance of insulin-dependent diabetics with a low-fat diet

Compliance with medical therapy is widely researched yet unpredictable. When counseled by a dietitian to begin a low-fat (25%) diabetic diet, subjects significantly decreased fat intake but did not achieve the prescribed 25% fat level. The significantly lower fat intake after instruction identified the registered dietitian as an effective behavioral change agent. Six compliance predictors obtained at an initial interview accounted for 77% of the variance in compliance.

[Typing of amyloidoses intra vitam by tissue biopsy using antibodies. Report on 2 patients]

The value of the immunohistochemical classification of amyloid-syndromes has been illustrated in two patients with generalized amyloidosis. Chemical types and exact diagnosis were recognized in biopsies (and later necropsies) using antisera against different purified amyloid fibril proteins and the indirect immunoperoxidase technique. The first case, originally diagnosed as "perireticular" amyloid, was diagnosed as "Ak-amyloidosis with kappa-Bence-Jones-proteinuria without apparent B-cell malignoma", the second case as "AA-amyloidosis reactive to periodic fever". The diagnosis and possible therapeutic measures are discussed in the light of the new classification of amyloid syndromes.

Chloride dependence of the HCO3 exit step in urinary acidification by the turtle bladder

To characterize the efflux of HCO-3 across the basolateral membrane of the H+-secreting cells of the turtle bladder, we examined the effect of substitution of gluconate or methyl sulfate for Cl- on the rate of acidification (JH). JH was measured as the short-circuit current in bladders in which Na+ transport was abolished with 10(-4) M ouabain. In hemibladders bathed in normal Ringer solution (Cl- = 122 mM) JH was 44.9 microA. Substitution of the Cl- resulted in a marked reduction in JH (12.5 microA with gluconate and 7.5 microA with methyl sulfate). Addition of Cl- to the mucosal surface had no effect on JH. In contrast, serosal addition of Cl- restored JH to control. The apparent Km for Cl- in gluconate Ringer was 0.13 mM. Serosal furosemide (1 mM) inhibited JH by 55% in Cl- Ringer. We conclude that HCO-3 exit across the basolateral membrane of the H+-secreting cell occurs via a Cl-HCO3 exchanger that has a high affinity for chloride.