When Can Children Perform Valsalva and Toynbee Maneuvers? An Exploratory Study

OBJECTIVES

Barochallenge-induced Eustachian tube dysfunction (ETD) is difficult to diagnose because the examination is often normal during clinical assessment. In adults, functional tympanometry testing, performed by asking the patient to Valsalva and Toynbee while measuring the pressure shift, can aid in the diagnosis of ETD. However, standardized values do not exist in children. We aim to determine the age at which children can perform these maneuvers and the normative values in this population.

METHODS

Patients with a normal basic ear examination 4 years and older, presenting to the pediatric Otolaryngology clinic, were recruited. Otoscopy, baseline tympanometry, followed by Valsalva and Toynbee maneuvers were performed. Because there are no pediatric norms, we hypothesized that children would achieve the same minimum normal pressure shift as cited in the adult literature (+20 daPa or higher for Valsalva and -20 daPa or lower for Toynbee). The data were analyzed using receiver operating characteristic curves and logistic regression.

RESULTS

One hundred sixty-eight children (276 ears) were assessed. Participants as young as 4 years old were able to perform a Valsalva and Toynbee. Age cut-offs at which children achieved adult norms were 12.5 years ( p = 0.016) and 8.5 years ( p = 0.071) for Valsalva and Toynbee maneuvers, respectively. Mean pressure shift ranged from +29 to -36 daPa, and males were 2.5 times more likely to achieve Toynbee compared with females ( p = 0.006).

CONCLUSIONS

Functional tympanometry testing may be used to help diagnose barochallenge-induced ETD in older children.

Indicators are Relational: Navigating Knowledge and Power in the Development and Implementation of Coastal-Marine Indicators

In many environment and resource management contexts (e.g., integrated coastal management, ecosystem-based fisheries management), indicator selection and development are perceived as a largely technical, bureaucratic, and scientific challenge. As such, choices about indicators and their application are often treated as external from everyday politics and dynamics of social power. Our aim here is to highlight the value of a relational perspective that weaves power and knowledge together in the context of indicator development and implementation. We highlight four critical dimensions of this relational perspective that may lead to better indicator process outcomes: 1) centering identity and positionality to reflect power differentials; 2) emphasizing the importance of indicator 'fit' and the politics of scale; 3) engaging rather than erasing social-ecological complexity; and 4) reflecting on social norms and relationships to foster adaptation and learning. These four dimensions are rarely considered in most indicator initiatives, including those that are more participatory in design and implementation. The dimensions we outline here emerge from the grounded experience of managers and practitioners, including indicator processes in which we are currently engaged, as well as a scoping review of the literature on indicators for coastal and marine governance and conservation specifically. However, the four dimensions and relational focus are relevant to a wide range of resource and environmental management contexts and provide a pathway to catalyze more effective indicator processes for decision-making and governance more generally.

Operative efficiency: comparison of methods to optimize the use of chlorhexidine gluconate applicators

BACKGROUND

With the high costs of operating room time, minimizing potential causes of time waste is financially beneficial to surgeons and hospitals. The time needed to activate a chlorhexidine gluconate surgical solution applicator presents an opportunity for optimization. Many techniques are employed to expedite the process, but there have been no studies comparing these techniques.

AIM

To determine the most efficient method for utilizing a chlorhexidine gluconate surgical prep applicator.

METHODS

Six techniques were tested to determine which caused the sponge of a Chloraprep™ applicator to become saturated quickest. These were a single squeeze (control), up-and-down shaking, side-to-side shaking, pressing the sponge on a surface (dab), pressing with cotton swabs (poke), and continuously squeezing the lever of the applicator. The time between the internal glass breaking in the applicator to the time of sponge saturation with solution was measured for each technique. Times were then compared to determine which technique best expedited the process.

FINDINGS

The side-to-side shake, up-and-down shake, and 'dab' techniques were each significantly faster than the control group. Side-to-side shaking had the fastest time to sponge saturation on average. The average difference in time to saturation between the side-to-side shake technique and the 'poke' technique may be as much as 27.5 s.

CONCLUSIONS

Utilization of the side-to-side shake technique, as well as the up-and-down shake and 'dab' techniques, significantly expedite the time it takes to use a chlorhexidine gluconate applicator. The time savings from employing these techniques could result in significant financial benefits.

The infectious thyroid nodule: a case report of mucormycosis associated with ibrutinib therapy

Background

Acute invasive fungal infections of the head and neck secondary to tyrosine kinase inhibitors are rare and potentially life-threatening events.

Case presentation

We report a case of mucormycosis of the thyroid gland in a patient known for chronic lymphocytic leukemia receiving ibrutinib who presented with a rapidly growing thyroid nodule and dysphonia. An acute invasive fungal infection was identified on a core needle biopsy; mucormycosis was confirmed on culture. The patient was successfully treated with surgical debridement and long-term antifungal therapy.

Conclusion

Patients on ibrutinib may be at risk of acute invasive fungal infections of the head and neck.

Ultrathin Y2O3:Eu3+nanodiscs: spectroscopic investigations and evidence for reduced concentration quenching

Here, we report the synthesis and spectral properties of ultrathin nanodiscs (NDs) of Y₂O₃:Eu³⁺. It was found that the NDs of Y₂O₃:Eu³⁺ with a thickness of about 1 nm can be fabricated in a reproducible, facile and self-assembling process, which does not depend on the Eu³⁺ concentration. The thickness and morphology of these NDs were determined with small angle x-ray scattering and transmission electron microscopy. We found that the crystal field in these nanoparticles deviates from both the cubic and monoclinic characteristics, albeit the shape of the ⁵D₀ → ⁷F _J (J = 0, 1, 2) transitions shows some similarity with the transitions in the monoclinic material. The Raman spectra of the non-annealed NDs manifest various vibration modes of the oleic acid molecules, which are used to stabilise the NDs. The annealed NDs show two very weak Raman lines, which may be assigned to vibrational modes of Y₂O₃ NDs. The concentration quenching of the Eu³⁺ luminescence of the NDs before annealing is largely suppressed and might be explained in terms of a reduction of the phonon density of states.

St Hugh's Military Hospital (Head Injuries), Oxford 1940-1945

Despite being open for only five years, St Hugh's Military Hospital (Head Injuries) has a seminal place in the history of neurology, neurosurgery and rehabilitation medicine. At its peak, during the Normandy campaign of 1944, it provided 430 beds for the treatment of service personnel. Between 1940 and 1945, 13,000 patients were referred to St Hugh's providing a unique opportunity for ground-breaking research into the management of head injuries. The doctors at St Hugh's collaborated with research scientists at Oxford University in many areas of fundamental research including the treatment of infection, the mechanics of brain injury, brain surgery, neuropsychiatry and rehabilitation, and the use of electroencephalograms. This paper documents these scientific advances and considers their influence on the practice of neurology and neurosurgery in the UK.

The place of James Arnott (1797-1883) in the development of local anaesthesia in dentistry

Dental disease in the form of caries and abscesses has been known since antiquity. Before the advent of anaesthesia, operations upon the mouth were painful. The introduction of general anaesthesia in the form of ether and chloroform seemed to provide a solution, but there was an unacceptable level of mortality. James Arnott introduced local anaesthesia by means of freezing with ice, which he considered safer. He waged a long campaign and his method received recognition and was used in France and the USA. His method stimulated the development of pharmacological anaesthesia.

Targeting protein tyrosine phosphatase σ after myocardial infarction restores cardiac sympathetic innervation and prevents arrhythmias

Millions of people suffer a myocardial infarction (MI) every year, and those who survive have increased risk of arrhythmias and sudden cardiac death. Recent clinical studies have identified sympathetic denervation as a predictor of increased arrhythmia susceptibility. Chondroitin sulfate proteoglycans present in the cardiac scar after MI prevent sympathetic reinnervation by binding the neuronal protein tyrosine phosphatase receptor σ (PTPσ). Here we show that the absence of PTPσ, or pharmacologic modulation of PTPσ by the novel intracellular sigma peptide (ISP) beginning 3 days after injury, restores sympathetic innervation to the scar and markedly reduces arrhythmia susceptibility. Using optical mapping we observe increased dispersion of action potential duration, supersensitivity to β-adrenergic receptor stimulation and Ca(2+) mishandling following MI. Sympathetic reinnervation prevents these changes and renders hearts remarkably resistant to induced arrhythmias.

Comparison of clinical and cone beam computed tomography measurements to diagnose furcation involvement

AIM

This study aimed to determine the degree of discrepancy between clinical measurement of furcation involvement (FI) and cone beam computed tomography image analysis of multirooted teeth.

METHODS

FI measurements obtained from clinical records were compared to CBCT images of the same teeth to determine the degree of discrepancy between CBCT FI grading and clinical FI grading.

RESULTS

Of the hundred and fifty-four sites analysed, 22% of FI measurements from probing and CBCT were in agreement. Fifty-eight percent of clinical FI recordings were overestimated, and 20% were underestimated when compared to CBCT analysis.

CONCLUSION

Clinical recording of FI is both over and underestimated compared to CBCT analysis. This was highest for probing recording grade I furcation involvement where it was highly overestimated. The occurrence of over and under estimation of FI will affect the assignment of prognosis to multirooted teeth, which can influence treatment planning for periodontal therapy and may result in inappropriate treatment.

Structural polymorphism of human DR antigens

DR ANTIGENS are polymorphic cell surface molecules whose expression is controlled by a locus closely linked or identical to the D locus of the major histocompatibility complex (MHC) of man (for reviews see refs 1, 2). They are functionally and structurally homologous to the murine la antigens determined by the I-E subregion of the MHC, a region which has been implicated in the genetic control of immune responses(3,4). Both sets of antigens are mainly expressed on cells associated with immune function (for reviews see refs 1, 2, 5), and are involved in mediating T-cell, B-cell and macrophage interactions required for the generation of immune responses(6-9). In addition, both consist of two non-covalently associated polypeptides, designated alpha and beta, with molecular weights of 34,000 and 28,000, respectively(10). The association of some DR antigens with increased susceptibility to certain diseases (for review see ref. 1) and the genetic restrictions imposed on cellular interactions by the HLA-D region(9,11) may represent the effects of structural variability among DR antigens. The aim of the studies reported here was to examine the nature and degree of structural variation among DR antigens isolated from cultured lymphoid B cells with different DR phenotypes. Such information may provide an understanding of the molecular mechanisms by which DR antigens mediate their function.

Structural polymorphism of I-E subregion antigens determined by a gene in the H-2K to I-B genetic interval

THE generation of immune responses in mice is influenced by Ir genes located in the I region of the major histocompatibility complex (MHC)(1). In some instances maximum responses require complementation by two genes, one in the I-A or I-B and the other in the I-E or I-C subregion(2,3). The effects of these genes are thought to be mediated by Ia alloantigens, which are cell surface molecules whose expression is controlled by the I region(4). This is based on the observations that anti-Ia sera inhibit in vitro immune responses(5,6), and soluble factors that enhance in vitro immune responses express Ia alloantigenic determinants(7,9). Jones et al.(10), using two-dimensional gel electrophoresis, observed that the expression of I-E subregion antigens is controlled by two genes, one in the I-A subregion, the other in the I-E subregion, and that the polymorphism of these antigens is influenced by an I-A subregion gene. As an explanation, the authors proposed that only one of the two polypeptide chains present in I-E immunoprecipitates is an I-E subregion product, the second being a product of the I-A subregion. Antisera obtained by cross-immunisation of I-E subregion-disparate strains of mice immunoprecipitates a molecular complex consisting of two chains, designated alpha and beta, with molecular weights of 32,000 and 29,000 respectively(11-14). Previous studies suggested that I-E antigens isolated from B10.A(5R) and B10.D2 mice had identical alpha-chains but different (beta)-chains(15). However, as these mice differed at multiple genetic regions, it was not possible to show which I subregion(s) determined the polymorphism of the E(beta) chain. Therefore, we investigated the effects of the I-A subregion on the polymorphism of I-E subregion antigens. We have now shown by peptide mapping that the I-E subregion polymorphism which Jones et al. found to be controlled by the I-A subregion probably reflects structural polymorphism of beta-chains controlled by an I-A subregion gene.

Innate immune responses to TLR2 and TLR4 agonists differ between baboons, chimpanzees and humans

BACKGROUND

African catarrhine primates differ in bacterial disease susceptibility.

METHODS

Human, chimpanzee, and baboon blood were stimulated with TLR-detected bacterial agonists and cytokine/chemokine induction assessed by real-time PCR.

RESULTS

Humans and chimpanzees shared similar cytokine/chemokine responses, while baboon cytokine/chemokine induction differed. Generally, responses were agonist independent.

CONCLUSIONS

These primates tend to generate species rather than agonist-specific responses to bacterial agonists.

Light-emitting nanocasts formed from bio-templates: FESEM and cathodoluminescent imaging studies of butterfly scale replicas

Nanocasts comprising of red-light-emitting cubic Y(2)O(3):Eu phosphors were made from butterfly wing scale bio-templates. We report herein the first cathodoluminescent images made from such nanocasts and show that valuable insights into the nature of the internal structure of the casts can be gained by the use of this technique. The casts faithfully reproduced the fine sub-micrometre size detail of the scales, as was made evident by both FESEM and cathodoluminescent images that were collected from the same sample areas using a hyphenated FESEM-CL instrument. There was excellent agreement between the FESEM and cathodoluminescent images, the image quality of the latter indicating that the Eu(3+) activator ions were evenly dispersed in the Y(2)O(3):Eu phosphor on a sub-micrometre scale. The casts were made by infilling the natural moulds with a Y(2)O(3):Eu precursor solution that was subsequently dried and fired to convert it into the phosphor material. This method provides a simple, low cost route for fabricating nanostructures having feature dimensions as small as 20 nm in size, and it has the potential to be applied to other metal oxide systems for producing nano-and micro-components for electronic, magnetic or photonic integrated systems.

Negative regulation of Th17 responses

The discovery of the Th17 lineage of T helper cells and the realization that this subset was implicated in the pathogenesis of a variety of inflammatory conditions has lead to an intense effort devoted to identifying the cytokines and transcription factors that promote their development. In contrast, less attention has been paid to understanding the cytokines that temper Th17 activity. Recent studies, however, have provided insights into the cytokines that limit these T cells. The aim of this article is to review our current understanding of the regulatory networks that limit T helper subsets and how they relate to the Th17 lineage.

Cellular and molecular mechanisms of secondary hyperparathyroidism

The objective of this review is to share important basic research insights into the mechanisms of secondary hyperparathyroidism. An understanding of these mechanisms is essential to more effectively treating the disease. Central underlying abnormalities are increased parathyroid hormone (PTH) gene expression and secretion, and parathyroid cell proliferation. Significant progress has been made in understanding these abnormalities at the cellular and molecular level, particularly their regulation. Studies point to a prominent role of calcium, phosphate and vitamin D as regulators of PTH and parathyroid cell proliferation. 1,25[OH]2 vitamin D3 decreases PTH synthesis and secretion. Small decreases in serum calcium and prolonged increases in serum phosphate as may occur in patients with chronic failure, increase PTH secretion, PTH gene expression, and parathyroid cell proliferation. Regulation at the level ofPTH gene expression is particularly significant given the limited amount of preformed mature PTH. It is now known that calcium and phosphate regulate PTH gene expression through changes in protective parathyroid cytosolic proteins that bind to an instability element in the PTH mRNA 3'-untranslated region and influence transcript stability. These findings may help guide the development of novel therapies for secondary hyperparathyroidism.

Novel seven coordination geometry of Sn(IV): crystal structures of phthalocyaninato bis(undecylcarboxylato)Sn(IV), its Si(IV) analogue, and phthalocyaninato bis(chloro)silicon(IV). The electrochemistry of the Si(IV) analogue and related compounds

Three newly elucidated crystal structures of group IV phthalocyaninato complexes are reported, along with data for two further SiPc carboxylate complexes. In one of these crystal structures, bis(undecylcarboxylate)Sn(IV) phthalocyanine, the tin ion is seven coordinate, which is a unique finding for this atom in phthalocyanine ring coordination. Comparison of these structures with other group IV phthalocyaninato and related structures reveals differences, illustrating features significant in the chemistries of Si(IV) and Sn(IV) ions. These differences are thought to originate from their differing sizes and polarizabilities. The structures show that the Sn(IV) ion can only occupy an in-plane location in the phthalocyaninato ring where it elongates toward the two axial ligands. When the axial ligands do not facilitate this elongation cis coordination is preferred and the Sn(IV) ion sits above the phthalocyaninato ring plane. In contrast, the Si(IV) structures, with smaller, harder (i.e., less polarizable) Si(IV) ions, are six coordinate with the Si(IV) ion in the phthalocyaninato ring plane in a distorted octahedral symmetry. The electronic spectra and cyclic voltammetry of some of the Si compounds indicate that on the electrode the oxidized/reduced species behave as though they are in a solid film, rather than a soluble freely diffusing species.

Parameters influencing membrane CD14 expression and soluble CD14 levels in sepsis

INTRODUCTION

Membrane (mCD14) and soluble (sCD14) CD14 are pattern recognition receptors for bacterial cell wall fragments. They play an important role in the generation of the innate immune response against bacterial pathogens. Differential expression of these receptors may be relevant for the clinical course of patients with sepsis.

PATIENTS AND METHODS

32 patients with an early onset of sepsis (duration of symptoms < 24h) were examined repeatedly by flow cytometry for expression of mCD14, and by ELISA for levels of sCD14, leukocyte elastase and C-reactive Protein (CRP).

RESULTS

At study entry, mCD14 expression was reduced in all patients with sepsis, but returned to normal levels during the course of the disease in survivors only. mCD14 was found to be inversely correlated with severity of disease, leukocyte elastase, and C-reactive protein. Among patients with severe disease and Apache II scores >or= 20, sCD14 levels at study entry were significantly higher in those who survived by day 28, as compared to non-survivors (p = 0.02).

CONCLUSION

The data presented are compatible with a recently published hypothesis derived from in vitro experiments suggesting that leukocyte elastase may be responsible for cleavage of mCD14 from the monocyte surface. The data also suggest that higher sCD14 levels may be beneficial in sepsis. Persistently reduced mCD14 expression seems to be a marker for severity of disease in patients with sepsis.

Advocacy groups dismayed by lack of funding in president's budget

HIV/AIDS advocates have expressed dismay, if not surprise, over the proposed funding for domestic HIV programs outlined in the budget submitted in the spring by President George W. Bush. Despite the reality of rising drug costs and increasing numbers of newly infected Americans, the Ryan White CARE Program was flat-funded in the proposal. Other programs fared no better, except for research and international HIV funding.

The IBD1 locus for susceptibility to Crohn's disease has a greater impact in Ashkenazi Jews with early onset disease

OBJECTIVE

Recent studies have suggested that a susceptibility gene located on chromosome 16 and designated IBD1 may contribute to the development of Crohn's disease (CD). However, these findings were observed in predominantly non-Jewish populations; in the three studies where Ashkenazi Jews were included for analysis, the results have been widely divergent. Because Ashkenazi Jews are known to have a higher incidence of the disease than non-Jews, we sought to determine whether this previously reported linkage could be extended to the Ashkenazi population. In addition, we examined whether Ashkenazi Jewish patients with an early age of onset (< or = 21 yr) showed greater evidence of linkage to this locus.

METHODS

Linkage analysis for the IBD1 region was performed on 123 Ashkenazi Jewish CD patients distributed among 53 families. Only patients with four Jewish grandparents were considered to be Jewish. Of the 123 Ashkenazi Jewish patients, 75 (61%) had an age of onset < or = 21 yr.

RESULTS

Ashkenazi Jews showed only modest evidence of linkage (nonparametric linkage 1.63, p = 0.05) to the IBD1 locus. However, when the Ashkenazi population was subdivided on the basis of age of onset, there was a striking increase in linkage in families where affected individuals had an age of onset < or = 21 yr (nonparametric linkage 3.02, p = 0.002). In contrast, there was no evidence of linkage in the Jewish families where all affected individuals had an age of onset > 21 yr.

CONCLUSIONS

The IBD1 gene plays a greater role in conferring susceptibility to CD in Jews with early onset disease than in Jews with late onset disease.

A conserved cis-acting element in the parathyroid hormone 3'-untranslated region is sufficient for regulation of RNA stability by calcium and phosphate

Calcium and phosphate regulate parathyroid hormone (PTH) gene expression post-transcriptionally by changes in protein-PTH mRNA 3'-untranslated region (UTR) interactions, which determine PTH mRNA stability. We have identified the protein binding sequence in the PTH mRNA 3'-UTR and determined its functionality. The protein-binding element was identified by binding, competition, and antisense oligonucleotide interference. The sequence was preserved among species suggesting its importance. To study its functionality in the context of another RNA, a 63-base pair cDNA PTH sequence was fused to the growth hormone (GH) gene. There is no parathyroid (PT) cell line and therefore an in vitro degradation assay was used to determine the stability of transcripts for PTH, GH, and a chimeric GH-PTH 63 nucleotides with PT cytosolic proteins. The full-length PTH transcript was stabilized by PT proteins from rats fed a low calcium diet and destabilized by proteins from rats fed a low phosphate diet, correlating with PTH mRNA levels in vivo. These PT proteins did not affect the native GH transcript. However, the chimeric GH transcript was stabilized by low calcium PT proteins and destabilized by low phosphate PT proteins, similar to the PTH full-length transcript. Therefore, we have identified a PTH RNA-protein binding region and shown that it is sufficient to confer responsiveness to calcium and phosphate in a reporter gene. This defined element in the PTH mRNA 3'-UTR is necessary and sufficient for the regulation of PTH mRNA stability by calcium and phosphate.

Induction of a novel mechanism of accelerated bacterial clearance by lipopolysaccharide in CD14-deficient and Toll-like receptor 4-deficient mice

Despite the lack of a proinflammatory response to LPS, CD14-deficient mice clear Gram-negative bacteria (Escherichia coli 0111) at least 10 times more efficiently than normal mice. In this study, we show that this is due to an early and intense recruitment of neutrophils following the injection of Gram-negative bacteria or LPS in CD14-deficient mice; in contrast, neutrophil infiltration is delayed by 24 h in normal mice. Similar results of early LPS-induced PMN infiltration and enhanced clearance of E. coli were seen in Toll-like receptor (TLR) 4-deficient mice. Furthermore, the lipid A moiety of LPS induced early neutrophil infiltration not only in CD14-deficient and TLR-4-deficient mice, but also in normal mice. In conclusion, the lipid A component of LPS stimulates a unique and critical pathway of innate immune responses that is independent of CD14 and TLR4 and results in early neutrophil infiltration and enhanced bacterial clearance.