Union of the European Phoniatricians' position statement on the exit strategy of phoniatric and laryngological services: staying safe and getting back to normal after the peak of coronavirus disease 2019 (issued on 25th May 2020)

BACKGROUND

The following position statement from the Union of the European Phoniatricians, updated on 25th May 2020 (superseding the previous statement issued on 21st April 2020), contains a series of recommendations for phoniatricians and ENT surgeons who provide and/or run voice, swallowing, speech and language, or paediatric audiology services.

OBJECTIVES

This material specifically aims to inform clinical practices in countries where clinics and operating theatres are reopening for elective work. It endeavours to present a current European view in relation to common procedures, many of which fall under the aegis of aerosol generating procedures.

CONCLUSION

As evidence continues to build, some of the recommended practices will undoubtedly evolve, but it is hoped that the updated position statement will offer clinicians precepts on safe clinical practice.

Ambient and laboratory observations of organic ammonium salts in PM1

Ambient measurements of PM₁aerosol chemical composition at Cabauw, the Netherlands, implicate higher ammonium concentrations than explained by the formation of inorganic ammonium salts. This additional particulate ammonium is called excess ammonium (e_NH4). Height profiles over the Cabauw Experimental Site for Atmospheric Research (CESAR) tower, of combined ground based and airborne aerosol mass spectrometric (AMS) measurements on a Zeppelin airship show higher concentrations ofe_NH4at higher altitudes compared to the ground. Through flights across the Netherlands, the Zeppelin based measurements furthermore substantiatee_NH4as a regional phenomenon in the planetary boundary layer. The excess ammonium correlates with mass spectral signatures of (di-)carboxylic acids, making a heterogeneous acid–base reaction the likely process of NH₃uptake. We show that this excess ammonium was neutralized by the organic fraction forming particulate organic ammonium salts. We discuss the significance of such organic ammonium salts for atmospheric aerosols and suggest that NH₃emission control will have benefits for particulate matter control beyond the reduction of inorganic ammonium salts.

Ischaemic necrosis of the tongue as a rare complication of cardiogenic shock

Ischaemic necrosis of the tongue is an unusual clinical finding. In most cases it is associated with vasculitis, particularly giant cell arteritis (GCA). Other causes include profound cardiogenic shock. We report a case of tongue necrosis in an 81-year-old Caucasian woman. The patient was admitted to the intensive care unit (ICU) for cardiogenic shock. Swelling of the tongue was reported before intubation and evolved into tongue ischaemia and necrosis of the tip of the tongue. After surgical debridement the patient recovered. To our knowledge, this is the second report of a patient surviving tongue necrosis resulting from cardiogenic shock.

The "Deglutition Handicap Index" a self-adminitrated dysphagia-specific quality of life questionnaire: sensibility to change

OBJECTIVE

The aim of this study is to assess the efficacy of UES's dysfunction treatments with the DHI (Deglutition Handicap Index).

MATERIAL AND METHOD

24 patients suffering of UES's dysfunction were included prospectively between 2008 and 2009 in 2 centers (France and Netherlands). Patients completed DHI before and after treatment. For statistics, Wilcoxon two-sample tests were used.

RESULTS

The mean score was 57 +/- 17 in the preoperative and 26 +/- 19 in the post operative time. The statistical difference was significant p < 0.0001. The difference is also significant for the 3 subscales (symptoms, functional, emotional).

CONCLUSION

The DHI has been validated in terms of content, concurrent, construct validity and temporal reliability. It can be used for assessing efficacy of treatments used for dysphagia.

Expression of Middle-Component RNA of Cowpea Mosaic Virus: In Vitro Generation of a Precursor to Both Capsid Proteins by a Bottom-Component RNA-Encoded Protease from Infected Cells

The expression of the middle-component (M) RNA of cowpea mosaic virus was studied by means of in vitro translation. In both the wheat germ extract and the rabbit reticulocyte lysate, M RNA was translated into two overlapping polypeptides of 95 and 105 kilodaltons. Incubation of these polypeptides with 30,000 x g supernatant fractions from cowpea mesophyll protoplasts inoculated with complete virus or with separate bottom (B) components alone resulted in extensive processing, yielding polypeptides of 60, 58, 48, and 47 kilodaltons. Similar proteolytic activity was found associated with the in vitro translation products from the bottom-component RNA, demonstrating that the protease present in infected cells is encoded by B RNA. Using antisera raised against the separate capsid proteins VP23 and VP37, it was shown that the 60-kilodalton cleavage product is the precursor to both capsid proteins. Cleavage of nascent 95- and 105- kilodalton polypeptides by the in vivo protease demonstrated that this capsid protein precursor is located C terminally within both polypeptides and that the synthesis of these two overlapping polypeptides is the result of two initiation sites on middle-component RNA. In addition, a second virus-induced proteolytic activity, capable of releasing VP23 from the 95- and 105-kilodalton polypeptides, was detected in leaves of infected plants, but not in infected mesophyll protoplasts. A model for the expression of the middle-component RNA is presented.

Evidence That the 32,000-Dalton Protein Encoded by Bottom-Component RNA of Cowpea Mosaic Virus is a Proteolytic Processing Enzyme

Translation of middle-component RNA of cowpea mosaic virus in vitro produced two polypeptides of 95 and 105 kilodaltons (95K and 105K, respectively) with overlapping amino acid sequences, which were specifically cleaved by a protease encoded by the bottom-component RNA. The proteolytic cleavage was studied by the addition of antibodies raised against various bottom-component RNA-encoded proteins to extracts prepared from bottom-component RNA-inoculated cowpea protoplasts. Since antiserum to the 32K polypeptide efficiently inhibited the proteolytic activity of such extracts, although antiserum to VPg or to the 170K polypeptide did not, evidence was obtained which indicates that the 32K polypeptide represents the protease involved. Fractionation of proteolytically active extract by glycerol gradient centrifugation demonstrated that 32K polypeptides do not exist as free proteins but are aggregated to the bottom-component RNA-encoded 170K, 84K, 60K, or 58K polypeptides. Maximal proteolytic activity was observed for 32K polypeptides associated with 170K polypeptides, suggesting that the activity was unstable and confined to newly synthesized molecules.

[Perceptive evaluation of substitution voices: the I(I) NFVo rating scale]

OBJECTIVES

Evaluation of a perceptual specific rating scale for specific severe non laryngeral dysphonia.

MATERIAL AND METHOD

113 speech samples from substitution voices were scored perceptually according to the IINFVo scale: overall quality impression (I), impression of Intelligibility (I), additive and unnecessary noise (N), speech fluency (F) and presence of voiced segments (Vo). Each parameter was scored on a visual analogue scale from 0 (minimally deviant) to 10 (maximally deviant substitution voicing). These samples were presented to semi-professional jury-members (second grade speech therapy students) and professional jury-members (phoniatricians and speech therapists, specialised in the oncological field).

RESULTS

Interindividual agreement between semi-professionals was moderate (0.57-0.68). Interindividual agreement between professionals was higher (0.82-0.86). These figures are similar or even better compared to the classical perceptual evaluation scale for laryngeal speech (GRBAS).

CONCLUSION

Our study suggests that the I(I)NFVo rating scale is suitable for perceptual evaluation of substitution voicing and consistency results are comparable with the classical perceptual rating scale (GRBAS).

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

OBJECTIVES

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

MATERIAL AND METHOD

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

RESULTS

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

CONCLUSION

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

Standard ENT clinical evaluation of the sleep-disordered breathing patient; a consensus report

Sleep disordered breathing (SDB) patients usually undergo an ENT clinical examination before any therapeutic decision. This clinical examination would be predictive about the occurrence of Obstructive Sleep Apnea Syndrome, cost effective, reproducible and would determine the sites of obstruction in the upper airways. To achieve this, ENT specialists from Belgium, representatives of academic hospitals in the country, have tried to establish an updated work-up in the clinical evaluation of the SDB patients. History, risk factors evaluation, excessive daytime sleepiness, static and dynamic evaluation of the upper airways (velopharynx aspect, tonsils grading, Mallampati score, Müller's maneuver, fiberoptic evaluation) have been standardized in a consensus report easily accessible to the vast majority of ENT specialists. This consensus must be understood as a clinical work-up to perform before the monitoring of breathing during sleep.

Acoustic analysis of snoring: review of literature

Acoustic analysis of snoring could make patient assessment more accurate, treatment planning more efficient and could provide objective documentation reliable for comparison. However, spectral characteristics are irregular and difficult to analyse. The authors give an overview of the available literature and the various applied methods. These methods differ in purpose and are subject to restrictions. Until now, acoustic analysis of snoring remains controversial. For linking the results of the acoustic analysis with anatomical levels or degree of obstruction, further study is needed to develop a reliable parameter.

Surgical treatment of the sleep-disordered breathing patient; a consensus report

Sleep disordered breathing patients may undergo surgical treatment after history, clinical examination and polysomnographic study if they demonstrate upper airway obstruction. This article focus on the surgical treatment designed for these patients. Sino-nasal surgery, rhinopharyngeal procedure, velopharyngeal procedures (Uvulopalato-pharyngoplasty, Laser assisted uvulopalatoplasty, Radiofrequency tissue volume reduction) as well as base of the tongue procedures were discussed among a panel of Belgian ENT specialists offering their experience in this field. Algorithm on corrective surgery as well as guidelines for postoperative management are proposed in the management of sleep disordered breathing patients.

Ectopic cervical thymus: case report and review of the literature

The authors present a case of ectopic cervical thymus in a 4-month-old child. Ectopic cervical thymus is an uncommon etiology of a neck mass in a child. It is often misdiagnosed preoperatively as a possible malignancy. It is usually located along the embryologic course of thymus migration from the angle of the mandible to the superior mediastinum. Its treatment is surgical since malignant transformation and respiratory infection have been described. No case of immune deficit after total thymectomy has been described in the literature.

Recurrent focal epithelial hyperplasia due to HPV13 in an HIV-positive patient

There are few reports on focal epithelial hyperplasia (FEH) in association with human immunodeficiency virus (HIV) infection; thus the relationship between them has not been completely clarified yet. We present a case of recurrent FEH in an HIV-positive man (the first described in Belgium), which, according to the PCR-DNA testing, was due to human papilloma virus type 13 (HPV13). To our knowledge, based on the accessible literature, this type of HPV has not been detected in any other documented study of FEH in HIV-positive patients before. Our patient experienced three recurrences of FEH in 1 year. It is therefore suggested that immunodeficiency due to HIV infection is responsible for the HPV-related FEH and the subsequent recurrences. In order to support the consideration of FEH as an oral manifestation of an HIV-related opportunistic infection, every new 'HPV-type' oral lesion in HIV-positive patients must be completely documented.

Surgical therapy in transsexual patients: a multi-disciplinary approach

A transsexual patient has the constant and persistent conviction that he or she belongs to the opposite sex, thus creating a deeply seated gender identity conflict. With psychotherapy being unsuccessful, it has been proven that in carefully selected patients, gender reassignment or adjusting the body to the mind (both with hormones and surgery) is the best way to normalize their lives. Optimal treatment of these patients requires the multidisciplinary approach of a gender team with the input of several specialties. Such a team consists of a nucleus of physicians who sees the patient more frequently: the psychiatrist, the endocrinologist, the plastic surgeon, the gynecologist and the urologist and a more peripheral group that sees the patients more incidentally: the psychologist, the otorhinolaryngologist, the dermatologist, the speech therapist, the lawyer, the nurse and the social worker. Between 1987 and 1999, a total of 71 male-to-female (MTF) and 54 female-to-male transsexuals have undergone gender confirming surgery in our hospital. This article gives a review and an update on the different surgical procedures as well as on the outcome in our patient population. The results in this series of patients clearly demonstrate that a close cooperation of the different surgical specialties, within our multidisciplinary gender team, is the key to success in treating transsexual patients.

Colonization of a voice prosthesis by Cryptococcus neoformans

Tracheoesophageal voice prostheses in laryngectomized patients commonly deteriorate due to the presence of yeasts, particularly Candida species. We describe the first case of colonization of such a device by Cryptococcus neoformans in a patient with a history of glottic carcinoma. The isolate showed an identical genomic pattern with C. neoformans from pigeon excreta in the patient's environment.

Cleft palate speech

Cleft palate is a known pathology but there exists a lot of controversy about the therapy. The aim of this paper is to give a brief overview of the pathology itself and its consequences particularly in speech. At this point the velar and velopharyngeal function are stressed.

99Tc(m) labelled HL91 versus computed tomography and biopsy for the visualization of tumour recurrence of squamous head and neck carcinoma

This phase I pilot study reports on (1) the safety and feasibility of 99Tc(m)-HL91, an amine oxime core radioligand that has shown oxygen dependent binding, and imaging; and (2) its usefulness for the visualization of local tumour recurrence of a biopsy proven squamous cell carcinoma of the head and neck (SCCHN) as compared to spiral computed tomogaphy (CT) and biopsy. Nine men (mean age 33 years, range 34-74 years) were prospectively included. For safety measurements, vital signs were recorded and serum chemical analysis carried out, with a complete blood cell count and urine analysis, and an ECG was performed prior to injection of 99Tc(m)-HL91 and repeated during the investigation. Single photon emission computed tomography (SPECT) scans of the head and neck, and of a standard, were performed at 2 h and 4 h post-injection of 740 MBq 99Tc(m)-HL91. Tumour-to-normal tissue background (T/N) ratios and percentage uptake were measured for all 99Tc(m)-HL91 scans. Spiral CT scans were obtained using a Somaton 4+ Siemens scanner within 1 week from the 99Tc(m)-HL91 scans. Based on CT and the 99Tc(m)-HL91 scan findings guided biopsies were performed. No adverse or subjective side effects were noticed. Vital signs, ECG findings, clinical laboratory, blood and urine assays remained stable in all patients. Spiral CT suggested local recurrence in 5/9 patients accompanied by nodal involvement in three, all of which proved positive on biopsy. 99Tc(m)-HL91 scintigraphy was false positive in one patient and true positive (TP) in 3/5 local recurrences and two out of three sites of lymph node involvement depicted by spiral CT. The mean T/N ratios at 2 h and 4 h in TPs were 1.28 (range 1.1-1.66) and 1.40 (range 1.0-1.6), respectively. The corresponding absolute percentages of 99Tc(m)-HL91 lesional uptake at 2 h and 4 h were mu = 0.05% (SD = 0.03%) and mu = 0.048% (SD = 0.035%). The findings suggest 99Tc(m)-HL91 is a safe radioligand and that metabolic binding in a large fraction but not all of local SCCHN recurrences may be expected. The inference that tumour 99Tc(m)-HL91 avidity could be a non-invasive measure of tumour hypoxia deserves however independent confirmation with needle oximetry.

Mycobacterium interjectum as causative agent of cervical lymphadenitis

A mycobacterial strain isolated from a lymph node of a 3-year-old female with cervical lymphadenitis was identified as Mycobacterium interjectum by means of sequencing of the 16S rRNA gene. Analysis of this case and previously published cases demonstrates the importance of M. interjectum as a causative agent of cervical lymphadenitis in young children.

Bilateral recurrent adult rhabdomyomas of the pharyngeal wall

Adult rhabdomyomas of the head and neck are uncommon benign skeletal muscle tumors. Only a few cases occurring in the pharyngeal wall have been described in the world literature. We present a case of recurrent bilateral rhabdomyomas in the pharynx and discuss the clinicopathological features of this lesion, comparing it to those of other neoplasms from which it must be differentiated. To our knowledge, bilaterality of this type of lesion has not been described previously. Although adult rhabdomyomas have a distinct histology, they often are mistaken for a variety of other lesions, particularly granular cell tumor.

Phonosurgery in gender dysphoria

A particular type of phonosurgery is voice change surgery in cases of gender dysphoria. This paper presents a review of the surgical techniques available for raising or lowering speaking fundamental frequency. A cricothyroid approximation to raise the vocal pitch is the most common procedure. This procedure results in an increase of about one octave immediately postoperatively and about half an octave after stabilization of the voice.

Postoperative radiotherapy of paranasal sinus tumours: a challenge for intensity modulated radiotherapy

BACKGROUND AND PURPOSE

Intensity modulated radiotherapy (IMRT) is used in our department for treatment of paranasal sinuses. We describe the methodology that was developed together with the clinical implementation, illustrated by a case report.

MATERIAL AND METHODS

Patient history, treatment and short follow-up are described. An IMRT, obtained by superposition of static beam segments was implemented. Electronic portal images, compared to digitally reconstructed radiographs (DRR) were used to evaluate and adjust patient positioning.

RESULTS, DISCUSSION AND CONCLUSION

IMRT is an appropriate and feasible treatment technique for head and neck cancer in anatomical regions that are difficult to treat. A high tumour dose can be combined with a good sparing of the surrounding organs at risk (OAR's).

MRI prior to major tumor surgery in the head and neck

MRI plays an important and specific role prior to tumor surgery in the head and neck region. It is especially interesting in providing a detailed description of the exact tumor extent close to the skull base and to investigate perineural and perivascular tumor spread. In selected cases this technique can give a presumed histopathological diagnosis for a mass that is clinically detected. This is especially true for some benign masses, such as hemangiomas, cysts and lipomas. The role of MRI with regard to a lymph node imaging survey in the neck is rather limited. MRI is moreover not routinely performed in neck regions where many motion artifacts can be expected, such as in the larynx.

Epidermolysis bullosa acquisita with combined features of bullous pemphigoid and cicatricial pemphigoid

Epidermolysis bullosa acquisita (EBA) is an acquired subepidermal blistering disease associated with autoantibodies against type VII collagen. The classical or mechanobullous form of EBA is characterized by skin fragility, trauma-induced blisters and erosions with mild mucous membrane involvement and healing with scars. Furthermore, bullous-pemphigoid-like and cicatricial pemphigoid-like features have been described. We report a patient who developed a bullous skin disease with upper airway obstruction requiring tracheotomy. The diagnosis of EBA was established by immunoblot, showing a band at 290 kD (collagen VII), and NaCl-split skin immunofluorescence (IgG deposition at the floor of the split). This case presented with clinical features of both bullous pemphigoid and cicatricial pemphigoid which to our knowledge is the first report of such a combination in EBA. The patient also presented tracheal involvement that has never been described either.

Membrane filtration test for rapid presumptive differentiation of four Candida species

A rapid enzymatic two-step test for the presumptive differentiation of four Candida species commonly occurring in various clinical samples is described. The technique involves membrane filtration of a liquid sample, followed by preincubation of the membrane filter on Sabouraud glucose agar supplemented with ticarcillin-clavulanic acid to yield microcolonies. In a separate assay step, parts of the filter are placed on absorbent pads impregnated with fluorogenic 4-methylumbelliferyl (4-MU) enzyme substrates (4-MU-N-acetyl-beta-D-galactosaminide, 4-MU-phosphate, 4-MU-pyrophosphate, and 4-MU-beta-D-galactoside) in combination with 0.1% digitonin acting as a membrane permeabilizer. The membrane filter in contact with the assay medium is incubated to allow cleavage of the enzyme substrate, resulting in fluorescent microcolonies under long-wavelength UV light. This approach, tested on 301 clinical samples, is able to presumptively differentiate C. albicans, C. glabrata, C. krusei, and C. tropicalis and to distinguish them from other Candida spp. in about 9 to 11 h. Overall agreement with the conventional methods of 94.4% (one Candida species present in the sample) to 83.8% (multiple Candida spp. present) was obtained. The false-negative rates with reference to identification by traditional methods were 1.3% (single species) and 3.8% (multiple species).

Clinical delivery of intensity modulated conformal radiotherapy for relapsed or second-primary head and neck cancer using a multileaf collimator with dynamic control

BACKGROUND AND PURPOSE

Concave dose distributions generated by intensity modulated radiotherapy (IMRT) were applied to re-irradiate three patients with pharyngeal cancer.

PATIENTS, MATERIALS AND METHODS

Conventional radiotherapy for oropharyngeal (patients 1 and 3) or nasopharyngeal (patient 2) cancers was followed by relapsing or new tumors in the nasopharynx (patients 1 and 2) and hypopharynx (patient 3). Six non-opposed coplanar intensity modulated beams were generated by combining non-modulated beamparts with intensities (weights) obtained by minimizing a biophysical objective function. Beamparts were delivered by a dynamic MLC (Elekta Oncology Systems, Crawley, UK) forced in step and shoot mode.

RESULTS AND CONCLUSIONS

Median PTV-doses (and ranges) for the three patients were 73 (65-78), 67 (59-72) and 63 (48-68) Gy. Maximum point doses to brain stem and spinal cord were, respectively, 67 Gy (60% of volume below 30 Gy) and 32 Gy (97% below 10 Gy) for patient 1; 60 Gy (69% below 30 Gy) and 34 Gy (92% below 10 Gy) for patient 2 and 21 Gy (96% below 10 Gy) at spinal cord for patient 3. Maximum point doses to the mandible were 69 Gy for patient 1 and 64 Gy for patient 2 with, respectively, 66 and 92% of the volume below 20 Gy. A treatment session, using the dynamic MLC, was finished within a 15-min time slot.

Invasive surgery for paranasal sinus cancer: is there still any indication for lateral rhinotomy and non endoscopic approaches?

A combined intracranial and transfacial approach for often very malignant lesions of the sino-nasal complex yields the best chance of curation. The operative risk diminishes in a centre with a large turnover after an initial learning curve and it is the only possibility to try to cure the patient from his or her disease. The removal of a rather small malignant lesion in the anterior part of the middle meatus can be safely done through the nostril with correct oncologic margins. In case of inoperability because of local destructions or because of the histological type (malignant melanoma e.g.) freeing up the nasal airway endoscopically can help patients symptomatically and repeatedly.

Primary sinonasal mucosal melanoma: three different therapeutic approaches to inoperable local disease or recurrence and a review of the literature

Sinonasal melanoma is an uncommon disease with a bad prognosis and a high local recurrence rate. The use of radiotherapy in such conditions remains controversial. A review of the literature is presented in an attempt to answer some of the questions regarding therapeutic options. Data on incidence, aetiology, pathology and prognosis are also provided. Case studies are reported of three patients with sinonasal melanoma referred to our department in a relatively short time period and needing radiotherapy as a single treatment modality, using a conformal three-dimensional treatment technique. One patient was also treated with temporary 1251 seeds, while another was treated using intensity modulation. Both intensity modulation and temporary 1251 seeds are feasible techniques, providing satisfactory dose distributions encompassing the tumour volume while sparing critical structures. Surgery remains the treatment of choice for sinonasal melanoma. Radiotherapy should be used postoperatively and is a good alternative in cases of inoperable disease. Adjacent critical structures limit the radiation dose to the tumour area, especially when high fraction doses are used. Therefore, beam intensity modulation and 1251 seeds can be used to increase the tumour dose without exceeding the radiation tolerance of the surrounding structures.

Laryngeal embryonal rhabdomyosarcoma in a child: MRI appearance

We report a rare case of a young girl with an embryonal rhabdomyosarcoma of the right aryepiglottic fold. Local disease recurrence, occurring 7 years after subtotal resection and adjuvant chemotherapy, was studied with plain radiography, CT and MRI. To the best of our knowledge, this is the first report illustrating the MRI characteristics of a laryngeal embryonal rhabdomyosarcoma in a child.

Schwannoma of the tip of the nose: MRI

We report a schwannoma with a rare location at the tip of the nose in a 20-year-old woman with an otherwise unremarkable medical history. The imaging findings underline the usefulness of MRI in narrowing down the differential diagnosis of masses in this region. Once the diagnosis was focussed on a neural origin of the mass, the exact nature of the tumour could not be predicted from the MRI, although the presence of a capsule on imaging studies as well as at operation suggested it was probably a schwannoma. A schwannoma must be considered when one encounters a sharply delineated mass at the tip of the nose, showing high signal on T2-weighted images and strongly contrast enhancement.

Compassionate use of amphotericin B lipid complex (Abelcet) in life-threatening fungal infections: report of 30 courses

OBJECTIVE: To report a single-center experience of compassionate use of amphotericin B lipid complex (ABLC) in patients with proven or suspected fungal infection who were or would have been unable to tolerate conventional amphotericin B. METHODS: Twenty-eight patients receiving 30 courses of ABLC for 22 proven invasive mycosis episodes (11 aspergillosis, seven candidosis, four miscellaneous) and eight suspected episodes are described. Seven patients were given ABLC first-line therapy because of conditions precluding the use of amphotericin B deoxycholate (Am B). Twenty-one patients, initially given Am B, were shifted to ABLC because of failure in four, nephrotoxicity of AM B alone or in combination with another drug in 15, and acute side effects in two. The initial dose of ABLC was 5 mg/kg per day; this could be lowered to 3 mg/kg per day or transiently interrupted in cases of impairment of renal function. RESULTS: A mean cumulative dose of 6107 mg (660--16 050) was given over a mean duration of 22 days (4--49). Clinical response rate was 63% (14/22), with mycologic eradication in 37% (9/17) in proven infections. For proven aspergillosis, corresponding rates were 54% (6/11) and 20% (2/10), and in proven candidosis 71% (5/7) and 60% (3/5), respectively. Twenty-one courses were complicated by one or more side effects: fever and chills (11), impairment of renal function requiring a transient reduction of drug dosage (14), hypotension (1). However, for the whole group, creatinine clearance before and after 2, 4 and 6 weeks of treatment remained quite stable. CONCLUSIONS: ABLC, with its low toxicity, enabled us to treat patients who were or would have been unable to tolerate an efficacious dose of Am B. No conclusions about efficacy can be drawn from this small-size, compassionate study. Well-designed studies to compare efficacy and safety of conventional amphotericin B and the various lipidic formulations should be implemented.

The root epidermis-specific pea gene RH2 is homologous to a pathogenesis-related gene

Two-dimensional gel electrophoresis of pea root and root hair proteins revealed the existence of at least 10 proteins present at elevated levels in root hairs. One of these, named RH2, was isolated and a partial amino acid sequence was determined from two tryptic peptides. Using this sequence information oligonucleotides were designed to isolate by PCR an RH2 cDNA clone. In situ hybridization studies with this cDNA clone showed that rh2 is not only expressed in root hairs, but also in root epidermal cells lacking these tubular outgrowths. During post-embryonic development the gene is switched on after the transition of protoderm into epidermis and since rh2 is already expressed in a globular pea embryo in the protoderm at the side attached to the suspensor, we conclude that the expression of rh2 is developmentally regulated. At the amino acid level RH2 is 95% homologous to the pea PR protein I49a. These gene encoding I49a is induced in pea pods upon inoculation with the pathogen Fusarium solani [12]. We postulate that rh2 contributes to a constitutive defence barrier in the root epidermis. A similar role has been proposed for chalcone synthase (CHS) and chitinase, pathogenesis-related protein that are also constitutively present in certain epidermal tissues.

Mastoiditis caused by atypical mycobacteria

Three case reports of mastoiditis caused by atypical mycobacteria are discussed and a review of the world literature is given. Our aim is to focus the attention of the ENT specialist and the pediatrician on these pathological agents in unilateral recurrent otitis media. The case reports illustrate the importance of histologic and microbiologic examination. Difficulties in the differential diagnosis are mentioned. The therapy is slightly different from lymphadenitis caused by atypical mycobacteria because for mastoiditis we prefer the combination of surgery with medical treatment.

Lipo-oligosaccharides of Rhizobium induce infection-related early nodulin gene expression in pea root hairs

This paper shows that lipo-oligosaccharides (Nod factors) synthesized by Rhizobium bacteria elicit the induction of infection-related early nodulin genes (PsENOD5 and PsENOD12) in pea root hairs. R. leguminosarum bv. viciae secretes a mixture of Nod factors containing a C18 fatty acid chain with 4 (C18:4) or 1 double bond (C18:1). Purified Nod factors harbouring either a C18:4 or a C18:1 acyl moiety induce the expression of the pea early nodulin genes, PsENOD5 and PsENOD12, but the kinetics of induction are different. The expression of both early nodulin genes is induced in a transient manner by the purified Nod factors while a mixture of the Nod factors extends the period during which these genes are expressed. In spite of the host-specific nature of the infection process, heterologous Nod factors of R. meliloti also induce the expression of PsENOD5 and PsENOD12 genes, though with a marked delay compared with the homologous compounds.

Involvement of Rhizobium leguminosarum nodulation genes in gene expression in pea root hairs

The mRNA population in pea root hairs was characterized by means of in vitro translation of total root hair RNA followed by 2-dimensional gel electrophoresis of the translation products. Root hairs contain several mRNAs not detectable in total RNA preparations from roots. Most of these root hair-specific mRNAs occur in elongating root hairs at higher levels than in mature root hairs. The expression of some genes in pea root hairs is typically affected by inoculation with Rhizobium leguminosarum. One gene, encoding RH-42, is specifically induced while the expression of another gene, encoding RH-44, is markedly enhanced. Using R. leguminosarum mutants it was shown that the nodC gene is required for the induction and enhancement of expression of the RH-42 and RH-44 genes, respectively, while the Rhizobium chromosomal gene pss1, involved in exopolysaccharide synthesis, is not essential. After induction of the nod genes with apigenin the bacteria excrete into the culture medium a factor that causes root hair deformation. This deformation factor stimulates the expression of the RH-44 gene but does not induce the expression of the gene encoding RH-42.

cDNA cloning and developmental expression of pea nodulin genes

A cDNA library prepared from pea nodule poly(A)(+) RNA was screened by differential hybridization with cDNA probes synthesized from root and nodule RNA respectively. From the cDNA clones that hybridized exclusively with the nodule probe five clones, designated pPsNod 6, 10, 11, 13 and 14 and each containing unique sequences, were further characterized together with one leghemoglobin and one "root-specific" cDNA clone. In vitro translation of RNA selected by the pPsNod clones showed that the corresponding genes encode nodulins with molecular weights ranging from 5 800 to 19 000. During pea root nodule development expression of the five PsNod genes starts more or less concomitantly with the onset of nitrogen fixing activity in the nodules and the time course of appearance and accumulation of the nodulin mRNAs is similar to that of leghemoglobin mRNA. In ineffective pea root nodules expression of the PsNod genes is induced but the final accumulation levels of the mRNAs are markedly reduced to various degrees. The expression of another nodulin gene, designated ENOD2, was followed using a heterologous soybean cDNA clone as probe. In pea root nodules the ENOD2 gene is expressed at least five days before the PsNod and leghemoglobin genes, and in contrast to the PsNod mRNAs the concentration of the ENOD2 mRNA is the same in wild type and fix (-) nodules. The results described suggest that in root nodules several regulatory mechanisms exist which determine the final nodulin mRNA amounts accumulating in the root nodule.

Rhizobium nod genes are involved in the induction of two early nodulin genes in Vicia sativa root nodules

Nodulin gene expresison was studied in Vicia sativa (common vetch) root nodules induced by several Rhizobium and Agrobacterium strains. An Agrobacterium transconjugant containing a R. leguminosarum symplasmid instead of its Ti-plasmid, that was previously shown to form "empty" nodules on pea, induced nodules on Vicia roots in which nodule cells were infected with bacteria. In the Vicia nodules induced by this transconjugant, two so-called early nodulin genes were found to be expressed, whereas in the nodules formed on pea the expression of only one early nodulin gene was detected. In both cases the majority of the nodulin genes was not expressed.Apparently, an intracellular location of the bacteria is not sufficient for the induction of the majority of the nodulin genes. All nodulin genes were expressed in nodules induced by cured Rhizobium strains containing cosmid clones that have a 10 kb nod region of the sym-plasmid in common. Since in tumours no nodulin gene expression was found at all, the Agrobacterium chromosome does not contribute to the induction of nodulin genes. Therefore it is concluded that the signal for the induction of the expression of the two Vicia early nodulin genes is encoded by the nod-region, and the signal involved in the induction of all other nodulin genes has to be located outside the sym-plasmid, on the Rhizobium chromosome. The apparent difference in early nodulin gene expression between pea and Vicia is discussed in the light of the usefulness of Agrobacterium transconjugants in the study of nodulin gene expression.

Microaerobiosis is not involved in the induction of pea nodulin-gene expression

Gene expression in pea roots grown in a medium with a low oxygen concentration was compared with that in nitrogen-fixing pea root nodules induced by Rhizobium bacteria. The results show that during microaerobiosis the expression of eight genes is increased. None of these belong to the group of genes earlier identified as nodulin genes. On the other hand, no enhanced transcription of microaerobic genes can be detected during nodule development and hybridizations of Northern blots, containing nodule RNA and RNA isolated from oxygen-stressed roots, show that the alcohol dehydrogenase genes are not expressed at a higher level in pea root nodules whereas a higher expression is observed during microaerobiosis. From these observations it can be concluded that it is unlikely that a low concentration of free oxygen induces the expression of nodulin genes. Furthermore, genes that are activated as a result of oxygen deficiency are not expressed in pea root nodules, indicating that if the concentration of free oxygen is low the nodule cells do not suffer under microaerobic conditions. Probably, leghemoglobin functions as an efficient oxygen buffer for the energy-generating process in both the plant cells and the bacteroids.

Expression of plant genes during the development of pea root nodules

The expression of plant genes involved in the pea-Rhizobium symbiosis was studied by analysing mRNA from root nodules. The RNA was translated in vitro and the translation products were separated by two-dimensional gel electrophoresis. The results show differential expression of nodulin genes during root nodule development. One gene encoding N-40' is expressed at a significant level 5 days before the leghemoglobin genes. Most other nodulin genes are expressed more of less concomitantly with the leghemoglobin genes whereas the N-21 mRNA is only present late during the development. In the development of ineffective root nodules induced by infection with different nod+fix- mutants of R. leguminosarum all nodulin genes are expressed except for the N-21 gene. The results suggest that neither bacteroid development, heme excretion nor nitrogen fixation are essential for the induction of nodulin gene expression in the host plant. Further, it appears that the amount of leghemoglobin in ineffective nodules is regulated at a post-transcriptional level.

Cowpea mosaic virus VPg: sequencing of radiochemically modified protein allows mapping of the gene on B RNA

A partial amino acid sequence of cowpea mosaic virus (CPMV) VPg radiochemically modified by chloramine-T and Bolton-Hunter reagent has been determined. VPg covalently bound to viral RNA chains (VPg-RNA) was iodinated with chloramine-T and Bolton-Hunter reagent to label tyrosine and lysine residues, respectively. [I]VPg-RNA was digested with nuclease P1 and the resulting [I]VPg-pU was purified by SDS-polyacrylamide gel electrophoresis and subjected to automated Edman degradation. Control experiments with chemically synthesized poliovirus VPg showed the feasibility of radiochemical microsequence analysis of protein that had been radiochemically modified by chloramine-T and Bolton-Hunter reagent. Analysis of CPMV [I]VPg-pU revealed the presence of tyrosine residues at position 12 and 14, and of lysine residues at position 3 and 20, respectively. In combination with Edman degradation of unlabeled CPMV VPg, which showed serine and arginine residues to be present at position 1 and 2, respectively, the data obtained allow the precise positioning of VPg within the 200 000 dalton (200 K) polyprotein encoded by CPMV B RNA and the prediction of its entire amino acid sequence. VPg is located at the COOH terminus of its 60 K, membrane-bound,precursor and proximal to the amino terminus of the protease-polymerase domain of the polyprotein. A processing scheme for the 200 K polyprotein is discussed in which Gln-Ser amino acid pairs act as the major signal for proteolytic cleavage.

Antibodies Against the Genome-Linked Protein VPg of Cowpea Mosaic Virus Recognize a 60,000-Dalton Precursor Polypeptide

We have prepared a rabbit antiserum specifically directed against the genome-linked protein (VPg) of cowpea mosaic virus by injecting an hydrolysate of purified virion RNA. Using this antiserum as a probe in combination with “Western” (protein) blots of subcellular fractions of cowpea mosaic virus-infected cowpea ( Vigna unguiculata ) cells, we have detected a bottom component RNA-encoded, 60,000-dalton polypeptide which is membrane bound and presumably represents the immediate precursor of VPg.