Study protocol P-MAPS: microbiome as predictor of severity in acute pancreatitis-a prospective multicentre translational study

Background

Acute pancreatitis (AP) is an inflammatory disorder that causes a considerable economic health burden. While the overall mortality is low, around 20% of patients have a complicated course of disease resulting in increased morbidity and mortality. There is an emerging body of evidence that the microbiome exerts a crucial impact on the pathophysiology and course of AP. For several decades multiple clinical and laboratory parameters have been evaluated, and complex scoring systems were developed to predict the clinical course of AP upon admission. However, the majority of scoring systems are determined after several days and achieve a sensitivity around 70% for early prediction of severe AP. Thus, continued efforts are required to investigate reliable biomarkers for the early prediction of severity in order to guide early clinical management of AP patients.

Methods

We designed a multi-center, prospective clinical-translational study to test whether the orointestinal microbiome may serve as novel early predictor of the course, severity and outcome of patients with AP. We will recruit 400 AP patients and obtain buccal and rectal swabs within 72 h of admission to the hospital. Following DNA extraction, microbiome analysis will be performed using 3rd generation sequencing Oxford Nanopore Technologies (ONT) for 16S rRNA and metagenomic sequencing. Alpha- and beta-diversity will be determined and correlated to the revised Atlanta classification and additional clinical outcome parameters such as the length of hospital stay, number and type of complications, number of interventions and 30-day mortality.

Discussion

If AP patients show a distinct orointestinal microbiome dependent on the severity and course of the disease, microbiome sequencing could rapidly be implemented in the early clinical management of AP patients in the future.

Trial registration: ClinicalTrials.gov Identifier: NCT04777812

Factors associated with relevant olfactory recovery after olfactory training: a retrospective study including 601 participants

OBJECTIVE

Olfactory training (OT) represents a therapeutic option for multiple etiologies of olfactory dysfunction (OD) that also benefits normosmic subjects. In this retrospective study, we report the effectiveness of OT and factors associated with relevant changes in olfactory function (OF) in large groups of normosmic participants and patients with OD, including a control group that performed no training.

METHODS

This was a retrospective pooled analysis including 2 treatment cohorts of 8 previously published studies. Adult participants that either presented with the major complaint of quantitative OD or normosmic volunteers were recruited at various ENT clinics and received OT or no training. The outcome was based on changes in objective olfactory test scores after OT.

RESULTS

A total of 601 patients with OD or normosmic subjects were included. OT was more effective compared to no training. No interaction was found between OT and OF. In multivariate analysis, higher baseline OF (adjusted odds ratio, aOR, 0.93) and posttraumatic (aOR, 0.29) or idiopathic OD (aOR, 0.18) compared to postinfectious causes were significantly associated with lower odds of relevant improvements in patients with OD receiving OT. Subgroup analysis of normosmic participants receiving OT further revealed a significant association of lower age and baseline olfactory function with improvements of overall OF.

CONCLUSIONS

This study demonstrated that OT was more effective than no training in patients with various causes of OD. Additionally, baseline olfactory performance and etiology of OD were identified as important factors associated with relevant improvements after OT.

Parosmia is Associated with Relevant Olfactory Recovery After Olfactory Training

OBJECTIVE/HYPOTHESIS

This study aims to determine the association between parosmia and clinically relevant recovery of olfactory function in patients with post-infectious olfactory dysfunction (PIOD) receiving olfactory training.

STUDY DESIGN

Retrospective cohort study.

METHODS

This was a retrospective cohort study of patients with PIOD that received olfactory training. Adult patients with the major complaint of quantitative smell loss were recruited and treated at several ENT clinics in German between 2008 and 2018. The outcome was based on the association between smell-loss related factors (including parosmia and phantosmia) and clinically relevant changes in overall and subdimension olfactory function of threshold, discrimination, and identification using binary logistic regression analysis.

RESULTS

A total of 153 participants with PIOD were included. Clinically relevant improvements in overall olfactory function were more likely in those that had lower baseline olfactory function. Relevant improvements in discrimination function were more likely in those that had lower baseline olfactory function and those that had parosmia at the initial visit. Similarly, relevant improvements in odor identification were more likely in those that had a lower baseline olfactory function and in those who had parosmia at the first visit. Clinically significant improvements in odor threshold were more likely in those who were older in age.

CONCLUSIONS

This study demonstrated that the presence of parosmia is associated with clinically relevant recovery in olfactory discrimination and identification function in patients with PIOD receiving olfactory training.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:618-623, 2021.

Factors associated with relevant olfactory recovery after olfactory training: a retrospective study including 601 participants

BACKGROUND

Olfactory training (OT) represents a therapeutic option for multiple etiologies of olfactory dysfunction (OD) that also benefits normosmic subjects. In this retrospective study, we report the effectiveness of OT and factors associated with relevant changes in olfactory function (OF) in large groups of normosmic participants and patients with OD, including a control group that performed no training.

METHODS

This was a retrospective pooled analysis including 2 treatment cohorts of 8 previously published studies. Adult partici- pants that either presented with the major complaint of quantitative OD or normosmic volunteers were recruited at various ENT clinics and received OT or no training. The outcome was based on changes in objective olfactory test scores after OT.

RESULTS

A total of 601 patients with OD or normosmic subjects were included. OT was more effective compared to no training. No interaction was found between OT and OF. In multivariate analysis, higher baseline OF (adjusted odds ratio, aOR, 0.93) and posttraumatic (aOR, 0.29) or idiopathic OD (aOR, 0.18) compared to postinfectious causes were significantly associated with lower odds of relevant improvements in patients with OD receiving OT. Subgroup analysis of normosmic participants receiving OT further revealed a significant association of age and baseline olfactory function with improvements of overall OF.

CONCLUSIONS

This study demonstrated that OT was more effective than no training in patients with various causes of OD. Additi- onally, baseline olfactory performance and etiology of OD were identified as important factors associated with relevant improve- ments after OT.

Game-specific abilities in elite youth football players: validity and sensitivity to change of subjective coach ratings compared to objectively-assessed data

BACKGROUND

Little is known on the accuracy of coaches' ratings of game-specific physical abilities in elite youth football players. The present study on elite youth football players aims to assess whether: 1) the coaches' subjective assessment of the level of performance of each athlete within the team is in accordance with objectively collected data; and 2) the coaches rate changes in the athletes' performance level accurately or not.

METHODS

Data on jumping ability, sprinting speed, change of direction and strength were collected in seven age groups at a football youth academy (N.=150). The diagnostic battery was repeated after seven months (N.=138). Before the second session, the head coaches completed Likert-scaled closed questions on: 1) the importance of running speed and reactive strength components and their relevance to the individual game performance of each of their athletes; 2) the level of performance of their athletes; 3) the change between the first and second performance testing results. Validity and sensitivity of change of their ratings in comparison to the performance data were calculated using analyses of interrelationship.

RESULTS

The data of the head coaches showed a low to medium effect size in the agreement with the performance data (Cohen's W=0.33-0.71). The evaluation of the change in level of performance was poorer (Cohen's W=0.04-0.2; not statistically significant).

CONCLUSIONS

Our results underline that functional/physical testing twice during a season may be crucial for displaying performance levels of elite youth football players. Simple self-reported ratings by the coach may be valid in recent performance level assessment but not for performance changes.

Position paper on olfactory dysfunction

Background

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: • Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. • Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. • Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. • Comprehensive chemosensory assessment should include gustatory screening. • Smell training can be helpful in patients with olfactory loss of several aetiologies.

Conclusions

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Early prediction of tumour response to PRRT

[177Lu-DOTA0, Tyr3]-octreotate (177Lu-octreotate) in peptide receptor radionuclide therapy (PRRT) offers direct intra-therapeutic dosimetry. The aim of this study was to compare tumour and non-tumour parameters and assess intra-individual variations. Patients, methods: Retrospective analysis of 53 consecutive PRRT treatment cycles (mean activity of 7.53 ± 0.46 GBq 177Lu-octreotate, intended four cycles at intervals of 10–14 weeks, standard nephroprotection) in 27 GEP NET patients. Extended planar dosimetry with serial wholebody imaging on selected, non-superimposed tumour and non-tumour regions; liver (LM), bone (BM), and other (OM) metastases. The per-cycle variation was compared with posttreatment response (CT/MRI three months post-treatment, modified SWOG criteria). Results: Residence time in tumor lesions (133–147 h) exceeded that in kidneys (93 h). Tumour-to-kidney absorbed dose ratios ranged from 14 to 28 (LM, BM, OM). Intra-individual per-cycle dose variation was insignificant for kidneys, but significant for metastases (LM, BM, and OM; p < 0.05). The mean per-cycle decrease of tumour absorbed dose (_D/A0[%]) was linked to morphologic response after PRRT. A mean decrease of >20% was predictive of a partial or minor remission in all 11 evaluable patients, while absent significant dose reduction indicated stable or progressive disease in 4/5 patients. The dose decrease was unrelated to volume effects and also observed for BM. Conclusion: Besides confirmation of a favourable tumour-to-kidney parameter relation for 177Lu-octreotate, stepwise intra-lesional comparison seems to imply a prognostic impact of tumor dosimetry: The early per-cycle change _D/A0 between treatment cycles may predict the outcome after PRRT. Larger studies are needed to confirm this finding.

Position paper on olfactory dysfunction

BACKGROUND

Olfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: - Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. - Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. - Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. - Comprehensive chemosensory assessment should include gustatory screening. - Smell training can be helpful in patients with olfactory loss of several aetiologies.

CONCLUSIONS

We hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.

Nasal Colonization with Staphylococcus Aureus is not Associated with the Severity of Symptoms or the Extent of the Disease in Chronic Rhinosinusitis

OBJECTIVES: There is an increasing knowledge that the severity of perennial allergic rhinitis is associated with nasal carriage of Staphylococcus aureus (S. aureus). The aim of this study was to evaluate the rate of bacterial colonization with S. aureus in the nose of subjects with and without chronic rhinosinusitis (CRS) and to correlate these findings with the severity of symptoms and the extent of the disease.

STUDY DESIGN AND SETTING: Open, prospective controlled trial.

METHODS: 190 subjects with CRS and 42 subjects with septal deviation without sinusitis (control subjects) were included in this study. Swabs were taken endoscopically from the middle meatus and bacteria were cultured and identified. Airway symptoms were assessed by subjects in standardized questionnaires and frequencies of respiratory tract infections were noted. The rhinosinusitis extent was graded by CT scan assessment. Analysis of variance, chi-square test, and Pearson's correlation test were applied for statistical analyses.

RESULTS: The S. aureus carriage rate was 25.5% in CRS and 31.4% in control subjects. Further facultative pathogens were cultured in 20.6% of subjects with CRS and in 8.5% of controls. 73.8% of S. aureus were ampicillin-resistant, multiresistant strains were cultured in 5.8%. Most airway symptoms and the frequencies of respiratory tract infections were significantly higher in the CRS group compared with control subjects. In post hoc comparison between the subgroups with and without S. aureus colonization, no significant differences were found between the extent of rhinosinusitis and the severity of airway symptoms.

CONCLUSIONS: Facultative pathogens were detected in more than 40% of CRS patients without acute respiratory tract infections. In contrast to the findings in atopic dermatitis and perennial allergic rhinitis, the colonization rate with S. aureus is not increased and S. aureus carriage is not a risk factor for the severity or the extent of rhinosinusitis.

Proinflammatory Effects of Staphylococcus Aureus Exotoxin B on Nasal Epithelial Cells

OBJECTIVE: The aim of this study was to evaluate the effects of Staphylococcus aureus exotoxin B (SE-B) on proinflammatory cytokine/chemokine releases in primary nasal epithelial cell cultures (NECC) of subjects with and without chronic rhinosinusitis (CRS).

STUDY DESIGN AND SETTING: NECC (CRS: n = 14; Controls: n = 11) were stimulated with SE-B. Protein concentrations of interleukin-(IL)-1β, IL-6, and IL-8 levels were measured in NECC supernatants by ELISA before (T0) and after 24 hr stimulation with SE-B (T1).

RESULTS: T0: supernatants of the NECC of CRS patients contained significant lower levels of IL-8 (2.1 ng/ml) compared to Controls (IL-8: 6.2 ng/ml; P < 0.01). T1: SE-B induced a significant increase of IL-6 in NECC ( P < 0.001). IL-1β was not detectable.

CONCLUSIONS: This is the first study evaluating the effects of exotoxins on NECC. SE-B showed proinflammatory effects on NECC.

SIGNIFICANCE: Our data suggest that resident NECC are involved in immunological responses to Staphylococcus aureus toxins, supplementing the so-called “superantigen hypothesis” in CRS.

IgM-enriched solution BT086 improves host defense capacity and energy store preservation in a rabbit model of endotoxemia

Introduction

The therapeutic value of intravenous immunoglobulin (IVIG) as an adjuvant therapy in sepsis remains debatable. We hypothesized that intravenous administration of BT086, a predominantly IgM IVIG solution, would improve host defense in an established rabbit model of endotoxemia and systemic sepsis.

Methods

New Zealand white rabbits were randomized into the following four groups: (1) the negative control group without lipopolysaccharide (LPS, control), (2) the positive control group with LPS infusion (LPS group), (3) the albumin‐treated LPS group (ALB+LPS group), and (4) the BT086‐treated LPS group (BT086 + LPS group). A standardized amount of E. coli was intravenously injected into all of the animals. The vital parameters, the concentration of E. coli in the blood and other organs, the residual granulocyte phagocytosis activity, and the levels of the inflammatory mediators were measured. Histological changes in the lung and liver tissue were examined following autopsy.

Results

The elimination of E. coli from the bloodstream was expedited in the BT086‐treated group compared with the LPS‐ and albumin‐treated groups. The BT086 + LPS group exhibited higher phagocytic activity of polymorphonuclear neutrophils (PMNs) than the control and ALB+LPS groups. The liver energy stores were higher in the BT086 + LPS group than in the other groups.

Conclusion

Our data suggest that the IgM‐enriched IVIG has the potential to improve host defense in a rabbit model of endotoxemia. Studies using different animal models and dosages are necessary to further explore the potential benefits of IgM‐enriched IVIG solutions.

Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience

BACKGROUND AND STUDY AIMS

Endoscopic full-thickness resection (EFTR) in the lower gastrointestinal tract may be a valuable therapeutic and diagnostic approach for a variety of indications. Although feasibility of EFTR has been demonstrated, there is a lack of safe and effective endoscopic devices for routine use. The aim of this study was to investigate the efficacy and safety of a novel over-the-scope device for colorectal EFTR.

PATIENTS AND METHODS

Between July 2012 and July 2014, 25 patients underwent EFTR at two tertiary referral centers. All resections were performed using the full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany). Data were collected retrospectively.

RESULTS

Indications for EFTR were: recurrent or incompletely resected adenoma with nonlifting sign (n = 11), untreated adenoma and nonlifting sign (n = 2), adenoma involving the appendix (n = 5), flat adenoma in a patient with coagulopathy (n = 1), diagnostic re-resection after incomplete resection of a T1 carcinoma (n = 2), adenoma involving a diverticulum (n = 1), submucosal tumor (n = 2), and diagnostic resection in a patient with suspected Hirschsprung's disease (n = 1). In one patient, the lesion could not be reached because of a sigmoid stenosis. In the other patients, resection of the lesion was macroscopically complete and en bloc in 20/24 patients (83.3 %). The mean diameter of the resection specimen was 24 mm (range 12 - 40 mm). The R0 resection rate was 75.0 % (18/24), and full-thickness resection was histologically confirmed in 87.5 %. No perforations or major bleeding were observed during or after resection. Two patients developed postpolypectomy syndrome, which was managed with antibiotic therapy.

CONCLUSIONS

Full-thickness resection in the lower gastrointestinal tract with the novel FTRD was feasible and effective. Prospective studies are needed to further evaluate the device and technique.

Endoscopic removal of over-the-scope clips using a novel cutting device: a retrospective case series

BACKGROUND AND STUDY AIMS

Over-the-scope clips (OTSCs; Ovesco Endoscopy, Tübingen, Germany) are extensively used for treatment of gastrointestinal perforations, leakages, fistulas, and bleeding. In this report, a new method of removing OTSCs using a prototype bipolar cutting device is described.

PATIENTS AND METHODS

A total of 11 patients underwent endoscopic removal of an OTSC. The OTSC was cut at two opposing sites by a prototype device (DC ClipCutter; Ovesco Endoscopy). The remaining clip fragments were extracted using a standard forceps.

RESULTS

Mean procedure time was 47 minutes (range 35 - 75 minutes). Cutting of the OTSC at two opposing sites was successful in all cases (100 %). Complete retrieval of all clip fragments was possible in 10 patients (91 %). The overall success rate for cutting and complete removal of the clip was 91 %. No major complications were observed.

CONCLUSIONS

Removal of OTSCs with the prototype device was feasible and effective. The device may be valuable for OTSC removal in emergency as well as elective indications.

[Position paper "Chemosensory testing for expert opinion in smell disorders"]

Providing expert opinion in the context of smell disorders is often challenging, not only with regard to general aspects of providing an expert opinion but particularly with regard to chemosensory testing. Currently there is no consensus which chemosensory test should be selected and how they should be executed. This positions paper from Committee on Olfaction and Gustation of the German Society of Otorhinolaryngology, Head and Neck Surgery aims to give concrete recommendations for chemosensory testing for providing expert opinion for smell disorders with regard to the selection and execution of these test.

Do the blinds smell better?

If people lose a sense organ, there is thought to be an increase in the remaining sensory functions. Previous studies showed ambiguous results on this topic. In a prospective matched pair case-control study on 46 blind and 46 normal-sighted subjects, the olfactory performance was examined using the Sniffin' Sticks Test [threshold-discrimination-identification (TDI) test], determining the olfactory threshold, the identification and the discrimination performance. There was no significant difference between the groups. Neither the overall olfactory performance (TDI score) nor any of its subtests did correlate with the vision or with the duration of blindness. The study could not detect any superior smell abilities of blind subjects as compared to sighted subjects.

Durability of stochastic antireflective structures--analyses on damage thresholds and adsorbate elimination

We fabricated stochastic antireflective structures (ARS) and analyzed their stability against high power laser irradiation and high temperature annealing. For 8 ps pulse duration and 1030 nm wavelength we experimentally determined their laser induced damage threshold to 4.9 (±0.3) J/cm(2), which is nearly as high as bulk fused silica with 5.6 (±0.3) J/cm(2). A commercial layer stack reached 2.0 (±0.2) J/cm(2). An annealing process removed adsorbed organics, as shown by XPS measurements, and significantly increased the transmission of the ARS. Because of their monolithic build the ARS endure such high temperature treatments. For more sensitive samples an UV irradiation proved to be capable. It decreased the absorbed light and reinforced the transmission.

[Cardioprotection]

The demographic change is associated with an increasing number of elderly patients with serious comorbidities. The prevalence of coronary heart disease in particular increases with age and raises the risk of perioperative myocardial ischemia. In the last few years various interventions have been evaluated to lower the perioperative risk for serious cardiovascular events. This includes cardioprotective medical interventions, for example with β-receptor blockers and statins. Current guidelines recommend that patients who are on β-receptor blockers or statins for chronic treatment of cardiovascular diseases should continue this medication throughout the perioperative period. Myocardial conditioning has been assessed to be effective under numerous experimental conditions and clinical trials have also provided evidence for myocardial protection by conditioning. Besides ischemic and anesthetic-induced preconditioning the noninvasive technique of remote preconditioning offers interesting possibilities, especially for patients with serious comorbidities; however, large scale randomized clinical multicentre trials are still needed. Regarding cardioprotective effectiveness, the clinical data for regional anesthesia are very heterogeneous; nevertheless regional anesthesia is very effective in postoperative pain therapy. Therefore regional anesthesia should be used as a part of multimodal therapy concepts to lower the risk of perioperative cardiovascular events.

Pro-inflammatory effects of ochratoxin A on nasal epithelial cells

Eosinophilic chronic rhinosinusitis (ECRS) largely consists of allergic fungal sinusitis, non-allergic fungal rhinosinusitis, aspirin-exacerbated ECRS, and superantigen-induced ECRS. The pathophysiology of ECRS is not completely understood, in particular, the role of mycotoxins remains unknown. The aim of this study was to evaluate the effects of one of the most widespread mycotoxin, ochratoxin A (OTA), on the release of pro-inflammatory cytokines such as interleukin-(IL)-6 and the CXC-chemokine IL-8 from nasal epithelial cell cultures (NEC) of subjects with and without ECRS. NEC (ECRS group: n = 16; controls: n = 7) were stimulated with OTA for 24 h. Protein concentrations of IL-6 and IL-8 levels were measured in NEC supernatants by ELISA prior and 24 h after addition of OTA. Baseline levels in the supernatants of NEC were 183.3 pg/ml for IL-6 and 384.6 pg/ml for IL-8. Stimulation with OTA induced a significant increase of IL-6 (p < 0.001) and IL-8 (p < 0.001) in both NEC of controls and ECRS, respectively. There were no significant differences between controls and ECRS. This is the first study evaluating the effects of a mycotoxin on epithelial airway cells. Our data show that the ubiquitous mycotoxin OTA has a strong pro-inflammatory effect on NEC resulting in the release of IL-6 and IL-8. Mycotoxins may promote inflammation in nasal mucosa.

Effects of short inter-stimulus intervals on olfactory and trigeminal event-related potentials

CONCLUSION

Chemosensory event-related potentials (CSERPs) were identified in all measurements using the 20 s and the 10 s inter-stimulus interval (ISI) protocol, reducing the recording time to 75% or 57% compared with the standard protocol. A possible explanation for the rising CSERP amplitudes by shortening the ISI in CO(2) stimulation is due to a phenomenon known as trigeminal sensitization during repeated stimulation.

OBJECTIVES

CSERPs are influenced by the ISI. The aim of this study was to evaluate the changes in CSERPs by decreasing the ISI from 30 s to 20 s or 10 s, respectively.

SUBJECTS AND METHODS

Ten normosmic healthy subjects participated this study. Phenyl ethyl alcohol (PEA), hydrogen sulphide (H(2)S) and carbon dioxide (CO(2)) were used in CSERP measurements with different ISI protocols (30 s (standard), 20 s and 10 s). Amplitudes and latencies of ISI protocols were submitted to ANOVA for repeated measurements and t tests for paired samples.

RESULTS

The amplitudes of CSERPs with PEA and H(2)S stimuli were decreasing with shortening the ISI significantly. In contrast, the highest amplitudes of trigeminal CSERPs were recorded with the 10 s ISI protocol with CO(2). The ANOVA revealed a significantly different effect of shortening the ISI on CSERPs on the right and the left side.

[Two- and three-dimensional, morphologic and functional MR-imaging in smelling disorders]

Olfactory dysfunction is a frequent diagnosis. This overview describes recent standards in structural imaging related to olfactory dysfunction, with magnetic resonance imaging being the most significant imaging tool both quantitatively and qualitatively. Relevant MRI-techniques to be applied in patients during routine clinical workup and the consecutive imaging evaluation are presented and discussed.

Long-term results of surgical treatment for recurrent respiratory papillomatosis

CONCLUSIONS

The presented results add further support to the observation that laser microsurgery is the preferential surgical treatment for recurrent respiratory papillomatosis (RRP). A meticulous follow-up for early recognition of local recurrence and malignant transformation is recommended.

OBJECTIVES

Endoscopic microsurgery continues to be the treatment of choice for RRP. The aim of this study was to evaluate the outcome of patients treated surgically. We focused on demographic data, recurrence rates, and treatment-related complications.

PATIENTS AND METHODS

The charts of 194 patients treated at our institution between 1963 and 1993 were analyzed retrospectively.

RESULTS

In all, 64 patients (33%) underwent a total of 137 operations using the CO2 laser; 130 patients (67%) underwent a total of 565 microlaryngeal operations by surgery with cold instruments. Five percent of the patients treated with conventional microlaryngeal surgery and none of the patients treated with laser surgery required tracheostomy (p<0.05). Postoperative glottic webs and scar formations were found in 6% of all patients after laser surgery and 20% after conventional surgery (p<0.05). The different methods of treatment did not affect the rate of recurrence (p=0.61) Malignant transformation or secondary airway carcinoma were observed in 4% of all patients.

Diagnostik von Riechstörungen - Standards und Forschung

Olfactory dysfunction has been reported to affect about 79,000 patients who were treated annually in German ORL-hospitals. The incidence of olfactory dysfunctions emphasizes the need for diagnostic strategies. This article features on the dysfunction of human olfaction including neurodegenerative diseases. Standard procedures for the psychophysical and objective assessment of olfactory function are presented. Current diagnostic imaging techniques for routine use and scientific approaches are discussed.

Long-term results of the combined modality therapy for advanced cervical metastatic head and neck squamous cell carcinoma

AIM

A consensus treatment strategy for advanced cervical metastatic head and neck squamous cell carcinoma has not been established. The aim of this retrospective study was to investigate the outcome of these patients uniformely using a strategy which consists of surgery for the primary tumor and the neck metastases followed by postoperative radio(chemo)therapy.

METHODS

We included a selected series of 518 patients with previously untreated head and neck squamous cell carcinoma. The overall survival (OS), the disease specific survival (DSS), the disease free survival (DFS), the local control (LC) and regional control (RC) estimates were calculated. The statistical relationship of various clinical and histopathological variables on the above mentioned estimates were analyzed.

RESULTS

The overall survival probability was 73.2% for pN0 stage, 43% for pN>1 stages and 31% for pN2c/pN3 stages. The pN stage significantly influenced the survival probabilities in oropharyngeal (p=0.0001) and laryngeal tumors (p<0.0001) in univariate analyses. In multivariate analysis, age, pT stage, pN stage, M stage, and extranodal spreading were independent risk factors for decreased disease-specific survival.

CONCLUSIONS

We could show that pN stage is an important independent prognostic factor in head and neck cancer. The presented multimodal treatment protocol provides excellent oncological outcomes and should therefore be standard of care for patients with operable advanced cervical metastatic head and neck squamous cell carcinoma.

[Idiopathic rhinitis]

Idiopathic Rhinitis (IR) is a term for a group of nasal diseases of unknown aetiology. Formerly, these diseases were called vasomotor rhinitis, but because there is no indication of a disorder in the vasomotor system, this term has been abandoned. Other terms, like non-infectious non-allergic rhinitis and non-allergic non-infectious perennial rhinitis are purely descriptive. Potential pathomechanisms in IR could be 1) neural dysfunction/dysregulation; 2) immunological inflammatory responses; and 3) changes of the permeability of the mucosa, leading to increase entrance of potential harmful substances. Idiopathic Rhinitis is a diagnosis by exclusion, meaning that a number of more or less defined nasal conditions as a cause of rhinitis have been excluded - not only allergic rhinitis. Although a considerable progress was made in the standardization of provocation tests or biomarkers in nasal secretions, there are today no specific test available to confirm the diagnosis rhinitis in many non allergic conditions. An evidence-based review of treatment outcomes shows topical sprays of steroids, antihistamines to be of benefit in idiopathic rhinitis. Furthermore, nasal saline solution is effective in many patients with IR. Multiple surgical procedures have been suggested for IR, but should be reserved for patients who fail medical therapy.

[Vallecular cyst as a rare cause of progressive inspiratory stridor]

BACKGROUND

Vallecular cysts are frequently observed, benign masses of the upper aerodigestiv tract. Usually they appear as harmless and asymptomatic and go unnoticed by the patient. In rare cases, obstructions of the upper airway due to monstrous vallecular cysts may become life threatening.

CASE

We report on a 69-year-old otherwise healthy woman with a rapidly progressive history of dyspnea caused by a pedicled vallecular cyst. Increasing stridor prompted emergency surgical resection.

CONCLUSION

Vallecular cysts that increase in size can cause dyspnea due to obstruction of the aditus of the larynx. This case demonstrates the need for surgical treatment at an early stage of pedicled vallecular cysts.

Post-infectious olfactory dysfunction exhibits a seasonal pattern

HYPOTHESIS

We investigated whether olfactory dysfunction following infections of the upper respiratory tract (post-URTI) has an incidence matching the seasonality of URTIs.

STUDY DESIGN

Retrospective study.

METHODS

In total, 457 patients (126 male, 331 female) with post-URTI olfactory loss were examined during a 6-year-period (1999-2004). Their records were assessed for age, sex, and time of onset of the disease. The severity of olfactory dysfunction was assessed using the "Sniffin' Sticks" (odour threshold, odour discrimination, and odour identification).

RESULTS

Incidence of post-URTI olfactory dysfunction exhibited seasonal fluctuations with deviations from the winter seasonality of URTIs. The overall incidence of the disease differed significantly between months. March (12.7%) and May (12.6%) were the months with the highest incidence of the disease throughout the year. The lowest incidence was observed in September (5.6%). Significant differences were found between these months and months with a high incidence of URTIs.

DISCUSSION

The peak incidence of post-URTI olfactory loss in March may be explained by the high incidence of influenza at this time. However, it is unclear why the incidence of the disease presents a second peak in May, when the incidence of respiratory viruses is relatively low. Climate conditions at this time might play a role in the susceptibility of the nasal epithelia towards certain viral infections, e.g. parainfluenza type III.

CONCLUSION

Post-URTI olfactory dysfunction exhibits spring seasonality with peaks in March and May and possible causative factors being influenza and parainfluenza viruses (type III), respectively.

Comparison of a centered 32P source wire system with a noncentered 90Sr/Y brachytherapy system for intracoronary β-radiation following PCI of diffuse in-stent restenosis

BACKGROUND

We investigated the potential impact of differences in effective radiation dose between the centered Guidant 32P source wire system and the noncentered Novoste 90Sr/Y BetaCath system on clinical and angiographic outcomes of intracoronary brachytherapy for the prevention of in-stent restenosis.

METHODS

From 10/00 to 05/04, a total of 400 patients underwent percutaneous coronary intervention (PCI) with brachytherapy for diffuse in-stent restenosis at our institution. Following balloon dilatation, patient Group A (n=200) was treated with the centered 32P Galileo source wire system, patient Group B (n=200) was treated with the noncentered 90Sr/Y BetaCath radiation system. In Group A, the prescribed dose of 20 Gy was applied in 1-mm depth of the vessel wall. In Group B, the prescribed dose of 18.4 Gy was applied for visual reference vessel sizes >2.7 and <3.35 mm, 23 Gy for >3.36 and <4.00 mm, and 25.3 Gy for >4.00 mm, each calculated at a distance of 2 mm from the center line of the radiation source. Patients received aspirin and clopidogrel over 12 months. Primary endpoint was target lesion revascularization (TLR) at 6 months. Secondary endpoints were the binary restenosis rate and major adverse cardiac event (MACE) at 30 days and 6 months.

RESULTS

At 30 days, one patient of each group underwent PCI at a nontarget lesion (0.5%). At 6 months, MACEs were equally distributed in both groups. Target lesion revascularization at 6 months was 5.9% in Group A and 9.2% in Group B (P=.08). Binary angiographic restenosis rate at 6 months was 5.5% in Group A and 11.2% in Group B (P=.014).

CONCLUSION

Intracoronary beta-radiation using the centered 32P source wire system yielded a significant reduction of recurrence rate compared to the noncentered 90S/Y BetaCath system after PCI of diffuse in-stent restenosis. There was a nonsignificant trend toward reduction of TLR among patients treated with the centered 32P source wire system.

Pulmonary delivery of therapeutic peptides via dry powder inhalation: effects of micronisation and manufacturing

Pulmonary drug delivery is increasingly appreciated as a route of administration for systemically acting proteins and peptides. A respirable particle size of the drug is a key requirement, but the fragile nature of many proteins may be a limitation for the application of conventional production processes. The aim of this study was to examine the effect of different micronisation processes on the degradation and aerodynamic properties of the GnRH-antagonist cetrorelix in order to enable its application by a dry powder inhaler (Novolizer). A modified pearl mill was used for milling in fluid propellant. Furthermore, a spray drying procedure was established using a novel process of atomisation and drying. Adhesive mixtures of lactose and 5-20% of micronised cetrorelix-acetate were prepared. Analysis by laser light scattering, HPLC, Karl Fischer, cascade impactor and scanning electron microscopy were performed to characterise the manufactured powders. Both micronisation procedures succeeded in producing small range particle size distributions, suitable for deep lung deposition (D50 = 1.6 microm for milling and 3.3 microm for spray drying). The pearl milled cetrorelix showed promising results when delivered by the Novolizer: a reproducible and highly efficient dispersion of the drug was achieved (around 60% of aerosolised drug < 5 microm). The spray dried drug was not suitable when processed as adhesive mixture.