Muscle K+, Na+, and Cl− disturbances and Na+-K+ pump inactivation: implications for fatigue

Membrane excitability is a critical regulatory step in skeletal muscle contraction and is modulated by local ionic concentrations, conductances, ion transporter activities, temperature, and humoral factors. Intense fatiguing contractions induce cellular K+ efflux and Na+ and Cl− influx, causing pronounced perturbations in extracellular (interstitial) and intracellular K+ and Na+ concentrations. Muscle interstitial K+ concentration may increase 1- to 2-fold to 11–13 mM and intracellular K+ concentration fall by 1.3- to 1.7-fold; interstitial Na+ concentration may decline by 10 mM and intracellular Na+ concentration rise by 1.5- to 2.0-fold. Muscle Cl− concentration changes reported with muscle contractions are less consistent, with reports of both unchanged and increased intracellular Cl− concentrations, depending on contraction type and the muscles studied. When considered together, these ionic changes depolarize sarcolemmal and t-tubular membranes to depress tetanic force and are thus likely to contribute to fatigue. Interestingly, less severe local ionic changes can also augment subtetanic force, suggesting that they may potentiate muscle contractility early in exercise. Increased Na+-K+-ATPase activity during exercise stabilizes Na+ and K+ concentration gradients and membrane excitability and thus protects against fatigue. However, during intense contraction some Na+-K+ pumps are inactivated and together with further ionic disturbances, likely precipitate muscle fatigue.

Increased number of forced repetitions does not enhance strength development with resistance training

Some research suggests that strength improvements are greater when resistance training continues to the point at which the individual cannot perform additional repetitions (i.e., repetition failure). Performing additional forced repetitions after the point of repetition failure and thus further increasing the set volume is a common resistance training practice. However, whether short-term use of this practice increases the magnitude of strength development with resistance training is unknown and was investigated here. Twelve basketball and 10 volleyball players trained 3 sessions per week for 6 weeks, completing either 4 x 6, 8 x 3, or 12 x 3 (sets x repetitions) of bench press per training session. Compared with the 8 x 3 group, the 4 x 6 protocol involved a longer work interval and the 12 x 3 protocol involved higher training volume, so each group was purposefully designed to elicit a different number of forced repetitions per training session. Subjects were tested on 3- and 6-repetition maximum (RM) bench press (81.5 +/- 9.8 and 75.9 +/- 9.0 kg, respectively, mean +/- SD), and 40-kg Smith Machine bench press throw power (589 +/- 100 W). The 4 x 6 and 12 x 3 groups had more forced repetitions per session (p < 0.01) than did the 8 x 3 group (4.1 +/- 2.6, 3.1 +/- 3.5, and 1.2 +/- 1.8 repetitions, respectively), whereas the 12 x 3 group performed approximately 40% greater work and had 30% greater concentric time. As expected, all groups improved 3RM (4.5 kg, 95% confidence limits, 3.1- 6.0), 6RM (4.7 kg, 3.1-6.3), bench press throw peak power (57 W, 22-92), and mean power (23 W, 4-42) (all p < or = 0.02). There were no significant differences in strength or power gains between groups. In conclusion, when repetition failure was reached, neither additional forced repetitions nor additional set volume further improved the magnitude of strength gains. This finding questions the efficacy of adding additional volume by use of forced repetitions in young athletes with moderate strength training experience.

Validation of an optical encoder during free weight resistance movements and analysis of bench press sticking point power during fatigue

During the concentric movement of the bench press, there is an initial high-power push after chest contact, immediately followed by a characteristic area of low power, the so-called "sticking region." During high-intensity lifting, a decline in power can result in a failed lift attempt. The purpose of this study was to determine the validity of an optical encoder to measure power and then employ this device to determine power changes during the initial acceleration and sticking region during fatiguing repeated bench press training. Twelve subjects performed a free weight bench press, a Smith Machine back squat, and a Smith Machine 40-kg bench press throw for power validation measures. All barbell movements were simultaneously monitored using cinematography and an optical encoder. Eccentric and concentric mean and peak power were calculated using time and position data derived from each method. Validity of power measures between the video (criterion) and optical encoder scores were evaluated by standard error of the estimate (SEE) and coefficient of variation (CV). Seven subjects then performed 4 sets of 6 free weight bench press repetitions progressively increasing from 85 to 95% of their 6 repetition maximum, with each repetition continually monitored by an optical encoder. The SEE for power ranged from 3.6 to 14.4 W (CV, 1.0-3.0%; correlation, 0.97-1.00). During the free weight bench press training, peak power declined by approximately 55% (p < 0.01) during the initial acceleration phase of the final 2 repetitions of the final set. Although decreases in power of the sticking point were significant (p < 0.01), as early as repetition 5 (-40%) they reached critically low levels in the final 2 repetitions (>-95%). In conclusion, the optical encoder provided valid measures of kinetics during free weight resistance training movements. The decline in power during the initial acceleration phase appears a factor in a failed lift attempt at the sticking point.

Modelling age and secular differences in fitness between basketball players

Concerns about the value of physical testing and apparently declining test performance in junior basketball players prompted this retrospective study of trends in anthropometric and fitness test scores related to recruitment age and recruitment year. The participants were 1011 females and 1087 males entering Basketball Australia's State and National programmes (1862 and 236 players, respectively). Players were tested on 2.6 +/- 2.0 (mean +/- s) occasions over 0.8 +/- 1.0 year. Test scores were adjusted to recruitment age (14-19 years) and recruitment year (1996-2003) using mixed modelling. Effects were estimated by log transformation and expressed as standardized (Cohen) differences in means. National players scored more favourably than State players on all tests, with the differences being generally small (standardized differences, 0.2-0.6) or moderate (0.6-1.2). On all tests, males scored more favourably than females, with large standardized differences (>1.2). Athletes entering at age 16 performed at least moderately better than athletes entering at age 14 on most tests (standardized differences, 0.7-2.1), but test scores often plateaued or began to deteriorate at around 17 years. Some fitness scores deteriorated over the 8-year period, most notably a moderate increase in sprint time and moderate (National male) to large (National female) declines in shuttle run performance. Variation in test scores between National players was generally less than that between State players (ratio of standard deviations, 0.83-1.18). More favourable means and lower variability in athletes of a higher standard highlight the potential utility of these tests in junior basketball programmes, although secular declines should be a major concern of Australian basketball coaches.

Muscle Na+-K+-ATPase activity and isoform adaptations to intense interval exercise and training in well-trained athletes

The Na+-K+-ATPase enzyme is vital in skeletal muscle function. We investigated the effects of acute high-intensity interval exercise, before and following high-intensity training (HIT), on muscle Na+-K+-ATPase maximal activity, content, and isoform mRNA expression and protein abundance. Twelve endurance-trained athletes were tested at baseline, pretrain, and after 3 wk of HIT (posttrain), which comprised seven sessions of 8 × 5-min interval cycling at 80% peak power output. Vastus lateralis muscle was biopsied at rest (baseline) and both at rest and immediately postexercise during the first (pretrain) and seventh (posttrain) training sessions. Muscle was analyzed for Na+-K+-ATPase maximal activity (3- O-MFPase), content ([3H]ouabain binding), isoform mRNA expression (RT-PCR), and protein abundance (Western blotting). All baseline-to-pretrain measures were stable. Pretrain, acute exercise decreased 3- O-MFPase activity [12.7% (SD 5.1), P < 0.05], increased α1, α2, and α3 mRNA expression (1.4-, 2.8-, and 3.4-fold, respectively, P < 0.05) with unchanged β-isoform mRNA or protein abundance of any isoform. In resting muscle, HIT increased ( P < 0.05) 3- O-MFPase activity by 5.5% (SD 2.9), and α3 and β3 mRNA expression by 3.0- and 0.5-fold, respectively, with unchanged Na+-K+-ATPase content or isoform protein abundance. Posttrain, the acute exercise induced decline in 3- O-MFPase activity and increase in α1 and α3 mRNA each persisted ( P < 0.05); the postexercise 3- O-MFPase activity was also higher after HIT ( P < 0.05). Thus HIT augmented Na+-K+-ATPase maximal activity despite unchanged total content and isoform protein abundance. Elevated Na+-K+-ATPase activity postexercise may contribute to reduced fatigue after training. The Na+-K+-ATPase mRNA response to interval exercise of increased α- but not β-mRNA was largely preserved posttrain, suggesting a functional role of α mRNA upregulation.

Studies of Otic Capsule Morphology and Gene Expression in the Mov13 Mouse – An Animal Model of Type I Osteogenesis Imperfecta

Type I osteogenesis imperfecta (OI) is a disorder of skeletal bones characterized by bone fragility and blue sclera, which can result from mutations in genes encoding for type I collagen--the COL1A1 and COL1A2 genes. Fifty percent of patients with type I OI develop hearing loss and associated histopathological changes in the otic capsule that are indistinguishable from otosclerosis, a major cause of acquired hearing loss. In an attempt to elucidate molecular and cellular mechanisms of hearing loss in type I OI, we have studied the Mov13 mouse, which has served as an animal model of type I OI by virtue of exhibiting variable transcriptional block of the COL1A1 gene. We studied the morphometry of the Mov13 otic capsule and compared expression levels of 60 genes in the otic capsule with those in the tibia and parietal bone of the Mov13 and wild-type mice. The degree of transcriptional block of the COL1A1 gene and its downstream effects differed significantly between the bones examined. We found that expression levels of bone morphogenetic protein 3 and nuclear factor kappa-B1 best distinguished Mov13 otic capsule from wild-type otic capsule, and that osteoprotegerin, caspase recruitment domain containing protein 1, and partitioning defective protein 3 best distinguished Mov13 otic capsule from Mov13 tibia and parietal bone. Although the Mov13 mouse did not demonstrate evidence of active abnormal otic capsule remodeling as seen in type I OI and otosclerosis, studying gene expression in the Mov13 mouse has provided evidence that osteocytes of the otic capsule differ from osteocytes in other bones.

Calpain-3 is autolyzed and hence activated in human skeletal muscle 24 h following a single bout of eccentric exercise

The function and normal regulation of calpain-3, a muscle-specific Ca(2+)-dependent protease, is uncertain, although its absence leads to limb-girdle muscular dystrophy type 2A. This study examined the effect of eccentric exercise on calpain-3 autolytic activation, because such exercise is known to damage sarcomeric structures and to trigger adaptive changes that help prevent such damage on subsequent exercise. Six healthy human subjects performed a 30-min bout of one-legged, eccentric, knee extensor exercise. Torque measurements, vastus lateralis muscle biopsies, and venous blood samples were taken before and up to 7 days following the exercise. Peak isometric muscle torque was depressed immediately and at 3 h postexercise and recovered by 24 h, and serum creatine kinase concentration peaked at 24 h postexercise. The amount of autolyzed calpain-3 was unchanged immediately and 3 h after exercise, but increased markedly (from approximately 16% to approximately 35% of total) 24 h after the exercise, and returned to preexercise levels within 7 days. In contrast, the eccentric exercise produced little autolytic activation of the ubiquitous Ca(2+)-activated protease, mu-calpain. Eccentric exercise is the first physiological circumstance shown to result in calpain-3 activation in vivo.

Single-nucleotide polymorphisms in the COL1A1 regulatory regions are associated with otosclerosis

Otosclerosis (MIM 166800) has a prevalence of 0.2-1% among white adults, making it the single most common cause of hearing impairment in this ethnic group. Although measles virus, hormones, human leukocyte antigen alleles and genetic factors have been implicated in the development of otosclerosis, its etiology remains unknown. In a focused effort to identify genetic factors in otosclerosis, we have mapped four disease loci (MIM 166800/605727/608244/608787); however, cloning the disease-causing genes in these intervals has not been successful. Here, we used a case-control study design to investigate the association between collagen type I genes and otosclerosis. We identified susceptibility and protective haplotypes in COL1A1 that are significantly associated with otosclerosis in the Caucasian population. These haplotypes alter reporter gene activity in an osteoblast cell line by affecting binding of transcription factors to cis-acting elements. Our data suggest that increased amounts of collagen alpha1(I) homotrimers are causally related to the development of otosclerosis. Consistent with this hypothesis, mouse mutants homozygous for a Col1a2 frameshift mutation on a C57BL/6J background that deposit only homotrimeric type I collagen have hearing loss.

Pectoralis Major Flap in Composite Lateral Skull Base Defect Reconstruction

OBJECTIVE

To report our experience with the pectoralis major myocutaneous flap (PMF) for the reconstruction of composite lateral temporal bone defects extending beyond the temporal line.

DESIGN

Retrospective review and illustration of specific technical modifications.

SETTING

Academic tertiary care center.

PATIENTS

Eight patients with composite lateral skull base defects that were reconstructed with the PMF between February 2001 and February 2006.

INTERVENTION

Reconstruction with the modified pedicled PMF.

MAIN OUTCOME MEASURES

Reconstruction outcomes and complications.

RESULTS

Eight patients (median age, 80 years) underwent total or near-total auriculectomy, wide skin excision, and lateral temporal bone resection as part of the surgical ablation, thus requiring obliteration of the middle ear cavity as well as extensive replacement of skin cover. All patients received radiation therapy. The median postsurgical follow-up was 9 months. Complete healing of the reconstructed surgical defect with no flap loss was achieved in all cases.

CONCLUSION

With specific technical modifications, the PMF can be reliably used for the reconstruction of composite lateral skull base defects extending up to and beyond the temporal line, making this flap an important alternative to free flap reconstruction in selected cases.

Superior semicircular canal dehiscence mimicking otosclerotic hearing loss

A puzzling aspect of middle ear surgery is the presence of an air-bone gap in a small number of cases with no apparent cause. We believe that some of these cases are due to unrecognized superior semicircular canal dehiscence (SSCD). We have now gathered experience from 20 patients with SSCD presenting with apparent conductive hearing loss without vestibular symptoms. All affected ears had SSCD on high-resolution CT scan. The common findings in these patients were: (1) the air-bone gaps occurred in the lower frequencies below 2,000 Hz, and ranged from 10 to 60 dB; (2) bone conduction thresholds below 2,000 Hz were sometimes negative (-5 dB to -15 dB); (3) the acoustic (stapedial) reflex was present; (4) measurement of umbo velocity by laser Doppler vibrometry showed slight hypermobility of umbo motion; (5) the vestibular-evoked myogenic potential response was present, with thresholds that were abnormally low, and (6) the middle ear was normal at exploratory tympanotomy, including normal mobility of the ossicles and a patent round window niche. We have investigated the mechanism of the air-bone gap due to SSCD using a theoretical framework, clinical research data and an animal model (chinchilla). Our research supports the hypothesis that SSCD introduces a 'third' window into the inner ear which produces the airbone gap by (1) shunting air-conducted sound away from the cochlea, thus elevating air conduction thresholds, and (2) increasing the difference in impedance between the scala tympani and scala vestibuli, thus improving thresholds for bone-conducted sound.

Effects of endurance training status and sex differences on Na+,K+-pump mRNA expression, content and maximal activity in human skeletal muscle

AIM

This study investigated the effects of endurance training status and sex differences on skeletal muscle Na+,K+-pump mRNA expression, content and activity.

METHODS

Forty-five endurance-trained males (ETM), 11 recreationally active males (RAM), and nine recreationally active females (RAF) underwent a vastus lateralis muscle biopsy. Muscle was analysed for Na+,K+-pump alpha1, alpha2, alpha3, beta1, beta2 and beta3 isoform mRNA expression (real-time reverse transcription-polymerase chain reaction), content ([3H]-ouabain-binding site) and maximal activity (3-O-methylfluorescein phosphatase, 3-O-MFPase).

RESULTS

ETM demonstrated lower alpha1, alpha3, beta2 and beta3 mRNA expression by 74%, 62%, 70% and 82%, respectively, than RAM (P<0.04). In contrast, [3H]-ouabain binding and 3-O-MFPase activity were each higher in ETM than in RAM, by 16% (P<0.03). RAM demonstrated a 230% and 364% higher alpha3 and beta3 mRNA expression than RAF, respectively (P<0.05), but no significant sex differences were found for alpha1, alpha2, beta1 or beta2 mRNA, [3H]-ouabain binding or 3-O-MFPase activity. No significant correlation was found between years of endurance training and either [3H]-ouabain binding or 3-O-MFPase activity. Significant but weak correlations were found between the number of training hours per week and 3-O-MFPase activity (r=0.31, P<0.02) and between incremental exercise VO2(peak)) and both [3H]-ouabain binding (r=0.33, P<0.01) and 3-O-MFPase activity (r=0.28, P<0.03).

CONCLUSIONS

Isoform-specific differences in Na+,K+-pump mRNA expression were found with both training status and sex differences, but only training status influenced Na+,K+-pump content and maximal activity in human skeletal muscle.

Dermatitis herpetiformis: no evidence of bone disease despite evidence of enteropathy

The majority of patients with dermatitis herpetiformis (DH) have small intestinal enteropathy that may result in bone loss. The objective of this study was to evaluate bone mineral density (BMD) in DH and to examine whether dietary treatment or degree of the small intestinal lesion correlate with BMD. Twenty-five patients with DH (18 men) were investigated. Detailed dietary assessment and duodenal biopsies were performed on all patients before entry into the study. BMD at lumbar spine and femur was determined by DXA scan. Bone biomarkers, vitamin D, and parathyroid status were assessed. Twenty patients had enteropathy. None of the patients had hypovitaminosis D or secondary hyperparathyroidism. Resorption and formation markers were within normal limits. BMD Z-scores were not significantly different from expected (-0.38; CI, -0.84 to 0.07) and femur (0.46; CI, -0.06 to 0.97). There was no relationship between BMD Z-scores and the severity of the degree of enteropathy. We conclude that enteropathy of differing severity is present in 80% of patients with DH, but this is not associated with bone disease.

Molecular biology of otosclerosis

Otosclerosis is a bone disease of the human otic capsule, which is among the most common causes of acquired hearing loss. The pathologic process is characterized by a wave of abnormal bone remodeling in specific sites of predilection within the endochondral layer of the temporal bone. Although the cause of otosclerosis remains uncertain, there is a clear genetic predisposition with half of all cases occurring in families with more than one affected member. There is also compelling evidence that measles virus may play a role in some cases. Ultimately, how genetic factors and viral infection result in otosclerosis must be explained by effects on the molecular factors that control bone remodeling.

Current research in otosclerosis

PURPOSE OF REVIEW

The aim of this article is to summarize and put into historical perspective current advances in research in otosclerosis, a disorder of the human temporal bone with a hereditary predisposition that is among the most common causes of acquired hearing loss.

RECENT FINDINGS

Genetic studies have revealed that otosclerosis is heterogeneous, with evidence for defects in at least seven genes associated with six distinct chromosomal loci. Measurements of high levels of osteoprotegerin expression in the normal otic capsule and soft tissues of the cochlea provide the first molecular insight as to why the normal otic capsule remodels minimally, if at all. Osteoprotegerin knockout mice provide the best available animal model to date to study abnormal otic capsule remodeling that closely resembles otosclerosis. There is mounting evidence that the measles virus plays an important role in pathogenesis of otosclerosis although the mechanisms by which the virus results in otosclerosis remain unknown. Quantitative measures of angiogenesis can reliably distinguish between clinical and histological otosclerosis. Advances in the emerging field of osteoimmunology will likely impact and benefit from the research in otosclerosis.

SUMMARY

Insights into molecular mechanisms that inhibit extensive remodeling in the normal otic capsule, and understanding of how these mechanisms are dysregulated in otosclerosis will allow future design of rational treatment strategies for otosclerosis.

Promoting absorption of drugs in humans using medium-chain fatty acid-based solid dosage forms: GIPET™

One of the most important and challenging goals in drug delivery is overcoming the poor oral absorption of high-value therapeutics that include peptides. Gastrointestinal Permeation Enhancement Technology (GIPET) attempts to address this question by safely delivering drugs across the small intestine in therapeutically relevant concentrations. GIPET is based primarily on promoting drug absorption through the use of medium-chain fatty acids, medium-chain fatty acid derivatives and microemulsion systems based on medium-chain fatty acid glycerides formulated in enteric-coated tablets or capsules. Importantly, these excipients are generally regarded as safe and the systems are formulated in such a way that there is no change in chemical composition of the active ingredient. More than 300 volunteers have been administered GIPET formulations in 16 Phase I studies of 6 separate drugs comprising both single- and repeat-dosing regimes. Oral bioavailability of alendronate, desmopressin and low-molecular-weight heparin in humans was increased using GIPET formulations compared with unformulated controls. GIPET was well tolerated by human subjects. Using fluxes of markers of epithelial permeability, the effects of GIPET on the human intestine were shown to be rapid, short-lived and reversible in vivo. These data suggest that GIPET formulations have genuine potential as a platform technology for safe and effective oral drug delivery of a wide range of poorly permeable drugs.

Interspersed normoxia during live high, train low interventions reverses an early reduction in muscle Na+, K +ATPase activity in well-trained athletes

Hypoxia and exercise each modulate muscle Na(+), K(+)ATPase activity. We investigated the effects on muscle Na(+), K(+)ATPase activity of only 5 nights of live high, train low hypoxia (LHTL), 20 nights consecutive (LHTLc) versus intermittent LHTL (LHTLi), and acute sprint exercise. Thirty-three athletes were assigned to control (CON, n = 11), 20-nights LHTLc (n = 12) or 20-nights LHTLi (4 x 5-nights LHTL interspersed with 2-nights CON, n = 10) groups. LHTLc and LHTLi slept at a simulated altitude of 2,650 m (F(I)O(2) 0.1627) and lived and trained by day under normoxic conditions; CON lived, trained, and slept in normoxia. A quadriceps muscle biopsy was taken at rest and immediately after standardised sprint exercise, before (Pre) and after 5-nights (d5) and 20-nights (Post) LHTL interventions and analysed for Na(+), K(+)ATPase maximal activity (3-O-MFPase) and content ([(3)H]-ouabain binding). After only 5-nights LHTLc, muscle 3-O-MFPase activity declined by 2% (P < 0.05). In LHTLc, 3-O-MFPase activity remained below Pre after 20 nights. In contrast, in LHTLi, this small initial decrease was reversed after 20 nights, with restoration of 3-O-MFPase activity to Pre-intervention levels. Plasma [K(+)] was unaltered by any LHTL. After acute sprint exercise 3-O-MFPase activity was reduced (12.9 +/- 4.0%, P < 0.05), but [(3)H]-ouabain binding was unchanged. In conclusion, maximal Na(+), K(+)ATPase activity declined after only 5-nights LHTL, but the inclusion of additional interspersed normoxic nights reversed this effect, despite athletes receiving the same amount of hypoxic exposure. There were no effects of consecutive or intermittent nightly LHTL on the acute decrease in Na(+), K(+)ATPase activity with sprint exercise effects or on plasma [K(+)] during exercise.

N-acetylcysteine attenuates the decline in muscle Na+,K+-pump activity and delays fatigue during prolonged exercise in humans

Reactive oxygen species (ROS) have been linked with both depressed Na(+),K(+)-pump activity and skeletal muscle fatigue. This study investigated N-acetylcysteine (NAC) effects on muscle Na(+),K(+)-pump activity and potassium (K(+)) regulation during prolonged, submaximal endurance exercise. Eight well-trained subjects participated in a double-blind, randomised, crossover design, receiving either NAC or saline (CON) intravenous infusion at 125 mg kg(-1) h(-1) for 15 min, then 25 mg kg(-1) h(-1) for 20 min prior to and throughout exercise. Subjects cycled for 45 min at 71% , then continued at 92% until fatigue. Vastus lateralis muscle biopsies were taken before exercise, at 45 min and fatigue and analysed for maximal in vitro Na(+),K(+)-pump activity (K(+)-stimulated 3-O-methyfluorescein phosphatase; 3-O-MFPase). Arterialized venous blood was sampled throughout exercise and analysed for plasma K(+) and other electrolytes. Time to fatigue at 92% was reproducible in preliminary trials (c.v. 5.6 +/- 0.6%) and was prolonged with NAC by 23.8 +/- 8.3% (NAC 6.3 +/- 0.5 versus CON 5.2 +/- 0.6 min, P < 0.05). Maximal 3-O-MFPase activity decreased from rest by 21.6 +/- 2.8% at 45 min and by 23.9 +/- 2.3% at fatigue (P < 0.05). NAC attenuated the percentage decline in maximal 3-O-MFPase activity (%Deltaactivity) at 45 min (P < 0.05) but not at fatigue. When expressed relative to work done, the %Deltaactivity-to-work ratio was attenuated by NAC at 45 min and fatigue (P < 0.005). The rise in plasma [K(+)] during exercise and the Delta[K(+)]-to-work ratio at fatigue were attenuated by NAC (P < 0.05). These results confirm that the antioxidant NAC attenuates muscle fatigue, in part via improved K(+) regulation, and point to a role for ROS in muscle fatigue.

Results after revision stapedectomy with malleus grip prosthesis

Revision stapedectomy with a malleus grip prosthesis is a technically challenging otologic procedure. The prosthesis is usually longer and extends deeper into the vestibule than a conventional stapes prosthesis, creating the potential to affect the vestibular sense organs. The prosthesis also bypasses the ossicular joints, which are thought to play a role in protecting the inner ear from large changes in static pressure within the middle ear. The prosthesis is in close proximity to the tympanic membrane, thus increasing the risk for its extrusion. We reviewed our experience with revision stapedectomy with the Schuknecht Teflon-wire malleus grip prosthesis in 36 ears with a mean follow-up of 23 months. The air-bone gap was closed to within 10 dB in 16 ears (44%) and to within 20 dB in 26 ears (72%). The incidence of postoperative sensorineural hearing loss was 8% (3 ears). There were no dead ears. Extrusion of the prosthesis occurred in 1 case (3%). Nearly 50% of patients reported various degrees of vertigo or disequilibrium during the first 3 weeks after surgery. These vestibular symptoms resolved by 6 weeks in all but 1 case. We did not find evidence of damage to the inner ear due to the length of the prosthesis or due to the potential for direct transmission of changes in static pressures within the middle ear to the labyrinth. Our results are similar to those published in the literature for malleus attachment stapedectomy and conventional revision incus stapedectomy.

Ionic mechanisms of excitation-induced regulation of Na+-K+-ATPase mRNA expression in isolated rat EDL muscle

This study investigated the effects of electrical stimulation on Na+-K+-ATPase isoform mRNA, with the aim to identify factors modulating Na+-K+-ATPase mRNA in isolated rat extensor digitorum longus (EDL) muscle. Interventions designed to mimic exercise-induced increases in intracellular Na+and Ca2+contents and membrane depolarization were examined. Muscles were mounted on force transducers and stimulated with 60-Hz 10-s pulse trains producing tetanic contractions three times at 10-min intervals. Ouabain (1.0 mM, 120 min), veratridine (0.1 mM, 30 min), and monensin (0.1 mM, 30 min) were used to increase intracellular Na+content. High extracellular K+(13 mM, 60 min) and the Ca2+ionophore A-23187 (0.02 mM, 30 min) were used to induce membrane depolarization and elevated intracellular Ca2+content, respectively. Muscles were analyzed for Na+-K+-ATPase α1–α3and β1–β3mRNA (real-time RT-PCR). Electrical stimulation had no immediate effect on Na+-K+-ATPase mRNA; however at 3 h after stimulation, it increased α1, α2, and α3mRNA by 223, 621, and 892%, respectively ( P = 0.010), without changing β mRNA. Ouabain, veratridine, and monensin increased intracellular Na+content by 769, 724, and 598%, respectively ( P = 0.001) but did not increase mRNA of any isoform. High intracellular K+concentration elevated α1mRNA by 160% ( P = 0.021), whereas A-23187 elevated α3mRNA by 123% ( P = 0.035) but reduced β1mRNA by 76% ( P = 0.001). In conclusion, electrical stimulation induced subunit-specific increases in Na+-K+-ATPase mRNA in isolated rat EDL muscle. Furthermore, Na+-K+-ATPase mRNA appears to be regulated by different stimuli, including cellular changes associated with membrane depolarization and increased intracellular Ca2+content but not increased intracellular Na+content.

Exercise Performance Falls over Time in Patients with Chronic Kidney Disease Despite Maintenance of Hemoglobin Concentration

Physical function is limited in patients with kidney disease, although previous studies have been confounded by anemia. What is not clear is how physical performance changes over time as renal function deteriorates. A cohort of 12 patients (10 male, two female; mean +/- SD age 49 +/- 11 yr) who had stages 3 to 4 chronic kidney disease without previous anemia were examined, and nine were followed for a 2-yr period. Assessments were made of peak oxygen consumption (VO2peak) by cycle ergometry, leg extension strength, and fatigue on an isokinetic dynamometer and thigh muscle cross-sectional area (TMCSA) by computed tomography. At baseline, creatinine clearance was 31 +/- 13 ml/min and hemoglobin concentration ([Hb]) was 129 +/- 9 g/L. VO2peak was low (1.88 L/min, 82% of predicted), and maximal isometric voluntary contraction was 188 +/- 42 Nm, with a TMCSA of 144 +/- 27 cm2. VO2peak correlated with creatinine clearance corrected for body surface area (r = 0.613, P = 0.034) but not to [Hb]. VO2peak adjusted for patient weight correlated with leg fatigue (r = -0.693, P = 0.012). For those with follow-up tests, there were falls in renal function by 28% (P = 0.007) and VO2peak by 9% (P = 0.03), whereas [Hb] did not change. Leg strength fell across a range of isokinetic speeds (P = 0.04), whereas no change in TMCSA was observed. In conclusion, exercise performance as measured by aerobic (VO2peak) and leg strength tests were reduced in patients with stages 3 to 4 chronic kidney disease. As renal function declined over time, there was a corresponding decline in exercise performance even when [Hb] was maintained.

Osteoprotegrin knockout mice demonstrate abnormal remodeling of the otic capsule and progressive hearing loss

OBJECTIVES

The otic capsule, when compared with other bones in the body, is unique in that it undergoes no significant remodeling of bone after development. We previously demonstrated that osteoprotegerin (OPG), which inhibits formation and function of osteoclasts, is produced at high levels in the inner ear of normal mice and secreted into the perilymph from where it diffuses into the surrounding otic capsule bone through a lacunocanalicular system. To test our hypothesis that the high level of OPG may be important in the inhibition of otic capsule remodeling, we studied the light microscopic histology of the otic capsule in OPG knockout mice for evidence of abnormal remodeling of bone. We also tested the hearing in OPG knockout mice to determine whether OPG and its influence on surrounding bone is important for auditory function.

METHODS

Temporal bone histopathology and pathophysiology were compared in homozygous OPG knockout mice and C57BL/6 (B6) mice, the background strain for the knockouts. Auditory function in age-matched animals from each group was evaluated at approximately 4-week intervals from 8 to 21 weeks using frequency-specific auditory brainstem responses (ABR) and distortion product otoacoustic emissions (DPOAE). After each of the last three evaluations, the cochleae from one mouse of each group were harvested, processed, and examined by light microscopy.

RESULTS

Osteoprotegerin knockout mice demonstrated abnormal remodeling of bone within the otic capsule with multiple foci showing osteoclastic bone resorption and formation of new bone. Such changes were not seen in the age-matched B6 controls. The active bone remodeling process in the knockout animals showed many similarities to otosclerosis seen in human temporal bones. Over the time period that we monitored, auditory function was significantly and progressively compromised in the knockout animals relative to B6 controls. At the earliest age of test (8 wk), the loss was apparent as a mild, high-frequency reduction in sensitivity by ABR. In contrast, DPOAE losses in the knockouts were substantial even at 8 weeks, and by 21 weeks, these losses exceeded our equipment limits. Results of ABR testing showed hearing sensitivity changes in the animals of the background strain were confined largely to the high frequencies, whereas OPG knockouts demonstrated substantial low-frequency shifts in addition to those at high frequencies.

CONCLUSIONS

The histopathological and pathophysiological findings in OPG knockout mice support the hypothesis that OPG is important in the inhibition of bone remodeling within the otic capsule and the maintenance of normal auditory function. This mouse may provide a valuable animal model of human otosclerosis.

Association between osteoporosis and otosclerosis in women

Similarities between osteoporosis and otosclerosis have been noted, including a similar association with the COL1A1 gene. Herein, the authors explore the possible clinical relationship between these two common disorders of bone. In this retrospective study, the medical charts of 100 women aged 50 through 75 years who had undergone stapedectomy for otosclerosis were reviewed and the prevalence of osteoporosis in these women was noted. Similarly, the prevalence of osteoporosis was determined in a control group of 100 women aged 50 to 75 years with presbycusis. Fifteen of 100 women with otosclerosis had a concomitant diagnosis of osteoporosis as compared with four of 100 women with presbycusis, yielding a significant clinical association (p = 0.007) between otosclerosis and osteoporosis. This study suggests an association between otosclerosis and osteoporosis, providing impetus and justification for future prospective clinical studies and related research.

Cystic fibrosis-related diabetes in adults

We aimed to examine the differences between patients with cystic fibrosis-related diabetes (CFRD), and those with normal glucose handling in adults with cystic fibrosis (CF) in Ireland. We conducted a retrospective analysis of patients who attend the national referral centre for adult CF. Patients were diagnosed as having CFRD by the American Cystic Fibrosis Foundation criteria for diagnosis of CFRD. Of 259 patients, 150 were classifiable and 81 (54%) were classified as having CFRD. The groups with and without CFRD were not significantly different with regard to age (median 28.4 vs 26.0 years), sex (males 56% vs 55%) or BMI (median 20.9 vs 21.3 kg/m2). The group with CFRD had poorer lung function (mean % predicted FEV1 49.9 vs 66.4, P < 0.001), poorer bone mineral density (T-scores at the lumbar spine -1.95 vs -1.44, P < 0.05 and femur -1.19 vs -0.57, P < 0.01) and a greater proportion of PSEUDOMONAS AERUGINOSA positive sputum cultures (82.5% vs 64.2%, P < 0.05). No patients with CFRD carried the R1 17H mutation whilst 19% of the group without CFRD were heterozygous for this defect (P < 0.001). In conclusion, CFRD was highly prevalent in adults. The presence of CFRD was associated with poorer lung function, poorer bone mineral density and an increased prevalence of PSEUDOMONAS AERUGINOSA in sputum. The R1 17H mutation may be protective for CFRD.

Prolonged submaximal exercise induces isoform-specific Na+-K+-ATPase mRNA and protein responses in human skeletal muscle

This study investigated effects of prolonged submaximal exercise on Na+-K+-ATPase mRNA and protein expression, maximal activity, and content in human skeletal muscle. We also investigated the effects on mRNA expression of the transcription initiator gene, RNA polymerase II (RNAP II), and key genes involved in protein translation, eukaryotic initiation factor-4E (eIF-4E) and 4E-binding protein 1 (4E-BP1). Eleven subjects (6 men, 5 women) cycled at 75.5% (SD 4.8%) peak O2uptake and continued until fatigue. A vastus lateralis muscle biopsy was taken at rest, fatigue, and 3 and 24 h postexercise. We analyzed muscle for Na+-K+-ATPase α1, α2, α3, β1, β2, and β3, as well for RNAP II, eIF-4E, and 4E-BP1 mRNA expression by real-time RT-PCR and Na+-K+-ATPase isoform protein abundance using immunoblotting. Muscle homogenate maximal Na+-K+-ATPase activity was determined by 3 -O-methylfluorescein phosphatase activity and Na+-K+-ATPase content by [3H]ouabain binding. Cycling to fatigue [54.5 (SD 20.6) min] immediately increased α3( P = 0.044) and β2mRNA ( P = 0.042) by 2.2- and 1.9-fold, respectively, whereas α1mRNA was elevated by 2.0-fold at 24 h postexercise ( P = 0.036). A significant time main effect was found for α3protein abundance ( P = 0.046). Exercise transiently depressed maximal Na+-K+-ATPase activity ( P = 0.004), but Na+-K+-ATPase content was unaltered throughout recovery. Exercise immediately increased RNAP II mRNA by 2.6-fold ( P = 0.011) but had no effect on eIF-4E and 4E-BP1 mRNA. Thus a single bout of prolonged submaximal exercise induced isoform-specific Na+-K+-ATPase responses, increasing α1, α3, and β2mRNA but only α3protein expression. Exercise also increased mRNA expression of RNAP II, a gene initiating transcription, but not of eIF-4E and 4E-BP1, key genes initiating protein translation.

Inner ear drug delivery via a reciprocating perfusion system in the guinea pig

Rapid progress in understanding the molecular mechanisms associated with cochlear and auditory nerve degenerative processes offers hope for the development of gene-transfer and molecular approaches to treat these diseases in patients. For therapies based on these discoveries to become clinically useful, it will be necessary to develop safe and reliable mechanisms for the delivery of drugs into the inner ear, bypassing the blood-labyrinthine barrier. Toward the goal of developing an inner ear perfusion device for human use, a reciprocating microfluidic system that allows perfusion of drugs into the cochlear perilymph through a single inlet hole in scala tympani of the basal turn was developed. The performance of a prototype, extracorporeal reciprocating perfusion system in guinea pigs is described. Analysis of the cochlear distribution of compounds after perfusion took advantage of the place-dependent generation of responses to tones along the length of the cochlea. Perfusion with a control artificial perilymph solution had no effect. Two drugs with well-characterized effects on cochlear physiology, salicylate (5 mM) and DNQX (6,7-Dinitroquinoxaline-2,3-dione; 100 and 300 microM), reversibly altered responses. The magnitude of drug effect decreased with distance from the perfusion pipette for up to 10 mm, and increased with dose and length of application.

Alkalosis increases muscle K+ release, but lowers plasma [K+] and delays fatigue during dynamic forearm exercise

Alkalosis enhances human exercise performance, and reduces K+ loss in contracting rat muscle. We investigated alkalosis effects on K+ regulation, ionic regulation and fatigue during intense exercise in nine untrained volunteers. Concentric finger flexions were conducted at 75% peak work rate (3 W) until fatigue, under alkalosis (Alk, NaHCO3, 0.3 g kg(-1)) and control (Con, CaCO3) conditions, 1 month apart in a randomised, double-blind, crossover design. Deep antecubital venous (v) and radial arterial (a) blood was drawn at rest, during exercise and recovery, to determine arterio-venous differences for electrolytes, fluid shifts, acid-base and gas exchange. Finger flexion exercise barely perturbed arterial plasma ions and acid-base status, but induced marked arterio-venous changes. Alk elevated [HCO3-] and PCO2, and lowered [H+] (P < 0.05). Time to fatigue increased substantially during Alk (25 +/- 8%, P < 0.05), whilst both [K+]a and [K+]v were reduced (P < 0.01) and [K+]a-v during exercise tended to be greater (P= 0.056, n= 8). Muscle K+ efflux at fatigue was greater in Alk (21.2+/- 7.6 micromol min(-1), 32 +/- 7%, P < 0.05, n= 6), but peak K+ uptake rate was elevated during recovery (15 +/- 7%, P < 0.05) suggesting increased muscle Na+,K+-ATPase activity. Alk induced greater [Na+]a, [Cl-]v, muscle Cl- influx and muscle lactate concentration ([Lac-]) efflux during exercise and recovery (P < 0.05). The lower circulating [K+] and greater muscle K+ uptake, Na+ delivery and Cl- uptake with Alk, are all consistent with preservation of membrane excitability during exercise. This suggests that lesser exercise-induced membrane depolarization may be an important mechanism underlying enhanced exercise performance with Alk. Thus Alk was associated with improved regulation of K+, Na+, Cl- and Lac-.

Virtual cisternoscopy: 3D MRI models of the cerebellopontine angle for lesions related to the cranial nerves

This study was conducted to show that high-resolution magnetic resonance imaging (MRI) can aid in the neurosurgical approach to lesions affecting the cranial nerves (CNs) in the cerebellopontine angle (CPA). Three patients with symptomatology related to CNs VII and VIII underwent MRI examinations performed on a 1.5-Tesla Siemens MR scanner. As part of these routine examinations, the imaging technique of constructive interference in the steady state (CISS) was used to collect a volume of data through the brainstem and internal auditory canals. This high-resolution technique acquires a three-dimensional (3D) volume of data at 0.7-mm intervals. Parameters included TR 12.3/TE 5.9, number of acquisitions of 2, a matrix of 230 x 512, bandwidth of 130 Hz per pixel, and time of 8:40. Data were transferred to a commercially available GE workstation and reconstructed into a 3D surface-rendered model. This interactive method allows the model to be visualized from any angle, including that of a standard skull base approach of suboccipital craniotomy for access to the CPA cistern. The images shown include the CPA cistern as seen from the suboccipital surgical approach. CNs V, VII, and VIII can easily be seen in relation to the pons and petrous face. The relationship between the CNs and acoustic neuromas and skull base tumors can be evaluated. Vascular structures, which are often seen in relation to CNs VII and VIII, can be viewed in a 3D format to determine the need for microvascular decompression. Direct intraoperative photographs taken through the operating microscope confirmed the anatomic accuracy of the 3D models. Imaging used for interactive neurosurgical planning must demonstrate a high degree of anatomic detail. Virtual cisternoscopy using CISS MRI technique can achieve the required resolution. Reconstruction algorithms to create surface rendering can generate images with similar 3D anatomic detail to that seen during neurosurgical approaches to the CPA cistern.

Oral bisphosphonates improve Bone Mineral Density in adults with cystic fibrosis

In adults with Cystic Fibrosis (CF) we sought to establish the effect of oral bisphosphonate therapy. Bone densitometry measured by dual energy X-ray absorptiometry (DXA), and clinical patient data, were reviewed retrospectively. Eighty-one patients (median age 27 years) had baseline and follow-up DXA, with an interval of 19.2 +/- 7.1 months. Thirty-six patients were treated with bisphosphonates (alendronate=23 and risedronate=13). Median follow-up Bone Mineral Density in the bisphosphonate group was 3.7% greater at the lumbar spine (95%CI 1.9 to 5.7%, P<0.0005) and 2.4% greater at the femur (95%CI 0.8 to 3.9%, P<0.005) than the group not treated with bisphosphonates. Oral bisphosphonate therapy had a beneficial effect on BMD in adults with CF.

Effects of sprint training on extrarenal potassium regulation with intense exercise in Type 1 diabetes

Effects of sprint training on plasma K+ concentration ([K+]) regulation during intense exercise and on muscle Na+-K+-ATPase were investigated in subjects with Type 1 diabetes mellitus (T1D) under real-life conditions and in nondiabetic subjects (CON). Eight subjects with T1D and seven CON undertook 7 wk of sprint cycling training. Before training, subjects cycled to exhaustion at 130% peak O2 uptake. After training, identical work was performed. Arterialized venous blood was drawn at rest, during exercise, and at recovery and analyzed for plasma glucose, [K+], Na+ concentration ([Na+]), catecholamines, insulin, and glucagon. A vastus lateralis biopsy was obtained before and after training and assayed for Na+-K+-ATPase content ([3H]ouabain binding). Pretraining, Na+-K+-ATPase content and the rise in plasma [K+] ([K+]) during maximal exercise were similar in T1D and CON. However, after 60 min of recovery in T1D, plasma [K+], glucose, and glucagon/insulin were higher and plasma [Na+] was lower than in CON. Training increased Na+-K+-ATPase content and reduced [K+] in both groups (P < 0.05). These variables were correlated in CON (r = -0.65, P < 0.05) but not in T1D. This study showed first that mildly hypoinsulinemic subjects with T1D can safely undertake intense exercise with respect to K+ regulation; however, elevated [K+] will ensue in recovery unless insulin is administered. Second, sprint training improved K+ regulation during intense exercise in both T1D and CON groups; however, the lack of correlation between plasma delta[K+] and Na+-K+-ATPase content in T1D may indicate different relative contributions of K+-regulatory mechanisms.

Carcinoid Tumor of the Middle Ear: Clinical Features, Recurrences, and Metastases

OBJECTIVE

Present four new cases of carcinoid tumor of the middle ear, two of which developed late recurrences and regional metastases. Review the literature to identify the clinical features, rate of recurrence, and incidence of metastasis of carcinoid tumor of the middle ear.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral hospital.

PATIENTS

Eligibility criteria consist of a diagnosis of carcinoid tumor of middle ear.

INTERVENTION

Surgical excision of primary and metastatic disease.

MAIN OUTCOME MEASURE

Clinical characteristics, rate of recurrence, and incidence of metastasis of carcinoid tumor of the middle ear.

RESULTS

Forty-six patients with carcinoid tumor of the middle ear are included in this report, 42 patients were identified from a review of the literature, and 4 new patients are presented. The most common presenting symptom was hearing loss. Surgical excision was the treatment with radical mastoidectomy being the most common procedure. Ten (22%) patients developed locally recurrent disease, and four (9%) developed regional metastases.

CONCLUSIONS

Carcinoid tumor of the middle ear is an infrequent cause of a middle ear mass, with only 46 cases published. Despite previous assertions of benignancy, the findings of this study suggest that carcinoid tumor of the middle ear is indeed a potential low-grade malignancy with documented metastatic potential. Almost all middle ear adenomatous tumors ("adenoma" and "carcinoid") show evidence of neuroendocrine differentiation, and so at least some middle ear carcinoids ("adenomas") appear to represent well-differentiated neuroendocrine carcinomas. Presentation and symptoms are consistent with a middle ear mass and rarely include carcinoid syndrome. Surgical treatment is recommended and tailored to the extent of disease. Patients with carcinoid tumor of the middle ear require indefinite follow-up for possible recurrence or metastasis.

Training leading to repetition failure enhances bench press strength gains in elite junior athletes

The purpose of this study was to investigate the importance of training leading to repetition failure in the performance of 2 different tests: 6 repetition maximum (6RM) bench press strength and 40-kg bench throw power in elite junior athletes. Subjects were 26 elite junior male basketball players (n = 12; age = 18.6 +/- 0.3 years; height = 202.0 +/- 11.6 cm; mass = 97.0 +/- 12.9 kg; mean +/- SD) and soccer players (n = 14; age = 17.4 +/- 0.5 years; height = 179.0 +/- 7.0 cm; mass = 75.0 +/- 7.1 kg) with a history of greater than 6 months' strength training. Subjects were initially tested twice for 6RM bench press mass and 40-kg Smith machine bench throw power output (in watts) to establish retest reliability. Subjects then undertook bench press training with 3 sessions per week for 6 weeks, using equal volume programs (24 repetitions x 80-105% 6RM in 13 minutes 20 seconds). Subjects were assigned to one of two experimental groups designed either to elicit repetition failure with 4 sets of 6 repetitions every 260 seconds (RF(4 x 6)) or allow all repetitions to be completed with 8 sets of 3 repetitions every 113 seconds (NF(8 x 3)). The RF(4 x 6) treatment elicited substantial increases in strength (7.3 +/- 2.4 kg, +9.5%, p < 0.001) and power (40.8 +/- 24.1 W, +10.6%, p < 0.001), while the NF(8 x 3) group elicited 3.6 +/- 3.0 kg (+5.0%, p < 0.005) and 25 +/- 19.0 W increases (+6.8%, p < 0.001). The improvements in the RF(4 x 6) group were greater than those in the repetition rest group for both strength (p < 0.005) and power (p < 0.05). Bench press training that leads to repetition failure induces greater strength gains than nonfailure training in the bench press exercise for elite junior team sport athletes.

A method for intracochlear drug delivery in the mouse

The confluence of two rapidly emerging research arenas - development of mouse models of human deafness and inner ear drug therapy for treatment and prevention of hearing loss - provides an opportunity for unprecedented approaches to study and treat deafness. Toward such goals, we have developed a method for intracochlear drug delivery in the mouse. The bulla was exposed using a ventral approach and the stapedial artery cauterized. An opening made into the inferior-medial aspect of the bulla, where the basal cochlear wall fuses with tympanic bulla, provided direct access to the scala tympani without separately opening the bulla or elevating auditory response thresholds. Cochlear responses, assayed by frequency-specific effects on ABRs and DPOAEs, were stable with infusion (1 microl/h) of an artificial perilymph solution (80 min). The glutamate receptor antagonist, CNQX (100 microM; 175 min), reduced ABR responses without affecting DPOAEs. Salicylate (5mM; 165 min) altered both. Both drugs had greatest effects at high frequencies, but distributed throughout the cochlea and were reversible. The safe delivery of drugs into the cochlea by this approach has immediate application in the study and treatment of various forms of human hearing loss that can be modeled in the mouse.

Stereotactic Radiotherapy for Vestibular Schwannomas: Favorable Outcome with Minimal Toxicity

OBJECTIVE:

To determine the outcome and toxicity in patients with vestibular schwannomas treated with conventionally fractionated stereotactic radiotherapy (SRT) and to identify prognostic factors that are predictive of outcome.

METHODS:

Between 1992 and 2001, 70 patients with vestibular schwannomas were treated with linear accelerator-based SRT in our institutions. Eleven patients had neurofibromatosis Type II (NF2). The median age was 53 years (range, 17–82 yrs). The median tumor volume was 2.4 cm3 (range, 0.05–21.1 cm3). The indications for SRT were distributed as follows: 47% newly diagnosed, 31% progressive tumors after watchful waiting, 3% adjuvant postoperative radiation, and 19% recurrent tumors after surgical resection. The median dose was 54 Gy in 1.8 Gy per fraction, prescribed to 95% of the isodose line. Relocatable stereotactic frames were used for daily treatments. The median follow-up was 45.3 months.

RESULTS:

Tumor recurrence was defined as progressive enlargement of tumor on follow-up magnetic resonance imaging studies. One patient had a tumor recurrence at 38 months after SRT. The actuarial tumor control rates were 100 and 98% at 3 and 5 years, respectively. Three patients with a median tumor volume of 16.2 cm3 required surgical resection for persistent or increasing symptoms at a median of 37 months. The actuarial freedom from resection rates were 98 and 92% at 3 and 5 years, respectively. In multivariate analysis, tumor volume at time of treatment was predictive for neurosurgical intervention (surgical resection or shunt placement) after SRT (P = 0.001). The 3- and 5-year actuarial rates of freedom from any neurosurgical intervention were 100 and 97% for patients with tumor volume less than 8 cm3 and 74 and 47% respectively for patients with tumor of at least 8 cm3 (P &lt; 0.0001). The 3-year actuarial rates of facial and trigeminal nerve preservation were 99 and 96%, respectively. Surgery before SRT was predictive of posttreatment trigeminal neuropathy. The 3-year actuarial rates of freedom from trigeminal neuropathy were 86 and 98% for patients with and without previous resection, respectively (P = 0.04). There was no difference in tumor control and cranial nerve function preservation rates seen in NF2 patients compared with non-NF2 patients. No second primary cancer or malignant transformation was observed.

CONCLUSION:

SRT in the conventionally fractionated approach results in a very favorable outcome with minimal toxicity, with results comparable to those of the best of the radiosurgery series. Patients with large tumors are more likely to undergo neurosurgical interventions after SRT. Patients who have undergone previous surgery are at increased risk of developing trigeminal neuropathy.

Depressed Na+-K+-ATPase activity in skeletal muscle at fatigue is correlated with increased Na+-K+-ATPase mRNA expression following intense exercise

We investigated whether depressed muscle Na+-K+-ATPase activity with exercise reflected a loss of Na+-K+-ATPase units, the time course of its recovery postexercise, and whether this depressed activity was related to increased Na+-K+-ATPase isoform gene expression. Fifteen subjects performed fatiguing, knee extensor exercise at ∼40% maximal work output per contraction. A vastus lateralis muscle biopsy was taken at rest, fatigue, 3 h, and 24 h postexercise and analyzed for maximal Na+-K+-ATPase activity via 3- O-methylfluorescein phosphatase (3- O-MFPase) activity, Na+-K+-ATPase content via [3H]ouabain binding sites, and Na+-K+-ATPase α1-, α2-, α3-, β1-, β2- and β3-isoform mRNA expression by real-time RT-PCR. Exercise [352 (SD 267) s] did not affect [3H]ouabain binding sites but decreased 3- O-MFPase activity by 10.7 (SD 8)% ( P < 0.05), which had recovered by 3 h postexercise, without further change at 24 h. Exercise elevated α1-isoform mRNA by 1.5-fold at fatigue ( P < 0.05). This increase was inversely correlated with the percent change in 3- O-MFPase activity from rest to fatigue (%Δ3- O-MFPaserest-fatigue) ( r = −0.60, P < 0.05). The average postexercise (fatigue, 3 h, 24 h) α1-isoform mRNA was increased 1.4-fold ( P < 0.05) and approached a significant inverse correlation with %Δ3- O-MFPaserest-fatigue( r = −0.56, P = 0.08). Exercise elevated α2-isoform mRNA at fatigue 2.5-fold ( P < 0.05), which was inversely correlated with %Δ3- O-MFPaserest-fatigue( r = −0.60, P = 0.05). The average postexercise α2-isoform mRNA was increased 2.2-fold ( P < 0.05) and was inversely correlated with the %Δ3- O-MFPaserest-fatigue( r = −0.68, P < 0.05). Nonsignificant correlations were found between %Δ3- O-MFPaserest-fatigueand other isoforms. Thus acute exercise transiently decreased Na+-K+-ATPase activity, which was correlated with increased Na+-K+-ATPase gene expression. This suggests a possible signal-transduction role for depressed muscle Na+-K+-ATPase activity with exercise.

Dexamethasone up-regulates skeletal muscle maximal Na+,K+ pump activity by muscle group specific mechanisms in humans

Dexamethasone, a widely clinically used glucocorticoid, increases human skeletal muscle Na+,K+ pump content, but the effects on maximal Na+,K+ pump activity and subunit specific mRNA are unknown. Ten healthy male subjects ingested dexamethasone for 5 days and the effects on Na+,K+ pump content, maximal activity and subunit specific mRNA level (alpha1, alpha2, beta1, beta2, beta3) in deltoid and vastus lateralis muscle were investigated. Before treatment, maximal Na+,K+ pump activity, as well as alpha1, alpha2, beta1 and beta2 mRNA levels were higher (P < 0.05) in vastus lateralis than in deltoid. Dexamethasone treatment increased Na+,K+ pump maximal activity in vastus lateralis and deltoid by 14 +/- 7% (P < 0.05) and 18 +/- 6% (P < 0.05) as well as Na+,K+ pump content by 18 +/- 9% (P < 0.001) and 24 +/- 8% (P < 0.01), respectively. Treatment with dexamethasone resulted in a higher alpha1, alpha2, beta1 and beta2 mRNA expression in the deltoid (P < 0.05), but no effects on Na+,K+ pump mRNA were detected in vastus lateralis. In conclusion, dexamethasone treatment increased maximal Na+,K+ pump activity in both vastus lateralis and deltoid muscles. The relative importance of transcription and translation in the glucocorticoid-induced regulation of Na+,K+ pump expression seems to be muscle specific and possibly dependent on the actual training condition of the muscle, such that a high Na+,K+ pump maximal activity and mRNA level prior to treatment prevents the transcriptional response to dexamethasone, but not the increase in Na+,K+ pump content and maximal activity.

Sleep disturbance at simulated altitude indicated by stratified respiratory disturbance index but not hypoxic ventilatory response

At high altitudes, the clinically defined respiratory disturbance index (RDI) and high hypoxic ventilatory response (HVR) have been associated with diminished sleep quality. Increased RDI has also been observed in some athletes sleeping at simulated moderate altitude. In this study, we investigated relationships between the HVR of 14 trained male endurance cyclists with variable RDI and sleep quality responses to simulated moderate altitude. Blood oxygen saturation (SpO2%), heart rate, RDI, arousal rate, awakenings, sleep efficiency, rapid eye movement (REM) sleep, non-REM sleep stages 1, 2 and slow wave sleep as percentages of total sleep time (%TST) were measured for two nights at normoxia of 600 m and one night at a simulated altitude of 2,650 m. HVR and RDI were not significantly correlated with sleep stage, arousal rate or awakening response to nocturnal simulated altitude. SpO2 was inversely correlated with total RDI (r = -0.69, P = 0.004) at simulated altitude and with the change in arousal rate from normoxia (r = -0.65, P = 0.02). REM sleep response to simulated altitude correlated with the change, relative to normoxia, in arousal (r = -0.63, P = 0.04) and heart rate (r = -0.61, P = 0.04). When stratified, those athletes at altitude with RDI >20 h(-1) (n = 4) and those with <10 h(-1) (n = 10) exhibited no difference in HVR but the former had larger falls in SpO2 (P = 0.05) and more arousals (P = 0.03). Neither RDI (without stratification) nor HVR were sufficiently sensitive to explain any deterioration in REM sleep or arousal increase. However, the stratified RDI provides a basis for determining potential sleep disturbance in athletes at simulated moderate altitude.

Sleep in athletes undertaking protocols of exposure to nocturnal simulated altitude at 2650 m

A popular method to attempt to enhance performance is for athletes to sleep at natural or simulated moderate altitude (SMA) when training daily near sea level. Based on our previous observation of periodic breathing in athletes sleeping at SMA, we hypothesised that athletes' sleep quality would also suffer with hypoxia. Using two typical protocols of nocturnal SMA (2650 m), we examined the effect on the sleep physiology of 14 male endurance-trained athletes. The selected protocols were Consecutive (15 successive exposure nights) and Intermittent (3x 5 successive exposure nights, interspersed with 2 normoxic nights) and athletes were randomly assigned to follow either one. We monitored sleep for two successive nights under baseline conditions (B; normoxia, 600 m) and then at weekly intervals (nights 1, 8 and 15 (N1, N8 and N15, respectively)) of the protocols. Since there was no significant difference in response between the protocols being followed (based on n=7, for each group) we are unable to support a preference for either one, although the likelihood of a Type II error must be acknowledged. For all athletes (n=14), respiratory disturbance and arousal responses between B and N1, although large in magnitude, were highly individual and not statistically significant. However, SpO2 decreased at N1 versus B (p<0.001) and remained lower on N8 (p<0.001) and N15 (p<0.001), not returning to baseline level. Compared to B, arousals were more frequent on N8 (p=0.02) and N15 (p=0.01). The percent of rapid eye movement sleep (REM) increased from N1 to N8 (p=0.03) and N15 (p=0.01). Overall, sleeping at 2650 m causes sleep disturbance in susceptible athletes, yet there was some improvement in REM sleep over the study duration.

Operative Management of Superior Semicircular Canal Dehiscence

OBJECTIVE

To assess the outcomes of patients undergoing surgical management of superior semicircular canal dehiscence (SSCD).

STUDY DESIGN

Retrospective review.

METHODS

The medical records of all patients undergoing surgical treatment for SSCD at our institution between 2000 and 2004 were reviewed.

RESULTS

Eleven patients underwent unilateral operative management via a middle fossa approach. Ten patients were treated successfully by canal plugging and one unsuccessfully by canal re-roofing. Plugging of SSCD provided resolution of sound- and pressure-induced nystagmus, autophony, and conductive hearing loss (HL). One patient experienced a mild high-frequency sensorineural HL and two patients experienced both a mild high-frequency sensorineural HL and a reduction in vestibular function. Two additional patients underwent exploration for SSCD but were found to have a thin layer of bone overlying the canal.

CONCLUSIONS

Plugging of the SSCD, while efficacious in alleviating the symptoms of the disease, may cause loss of labyrinthine function beyond the superior canal.

Aneurysmal expansion presenting as facial weakness: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Facial paralysis and hemifacial spasm are rare presentations of aneurysms in the posterior fossa. We report an unusual case of rapidly progressive facial palsy caused by the acute expansion of an arteriovenous malformation-associated anteroinferior cerebellar artery aneurysm. The case is notable for the rapid progression of symptoms and their precise correlation with radiographic changes, emphasizing the potential dynamic nature of aneurysms associated with arteriovenous malformations.

CLINICAL PRESENTATION

A 56-year-old woman with severe headache and nausea was seen in a local emergency room, where she underwent a neurological examination with unremarkable results and a head computed tomographic scan demonstrating acute hemorrhage in the ambient cisterns. Conventional and computed tomographic angiograms demonstrated an arteriovenous malformation in the right cerebellopontine angle fed by the anteroinferior cerebellar and superior cerebellar arteries. A micro-aneurysm measuring 3 mm was noted within the internal carotid artery on the meatal loop of the anteroinferior cerebellar artery. Two weeks later, a rapidly progressive right facial weakness developed in the patient, progressing to complete facial plegia over 12 hours, and complete sensory neural hearing loss. Repeat angiography demonstrated expansion of the previously visualized aneurysm to 8 x 4 mm.

INTERVENTION

The patient was taken to surgery for clipping of the aneurysm, which required petrous drilling to unroof the canal. She has experienced substantial recovery of facial nerve function.

CONCLUSION

Although compression of the VIIth-VIIIth nerve complex is an unusual presentation for posterior fossa aneurysms, it represents an important potential complication of vascular pathological features. The rapid aneurysmal expansion, confirmed by imaging and correlating with the rapid onset of symptoms, gives an impressive demonstration of the anatomic changes that can occur in an aneurysm associated with an arteriovenous malformation.

Aneurysmal Expansion Presenting as Facial Weakness: Case Report and Review of the Literature

OBJECTIVE AND IMPORTANCE:

Facial paralysis and hemifacial spasm are rare presentations of aneurysms in the posterior fossa. We report an unusual case of rapidly progressive facial palsy caused by the acute expansion of an arteriovenous malformation-associated anteroinferior cerebellar artery aneurysm. The case is notable for the rapid progression of symptoms and their precise correlation with radiographic changes, emphasizing the potential dynamic nature of aneurysms associated with arteriovenous malformations.

CLINICAL PRESENTATION:

A 56-year-old woman with severe headache and nausea was seen in a local emergency room, where she underwent a neurological examination with unremarkable results and a head computed tomographic scan demonstrating acute hemorrhage in the ambient cisterns. Conventional and computed tomographic angiograms demonstrated an arteriovenous malformation in the right cerebellopontine angle fed by the anteroinferior cerebellar and superior cerebellar arteries. A micro-aneurysm measuring 3 mm was noted within the internal carotid artery on the meatal loop of the anteroinferior cerebellar artery. Two weeks later, a rapidly progressive right facial weakness developed in the patient, progressing to complete facial plegia over 12 hours, and complete sensory neural hearing loss. Repeat angiography demonstrated expansion of the previously visualized aneurysm to 8 × 4 mm.

INTERVENTION:

The patient was taken to surgery for clipping of the aneurysm, which required petrous drilling to unroof the canal. She has experienced substantial recovery of facial nerve function.

CONCLUSION:

Although compression of the VIIth–VIIIth nerve complex is an unusual presentation for posterior fossa aneurysms, it represents an important potential complication of vascular pathological features. The rapid aneurysmal expansion, confirmed by imaging and correlating with the rapid onset of symptoms, gives an impressive demonstration of the anatomic changes that can occur in an aneurysm associated with an arteriovenous malformation.

Osteoprotegerin in the Inner Ear May Inhibit Bone Remodeling in the Otic Capsule

OBJECTIVES

To elucidate factors that may be responsible for the inhibition of remodeling of bone within the otic capsule.

METHODS

Expression of osteoprotegerin (OPG), receptor activator of nuclear factor kappa B (RANK), and RANK ligand (RANKL) were assayed in samples of bone obtained from the otic capsule, calvarium, and femur, and from the soft tissue within the cochlea using semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR) in mice. Immunostaining was used for histologic localization of the gene products. An enzyme-linked immunosorbent assay (ELISA) was used to quantify the amount of OPG within perilymph, serum, and cerebrospinal fluid. The micro-anatomy of the interface between the otic capsule and the fluid spaces of the cochlea was investigated by brightfield and phase-contrast microscopy and by three-dimensional reconstruction in the mouse and human.

RESULTS

OPG, a powerful inhibitor of bone remodeling, was expressed at extremely high levels within the soft tissue of the cochlea and was present in the perilymph at very high concentrations. The OPG produced within the inner ear may diffuse into the surrounding otic capsule, where it may be responsible for inhibition of bone turnover. Our anatomic studies revealed an extensive system of interconnected canaliculi within the otic capsule that had direct openings into the fluid spaces of the inner ear, thus providing a possible anatomic route for the diffusion of OPG from the inner ear into the surrounding bone.

CONCLUSION

OPG, a potent inhibitor of osteoclast formation and function, is expressed at high levels within the inner ear and is secreted into the perilymph and the surrounding bone and may serve to inhibit active bone remodeling within the otic capsule, especially immediately adjacent to the cochlea. By this means, the cochlear soft tissue may control the nature of the surrounding petrous bone.

Hypoxic ventilatory response is correlated with increased submaximal exercise ventilation after live high, train low

This study tested the hypothesis that live high, train low (LHTL) would increase submaximal exercise ventilation (V(E)) in normoxia, and the increase would be related to enhanced hypoxic ventilatory response (HVR). Thirty-three cyclists/triathletes were divided into three groups: 20 consecutive nights of hypoxia (LHTLc, n = 12), 20 nights of intermittent hypoxia (4x5-night 'blocks' of hypoxia interspersed by two nights of normoxia, LHTLi, n = 10), or control (CON, n = 11). LHTLc and LHTLi slept 8-10 h per night in normobaric hypoxia (2,650 m), and CON slept under ambient conditions (600 m). Resting, isocapnic HVR (DeltaV(E)/Deltablood oxygen saturation) was measured in normoxia before (PRE) and after 15 nights (N15) hypoxia. Submaximal cycle ergometry was conducted PRE and after 4, 10, and 19 nights of hypoxia (N4, N10, and N19 respectively). Mean submaximal exercise V(E) was increased (P < 0.05) from PRE to N4 in LHTLc [74.4 (5.1) vs 80.0 (8.4) l min(-1); mean (SD)] and in LHTLi [69.0 (7.5) vs 76.9 (7.3) l min(-1)] and remained elevated in both groups thereafter, with no changes observed in CON at any time. Prior to LHTL, submaximal V(E) was not correlated with HVR, but this relationship was significant at N4 (r = 0.49, P = 0.03) and N19 (r = 0.77, P < 0.0001). Additionally, the increases in submaximal V(E) and HVR from PRE to N15-N19 were correlated (r = 0.51, P = 0.02) for the pooled data of LHTLc and LHTLi. These results suggest that enhanced hypoxic chemosensitivity contributes to increased exercise V(E) in normoxia following LHTL.

Postauricular Periosteal-Pericranial Flap for Mastoid Obliteration and Canal Wall Down Tympanomastoidectomy

OBJECTIVE

To describe an effective technique for mastoid cavity obliteration in canal wall down tympanomastoidectomy for chronic otitis media and review its efficacy in producing a dry, low-maintenance, small mastoid cavity.

DESIGN

: Retrospective clinical study of a consecutive series of procedures from 1995 to 2000.

SETTING

Tertiary referral center and institutional academic practice in otology and neurotology.

PATIENTS

Sixty consecutive procedures for active chronic otitis media with a minimum follow-up of 12 months (mean, 31 mo; range, 12-80 mo).

INTERVENTION

All patients had canal wall down mastoidectomy with simultaneous tympanoplasty including split-thickness skin grafting. An inferiorly pedicled, periosteal-pericranial flap was used in conjunction with autologous bone pate to obliterate the mastoid cavity. The additional length provided by the pericranial extension of the flap permitted it to reach superior to the lateral canal and into the sinodural angle, with improved coverage of bone pate and better reduction of cavity size.

OUTCOME MEASURES

The primary outcome measure was control of suppuration and creation of a dry, low-maintenance mastoid cavity, which was assessed using a previously developed semiquantitative scale. This scale includes a temporal dimension to assess control of infection. Secondary outcome measures included postoperative complications (i.e., hematoma, infection, flap necrosis, and meatal stenosis) and incidence of recurrent or residual cholesteatoma.

RESULTS

Forty-nine ears (82%) maintained a small, dry, healthy mastoid cavity. Five ears (8%) had intermittent otorrhea easily controlled by topical treatment. Six ears (10%) had suboptimal control of otorrhea, of which four had meatal stenosis. There were no residual or recurrent cholesteatomas. Outcomes remained stable over progressively longer follow-up, up to 80 months.

CONCLUSION

Obliteration of a canal wall down mastoid cavity by a postauricular periosteal-pericranial flap with autologous bone pate is a reliable and effective technique that results in a dry, trouble-free mastoid cavity in 90% of patients with active chronic otitis media.

Prolonged exercise to fatigue in humans impairs skeletal muscle Na+-K+-ATPase activity, sarcoplasmic reticulum Ca2+release, and Ca2+uptake

Prolonged exhaustive submaximal exercise in humans induces marked metabolic changes, but little is known about effects on muscle Na+-K+-ATPase activity and sarcoplasmic reticulum Ca2+regulation. We therefore investigated whether these processes were impaired during cycling exercise at 74.3 ± 1.2% maximal O2uptake (mean ± SE) continued until fatigue in eight healthy subjects (maximal O2uptake of 3.93 ± 0.69 l/min). A vastus lateralis muscle biopsy was taken at rest, at 10 and 45 min of exercise, and at fatigue. Muscle was analyzed for in vitro Na+-K+-ATPase activity [maximal K+-stimulated 3- O-methylfluorescein phosphatase (3- O-MFPase) activity], Na+-K+-ATPase content ([3H]ouabain binding sites), sarcoplasmic reticulum Ca2+release rate induced by 4 chloro- m-cresol, and Ca2+uptake rate. Cycling time to fatigue was 72.18 ± 6.46 min. Muscle 3- O-MFPase activity (nmol·min−1·g protein−1) fell from rest by 6.6 ± 2.1% at 10 min ( P < 0.05), by 10.7 ± 2.3% at 45 min ( P < 0.01), and by 12.6 ± 1.6% at fatigue ( P < 0.01), whereas3[H]ouabain binding site content was unchanged. Ca2+release (mmol·min−1·g protein−1) declined from rest by 10.0 ± 3.8% at 45 min ( P < 0.05) and by 17.9 ± 4.1% at fatigue ( P < 0.01), whereas Ca2+uptake rate fell from rest by 23.8 ± 12.2% at fatigue ( P = 0.05). However, the decline in muscle 3- O-MFPase activity, Ca2+uptake, and Ca2+release were variable and not significantly correlated with time to fatigue. Thus prolonged exhaustive exercise impaired each of the maximal in vitro Na+-K+-ATPase activity, Ca2+release, and Ca2+uptake rates. This suggests that acutely downregulated muscle Na+, K+, and Ca2+transport processes may be important factors in fatigue during prolonged exercise in humans.