[Flexible bronchoscopy in the diagnosis of foreign body aspiration]

Foreign body aspiration (FBA) should be suspected in every child with acute onset of cough or wheezing. Although a choking episode occurs in 80-90% of cases of FBA, it is not necessarily diagnostic. Furthermore, in many cases neither physical examination nor chest x-ray, including fluoroscopy, are diagnostic; their results may be completely normal in up to 17-25% of cases of FBA. Bronchoscopy is therefore mandatory when there is a convincing history of FBA, regardless of physical or radiologic findings. This can be done with either the flexible or rigid bronchoscope, or with both.

Cyfra 21-1. A new potential tumor marker for squamous cell carcinoma of head and neck

OBJECTIVE

Evaluation of Cyfra 21-1 (cytokeratin fraction 21-1) in squamous cell carcinoma of the head and neck.

DESIGN

Prospective study.

PATIENTS

Serum Cyfra 21-1 concentration was measured in 250 samples from patients with squamous cell carcinoma of head and neck, patients with benign tumors of head and neck, healthy control subjects, and patients in remission from squamous cell carcinoma of head and neck.

RESULTS

Cyfra 21-1 concentration was elevated in 60% of the new patients with squamous cell carcinoma but only in 8% of patients with benign tumors and 3.5% of the healthy controls. At a cutoff of 1.3 ng/mL, the sensitivity of the test was 60%, the specificity was 94%, positive predictive value was 75%, and negative predictive value was 89%. The marker levels tended to follow the clinical course of the disease and were useful for therapy monitoring. Cyfra 21-1 levels were in good correlation with the tumor stage expressed by the local (T) and the lymphatic spread (N) and were inversely correlated with histologic grade, eg, higher in poorly differentiated carcinoma than in well-differentiated squamous cell carcinoma.

CONCLUSION

Cyfra 21-1 evaluation in head and neck squamous cell carcinoma is worthwhile for performance of an ample study that will prove and establish its routine use.

Interventional neurology: botulinum toxin as a potent symptomatic treatment in neurology

Local injections of botulinum toxin is a well-accepted treatment for focal dystonias, hemifacial spasms and strabismus. Its use by skilled neurologists has been reported to be safe and effective. We report our experience with botulinum toxin injections in 108 patients with various central nervous system disorders. Botox was effective in upper face dystonia (86% improvement), spastic dysphonia (92% improvement), platysma muscle spasms and spasmodic torticollis (range of movement 61%, pain and tension 90%). It was also very effective in a few patients with apraxia of eyelid opening, parkinsonian jaw tremor, teeth clenching, palatal myoclonus and adductor leg spasticity. No serious side effects were recorded. Botulinum toxin is a useful symptomatic treatment for many neurological disorders, and one of the leading mode of treatments in the new subspecialty in neurology called "Interventional neurology."

[Botulinum toxin for palatal myoclonus and spastic dysphonia]

Botulinum toxin (B; Botox), produced by the anaerobic bacterium Clostridium botulinum, causes temporary paralysis by blocking the presynaptic release of acetylcholine at the neuromuscular junction. This action is clinically used to alleviate muscle spasm by injecting the toxin directly into the overactive muscle. We report our experience with B injections in 2 women, aged 20 and 21, respectively, 1 of whom had bilateral palatal myoclonus and the other adductor spastic dysphonia. Both showed remarkable improvement of conditions for which, until now, we had no effective treatment. These are the first cases in Israel treated with B for otorhinolaryngological conditions.

Ciliary ultrastructure in primary ciliary dyskinesia and other chronic respiratory conditions: the relevance of microtubular abnormalities

Twenty-eight subjects with chronic respiratory disease were investigated for clinical data, ciliary beat frequency of nasal mucosa (10 cases), and ciliary ultrastructure. The cases were divided into two groups: those considered compatible with primary ciliary dyskinesia (genetic), and those not fitting into this category (others). A case was defined as genetic if one or more of the following were present: dextrocardia, ciliary beat frequency less than 10 Hz, or an average dynein arm count (outer, inner, or both) of less than two per ciliary cross-section. In each of the genetic cases at least two of these parameters were present. The percentage of malformed microtubules was calculated from the total number of evaluated cross-sections for each case. Ciliary microtubular abnormalities of any kind were no more frequent in cases of primary ciliary dyskinesia than in other cases. The same was true for transposition and radial spoke defects.

Herpes zoster oticus: treatment with acyclovir

Herpes zoster oticus produces facial paralysis with a low recovery rate. Acyclovir, a specific virostatic drug, was given intravenously in five herpes zoster oticus patients, and in three of them was followed by oral therapy. In follow-ups of 1 to 24 months, one patient had grade I recovery, three patients grade II, and one grade III. These good results encourage the use of acyclovir in herpes zoster oticus patients.

Diving-related inner ear injuries

Diving-related inner ear barotrauma (IEB) and inner ear decompression sickness (IEDS) most often result in permanent severe cochleovestibular deficits, unless immediate diagnosis is reached and the correct treatment is commenced early. Nine cases of sport-diving-induced inner ear injuries that were referred to the Israeli Naval Hyperbaric Institute between October 1987 and September 1989 are presented with regard to evaluation, treatment, and follow-up. The diagnosis was IEB in five divers and IEDS in four. Explorative tympanotomy was carried out with remarkable results in two patients with IEB, while the remaining three were relieved by bed rest alone. Three of the four IEDS patients were recompressed according to the extended US Navy Table 6 with good short-term results. The role of complete otoneurological evaluation in the decision-making process leading to the correct diagnosis and treatment is emphasized.

Congenital middle ear encephalocele initially seen with facial paresis

Congenital middle ear encephalocele (CMEE) is a rare entity, previously reported in only 29 patients. It might originate from dehiscence of the tegmen tympani or antri or the bony plate of the posterior fossa. The common presenting symptoms are spontaneous cerebrospinal fluid (CSF) otorrhea and/or rhinorrhea, persistent "serious otitis media," conductive hearing loss, and, occasionally, recurrent meningitis. We report a case of CMEE initially seen with progressive facial paresis, review the previously reported cases of CMEE, and discuss the pathogenesis and surgical management.

[Laryngeal neuroendocrine carcinoma (carcinoid)]

Neuroendocrine carcinoma (carcinoid), is a rare laryngeal malignancy with aggressive behavior. The 5-year survival rate is only about 10%, mainly because of distant metastases. We describe a patient with neuroendocrine carcinoma of the larynx, large cell type, without evidence of regional or distant metastases. Treatment included total laryngectomy and adjuvant radiotherapy to the neck. There was no evidence of disease at 6-month follow-up.

Hyperbaric oxygenation for necrotizing (malignant) otitis externa

Two patients with extensive necrotizing otitis externa have been treated by hyperbaric oxygenation. One patient had facial nerve palsy and the other suffered from skull base involvement. Due to severe side effects, the preferred combined intravenous antibiotic therapy was changed to monotherapy in one case and completely withdrawn in the second. This was done before the commencement of hyperbaric oxygenation, while the necrotizing infection was still active. Hyperbaric oxygenation therapy was followed by complete resolution of the necrotizing otitis externa, which did not recur. The pathogenesis of the disease and mechanisms by which hyperbaric oxygenation might be of benefit are described. We conclude that hyperbaric oxygenation should be considered as adjuvant therapy for necrotizing otitis externa whenever a therapeutic pressure chamber is available.

Effect of body posture on radionuclide measurements of gastric emptying

The purpose of this investigation was to compare the effect of body posture on gastric emptying measurements of radiolabeled meals. Eight healthy male subjects were studied on four separate days. During each study subjects were fed a standardized meal of beef stew labeled with technetium-99m sulfur colloid, and orange juice. Measurements of solid-phase gastric emptying rates were obtained by a gamma camera. Subjects were studied in the lying, sitting, standing, or combined sitting-standing postures. The results demonstrated that the lying position significantly slowed gastric emptying compared to all other positions. Conversely, a decrease in emptying times of 51% and 35% occurred in the combined sitting-standing position compared to the lying and sitting position. These results support a marked effect of body posture on the radionuclide measurement of gastric emptying.

Circadian variation in gastric emptying of meals in humans

Circadian changes in drug absorption have been documented for several orally administered drugs in humans. To determine whether gastric emptying could account for these changes, morning (8 AM) and evening (8 PM) gastric emptying rates were measured in 16 healthy male subjects synchronized with diurnal activity and nocturnal rest. Gastric emptying half-times for the evening meal were significantly (p less than 0.001) longer for solids but not liquids when compared with morning emptying half-times. The increase in evening meal emptying time (53.6%) may account for the evening delay in reaching peak plasma concentrations documented for several drugs.

Tonsillar leiomyoma

Tumors of smooth muscle origin are rare in the oral cavity. To date, only eighty-three cases of oral leiomyomas have been reported. A first case of tonsillar leiomyoma in a 73-year-old male is presented. The theories of origin and the various histologic types of oral leiomyomas are discussed. Leiomyoma can easily be confused with other spindle-cell tumours. Special stains are necessary to reach a correct diagnosis. It is sometimes difficult to differentiate benign leiomyoma from malignant leiomyosarcoma. The use of mitotic figure count to indicate malignant behaviour is not always reliable. The need for wide surgical excision of the tumour, complete sectioning and examination of the specimen and meticulous follow-up of the patient for evidence of recurrence are emphasized.

Biosynthesis of bacterial glycogen. Primary structure of Escherichia coli 1,4-alpha-D-glucan:1,4-alpha-D-glucan 6-alpha-D-(1, 4-alpha-D-glucano)-transferase as deduced from the nucleotide sequence of the glg B gene

The nucleotide sequence of the glg B gene, coding for branching enzyme (EC 2.4.1.18), was elucidated. It consists of 2181 base pairs specifying a protein of 727 amino acids. The deduced amino acid sequence was consistent with the amino acid analysis that was obtained with the pure protein as well as with the molecular weight determined from sodium dodecyl sulfate-gel electrophoresis. The deduced amino acid sequence was also consistent with the amino-terminal amino acid sequence and the amino acid sequence analysis of various peptides obtained from CNBr degradation of purified branching enzyme.

Cloning and expression of the Escherichia coli glgC gene from a mutant containing an ADPglucose pyrophosphorylase with altered allosteric properties

A mutant strain of Escherichia coli K-12, designated 618, accumulates glycogen at a faster rate than wild-type strain 356. The mutation affects the ADPglucose pyrophosphorylase regulatory properties (N. Creuzat-Sigal, M. Latil-Damotte, J. Cattaneo, and J. Puig, p. 647-680, in R. Piras and H. G. Pontis, ed., Biochemistry of the Glycocide Linkage, 1972). The enzyme is less dependent on the activator, fructose 1,6 bis-phosphate for activity and is less sensitive to inhibition by the inhibitor, 5'-AMP. The structural gene, glgC, for this allosteric mutant enzyme was cloned into the bacterial plasmid pBR322 by inserting the chromosomal DNA at the PstI site. The glycogen biosynthetic genes were selected by cotransformation of the neighboring asd gene into an E. coli mutant also defective in branching enzyme (glgB) activity. Two recombinant plasmids, pEBL1 and pEBL3, that had PstI chromosomal DNA inserts containing glgC and glgB were isolated. Branching enzyme and ADPglucose pyrophosphorylase activities were increased 240- and 40-fold, respectively, in the asd glgB mutant, E. coli K-12 6281. The E. coli K-12 618 mutant glgC gene product was characterized after transformation of an E. coli B ADPglucose pyrophosphorylase mutant with the recombinant plasmid pEBL3. The kinetic properties of the cloned ADPglucose pyrophosphorylase were similar to those of the E. coli K-12 618 enzyme. The inserted DNA in pEBL1 was arranged in opposite orientation to that in pEBL3.

Value of a 24-hour image (four-phase bone scan) in assessing osteomyelitis in patients with peripheral vascular disease

The delayed images of the four-phase 99mTc phosphonate bone scan are compared with the delayed images of the three-phase study in patients with diabetes mellitus and/or peripheral vascular disease and suspected osteomyelitis. Three-phase bone imaging includes an immediate postinjection radionuclide angiogram, a blood-pool image, and delayed static images to 7 hr. The four-phase study adds a 24-hr static image. The scan is positive for osteomyelitis if images show progressively increasing lesion to background activity ratios over time. The results of analyzing 21 three- and four-phase bone scans in 17 patients were correlated with clinical course, cultures, and/or x-rays, gallium scans, and CT scans. The accuracy of four-phase bone imaging for diagnosing osteomyelitis was 85%; for three phase, 80%. Sensitivity for four phase was 80%; specificity was 87%. Sensitivity for three phase was 100%; specificity was 73%. Since overall accuracy of the four-phase study is slightly better than three phase, in these patients with diabetes mellitus and/or peripheral vascular disease, the addition of a 24-hr image, creating a four-phase bone scan, is recommended.

Prospective reimbursement for state-of-the-art medical practice: the case for invasive electrophysiologic evaluation

This study is an examination of the economic consequences of invasive electrophysiologic (EP) evaluation for recurrent supraventricular tachycardia (SVT) and ventricular tachycardia (VT) on a tertiary health care facility during 1980 and 1981. The average cost of hospitalizations for EP evaluation was substantial (SVT, $6,990; VT, $13,897), as was the length of hospital stay (SVT, 12 +/- 8 days; VT, 24 +/- 8 days). The cost of a single EP procedure in the study period averaged $695 (range $200 to $1,206). During follow-up (1 to 3 years), there was substantial improvement in arrhythmia control on EP-based therapy in SVT and VT compared with prior empirical therapy. Cost:benefit analysis strongly favored EP-based therapy over empirical therapy (SVT, 6:1; VT, 18:1) in this follow-up period. Comparison with cost of noninvasive techniques for VT evaluation showed that EP evaluation had comparable cost. Current prospective reimbursement schedules have no DRG category for EP evaluation and do not fairly compensate hospitals for invasive or noninvasive arrhythmia studies. Invasive EP evaluation is both clinically effective and cost-effective in the management of patients with recurrent SVT and VT. Prospective reimbursement plans should include a specific DRG category for these studies.