Evidence for an integrated oral sensory module in the human anterior ventral insula

Taste, which is almost always accompanied by other oral sensations, serves to identify potential nutrients and toxins. The present study was designed to determine the influence of sensory modality (chemesthetic vs. gustatory) and physiological significance (potentially nutritive vs. potentially harmful) on insular response to oral stimulation. Sixteen subjects underwent functional magnetic resonance imaging scanning while receiving 2 potentially nutritive solutions (sucrose and NaCl), 2 potentially harmful solutions (quinine and capsaicin, a chemesthetic stimulus), and a tasteless control solution. We identified a region of anterior ventral insula that responded to oral stimulation irrespective of modality or physiological significance. However, when subjects tasted a potentially nutritive stimulus, the connectivity between the insula and a feeding network including the hypothalamus, ventral pallidum, and striatum was greater than when tasting a potentially harmful stimulus. No differential connectivity was observed as a function of modality (gustatory vs. chemesthetic). These results support the existence of an integrated supramodal flavor system in the anterior ventral insula that preferentially communicates with the circuits guiding feeding when the flavor is potentially nutritive.

Analysis of human papillomavirus in schneiderian papillomas as compared to chronic sinusitis and normal nasal mucosa

Schneiderian papillomas (SPs) are tumours arising from the surface epithelium (schneiderian epithelium) of the nasal cavity and paranasal sinuses. Evidence points toward a viral etiology, specifically human papillomavirus (HPV). Although substantial data indicate HPV as a likely etiology, little is known about the role of HPV in benign nasal pathologies or in normal nasal mucosa. The objective of this study was to characterize the relationship between HPV and SP, chronic sinusitis (CS), and normal nasal mucosa. A case-control study was undertaken, matching patients with SP to patients with CS. Patients with normal nasal mucosa served as a control group. All patients had their tissues analyzed for the presence of various HPV subtypes using line blot assay. A total of 168 patients were identified (74 SP, 74 CS, 20 control). Of these, 70 (41.7%) had detectable deoxyribonucleic acid and 9 of 70 (12.9%) had detectable HPV of subtypes 6, 11, and 16. None had detectable HPV type 18. Significant differences were detected in the presence of HPV in the CS, SP, and control groups, as well as in the presence of low- versus high-risk subtypes among investigation and control groups. Significant differences exist in HPV infectivity among SP, benign nasal pathologies such as CS, and normal nasal mucosa. Human papillomavirus plays an important role, at least in part, in the development of SP, with types 6, 11, and 16 being more pivotal than other types. Line blot assay is a useful technique in identifying HPV in SP.

Clinical manifestations of sinonasal pathology during pregnancy

OBJECTIVE

Pregnancy may confer a number of conditions related to the head and neck. The objective of this study was to evaluate the clinical manifestations of sinonasal pathology that occur during pregnancy.

METHODS

Thirty-three pregnant patients were evaluated for the occurrence of rhinorrhea, congestion, epistaxis, or acute sinusitis during the first trimester of pregnancy, controlling with 28 women of child-bearing age. A visual analogue scale was used to grade the severity of each symptom. Statistical analysis was carried out to assess for significant differences in the prevalence and severity of symptomatology between cases and controls.

RESULTS

Compared to the control group, there was no statistically significant difference in the prevalence of congestion, epistaxis, rhinorrhea, or acute sinusitis. There was no statistically significant difference in the severity of any presenting symptom between pregnant and control group patients.

CONCLUSION

Pregnancy is not associated with an increased prevalence or severity of nasal symptomatology during early pregnancy. The influence of hormonal changes on nasal physiology during pregnancy is discussed with a view toward safe management.

Unique characteristics of malignant schneiderian papilloma

PURPOSE

To ascertain the characteristics unique to malignant schneiderian papilloma (MSP).

METHODS

A case-control study of all schneiderian papilloma (SP) patients treated between 1978 and 1997 was conducted. Comparison was made between patients with MSP and patients with benign SP (BSP).

RESULTS

A diagnosis of SP was made in 72 patients. Malignant changes, all of them the inverted papilloma subtype, were found in 8 of these patients. Three were diagnosed carcinoma in situ, and 5 were defined as invasive squamous cell carcinoma. At presentation, the MSP patients had significantly larger tumor spread into the ethmoid and sphenoid sinuses. The recurrence rate was significantly lower in SP patients treated with extensive surgical procedures. An association was found between the presence of malignant lesions and positive smoking history, subjective awareness of a nasal mass, and ethmoid and sphenoid sinus involvement. Also, histologic multicentricity was a feature more often seen in MSP than BSP and was a significant correlate with malignancy.

CONCLUSION

The physician evaluating a patient with SP should be aware of the features described and of their possible association with a malignant lesion.

Endoscopic repair of cerebrospinal fluid rhinorrhea: is it the treatment of choice?

Between 1991 and 1998, 12 patients with cerebrospinal fluid rhinorrhea were operated on using the intranasal endoscopic approach. The procedure was successful in 10 cases. The endoscopic approach failed in two patients who had larger bony defects and herniating meningoencephaloceles. This paper analyzes the case material with respect to the etiology and site of leakage. The value of computed tomography and magnetic resonance imaging for preoperative localization of the leak is discussed. The technique of underlay fascia graft is described and discussion ensues regarding potential pitfalls that may lead to failure of leak closure.

Fibromatosis

Fibromatosis represents a diverse group of fibroproliferative tumours. Their behaviour and pathological qualities are situated in an intermediate position between benign and malignant disease. The following represents the pathological and radiological presentation of a 29-year-old female with fibromatosis.

Effect of steroids on nasal inflammatory cells and cytokine profile

OBJECTIVES

To assess the cellular and humoral effects of unilateral topical steroid application on the nasal mucosa of chronic sinusitis patients.

STUDY DESIGN

Cohort study with randomized grouping.

METHODS

Chronic sinusitis patients awaiting endonasal sinus surgery were randomly divided into a study group and a control group. All patients underwent allergy studies and categorized as allergic or nonallergic. Patients in the study group were exposed unilaterally to fluticasone propionate nasal spray, 100 microg/day for 4 to 6 weeks before the planned surgery. The control group was not exposed to steroids. At the time of surgery, anterior ethmoid mucosa specimens were obtained. The samples were immunostained for CD3, MBP, CD68, elastase, and tryptase. In situ hybridization was used for the detection of interleukin (IL)-4, IL-5, and interferon gamma (IFN-gamma) mRNA. The results were compared between the treated and untreated sides of exposed patients, as well as with nontreated controls.

RESULTS

Twenty-one patients consented to participate in the study. The number of CD3-, MBP-, and tryptase-positive cells was significantly less in the treated and untreated sides of exposed patients, compared with unexposed controls. IL-4 and IL-5 mRNA were significantly downregulated in the treated side of allergic patients, as compared with nontreated patients. This effect could not be shown for IL-4 in nonallergic patients.

CONCLUSIONS

Topical steroid therapy had an anti-inflammatory effect on both allergic and nonallergic chronic sinusitis patients. The unilateral application of the steroid spray affected the contralateral side as well.

Sinonasal schneiderian papilloma

OBJECTIVE

Schneiderian papilloma of the paranasal sinuses is a locally aggressive benign epithelial tumour with malignant potential.

METHOD

A retrospective analysis of 72 patients as seen at our institution from 1978 to 1997 was conducted.

RESULTS

The most frequent symptoms at time of presentation were nasal obstruction, presence of a nasal mass, and nasal discharge. The most common sites of involvement were the maxillary antrum (58.3%), lateral nasal wall (41.7%) and ethmoid sinus (37.5%). Histologic examination confirmed all 72 instances of schneiderian papilloma, with 55/72 (76.4%) being of the inverted type, 13/72 (18.1%) being the fungiform type, and 4/72 (5.5%) being the cylindrical type. An associated malignancy or potential premalignant condition was present in 15 patients (20.8%), with 8 (11.1%) exhibiting dysplastic changes, 4 patients (5.5%) found to have carcinoma in situ, and 3 patients (4.2%) found to have invasive carcinoma. Conservative surgical excision was performed in 37 (51.4%) with more radical surgery, including lateral rhinotomy and medial maxillectomy performed in 35 (48.6%) patients. Recurrence was seen in 17/37 (45.9%) patients treated conservatively compared to 0/35 (0.0%) patients treated aggressively.

CONCLUSIONS

Our results indicate that more aggressive surgery is associated with a more definitive treatment and significantly less recurrence and, as such, is the management of choice in cases of schneiderian papilloma. Furthermore, our results indicate the need for long-term follow-up, and the applicability of sinus endoscopy in doing so.

Basement membrane material (hyaline globules) in synovial sarcoma. A case report with description of a potential diagnostic pitfall

BACKGROUND

Synovial sarcoma (SS), a malignant mesenchymal tumor, has a biphasic growth pattern characteristically. Histologically and cytologically the tumor can pose diagnostic difficulty when the epithelial component is predominant.

CASE REPORT

A 22-year-old female presented with a rapidly enlarging mass on the lower left side of the neck. Fine needle aspiration of the tumor yielded abundant, discohesive round-oval cells mingled with amorphous hyaline material, raising a suspicion of medullary carcinoma of the thyroid. In addition, air-dried, Giemsa-stained smears demonstrated rosettelike structures with central magenta globular material, mimicking adenoid cystic carcinoma. However, histologic examination of the excised tumor, including immunohistochemical and ultrastructural studies, proved it to be a typical SS with copious basement membrane accumulations.

CONCLUSION

The cytologic appearance of SS can be confusing. However, a false diagnosis may be avoided if adequate needle sampling is ensured and clinical correlation considered.

[Medical records audit in primary care clinics of the Israel Navy]

The primary care clinics of the Israeli Defense Forces are similar to those of the civilian health system, yet some characteristics are unique: Soldiers are a young, healthy population; their physicians are either serving in the reserves for short periods, or are primary care physicians of the regular army; and during military service the soldier is usually treated in several different primary care clinics. A detailed medical record facilitates communication between the various primary care physicians. As part of a 2-year quality assurance project all naval clinics in Israel were surveyed at 6-month intervals. From the clinic records, 685 encounters involving the 7 most common problems were randomly chosen. We evaluated the quality of the medical records of these encounters scoring them according to subjective, objective assessment and therapeutic and evaluative plan (SOAP) Each record was evaluated by 2 physicians and scored from 0 to 100, using fixed criteria. The score for the therapeutic and evaluative plan was significantly higher than that of the other parts of the medical record (80% vs. 55-59%, p < 0.001). The score of the primary care physicians was significantly higher than that of physicians of the reserves (73% vs. 63%, p < 0.001). Encounters involving upper respiratory tract infections and abdominal pain scored higher than those involving other common problems. The medical recording process has a fundamental role in medical care. Our findings suggest that the subjective, objective and assessment parts of naval medical records need improvement. Further studies might help improve the quality of primary medical care.

Syncytial variant of nodular sclerosing Hodgkin's disease presenting as a thyroid nodule. A case report

The fine needle aspiration cytology of a thyroid nodule in a 19-year-old female showed Reed-Sternberg (RS) cell variants in clusters, thereby suggesting the possibility of syncytial variant of nodular sclerosing Hodgkin's disease (NSHD). A similar picture was observed on imprint smears of an excised cervical lymph node, the histology of which confirmed the original diagnosis. Following chemotherapy, the nodule disappeared. The patient was spared major thyroid surgery. It is important to recognize the rare morphologic variants and unusual clinical presentations of common diseases in order to perform appropriate studies that will ensure that the patient receives the best clinical management. Morphologic clues that should arouse the cytopathologist's awareness of this rare variant of NSHD are presented.

The generation of an allospecific suppressor factor in culture

When mouse spleen cells were stimulated by irradiated allogeneic cells in a mixed lymphocyte culture for 96 hours, allospecific suppressor cells were generated that could inhibit the replicative processes when transferred to another MLR. When the primed cells were purified on Ficoll and incubated alone for another 24 hours, they released into the medium a subcellular factor which could also suppress MLR allospecifically. Evidence is provided that the cells which generate this factor arise by cooperation of at least two types of T-lymphocytes, one of which is the progenitor of the suppressor cell and the other an essential accessory cell. Adherent cells were shown to be also essential for the priming of suppressor lymphocytes.

Studies of allospecific suppressor cells in culture

Allospecific suppressor T cells can be generated by allostimulating thymus, spleen and lymph node cells in culture. Bone marrow cells do not yield suppressor lymphocytes. While the efficiency of thymocytes for suppressor cell generation decreases with the age of thymus donors, the efficiency of spleen increases with age. Generation of suppressor lymphocytes depends on cell replication and protein synthesis. The suppressor function as such does not require cell replication. Induction of suppressor T cells in culture requires cell to cell interaction of cortical type and medullar type T cells.

Studies on suppressor T cells in tolerance

(1) Evidence is provided that tolerance induced in mice to HSA depends on a suppressive mechanism which inhibits the responsiveness of potentially competent cells. (2) the suppression is apparently the function of suppressor T cells which are comparatively radiosensitive and are resistant to cortisone. (3) The cortisone resistant suppressor cells are apparently the progeny of cortisone-sensitive precursors, the differentiation of which into mature suppressors seems to be signalled by antigen. (4) The precursor lymphocytes are comparatively short functioning cells (about 14 days), while the mature suppressor T cells function for at least two months.

The mechanism of breakdown of immune tolerance to a protein antigen in rabbits

Rabbits made tolerant to human serum albumin (HSA) were hyperimmunized with either HSA or bovine serum albumin (BSA) incorporated in Freund's complete adjuvant. Eventually, anti-HSA antibodies could be demonstrated which represented most likely a boosted response to minor determinants to which the animals had not been made tolerant. This response was suppressed by a series of intravenous antigen injections and the animals relapsed into a state of unresponsiveness. Renewal of hyperimmunization with BSA in adjuvant did not terminate tolerance a second time, while identical treatment with suphanilated HSA did induce an anti-HSA response again. The theoretical aspects of tolerance breakdown are discussed in the light of these findings.

The kinetics of immune tolerance to human serum albumin induced in sublethally x-irradiated rabbits

Kinetic studies of immune tolerance induction to HSA in sublethally X-rayed rabbits revealed that tolerance can be induced in this system with small amounts of antigen which in non-irradiated animals would constitute small immunizing doses. This, however, depends on a proper schedule of antigen administration which has to be spread over the 8 weeks of post-radiation recovery, although tolerance can be induced by this method even when this antigen treatment is postponed as long as 4 weeks after X-irradiation.

Since the lymphoid system recovers rapidly from sublethal radiation injury, and since it was found that by the end of 4 weeks the lymphoid organs demonstrate good cellular repopulation, the conclusion was arrived at that the two processes, namely that of lymphoid recuperation and that of transition from susceptibility to tolerance into the state of immunocompetence, progress independently. These observations raise some questions relevant to theories of the cellular basis of immune tolerance.