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Putrik P, Grobler L, Lalor A, Ramsay H, Gorelik A, Karnon J, Parker D, Morgan M, Buchbinder R, O'Connor D. Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities. Cochrane Database Syst Rev 2024; 3:CD013880. [PMID: 38426600 PMCID: PMC10905654 DOI: 10.1002/14651858.cd013880.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
BACKGROUND The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents. OBJECTIVES Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. MAIN RESULTS We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.
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Affiliation(s)
- Polina Putrik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Liesl Grobler
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Aislinn Lalor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Primary and Allied Health Care, Monash University, Melbourne, Australia
| | - Helen Ramsay
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alexandra Gorelik
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan Karnon
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Deborah Parker
- Faculty of Health, The University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Morgan
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Rachelle Buchbinder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Denise O'Connor
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Tsakok T, Saklatvala J, Rispens T, Loeff FC, de Vries A, Allen MH, Barbosa IA, Baudry D, Dasandi T, Duckworth M, Meynell F, Russell A, Chapman A, McBride S, McKenna K, Perera G, Ramsay H, Ramesh R, Sands K, Shipman A, Burden AD, Griffiths CE, Reynolds NJ, Warren RB, Mahil S, Barker J, Dand N, Smith C, Simpson MA. Development of antidrug antibodies against adalimumab maps to variation within the HLA-DR peptide-binding groove. JCI Insight 2023; 8:e156643. [PMID: 36810251 PMCID: PMC9977494 DOI: 10.1172/jci.insight.156643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/13/2023] [Indexed: 02/23/2023] Open
Abstract
Targeted biologic therapies can elicit an undesirable host immune response characterized by the development of antidrug antibodies (ADA), an important cause of treatment failure. The most widely used biologic across immune-mediated diseases is adalimumab, a tumor necrosis factor inhibitor. This study aimed to identify genetic variants that contribute to the development of ADA against adalimumab, thereby influencing treatment failure. In patients with psoriasis on their first course of adalimumab, in whom serum ADA had been evaluated 6-36 months after starting treatment, we observed a genome-wide association with ADA against adalimumab within the major histocompatibility complex (MHC). The association signal mapped to the presence of tryptophan at position 9 and lysine at position 71 of the HLA-DR peptide-binding groove, with both residues conferring protection against ADA. Underscoring their clinical relevance, these residues were also protective against treatment failure. Our findings highlight antigenic peptide presentation via MHC class II as a critical mechanism in the development of ADA against biologic therapies and downstream treatment response.
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Affiliation(s)
- Teresa Tsakok
- Department of Medical and Molecular Genetics and
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- St John’s Institute of Dermatology, Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
| | | | - Theo Rispens
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, Netherlands
| | - Floris C. Loeff
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory, Amsterdam, Netherlands
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Annick de Vries
- Biologics Lab, Sanquin Diagnostic Services, Amsterdam, Netherlands
| | - Michael H. Allen
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Ines A. Barbosa
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - David Baudry
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Tejus Dasandi
- St John’s Institute of Dermatology, Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
| | - Michael Duckworth
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Freya Meynell
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Alice Russell
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Anna Chapman
- Department of Dermatology, Queen Elizabeth Hospital, London, United Kingdom
| | - Sandy McBride
- Department of Dermatology, Royal Free London National Health Service Foundation Trust, London, United Kingdom
| | - Kevin McKenna
- Department of Dermatology, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Gayathri Perera
- Department of Dermatology, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Helen Ramsay
- Department of Dermatology, Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - Raakhee Ramesh
- Department of Dermatology, Sandwell and West Birmingham National Health Service Trust, Birmingham, United Kingdom
| | - Kathleen Sands
- Department of Dermatology, East Kent Hospitals University National Health Service Foundation Trust, Kent, United Kingdom
| | - Alexa Shipman
- Department of Dermatology, Portsmouth Hospitals National Health Service Trust, Portsmouth, United Kingdom
| | | | - A. David Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Christopher E.M. Griffiths
- Dermatology Centre, Salford Royal National Health Service Foundation Trust, Manchester, United Kingdom
- The University of Manchester, Manchester Academic Health Science Centre, National Institute for Health Research Manchester Biomedical Research Centre, Manchester, United Kingdom
| | - Nick J. Reynolds
- Department of Dermatology, Royal Victoria Infirmary, Newcastle upon Tyne NHS Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Translational and Clinical Medicine, Faculty of Medical Sciences, Framlington Place, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard B. Warren
- Dermatology Centre, Salford Royal National Health Service Foundation Trust, Manchester, United Kingdom
- The University of Manchester, Manchester Academic Health Science Centre, National Institute for Health Research Manchester Biomedical Research Centre, Manchester, United Kingdom
| | - Satveer Mahil
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- St John’s Institute of Dermatology, Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
| | - Jonathan Barker
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- St John’s Institute of Dermatology, Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
| | - Nick Dand
- Department of Medical and Molecular Genetics and
- Health Data Research UK, London, United Kingdom
| | - Catherine Smith
- St John’s Institute of Dermatology, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- St John’s Institute of Dermatology, Guy’s and St Thomas’ National Health Service Foundation Trust, London, United Kingdom
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Ramsay H, Simon D, Steele E, Hebert A, Oleschuk RD, Stamplecoskie KG. The power of fluorescence excitation–emission matrix (EEM) spectroscopy in the identification and characterization of complex mixtures of fluorescent silver clusters. RSC Adv 2018; 8:42080-42086. [PMID: 35558801 PMCID: PMC9092091 DOI: 10.1039/c8ra08751b] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 12/10/2018] [Indexed: 12/17/2022] Open
Abstract
Silver and gold clusters have received a lot of recent attention for their use in biomedical imaging. However, crude solutions of clusters are often complex mixtures, leading to discrepancies in their identification and characterization; important factors in determining their utility in biological applications. In the present study, silver clusters were separated for analysis using reverse-phase high performance liquid chromatography, which has previously been implemented in the efficient separation of gold clusters. Using fluorescence excitation–emission matrix (EEM) spectroscopy, we have demonstrated that a certain family of glutathione-protected silver clusters, previously thought to be one optically distinct species, is better described as a complex mixture of at least three distinct silver cluster species, each possessing unique optical properties. Based on these findings, EEM spectroscopy can be implemented as a powerful technique for determining the purity of complex mixtures, especially when other techniques, including mass spectrometry, fail to provide adequate characterization of a given material. EEM spectroscopy can be implemented as a powerful technique for determining the purity of complex mixtures, especially when other techniques, including mass spectrometry, fail to provide adequate characterization of a given material.![]()
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Affiliation(s)
- H. Ramsay
- Department of Chemistry
- Queen's University
- Kingston
- Canada
| | - D. Simon
- Department of Chemistry
- Queen's University
- Kingston
- Canada
| | - E. Steele
- Department of Chemistry
- Queen's University
- Kingston
- Canada
| | - A. Hebert
- Department of Chemistry
- Queen's University
- Kingston
- Canada
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Kelleher I, Ramsay H, DeVylder J. Psychotic experiences and suicide attempt risk in common mental disorders and borderline personality disorder. Acta Psychiatr Scand 2017; 135:212-218. [PMID: 28185269 DOI: 10.1111/acps.12693] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Recent research has demonstrated a strong relationship between psychotic experiences and suicidal behaviour. No research to date, however, has investigated the role of borderline personality disorder (BPD) in this relationship, despite the fact that BPD is highly comorbid with common mental disorders and is associated with both recurrent suicidal behaviour and psychotic experiences. This paper examined the relationship between psychotic experiences and suicide attempts, including interrelationships with BPD and common mental disorders. METHOD We used the 2007 Adult Psychiatric Morbidity Study, a stratified, multistage probability sample of households in England, which recruited a nationally representative sample aged 16 years and older. Participants were assessed for common mental disorders, BPD (clinical and subclinical), suicidal behaviour, and psychotic experiences. RESULTS Approximately 4% of the total sample (n = 323) reported psychotic experiences. Psychotic experiences were associated with increased odds of suicide attempts in individuals with BPD (OR = 2.23, 95% CI = 1.03-4.85), individuals with a common mental disorder (OR = 2.47, 95% CI = 1.37-4.43), individuals without a common mental disorder (OR = 3.99, 95% CI = 2.47-6.43), and individuals with neither a common mental disorder nor BPD (OR = 3.20, 95% CI = 1.71-5.98). CONCLUSION Psychotic experiences are associated with high odds of suicidal behaviour in individuals with and without psychopathology. This relationship is not explained by clinical or subclinical BPD.
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Affiliation(s)
- I Kelleher
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H Ramsay
- Department of Psychiatry, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Psychiatry, University of Oulu, Oulu, Finland
| | - J DeVylder
- Department of Social Work, University of Maryland, Baltimore, MD, USA
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5
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Affiliation(s)
- J P Vasama
- Department of Otolaryngology, Helsinki University Central Hospital, Finland
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Kuleshov Y, Fawcett R, Qi L, Trewin B, Jones D, McBride J, Ramsay H. Trends in tropical cyclones in the South Indian Ocean and the South Pacific Ocean. ACTA ACUST UNITED AC 2010. [DOI: 10.1029/2009jd012372] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Walker E, Mayes B, Ramsay H, Hewitt H, Bain B, Christie CDC. Socio-demographic and clinical characteristics of Jamaican adolescents with HIV/AIDS. W INDIAN MED J 2004; 53:332-8. [PMID: 15675500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND Clinical symptomatology and socio-demographic factors have not been characterized in Jamaican adolescents with HIV/AIDS. METHODS We studied these factors in 25 HIV-positive Jamaican adolescents, 10-19 years of age, who were seen at the Centre for HIV/AIDS Research, Education, and Services (CHARES) between the years 1996 and 2002. Data were collected between June 2003 and August 2003 from CHARES social work files and The University Hospital of the West Indies (UHWI) medical records. Microsoft Excel was used to compile descriptive statistics for the data. RESULTS The mean age of HIV diagnosis was 15.6 (+/-3.09) years, and the mean age of enrollment at CHARES was 16.3 (+/- 2.9) years. Consensual sexual intercourse was the most prominent mode of transmission (56%), followed by vertical transmission (16%), unknown (16%), forced sexual intercourse (8%), and blood transfusion (4%). The predominant clinical presentations among these adolescent patients were generalized dermatitis (77.2%) and lymphadenopathy (50%). Of the patients for whom clinical status could be determined, 70% were "Severely Symptomatic ". Of these patients only 14% were recommended for antiretroviral treatment. CONCLUSIONS These findings reinforce the need to globally incorporate the goal of the 2002 Joint United Nations Programme on HIV/AIDS (UNAIDS) "to provide reproductive health services, including low-cost or free condoms, voluntary counselling and testing, diagnosis and treatment of sexually transmitted diseases and infections for adolescents in order to effectively prevent HIV infection " (1).
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Affiliation(s)
- E Walker
- The University of West Indies, Kingston 7, Jamaica
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Palva T, Pääkkö P, Ramsay H, Chrobok V, Simáková E. Apoptosis and regression of embryonic mesenchyme in the development of the middle ear spaces. Acta Otolaryngol 2003; 123:209-14. [PMID: 12701742 DOI: 10.1080/0036554021000028105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Apoptosis was studied using temporal bones from three fetuses representing different times of gestation and from three neonates. Paraffin-embedded sections 20-microm thick were studied using the terminal deoxynucleotide transferase-mediated dUTP nick-end labeling method based on 3'-end-labeling of fragmented DNA. Phenotyping of the immune cells was performed using regular monoclonal antibodies. In the bone marrow the granulocyte series dominated and the number of cells in the macrophage series was noticeably fewer, with apoptotic cells occurring in both. In the embryonic mesenchyme, solitary apoptotic cells occurred in all locations in both the fetuses and neonates. Apoptosis is a basic factor in the regression of embryonal mesenchyme, but may not be preprogrammed. Basic scientific data obtained from modified tissue cultures show that mechanical forces cause cells to switch between different genetic programs. It is suggested that the act of swallowing causes periodic changes in the amniotic fluid pressure and provides the necessary force for regression of the mesenchyme by apoptosis.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Helsinki, Finland.
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Mattila PS, Ramsay H. [Abundant hemorrhage in the ear after tympanostomy]. Duodecim 2002; 115:89,91. [PMID: 11842799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- P S Mattila
- HYKS:n korvaklinikka, Haartmaninkatu 4 E 00290 Helsinki
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Deloukas P, Matthews LH, Ashurst J, Burton J, Gilbert JG, Jones M, Stavrides G, Almeida JP, Babbage AK, Bagguley CL, Bailey J, Barlow KF, Bates KN, Beard LM, Beare DM, Beasley OP, Bird CP, Blakey SE, Bridgeman AM, Brown AJ, Buck D, Burrill W, Butler AP, Carder C, Carter NP, Chapman JC, Clamp M, Clark G, Clark LN, Clark SY, Clee CM, Clegg S, Cobley VE, Collier RE, Connor R, Corby NR, Coulson A, Coville GJ, Deadman R, Dhami P, Dunn M, Ellington AG, Frankland JA, Fraser A, French L, Garner P, Grafham DV, Griffiths C, Griffiths MN, Gwilliam R, Hall RE, Hammond S, Harley JL, Heath PD, Ho S, Holden JL, Howden PJ, Huckle E, Hunt AR, Hunt SE, Jekosch K, Johnson CM, Johnson D, Kay MP, Kimberley AM, King A, Knights A, Laird GK, Lawlor S, Lehvaslaiho MH, Leversha M, Lloyd C, Lloyd DM, Lovell JD, Marsh VL, Martin SL, McConnachie LJ, McLay K, McMurray AA, Milne S, Mistry D, Moore MJ, Mullikin JC, Nickerson T, Oliver K, Parker A, Patel R, Pearce TA, Peck AI, Phillimore BJ, Prathalingam SR, Plumb RW, Ramsay H, Rice CM, Ross MT, Scott CE, Sehra HK, Shownkeen R, Sims S, Skuce CD, Smith ML, Soderlund C, Steward CA, Sulston JE, Swann M, Sycamore N, Taylor R, Tee L, Thomas DW, Thorpe A, Tracey A, Tromans AC, Vaudin M, Wall M, Wallis JM, Whitehead SL, Whittaker P, Willey DL, Williams L, Williams SA, Wilming L, Wray PW, Hubbard T, Durbin RM, Bentley DR, Beck S, Rogers J. The DNA sequence and comparative analysis of human chromosome 20. Nature 2001; 414:865-71. [PMID: 11780052 DOI: 10.1038/414865a] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The finished sequence of human chromosome 20 comprises 59,187,298 base pairs (bp) and represents 99.4% of the euchromatic DNA. A single contig of 26 megabases (Mb) spans the entire short arm, and five contigs separated by gaps totalling 320 kb span the long arm of this metacentric chromosome. An additional 234,339 bp of sequence has been determined within the pericentromeric region of the long arm. We annotated 727 genes and 168 pseudogenes in the sequence. About 64% of these genes have a 5' and a 3' untranslated region and a complete open reading frame. Comparative analysis of the sequence of chromosome 20 to whole-genome shotgun-sequence data of two other vertebrates, the mouse Mus musculus and the puffer fish Tetraodon nigroviridis, provides an independent measure of the efficiency of gene annotation, and indicates that this analysis may account for more than 95% of all coding exons and almost all genes.
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Affiliation(s)
- P Deloukas
- The Wellcome Trust Sanger Institute, Hinxton, Cambridge CB10 1SA, UK.
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Abstract
HYPOTHESIS An influx of amniotic fluid cellular content (AFCC) into the middle ears during birth may lead to the development of a chronic inflammatory process in the form of varying amounts of granulation tissue even if signs of otitis media are absent. This foreign body neonatal otitis media may predispose the child to recurrent otitis media. BACKGROUND Foreign body neonatal otitis media caused by AFCC was described by Aschoff and elaborated by Wittmaack 100 years ago. Recent studies have shown how AFCC spreads to various middle ear compartments and causes histologic changes, the severity of which is related to the amount of AFCC. Specific elements become phagocytized after the first months of life but have caused the formation of inflammatory polyps and granulation tissue with round cell secretions in the meantime. METHODS Ten temporal bones from the Temporal Bone Foundation, derived from infants aged 5 months to 1 year 11 months, were serially sectioned at 20 microm, saved at 0.2-mm intervals, numbered, and stained with hematoxylin and eosin. Every slide was studied for the presence, nature, and stage of pathologic tissue changes of the middle ear and the mastoid antrum. RESULTS Pseudocystic granulation tissue was massive in the temporal bone of the 8-month-old child born through thick meconium. Severe changes were present in the temporal bones of two infants aged 5 months, one of which showed traces of AFCC. In the temporal bones of two older children, long-standing changes were minor, one of them still showed traces of AFCC. Fresh acute changes and long-standing histologic changes occurred side by side. CONCLUSIONS Neonatal otitis media caused by AFCC can give rise to extensive granulation tissue and round cell secretion, which is likely to make the ear susceptible to infectious otitis media. Cumulative development of granulation tissue as a result of infection may lead to blockage of attic aeration and drainage pathways, causing irreversible adhesive otitis media. A data base should be formed of all neonates born through meconium-stained amniotic fluid to allow a comparison with those born through clear fluids. Surgery with the creation of auxiliary aeration pathways becomes advisable in the treatment of ears with massive development of granulation tissue.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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Affiliation(s)
- J P Vasama
- Department of Otolaryngology, Helsinki University Central Hospital, Finland
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Abstract
In this study, 24 temporal bones with an age range from neonates to 23-month-old infants were serially sectioned and studied for the spread and fate of amniotic fluid cellular content (AFCC) in the middle ear and mastoid. Most children had had either a moderate or massive contamination. AFCC clusters were found to spread to all compartments, with the sites of predilection being the stapes region, the lower lateral attic and the tympanic isthmus. AFCC created an intensive foreign body giant cell reaction and the foreign material practically dissolved in 5 months as a result of the organization process. Tiny remnants of AFCC appeared as late as 15 months after birth. It seems likely that AFCC contamination predisposes the ears to recurring otitis media. The sequalae of the massive granulation tissue development involves obliteration of Prussak's space and its aeration routes, as well as blockage of the tympanic isthmus, leading to extensive disease in the major attic compartments.
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Affiliation(s)
- H Ramsay
- Department of Otolaryngology, University of Helsinki, Finland
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14
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Abstract
OBJECTIVE the purpose of this study was to document the aeration and drainage pathways of Prussak's space. METHODS 55 temporal bones with an age range from neonate to 11 years of age were serially sectioned to 20 microns, every 10th section was saved and stained by Hematoxylin eosin. Each consecutive section was studied as to the connections of Prussak's space to adjacent compartments and measurements of the dimensions were made for both Prussak's space and its aeration pathways. RESULTS the classic aeration pathway via the posterior pouch, as described by Prussak in 1867, was found in 34 ears (62%). In 19 (36%), aeration occurred superior to the posterior pouch in the region of the lower lateral attic and the upper mesotympanum. In these ears the posterior pouch had formed, but its superior limit ended blindly in the tympanic membrane. In two temporal bones the aeration pathway was from the anterior pouch and in these cases also a blind posterior pouch had developed. In one temporal bone an auxiliary pathway in addition to the route via the posterior pouch was through the roof (the lateral malleal ligamental fold) of Prussak's space to the overlying lateral malleal space. The height of the posterior pouch varied with a range from 0.5 to 2.4 mm, and the greatest width, which was towards the posterior tympanic spine, varied from 1.6 to 3.2 mm. The superiorly blind posterior pouch was shorter, ranging from 0.4 to 1.2 mm in height. The most frequent route of the chorda tympani nerve was running from 0.5 to 1 mm medial to the posterior malleal ligament in the anterior half of the pouch, joining it posteriorly, or it was connected to it by a short fold, 37 ears (67%). In 18 cases (33%) the chorda was surrounded by its own fold, thus entirely separate from the posterior malleal ligamental fold during its entire course across the tympanum. CONCLUSIONS we have made a detailed documentation of the aeration and drainage pathways of Prussak's space and the findings concur, with important modifications, with Prussak's original description. There is no evidence for contemporary claims that Prussak's space would be aerated superiorly between the lateral incudal and malleal folds. Prussak's space and its aeration pathway is an unit of its own, entirely separate of the major epitympanic compartments which are aerated via the tympanic isthmus. Due to frequent disease processes in the lower lateral attic and posterior mesotympanum, Prussak's space and its aeration pathway are likely to become blocked. This may lead to obliteration of Prussak's space and to the development of retraction pocket or papillary ingrowth cholesteatoma.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University Central Hospital, Haartmanstr. 4, fin-00290 Helsinki, Finland
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15
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Konttinen YT, Ramsay H, Hietanen J, Sorsa T, Nordstrom D. Otitis externa sicca/fibrotising external otitis (FEO) as a complication of Sjögren's syndrome. Clin Exp Rheumatol 2000; 18:746-8. [PMID: 11138341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Sjögren's syndrome (SS) is a condition characterized by sicca symptoms and by autoimmune features. We describe two SS patients with otitis externa fibroticans/sicca. One of these 2 patients developed a lesion of the tympanic membrane making it necessary to perform a tympantomy and meatoplasty. Our findings suggest firstly that the epithelial cell-mediated secretion of lamellar bodies and the production of the permeability barrier are defective in SS. Secondly, local moisturing and/or topical corticosteroid treatment in SS patients with sicca symptoms in the auditory canal could help to avoid reconstructive surgical treatment.
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Affiliation(s)
- Y T Konttinen
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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16
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Palva T, Johnsson LG, Ramsay H. Attic aeration in temporal bones from children with recurring otitis media: tympanostomy tubes did not cure disease in Prussak's space. Am J Otol 2000; 21:485-93. [PMID: 10912692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
HYPOTHESIS Blockage of the aeration pathways to the attic may cause circumscribed or widespread alterations that are difficult to diagnose clinically. The narrow route via the posterior pouch to Prussak's space is especially vulnerable to obstruction in recurring otitis media. BACKGROUND Recent studies of the epitympanic diaphragm and compartments have clarified the anatomy of the attic aeration and drainage pathways and emphasized the role of their patency in the healing process of middle ear infections. In neonatal otitis media, the amniotic fluid cellular content (AFCC) has proved to be a good indicator in outlining the areas where inflammation products concentrate, possibly causing early blockage of ventilation. METHODS Twenty-eight temporal bones from 14 children were studied; 4 of these children had experienced bilateral recurring otitis media. In the latter group, 1 ear was studied by microdissection and the other by serial sectioning. RESULTS Prussak's space was involved in all 4 pairs of bones and either contained thick mucus, contained secretion in the process of organization, or was obliterated. The tympanic isthmus was fully obstructed in 1, partially blocked in 2, and open in 5 specimens. CONCLUSIONS If a thick mature connective tissue mass develops under the epidermal layer of Shrapnell's membrane during an obliteration process of Prussak's space, the condition may stay stable and benign. Severe retraction of Shrapnell's membrane represents a likely forerunner of a retraction pocket cholesteatoma. Systematic otomicroscopy allows early detection, and cure can be achieved by minor surgery. In some children, despite the treatment of recurring otitis media with ventilation tubes, the attic and mastoid can be extensively involved, necessitating atticomastoidectomy and the creation of new pathways for attic aeration.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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17
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Palva T, Ramsay H. Endoscopy of the middle ear. Am J Otol 2000; 21:288-9. [PMID: 10733200 DOI: 10.1016/s0196-0709(00)80025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Palva T, Northrop C, Ramsay H. Effect of amniotic fluid cellular content on attic aeration pathways: histologic observations of infants aged 2 to 4 months. Am J Otol 2000; 21:62-70. [PMID: 10651437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
HYPOTHESIS The tissue-fixed amniotic fluid cellular content (AFCC) in the middle ear and mastoid antrum causes foreign body type reactions that may later severely restrict the aeration pathways to the main attic and to Prussak's space. BACKGROUND It was shown by Aschoff 100 years ago that AFCC remained in the neonate ears and caused sterile otitis media. Recent data show that children born through thick meconium are at risk for large quantities of AFCC entering the middle ear cleft, the ensuing inflammatory reaction being related to the amount of AFCC. Spread of AFCC in the neonate occurred along the aeration pathways with corresponding tissue fixation but further systematic data in young infants are lacking. METHODS Five temporal bones of three infants aged 2 to 4 months were embedded in celloidin, serially sectioned at 20 microns, and every 10th section stained with Hematoxylin and eosin and mounted on slides. All slides were studied and relevant details of aeration pathways and all compartments photographed. RESULTS The histologic changes were characterized by the development of masses of pseudocystic granulation tissue, with some remnants of the original AFCC, mainly in the form of fragments of hair. The tympanic isthmus was involved to varying extent, maximally to half of its size. Posterior tympanum and the stapes region had masses of fresh granulation tissue, the maturing of which might cause marked indrawing of the posterior pars tensa and further reduction of the tympanic isthmus. Aeration of Prussak's space was severely involved in two bones, favored by the narrow pathway through the posterior pouch. Features of recent acute or secretory otitis media were associated with the early changes caused by AFCC. CONCLUSIONS The granulation tissue in this age group is immature and its final fate is decided by the nature of the future ear disease. If the AFCC contamination is slight, the granulation tissue after maturing may appear only in the form of thin cords and sheets, a frequent chance finding in ear surgery. Large amount of AFCC may lead to chronic inflammation, which may predispose the child to recurring middle ear infections during infancy. Further histologic and clinical studies in older infants and young children are needed to find out the final outcome after a massive AFCC contamination of the new-born middle ear.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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19
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Palva T, Northrop C, Ramsay H. Supratubal recess in neonates and infants. Int J Pediatr Otorhinolaryngol 1999; 50:99-107. [PMID: 10576609 DOI: 10.1016/s0165-5876(99)00229-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The fetal development of the supratubal recess and of the tensor fold was described by Hammar in 1902. Recent studies claim that neither structure is regularly present in neonates and controversial views have been presented of the separation of the anterior attic and supratubal recess. The objective of this study is to clarify these issues. METHODS Twenty temporal bones, 13 neonate and seven infant, were studied either by microdissection of fresh (five bones) or formalin stored (two) specimens, or by serial sectioning after formalin fixation and decalcification (13 bones). The serial sections were cut to 20 microm, every tenth section saved and stained by hematoxylin eosin. RESULTS In all specimens the separating structure between the anterior attic and supratubal recess was the tensor fold. It was intact in 15 bones while five showed a membrane defect. In vertically oriented folds the recess was deep and in horizontally oriented folds shallow. In 19 bones the tensor fold inserted superiorly to a soft tissue insertion ring of varying thickness and only once directly to a shallow transverse crest. The breadth of the tensor fold near the tensor tendon showed only little variation, whereas its height, and the distance from the tensor tendon to the supratubal tegmen varied in larger limits. CONCLUSIONS The tensor fold and the supratubal recess are present already in the neonate and thus develop during the fetal period. The shape of the recess is determined by the fold direction and its size grows in conjunction with the other middle ear spaces. The transverse crest has no apparent influence on the position of the tensor fold. The easiest method to study the integrated whole of the anterior attic and supratubal recess is to view them alternatively from the anterior and superior microdissection approaches. Clinically, removal of the tensor fold creates an efficient additional aeration route from the supratubal recess to the anterior attic.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, Helsinki University Central Hospital, Finland
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20
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Hedström J, Grenman R, Ramsay H, Finne P, Lundin J, Haglund C, Alfthan H, Stenman UH. Concentration of free hCGbeta subunit in serum as a prognostic marker for squamous-cell carcinoma of the oral cavity and oropharynx. Int J Cancer 1999; 84:525-8. [PMID: 10502732 DOI: 10.1002/(sici)1097-0215(19991022)84:5<525::aid-ijc14>3.0.co;2-q] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This study was conducted to evaluate the clinical usefulness of serum hCGbeta in the diagnosis and prognosis of patients (n = 59) with cancers of the oral cavity and oropharynx. As a reference marker we used squamous-cell carcinoma antigen (SCCAg). A blood sample was obtained from all patients before primary surgery. Serum hCGbeta was determined by a time-resolved immunofluorometric assay (IFMA) and SCCAg by a solid phase immunoenzymometric assay. Elevated preoperative hCGbeta levels were observed in 8 (14%) and elevated SCCAg in 12 (20%) out of 59 patients. Patients with preoperatively elevated hCGbeta had a shorter recurrence-free survival when compared with those with normal hCGbeta levels (log-rank Chi-squared = 6.83, p =.009), and the risk-ratio for recurrence during follow-up for those was 3.6 (95% CI = 1.29-9.94). In a Cox multivariate model hCGbeta (p = 0.039) and stage (p = 0.044) were independent prognostic factors. SCCAg showed no correlation with recurrence-free survival. We conclude that determination of hCGbeta in serum is a potential marker in the prognostic evaluation of patients with SCC of the oral cavity and oropharynx.
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Affiliation(s)
- J Hedström
- Department of Otorhinolaryngology, University of Helsinki, Helsinki, Finland.
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21
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Jerome CP, Johnson CS, Vafai HT, Kaplan KC, Bailey J, Capwell B, Fraser F, Hansen L, Ramsay H, Shadoan M, Lees CJ, Thomsen JS, Mosekilde L. Effect of treatment for 6 months with human parathyroid hormone (1-34) peptide in ovariectomized cynomolgus monkeys (Macaca fascicularis). Bone 1999; 25:301-9. [PMID: 10495134 DOI: 10.1016/s8756-3282(99)00166-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A potential negative side effect of intermittent parathyroid hormone (PTH) therapy to treat osteoporosis is the loss of cortical bone concomitant with increased cancellous bone mass. We addressed this issue by studying the effects of PTH on whole-body, axial, and appendicular bone mass in an animal model with haversian cortical bone remodeling. Ovariectomized, young adult female cynomolgus monkeys were assigned to placebo (n = 9) or PTH groups (n = 10). The PTH group received 10 microg/kg synthetic human PTH(1-34) peptide by subcutaneous injection, 3 days/week for 6 months, and the placebo group received vehicle. Multiple endpoints of bone mass, strength, and turnover in the axial and appendicular skeleton were assessed, including dual-energy X-ray absorptiometry (DEXA), quantitative computed tomography (qCT), analysis of serum (calcium, phosphorus, alkaline phosphatase, osteocalcin, and tartrate-resistant acid phosphatase) and urinary (calcium and creatinine) biomarkers, histomorphometry, and biomechanical testing. Compared with placebo-treated animals, PTH-treated monkeys had no change in whole-body bone mass, but a 6.7% increase in spinal areal bone mineral density (aBMD) was observed. Cortical bone mass measured by qCT at appendicular sites was not affected by PTH treatment, but there were significant increases in cancellous bone mass in the proximal tibia, and a similar trend in the distal radius. Small, transient increases in serum and urinary calcium were observed, but there were no treatment-related effects on other biochemical endpoints. Increased bone formation rate (BFR/BV) in the midradius and midfemur was accompanied by a nonsignificant increase in midfemur porosity. Increased vertebral cancellous bone volume (BV/TV) was associated with greater trabecular and interstitial thickness with no effect on wall thickness. Increases in bone strength were observed in both axial (vertebral maximum stress and load at fracture) and appendicular (femoral neck fracture load) skeleton. Together, these results indicate that PTH therapy in the cynomolgus monkey results in a net gain of spinal and appendicular cancellous bone mass with no adverse effect on cortical bone.
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Affiliation(s)
- C P Jerome
- SkeleTech, Inc., Bothell, WA 98021, USA.
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22
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Abstract
Six full-term neonatal temporal bones, with meconium contaminated amniotic fluid aspiration of varying degrees, were serially sectioned at 20 microm and every tenth section was stained by hematoxylin eosin and mounted on slides. All stained sections were studied, the data recorded and relevant details of all compartments photographed. In addition, four normal neonate temporal bones were studied, one by serial sectioning and three by microdissection. The lateral incudomalleal and tensor folds were present in all, membrane defects in the tensor fold were seen in two normal ears. Three ears in the aspiration group had much fetal tissue present rendering Prussak's space small. Four ears with aspiration had remnants of incus intercrural (medial) folds. The amniotic fluid cellular content (AFCC) was sparse or nonexistent in the supratubal recess, Prussak's space and hypotympanum. It concentrated to the areas around the stapes, to sinus tympani and round window niche, to lower lateral attic and posterior pouch, medial attic and in lesser amounts to superior attic, mastoid antrum and air cells. Massive amounts of AFCC in tympanic isthmus and posterior pouch may lead to formation of granulation tissue and blockage of the aeration pathways to attic proper and to Prussak's space. These changes may initiate the development of chronic secretory otitis media in infants.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, Helsinki University Central Hospital, Finland
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23
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Palva T, Ramsay H. Chronic inflammatory ear disease and cholesteatoma: creation of auxiliary attic aeration pathways by microdissection. Am J Otol 1999; 20:145-51. [PMID: 10100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
HYPOTHESIS The attic compartments, except for Prussak's space, are aerated through the tympanic isthmus. The aim of this study was to develop aeration pathways that would bypass the isthmus in surgery for chronic inflammatory ear disease and cholesteatoma. BACKGROUND Microdissection of the epitympanum has shown that the anterior attic and the supratubal recess are separated by the tensor fold, the excision of which creates a large new aeration pathway. METHODS Earlier surgical experience was reexamined as to the access to the tensor fold. Twenty temporal bones were dissected to create clinically useful new surgical routes for tensor fold removal in the presence of an intact ossicular chain. RESULTS An endaural atticotomy, extended to the supratubal recess, allows excision of the tensor fold; however, the excision must be performed blindly. Cutting the neck of the malleus to allow lateral lifting of the manubrium exposes the tensor tendon and allows rapid excision of the fold. The elasticity of the tendon assists in approximation of the cut edges. In canal wall up surgery, removal of the lateral attic bone until the root of the zygoma exposes the anterior surface of the head of the malleus and the lateral portion of the transverse crest. Drill-out of the crest leads directly to the posterior side of the tensor fold, allowing its excision under direct vision. Thinning of the attic bone lateral to the body and short process of the incus allows simultaneous removal of the lateral incudomalleal fold. CONCLUSIONS When the ossicular chain is discontinuous, tensor fold resection can be made under direct vision. With an intact chain, cutting of the neck of the malleus used in tympanic glomus tumors causes no hearing changes, allows complete fold excision, and is adaptable to chronic ear surgery. The frontolateral attic route for removal of tensor fold, together with the lateral incudomalleal fold, can be used in the canal wall up surgery to improve attic aeration.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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24
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Abstract
Although ovariectomized cynomolgus monkeys are used extensively for studies examining perimenopausal changes in the skeleton, very little is known about the changes that occur naturally during growth and aging in these animals. To evaluate the changes in bone during growth and aging in female cynomolgus monkeys, 29 monkeys ranging from 3 years to >22 years of age were given a bone fluorochrome label and iliac biopsies were collected. Serum and urine were collected at the time of biopsy to determine alkaline phosphatase (ALP), osteocalcin, tartrate-resistant acid phosphatase (TRAP), serum and urinary calcium, estradiol, urinary creatinine, and urinary CrossLaps levels. The biopsies from 8 young (3-4 years of age), 13 mature (11-16 years of age) and 8 old (>22 years of age) were analyzed histomorphometrically. ALP, TRAP, and urinary CrossLaps levels were lower in the mature and old monkeys when compared with the young group. Urinary calcium/urinary creatinine levels increased with age. Bone volume (BV/TV), trabecular number (Tb.N), bone formation rate (BFR), and activation frequency (Ac.f) were greatest in the young monkeys and declined in the older groups. The biomarker and histomorphometric indices in the young animals reflect the growth that was occurring in this group. The older monkeys do not appear to differ significantly between 10 and 22 years of age.
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Affiliation(s)
- C J Lees
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1040, USA.
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25
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Ramachandran S, Lear JT, Ramsay H, Smith AG, Bowers B, Hutchinson PE, Jones PW, Fryer AA, Strange RC. Presentation with multiple cutaneous basal cell carcinomas: association of glutathione S-transferase and cytochrome P450 genotypes with clinical phenotype. Cancer Epidemiol Biomarkers Prev 1999; 8:61-7. [PMID: 9950241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
We previously reported associations between numbers of basal cell carcinomas (BCCs) and glutathione S-transferase (GSTM1 and GSTT1) and cytochrome P450 (CYP2D6) genotypes. Thus, although GSTM1 AB is protective, GSTM1 null, GSTT1 null, and CYP2D6 EM are associated with increased numbers of lesions. Here, we examine the hypothesis that these genotypes are associated with high-risk subgroups. The subgroup studied comprised 119 patients with more than one previously unidentified BCC at first or later presentations [multiple presentation phenotype (MPP)]. These patients were part of a group of 773 BCC patients that also included 567 patients with one BCC and 87 patients with only one lesion at each presentation [single presentation phenotype (SPP)] but who developed multiple BCCs. The number of tumors in the MPP was significantly greater than that in the SPP groups. In the MPP but not SPP patients, GSTM1 AB, GSTT1 null, and CYP2D6 EM were significantly associated with BCC numbers, suggesting that previously observed associations reflect the influence of these genes only in the MPP cases. There was no evidence that MPP patients had received more UV exposure. We also determined whether the increased numbers of BCC in the MPP cases reflects an association with the truncal tumor phenotype. The values of the rate ratios indicated that the MPP is a marker for the risk of many BCCs, although the combination of MPP and a truncal tumor is a higher-risk phenotype. The data demonstrate the heterogeneity in BCC patients, which reflects differences in genetic factors that determine skin response to UV.
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Affiliation(s)
- S Ramachandran
- Clinical Biochemistry Research Laboratory, School of Postgraduate Medicine, Keele University, Staffordshire, England
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26
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Affiliation(s)
- H Ramsay
- School of Philosophy, La Trobe University, Faculty of Humanities, VIC 3083, Bundoora, Australia
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27
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Palva T, Ramsay H, Böhling T. Lateral and anterior view to tensor fold and supratubal recess. Am J Otol 1998; 19:405-414. [PMID: 9661747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
HYPOTHESIS The aim of this study was to find suitable methods for basic anatomic evaluation of the supratubal recess and the anterior surface of the tensor fold. BACKGROUND The current method of superior microdissection via the middle fossa floor provides a good picture of the anatomy and pathology of the epitympanum, but the supratubal recess can be evaluated only after excision of the tensor fold. Postinflammation changes cannot be examined accurately because destruction of the tensor fold necessarily alters the anatomic details. METHODS Eight temporal bones were studied via a lateral and 14 via an anterior approach, both complemented by the superior microdissection. Data on 51 earlier superior dissections were reevaluated as to the state of the supratubal recess. Histology was documented from eight biopsy specimens and of four serially sectioned temporal bones, two normal and two infected. RESULTS The lateral route offered a good view to the tensor tendon and lower portion of the tensor fold, but the anterior malleal ligament obstructed the view to the fold's upper portion. The anterior route offered excellent visibility to the anterior pouch, mesotympanum, tensor fold, and the whole supratubal recess. The tensor fold was mostly fixed superiorly to the bony roof with a narrow or broad soft band of composite tissue, infrequently to the transverse crest directly. Inflammatory changes spread from the tympanic isthmus region to the supratubal space over the fold and, if extensive, formed broad inflammatory and scar tissue bands between the fold and the anterior bony wall. CONCLUSIONS The supratubal recess and the mesotympanum can best be evaluated via the anterior approach, which should be added to the temporal bone microdissection program. It serves well as the starting route, followed by the conventional superior dissection of the epitympanum. The knowledge gained is indispensable in surgery for chronic otitis media for creation of a large common middle ear air space and functioning aeration pathways.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, Helsinki University Central Hospital, Finland
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28
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Abstract
A series of 80 temporal bones included four specimens from infection-free new-born children. The microdissections showed that the epitympanic diaphragm in the new-born consists, in addition to the position fixed ligamental folds and ossicles, of only two position changing duplicate folds. These were the lateral incudomalleal fold, separating the upper and lower lateral attics, and the tensor fold, separating the anterior epitympanum from the supratubal recess. All other duplicate folds present during the fetal development had disappeared, a finding in accordance with the study on fetuses by Hammar in 1902 and with our own microdissection findings in normal adult temporal bones. Folds in other locations, even if until lately considered as participants of a normal epitympanic diaphragm, are of inflammatory origin.
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Affiliation(s)
- T Palva
- Helsinki Ear, Nose and Throat Hospital, University of Helsinki, Finland
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29
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Pitkäranta A, Carpén O, Ramsay H. Fibromyxoma of the Temporal Bone. Otolaryngol Head Neck Surg 1997; 117:S201-3. [PMID: 9419148 DOI: 10.1016/s0194-59989770102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- A Pitkäranta
- Department of Otolaryngology, University of Helsinki, Finland
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30
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Affiliation(s)
- A Pitkäranta
- Department of Otolaryngology, University of Helsinki, Finland
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31
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Palva T, Ramsay H, Böhling T. Tensor fold and anterior epitympanum. Am J Otol 1997; 18:307-16. [PMID: 9149823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
HYPOTHESIS The aim of this study was to investigate the anatomy and pathology of the anterior epitympanum and of the tensor fold. BACKGROUND Early studies reported data that are primarily still relevant, but contemporary reports present conflicting data, including several erroneous concepts. METHODS Fifty-one temporal bones were dissected, and the anatomic details were photographed in 42 normal and nine infected bones. Histology was documented from seven serially sectioned bones, five normal and two infected. RESULTS The tensor fold formed the frontal wall of the anterior epitympanum between tensor tendon and attic bony wall, the anterior insertion consisting of composite connective and fatty tissue with some bone trabeculae. The transverse crest was posterior to it and extended from the anterior tympanic spine to the facial canal. The tensor fold angle in 78% of the specimens was between 45 degrees and 80 degrees, seldom horizontal, and the size of the supratubal recess (or space) increased as the fold angle increased. In 14 ears (27%) the fold had a membrane defect connecting the two spaces. Blockade of the tympanic isthmus caused inflammatory obliteration of the anterior epitympanum when the tensor fold was intact. CONCLUSIONS The anterior epitympanum, a closed space around the anterior half of the head of the malleus, is normally closed by an intact tensor fold, but about one fourth of ears may show membrane defects. Aeration occurs via the tympanic isthmus through a constriction formed by the head of the malleus with the medial attic wall. In surgery for ears with epitympanal pathology, incus transposition should be combined with resection of the thin portion of the tensor fold for safeguarding permanent attic aeration.
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Affiliation(s)
- T Palva
- Helsinki Ear, Nose and Throat Hospital, Finland
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Abstract
PURPOSE This retrospective study investigates the general outcome and subjective impression of patients who have undergone surgery for otosclerosis. Postoperative complaints and complications, as well as hearing results, are also reported. MATERIALS AND METHODS Questionnaire and audiomeric results of 246 stapes surgery patients (270 operations) were studied. RESULTS Hearing results showed a mean improvement in pure-tone average of 26 dB and air-bone gap closure to within 10 dB in 214 cases (79%). No serious complications or profound sensorineural hearing loss occurred. Patients were generally pleased with surgery, and subjective evaluation of benefit corresponded with objective audiometric result. However, a variety of complaints, such as vertigo, tinnitus, loud noise intolerance, pain, chorda tympani symptoms, and sound distortion problems, were reported. Most of these symptoms correlated significantly with the patients' subjective opinion of the surgical outcome. CONCLUSION Patients as well as surgeons consider hearing improvement as the main indicator of success in surgery for otosclerosis. However, postoperative symptoms and complaints can be expected in a certain percentage of patients. Because these can influence the general outcome of surgery, the ear surgeon should try to painstakingly refine his technique in an effort to minimize their sources. They should also be discussed in preoperative patient counseling.
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Affiliation(s)
- H Ramsay
- Department of Otolaryngology, University Central Hospital, Helsinki, Finland
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Palva T, Ramsay H. Incudal folds and epitympanic aeration. Am J Otol 1996; 17:700-8. [PMID: 8892564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Thirty-seven temporal bones were dissected, and the posterior tympanic and epitympanic folds recorded and photographed. Histologic details were documented from four serially sectioned temporal bones, two normal and two inflamed. Of these 41 specimens, 31 were normal, and 10 showed signs of inflammation. The type for the lateral fold was incudomalleal in 16 and incudal in 25 ears. Incus intercrural and incudostapedial folds appeared only exceptionally. Medial and superior incudal folds were not present in normal ears. The anterior tympanic isthmus was a constant, large aeration pathway. In chronically inflamed ears, its partial or total block was caused by polypoid or large sheet-like folds. Inactive sequelae appeared as mature, simple, one-layer or extensive multilayer networks of webs, connected with a deeply indrawn incudomalleal fold. The small posterior isthmus was open to the incudal fossa in 13 ears, and in 28, it was sealed off by a posterior incudal fold. The mastoid air cell tracks were (in ten of 37 dissected ears) open to the incudal fossa, or directly, to the posterior tympanum. Auxiliary pathways due to membrane defects were found in both the horizontal and descending portions of the incudomalleal fold. Excepting the chordal, incudomalleal, and posterior incudal folds, fold-like webs in the posterior tympanum and epitympanum are of inflammatory origin.
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Affiliation(s)
- T Palva
- Helsinki Ear, Nose and Throat Hospital, University of Helsinki, Finland
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Palva T, Ramsay H, Böhling T. Prussak's space revisited. Am J Otol 1996; 17:512-20. [PMID: 8841695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Thirty temporal bones were dissected under the operating microscope, and four whole temporal bone specimens were studied by light microscopy for evaluation of the lateral malleal space and Prussak's space. In all specimens Prussak's space showed a blind end toward the anterior pouch and communicated with the posterior pouch. Its roof consisted of the lateral malleal ligamental fold, which was always strongest in its anterior half and as a rule had a thin area in its posterior portion. In four ears there was a membrane defect connecting Prussak's space to the lateral malleal space. The latter did not contain additional folds and communicated freely with the upper attic. The pathways for spread of an acquired primary cholesteatoma from Prussak's space are outlined.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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Ramsay H, House JR, Beattie JL, Moore JK. A simple technique for introducing anterograde and retrograde tracers into the vestibular and cochlear sensory organs. Acta Otolaryngol 1996; 116:39-43. [PMID: 8820348 DOI: 10.3109/00016489609137710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The standard method for labeling the afferent and efferent innervation of the cochlear and vestibular sensory organs is by microinjection of tracer substances into the labyrinth. Injection of small amounts of tracer often result in incomplete and inconsistent labeling, but large injections can cause spurious labeling of brainstem structures due to diffusion from perilymph to cerebrospinal fluid. Effective labeling with minimal artifact can, however, be achieved by a relatively simple method involving placement of a tracer-saturated pledglet of gelatin sponge in the round window after rupture of its membrane. The gelatin sponge simultaneously acts as a continuous-release vehicle for the tracer and prevents reflux of perilymph and tracer into the middle ear cavity. Use of this technique produces labeling with a degree of intensity and anatomic detail that rivals that seen with more complicated methods of tracer placement.
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Affiliation(s)
- H Ramsay
- ENT Department, Helsinki University Central Hospital, Finland
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Abstract
The results of surgery in a series of 452 ears having either myringoplasty (281 ears) or tympanoplasty (171 ears) were studied in relation to the experience of the surgeons. The trainees received an annual course in temporal bone dissection and were given daily surgical instruction in the operating theatre. The 142 ears operated by them showed less disease than those operated upon by the programme chairman (114 ears) and by the faculty (196 ears). The performance of the trainees was safe, and as to healed tympanic membrane and hearing results all studied parameters were statistically equal to those of the faculty. Repair of anterior perforations proved to be the most difficult and the overall results of both the faculty and trainees left place for improvement. On-line recording of surgical data and annual evaluation of an individual surgeon's results is suggested as a necessary means for continuous post-graduate training.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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Kairemo K, Jekunen A, Ramsay H, Jääskelä-Saari H. Use of bleomycin in radiochemotherapy. J Nucl Med 1995; 36:1531-2. [PMID: 7543148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Ramsay H. [Treatment of otosclerosis--points of view from Finland]. Lakartidningen 1995; 92:620. [PMID: 7861852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
Middle ear imaging constitutes a homogeneous test battery for evaluation of neurotological disease. The imaging comprises infra-sound fistula test, ABR, tympanoscopy, ECoG, and trans-promontiorial cochlear blood flow measurement. We used a fistula test with infra-sound loading on posturography. In tympanoscopy we used 5 degrees and 25 degrees endoscopes with a diameter of 1.9 mm and length of 125 mm. In blood flow measurement we used laser-Doppler system with a stainless steel tip placed on the basal turn against stira vascularis. The flux was analyzed with a computer with custom-made software. In ECoG, a silver ball electrode was placed on the round window. In 64 cases evaluated we were not able to verify a spontaneous PLF by tympanoscopy. Symptoms typical for spontaneous PLF with positive fistula test turned out to be caused by endolymphatic hydrops. Sudden deafness usually did not show reduced cochlear blood flow, but often an endolymphatic hydrops. Fistula test was positive in about 25% of cases with endolymphatic hydrops. Tympanoscopy caused very few complication. The procedure takes about one hour and is done ambulatorily.
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Affiliation(s)
- I Pyykkö
- Department of Otolaryngology, University Hospital of Helsinki, Finland
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Kairemo KJ, Ramsay H, Nikula TK, Hopsu EV, Taavitsainen MJ, Bondestam S, Hiltunen JV. A low pH 111In-bleomycin complex: a tracer for radiochemotherapy of head and neck cancer. J Nucl Biol Med (1991) 1994; 38:135-9. [PMID: 7543289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Bleomycin (BLM) is a well known natural antibiotic. It is toxic to dividing cells and has been used for the treatment of several forms of cancer. BLM has been labeled with various cations, but most of them have turned out be unstable in in-vivo experiments. In-BLM demonstrated high bone marrow uptake, but using 111In-bleomycin complex (BLMC) formed at low pH, the low in vivo stability and high bone marrow seeking behavior of the molecule could be avoided. The idea of using BLMC in combined radiotherapy and chemotherapy is intriguing. In this study we examined the effects of 111In-A'2a-c-BLMC in the treatment of 31 head and neck cancer patients. Findings were compared with those of surgery, and pre-operative radiology. The injected activity was 85-110 MBq, and the specific activity was approximately 100 MBq/mg. The half-life of 111In activity in serum varied from 1.5 to 3.1 hours. Maximum activity in the urine was achieved in all patients within 3 hours, and the average half-life in urine was 2 hours. In most patients 50% was excreted within 3 hours, in some 70%; in all patients > 95% of the activity was excreted within 22 hours. In surgical samples from 24 patients the best tumor-to-tissue ratios were: fat 60:1, bone 17:1, muscle 12:1, blood 3.6:1. All patients were examined on the injection day with ultrasonography of the neck. Using 111In-BLMC we missed a few small lymph nodes in 2 patients, but there were no false positive findings.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K J Kairemo
- Department of Diagnostic Radiology, Helsinki University Central Hospital, Finland
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Ramsay H. Teaching Aquafit: A handbook for teachers of aquafit. Physiotherapy 1992. [DOI: 10.1016/s0031-9406(10)61559-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
A case of myxoma of the external auditory meatus is described. The patient presented with a recurring tumour which had not been correctly diagnosed although the growth had been removed ten times over a period of two years. The tumour was skin covered, contained gelatinous material and was attached to the tympanic membrane and anterior canal wall. Following recognition of the tumour as myxoma, removal was performed with sufficiently wide margins and there has been no recurrence during follow-up for one year.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki
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Abstract
The outcome of surgery was analyzed in 76 otosclerosis patients (82 operations) undergoing revisions during the period 1986-89. The ears were divided into 3 groups based on preoperative A-B gaps 1) larger than 25 dB, 2) between 10 to 25 dB, and 3) less than 10 dB. A final hearing gain of more than 11 dB was recorded in 76%, 40% and 10% of the ears in groups 1, 2 and 3, respectively. In the groups with conductive component none of the ears deteriorated. In the sensorineural group 2 patients suffered further loss of 10 and 29 dB, respectively, and one ear became deaf. At revision the most common causes of conductive impairment were found to be dislocation of the prosthesis, remnants of footplate or new bone growth. Fistula was suspected in 10 ears and verified in 5. Several reconstruction methods must be mastered.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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Abstract
Biopsy specimens from middle ear mucosa of patients with secretory (SOM) and chronic (COM) otitis media as well as specimens of adenoid and tonsil tissue were studied for mast cells. Effusion fluid, nasopharyngeal secretion and supernatant of crushed adenoid tissue were analyzed for histamine with a radioenzymatic method. Astra blue (AB) safranine stained highly significantly more mast cells than did toluidine blue. Mast cell counts in SOM and COM were similar. There were significantly more mast cells in adenoid subepithelial tissue than in middle ear mucosal subepithelial layer. For epithelium the counts were within the same range in adenoids and middle ear mucosa. Histamine concentrations were significantly higher than plasma levels for SOM fluid and nasopharyngeal secretion. Crushed adenoid tissue showed values over 100 times higher than the histamine level in the secretion.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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Abstract
The outcome of surgery was analyzed in 76 otosclerosis patients (82 operations) undergoing revisions during the period 1986-89. The ears were divided into 3 groups based on preoperative A-B gaps 1) larger than 25 dB, 2) between 10 to 25 dB, and 3) less than 10 dB. A final hearing gain of more than 11 dB was recorded in 76%, 40% and 10% of the ears in groups 1, 2 and 3, respectively. In the groups with conductive component none of the ears deteriorated. In the sensorineural group 2 patients suffered further loss of 10 and 29 dB, respectively, and one ear became deaf. At revision the most common causes of conductive impairment were found to be dislocation of the prosthesis, remnants of footplate or new bone growth. Fistula was suspected in 10 ears and verified in 5. Several reconstruction methods must be mastered.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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Abstract
This cholesteatoma series comprises 84 ears, 81 of which had a labyrinthine fistula and 3 a horizontal semicircular canal opening that arose as a surgical complication. In 49 ears (58.3%), the operation was a primary one; in 35 ears (41.7%), it was a revision. Of all ears, 21 (25%) were deaf preoperatively. The fistula was located in the horizontal canal in 76 ears (90.4%). The matrix was removed in all these ears, and the fistula was covered with fibrin glue and fascia or periosteum. Hearing was preserved in all 57 ears in which matrix removal was carried out as the planned last stage. These included three ears in which the membranous canal was cut deliberately. Surgery that was performed against established rules caused deafness in three ears. Accidental opening of the horizontal canal caused no sensorineural loss in two ears as the fistulas were sealed immediately, while one ear in which the opening was not immediately recognized became deaf.
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Affiliation(s)
- T Palva
- Department of Otolaryngology, University of Helsinki, Finland
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Hytönen M, Pyykkö I, Aalto H, Juhola M, Ramsay H. Vestibulo-ocular and vestibulo-spinal reflexes in evaluation of vestibular lesions. Acta Otolaryngol Suppl 1989; 468:231-4. [PMID: 2635510 DOI: 10.3109/00016488909139052] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In order to evaluate to what extent different diseases causing vertigo can be detected by studying vestibulo-spinal and vestibulo-ocular reflexes, 146 patients were examined. The diagnosis classes were: periodical attacks, position induced attacks, vestibular neuronitis, brain concussion, cerebrovascular disorders and acoustic neurinoma. Dynamic posturography was performed on all the patients, standard bithermal caloric test on 129 and voluntary saccades on 127 patients. The proportion of pathological test results in posturography exceeded that in the caloric test in all but one diagnosis class. In vestibular neuronitis the amount of abnormal test results was low in posturography, probably due to vestibular compensation. Posturography tested with eyes open and with 80 Hz vibration revealed disturbances in equilibrium the most sensitively.
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Affiliation(s)
- M Hytönen
- Department of Otolaryngology, Helsinki University Central Hospital, Finland
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Ramsay H. Chorea gravidarum. Med J Aust 1984; 140:631-2. [PMID: 6717343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Affiliation(s)
- Helen Ramsay
- Chhapara Christian Health CentreChhapara, District SeoniMadhya PradeshIndia
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