Position paper on olfactory dysfunction: 2023

BACKGROUND

Since publication of the original Position Paper on Olfactory Dysfunction in 2017 (PPOD-17), the personal and societal burden of olfactory disorders has come sharply into focus through the lens of the COVID-19 pandemic. Clinicians, scientists and the public are now more aware of the importance of olfaction, and the impact of its dysfunction on quality of life, nutrition, social relationships and mental health. Accordingly, new basic, translational and clinical research has resulted in significant progress since the PPOD-17. In this updated document, we present and discuss currently available evidence for the diagnosis and management of olfactory dysfunction. Major updates to the current version include, amongst others: new recommendations on olfactory related terminology; new imaging recommendations; new sections on qualitative OD and COVID-19 OD; updated management section. Recommendations were agreed by all co-authors using a modified Delphi process.

CONCLUSIONS

We have provided an overview of current evidence and expert-agreed recommendations for the definition, investigation, and management of OD. As for our original Position Paper, we hope that this updated document will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency, and generalisability of work in this field.

Kynurenic Acid: A Novel Player in Cardioprotection against Myocardial Ischemia/Reperfusion Injuries

BACKGROUND

Myocardial infarction is one of the leading causes of mortality worldwide; hence, there is an urgent need to discover novel cardioprotective strategies. Kynurenic acid (KYNA), a metabolite of the kynurenine pathway, has been previously reported to have cardioprotective effects. However, the mechanisms by which KYNA may be protective are still unclear. The current study addressed this issue by investigating KYNA's cardioprotective effect in the context of myocardial ischemia/reperfusion.

METHODS

H9C2 cells and rats were exposed to hypoxia/reoxygenation or myocardial infarction, respectively, in the presence or absence of KYNA. In vitro, cell death was quantified using flow cytometry analysis of propidium iodide staining. In vivo, TTC-Evans Blue staining was performed to evaluate infarct size. Mitochondrial respiratory chain complex activities were measured using spectrophotometry. Protein expression was evaluated by Western blot, and mRNA levels by RT-qPCR.

RESULTS

KYNA treatment significantly reduced H9C2-relative cell death as well as infarct size. KYNA did not exhibit any effect on the mitochondrial respiratory chain complex activity. SOD2 mRNA levels were increased by KYNA. A decrease in p62 protein levels together with a trend of increase in PARK2 may mark a stimulation of mitophagy. Additionally, ERK1/2, Akt, and FOXO3α phosphorylation levels were significantly reduced after the KYNA treatment. Altogether, KYNA significantly reduced myocardial ischemia/reperfusion injuries in both in vitro and in vivo models.

CONCLUSION

Here we show that KYNA-mediated cardioprotection was associated with enhanced mitophagy and antioxidant defense. A deeper understanding of KYNA's cardioprotective mechanisms is necessary to identify promising novel therapeutic targets and their translation into the clinical arena.

Hedonic perception of odors in children aged 5-8 years is similar across 18 countries: Preliminary data

OBJECTIVE

Olfactory preference emerges very early in life, and the sense of smell in children rapidly develops until the second decade of life. It is still unclear whether hedonic perception of odors is shared in children inhabiting different regions of the globe.

METHODS

Five-hundred ten healthy children (N = 510; n_girls = 256; n_boys = 254) aged from 5 to 8 years from 18 countries rated the pleasantness of 17 odors.

RESULTS

The hedonic perception of odors in children aged between 5 and 8 years was rather consistent across 18 countries and mainly driven by the qualities of an odor and the overall ability of children to label odorants.

CONCLUSION

Conclusions from this study, being a secondary analysis, are limited to the presented set of odors that were initially selected for the development of U-Sniff test and present null findings for the cross-cultural variability in hedonic perception of odors across 18 countries. These two major issues should be addressed in the future to either contradict or replicate the results presented herewith. This research lays fundament for posing further research questions about the developmental aspects of hedonic perception of odors and opens a new door for investigating cross-cultural differences in chemosensory perception of children.

Position and integrity of uterine scar are determined by degree of cervical dilatation at time of Cesarean section

OBJECTIVE

Abnormal placental invasion is more common after an elective Cesarean delivery, suggesting that prelabor Cesarean section (CS) increases the likelihood of the CS scar being above the internal cervical os and predisposing to a scar pregnancy in the future. The aim of this study was to assess the location and integrity of the CS scar in postpartum women delivered by CS at different stages of labor.

METHODS

This was a prospective cohort study of women at term who underwent a CS for the first time. In all women, cervical dilatation was determined by digital examination at the time of the CS. All patients had a transvaginal ultrasound examination to assess the location of the CS scar in relation to the internal cervical os, as well as the presence of a scar niche.

RESULTS

A total of 407 pregnant women were recruited into the study: 103 with cervical dilatation ≤ 2 cm, 261 with cervical dilatation 3-7 cm and 43 with cervical dilatation ≥ 8 cm at the time of the CS. A statistically significant correlation was observed between cervical dilatation at the time of the CS and the position of the CS scar. The scar was positioned in the uterus above the internal cervical os in 97.1% (100/103) of women delivered at a cervical dilatation of 0-2 cm, whereas the scar was located at or below the internal cervical os in 97.7% (42/43) of cases delivered at a cervical dilatation of 8-10 cm (P < 0.001). A uterine-scar defect (niche) was observed in 38.1% (64/168) of women with the scar located above, compared with 18.0% (43/239) of those with the scar situated at or below, the internal cervical os (P < 0.001).

CONCLUSIONS

Prelabor and early-labor Cesarean delivery are associated with an increased prevalence of a scar in the uterine cavity as well as a scar niche. CS in late labor is associated with the uterine scar being situated in the endocervical canal and with a lower incidence of a niche. The position and integrity of the CS scar after prelabor and early-labor Cesarean delivery explain the predisposition to abnormal placental invasion in subsequent pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Safe practice guidance: a review for otorhinolaryngologists during COVID-19 pandemic and after reopen process

COVID-19’s rapid sweep across the world has caused an extraordinary disruption to the otorhinolaryngology (ORL) profession and its subspecialties including the rhinology section. The present pandemic forced our specialty practitioners to make quick clinical and practice management decisions. Staff safety must receive the highest prioritization along with strategies to provide the highest quality care. The purpose of the present manuscript is to provide a narrative review of the current knowledge and committee practices regarding ORL (including rhinology) professionals' safe practice during COVID-19 pandemic and after reopen process. The present review findings will allow the clinical practitioners to understand the factors involved in reducing the risk of transmission of COVID-19 in the ORL and rhinology settings, personal protective equipment (PPE) for different ORL and rhinology practices and criteria of practice in outpatient clinic (OPC), emergency operations and ORL surgeries. The emerging evidence based on COVID-19 is rapidly changing. Further updates may be needed to this review as new details or evidence emerge. ORL including rhinology doctors should consider the specific conditions of each individual place of work and comply with all applicable legislations.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Tryptophane-kynurenine pathway in the remote ischemic conditioning mechanism

The actual protective mechanisms underlying cardioprotection with remote ischemic conditioning (RIC) remain unclear. Recent data suggest that RIC induces kynurenine (KYN) and kynurenic acid synthesis, two metabolites derived from tryptophan (TRP), yet a causal relation between TRP pathway and RIC remains to be established. We sought to study the impact of RIC on the levels of TRP and its main metabolites within tissues, and to assess whether blocking kynurenine (KYN) synthesis from TRP would inhibit RIC-induced cardioprotection. In rats exposed to 40-min coronary occlusion and 2-h reperfusion, infarct size was significantly smaller in RIC-treated animals (35.7 ± 3.0% vs. 46.5 ± 2.2%, p = 0.01). This protection was lost in rats that received 1-methyl-tryptophan (1-MT) pretreatment, an inhibitor of KYN synthesis from TRP (infarct size = 46.2 ± 5.0%). Levels of TRP and nine compounds spanning its metabolism through the serotonin and KYN pathways were measured by reversed-phase liquid chromatography-tandem mass spectrometry in the liver, heart, and limb skeletal muscle, either exposed or not to RIC. In the liver, RIC induced a significant increase in xanthurenic acid, nicotinic acid, and TRP. Likewise, RIC increased NAD-dependent deacetylase sirtuin activity in the liver. Pretreatment with 1-MT suppressed the RIC-induced increases in NAD-dependent deacetylase sirtuin activity. Altogether, these findings indicate that RIC mechanism is dependent on TRP-KYN pathway activation.

P04.03 Radiotherapy for subependymal giant cell astrocytoma: time to challenge a historical ban? Case report and review of the literature

BACKGROUND

Subependymal giant cell astrocytoma (SEGA) is a low-grade glioma that occurs in patients with tuberous sclerosis complex (TSC). SEGA typically grows within the ventricles causing hydrocephalus and sudden death. Surgical resection is the traditionally preferred treatment and expert opinion advises strongly against the use of radiotherapy, insomuch that it is not even mentioned as a treatment option in reviews or guidelines. Nevertheless, surgical resection of big volume or bilaterally growing SEGA can be very challenging. Recently, success has been reported with the use of mTOR inhibitor, everolimus, in reducing tumor volume. However, regrowth was observed after drug cessation requiring long-term if not life-long drug administration and thus raising concerns regarding side effects and high treatment costs. Here, we report about a case with inoperable bilateral SEGA that was successfully treated with fractionated stereotactic radiotherapy alone (30x2Gy) with a follow up period of 8 years before being treated with everolimus for renal involvement of TSC. Currently, the patient has been followed up for 13 years.

MATERIAL AND METHODS

All of the patient’s pre and post treatment MRI’s were used for detailed volumetric assessment of the response of the SEGA on each side separately. Systematic review of the literature was conducted via PubMed and Up-to-date using the search terms: ‘treatment of SEGA’, ‘radiotherapy in SEGA’, ‘SRS in SEGA’, ‘treatment of tuberous sclerosis complex’, ‘radiotherapy treatment in low grade astrocytoma’, etc. The article references were queried for the terms ‘radiotherapy’, ‘induced tumors’ and ‘malignant tumors’. Secondary references were added to the database and reprocessed similarly. Reviews about radiation-induced tumors were also added to the database. Attention was given to reports containing data about irradiated SEGA and about high-grade brain tumors in TSC patients. The database was locked on 1-02-2018 containing 1298 article references and 780 full-text articles.

RESULTS

In our case, the successive volumetric assessments on MRI’s demonstrated 80% volume reduction after radiotherapy alone, further enhanced to 90% after everolimus administration. Literature review shows no valid evidence for contra-indicating fractionated stereotactic radiotherapy in SEGA and shows that surgery is still associated with high re-operation and post-operative complications rates.

CONCLUSION

A slow progressive response of SEGA on both sides to radiotherapy was observed similar to the response seen in other benign intracranial tumors. We believe that stereotactic radiotherapy alone or sequentially combined with everolimus deserves to be studied as an alternative to resection in difficult cases that do not require immediate volume reduction.

Anomalous behavior above the Curie temperature in (Nd1-x Gd x )0.55Sr0.45MnO3 (x = 0, 0.1, 0.3 and 0.5)

Magnetic properties were studied just above the ferromagnetic–paramagnetic (FM–PM) phase transition of (Nd_1−xGd_x)_0.55Sr_0.45MnO₃ with x = 0, 0.1, 0.3 and 0.5. The low-field inverse susceptibility (χ⁻¹) of Nd_0.55Sr_0.45MnO₃ exhibits a Curie–Weiss-PM behavior. For x ≥ 0.1, we observe a deviation in χ⁻¹(T) behavior from the Curie–Weiss law. The anomalous behavior of the χ⁻¹(T) was qualified as Griffiths phase (GP)-like. The study of the evolution of the GP through a susceptibility exponent, the GP temperature and the temperature range of the GP reveals that the origin of the GP is primary due to the accommodated strain. Likewise, the magnetic data reveal distinct features visible only for x = 0.5 at a low magnetic field that can be qualitatively understood as the result of ferromagnetic polarons, entailed by the strong effect of chemical/structural disorder, whose concentration increases upon cooling towards the Curie temperature. We explained the magnetic properties at a high temperature for the heavily Gd-doped sample (x = 0.5) within the phase-separation scenario as an assembly of ferromagnetic nanodomains, antiferromagnetically coupled by correlated Jahn–Teller polarons.

Magnetic properties were studied just above the ferromagnetic–paramagnetic (FM–PM) phase transition of (Nd_1−xGd_x)_0.55Sr_0.45MnO₃ with x = 0, 0.1, 0.3 and 0.5.

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women

OBJECTIVE

To assess the effect of levator ani muscle (LAM) coactivation at term on outcome of labor in nulliparous women.

METHODS

This was a prospective study of 284 low-risk nulliparous women with a singleton pregnancy at term recruited before the onset of labor. The anteroposterior diameter of the levator hiatus was measured in each woman on transperineal ultrasound at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver before and after visual feedback. LAM coactivation was defined as a reduction in the anteroposterior diameter of the levator hiatus on maximum Valsalva maneuver in comparison with that at rest. The association of pelvic hiatal diameter values and LAM coactivation with mode of delivery and duration of labor was assessed.

RESULTS

No significant difference was found between women who underwent Cesarean delivery and those who had a vaginal delivery with regard to the anteroposterior diameter of the levator hiatus at rest, on pelvic floor muscle contraction and on Valsalva maneuver. Longer second stage of labor was associated with shorter anteroposterior diameter of the levator hiatus on all assessments, but in particular at rest and on Valsalva both before and after visual feedback. LAM coactivation was found in 89 (31.3%) and 75 (26.4%) women before and after visual feedback, respectively. Post visual feedback, women with LAM coactivation had a significantly longer second stage of labor than did those without LAM coactivation (83 ± 63 vs 63 ± 42 min; P = 0.006). On Cox regression analysis, LAM coactivation post visual feedback was an independent predictor of longer second stage of labor (adjusted hazard ratio, 1.499 (95% CI, 1.076-2.087); P = 0.017).

CONCLUSION

LAM coactivation in nulliparous women at term is associated with a longer second stage of labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

How reliable is fetal occiput and spine position assessment prior to induction of labor?

OBJECTIVES

To assess the reliability of fetal occiput and spine position determination in nulliparous women prior to induction of labor (IOL), and to evaluate identification of fetal occiput and spine positions prior to IOL in the prediction of labor outcome.

METHODS

A series of 136 nulliparous women were recruited prospectively, immediately after the decision to perform IOL was made. Transabdominal ultrasound was performed to determine fetal head and spine positions. After at least 1 h, and prior to IOL, fetal occiput and spine positions were reassessed. Fetal occiput and spine positions were then compared between women who underwent vaginal delivery and those who delivered by Cesarean section.

RESULTS

On the first and second assessments, respectively, fetal occiput position was anterior in 55 (40.4%) and 62 (45.6%) women, transverse in 52 (38.2%) and 49 (36.0%) women, and posterior in 29 (21.3%) and 25 (18.4%) women, while fetal spine position was anterior in 58 (42.6%) and 52 (38.2%) women, transverse in 42 (30.9%) and 50 (36.8%) women, and posterior in 36 (26.5%) and 34 (25.0%) women. Discordance between the first and second assessments of fetal occiput position was identified in 34 (25.0%) women, whereas discordance of fetal spine position was observed in 40 (29.4%) women. The incidence of fetal occiput posterior position in women undergoing Cesarean section was comparable to that in the vaginal-delivery group (19 (18.8%) vs 6 (17.1%); P = 0.826), which was similarly the case for fetal posterior spine position (27 (26.7%) vs 7 (20%); P = 0.428). Women with fetal occiput posterior position had a longer induction-to-delivery interval in comparison to those with non-occiput posterior fetal position (1786 ± 805 vs 1347 ± 784 min; P = 0.013).

CONCLUSIONS

Fetal occiput and spine positions are dynamic in a considerable proportion of women undergoing IOL, and their assessment does not seem to correlate with mode of delivery. Occiput and spine position assessment in women prior to IOL is unlikely to be clinically useful. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Position paper on olfactory dysfunction

Background

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

Conclusions

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

Position paper on olfactory dysfunction

BACKGROUND

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

CONCLUSIONS

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

Increase in Cardiac Ischemia-Reperfusion Injuries in Opa1+/- Mouse Model

Background

Recent data suggests the involvement of mitochondrial dynamics in cardiac ischemia/reperfusion (I/R) injuries. Whilst excessive mitochondrial fission has been described as detrimental, the role of fusion proteins in this context remains uncertain.

Objectives

To investigate whether Opa1 (protein involved in mitochondrial inner-membrane fusion) deficiency affects I/R injuries.

Methods and Results

We examined mice exhibiting Opa1^delTTAG mutations (Opa1^+/-), showing 70% Opa1 protein expression in the myocardium as compared to their wild-type (WT) littermates. Cardiac left-ventricular systolic function assessed by means of echocardiography was observed to be similar in 3-month-old WT and Opa1^+/- mice. After subjection to I/R, infarct size was significantly greater in Opa1^+/- than in WTs both in vivo (43.2±4.1% vs. 28.4±3.5%, respectively; p<0.01) and ex vivo (71.1±3.2% vs. 59.6±8.5%, respectively; p<0.05). No difference was observed in the expression of other main fission/fusion protein, oxidative phosphorylation, apoptotic markers, or mitochondrial permeability transition pore (mPTP) function. Analysis of calcium transients in isolated ventricular cardiomyocytes demonstrated a lower sarcoplasmic reticulum Ca²⁺ uptake, whereas cytosolic Ca²⁺ removal from the Na⁺/Ca²⁺ exchanger (NCX) was increased, whilst SERCA2a, phospholamban, and NCX protein expression levels were unaffected in Opa1^+/- compared to WT mice. Simultaneous whole-cell patch-clamp recordings of mitochondrial Ca²⁺ movements and ventricular action potential (AP) showed impairment of dynamic mitochondrial Ca²⁺ uptake and a marked increase in the AP late repolarization phase in conjunction with greater occurrence of arrhythmia in Opa1^+/- mice.

Conclusion

Opa1 deficiency was associated with increased sensitivity to I/R, imbalance in dynamic mitochondrial Ca²⁺ uptake, and subsequent increase in NCX activity.

Self-assembled carbohydrate hydrogels for prolonged pain management

CONTEXT

Nanoparticulate systems are new tools that promise a revolution in the field of drug delivery. Among their numerous benefits, polyelectrolyte complexes (PECs) have shown to provide a barrier to drug release.

OBJECTIVE

In this study, PECs, in the form of self-assembled polymeric nanogels, have been studied as potential drug carriers of the freely soluble drug tramadol HCL trying to achieve a prolonged percutaneous permeation.

METHODOLOGY

The hydrogels were subjected to swelling, rheology, release and permeation studies and were characterized by FTIR spectroscopy and scanning electron microscopy.

RESULTS

P2 hydrogel composed of chitosan-carrageenan (1-1) PEC attained the most compromised rheological shear-thinning thixotropic behavior, good bioadhesive properties, the most retarded release and permeation with an f2 value <50 compared to chitosan hydrogel, altogether with non-irritancy to the skin. SEM photographs showed that P2 has spherical nanosized particles structure.

CONCLUSION

This approach can provide us promising results for an around-the-clock analgesia with better safety and tolerability profile.

Polymeric matrix system for prolonged delivery of tramadol hydrochloride, part I: physicochemical evaluation

Management of moderate or severe chronic pain conditions is the burden of clinicians dealing with patients trying to improve their quality of life and diminish their suffering. Although not a new opioid, tramadol has been recently rediscovered and widely used; this may be due to its favorable chronic safety and dependence profiles together with its high potency. Tramadol is a centrally acting analgesic with half-life of approximately 6 h; therefore, it requires frequent dosing. It is freely soluble in water; hence, judicious selection of retarding formulations is necessary. The current study is focused on the innovation of a novel, simple, monolayer, easy-to-use, cost-effective, and aesthetically acceptable bioadhesive transdermal delivery system overcoming the defects of the conventional "patch" as carrier system for tramadol, ensuring its adequate delivery, along with the physicochemical evaluation of the designed formulations. Monolithic tramadol matrix films of chitosan, different types of Eudragit, and binary mixtures of both were prepared. As a single-polymer film, chitosan film showed best properties except for somewhat high moisture uptake capacity, insufficient strength and rapid release, and permeation. Polymer blends were monitored in order to optimize both properties and performance. Promising results were obtained, with chitosan-Eudragit NE30D (1:1) film showing the most desirable combined, sufficiently rapid as well as prolonged release and permeation profiles along with satisfactory organoleptic and physicochemical properties.

Design of a transdermal delivery system for aspirin as an antithrombotic drug

Aspirin has become the gold standard to which newer antiplatelet drugs are compared for reducing risks of cardiovascular diseases, while keeping low cost. Oral aspirin has a repertoire of gastrointestinal side effects even at low doses and requires high frequent dosing because it undergoes extensive presystemic metabolism. Transdermal delivery offers an alternative route that bypasses the gut and may be more convenient and safer for aspirin delivery especially during long-term use. This study comprised formulation of aspirin in different topical bases. Release studies revealed that hydrocarbon gel allowed highest drug release. In vitro permeation studies revealed high drug permeation from hydrocarbon gel. Several chemical penetration enhancers were monitored for augmenting the permeation from this base. Combination of propylene glycol and alcohol showed maximum enhancing effect and, hence, was selected for biological investigation. The biological performance of the selected formulation was assessed by measuring the inhibition of platelet aggregation relevant to different dosage regimens aiming to minimize both drug dose and frequency of application. The results demonstrated the feasibility of successfully influencing platelet function and revealed that the drug therapeutic efficacy in transdermal delivery system is dose independent. Biological performance was re-assessed after storage and the results revealed stability and persistent therapeutic efficacy.

Assessment of splenic functions in patients with hepato-splenic schistosomiasis using non-invasive techniques

This study was carried out on forty cases, classified into 3 groups; group I: 10 healthy controls subjects, group II: 20 patients with hepatosplenic schistosomiasis and group III: 10 bilharzial patients who underwent total splenectomy. All cases were subjected to clinical examination, abdominal ultrasonography, rectal snips and laboratory investigations which included: stool and urine analysis, complete blood picture, IHAT for bilharziasis, liver function tests, viral markers, estimaton of T-lymphocyte subpopulations (CD(+)3, CD(+)4, & CD(+)8) by flow Cytometry, silver stained blood films to detect argyrophilic inclusions and 99mTc sulphur colloid splenic scan which was applied to group II only. The present results revealed varying degrees of hypersplenism (anaemia, leukopenia & thrombocytopenia) in GII. Seventy percent of this group was positive for HbsAg, HCV or both in association with schistosomiasis. Abnormal red blood cells (acanthocytes, target cells, pitted cells & normoblasts) and inclusion bodies (Howell Jolly bodies, argyrophilic inclusions & pappenhiemer bodies) were detected with different values in GIII. CD(+)4 cells were moderately reduced in GII while they were markedly decreased in GIII. CD(+)8 cells were elevated in GII and returned nearly to the normal values in GIII with decrease in number of total T-lymphocytes. Most patients of GII showed marked squestration of 99mTc labelled R.B.Cs. in the spleen with reversed hepatic/splenic ratio (normally hepatic/splenic ratio is over two). IHAT showed positivity in 90% of patients in GII while it was 50% in GIII. Although total splenectomy improved the haematological pattern and the cytopenias, which are prominent features in hepatosplenic schistosomiasis, yet the immunological profile was still altered. So, it is recommended to perform segmental splenectomy with retention of a normal mass of functioning residual spleen to preserve more immunological function and to protect against life-threatening occurrence of post-splenectomy sepsis.

Human portal serum stimulates cell proliferation in immature Schistosoma mansoni

Schistosomula of Schistosoma mansoni were incubated in RPMI 1640 medium containing 10% fetal calf serum, 10% human portal venous or 10% human peripheral venous sera in the presence of bromodeoxyuridine (BrdU) in order to measure differences in cell proliferation. The rates of cell proliferation as expressed by BrdU labelling indices (BLI) were determined as a function of time of incubation by immunohistochemistry using monoclonal antibody to BrdU. Compared to schistosomula cultured in the presence of RPMI plus 10% fetal calf serum, BLIs were increased by 60% in the presence of human portal, but not in peripheral serum. This stimulatory effect was substantially reproduced by a fraction of portal serum with a molecular weight range between 1 and 50 kDa. However, in the presence of human peripheral venous serum, either whole or fractionated, schistosomula showed no significant difference compared to RPMI plus 10% fetal calf serum alone. Furthermore, human portal serum fractions of molecular weight greater than 50 kDa also revealed no significant difference relative to control. The results indicate that portal venous serum component(s) of a molecular weight range higher than most simple nutrients can greatly stimulate the rate of cell proliferation of Schistosoma mansoni schistosomula.

Endoscopic transnasal surgery in antrochoanal polyp

The current treatment of antrochoanal polyp is simple avulsion of the nasal part with or without removal of the antral part. The antral part is removed through a Caldwell-Luc antrostomy, inferior meatal antrostomy, or middle meatal antrostomy. In this study, endoscopic surgery was performed in 22 cases of antrochoanal polyps where the antral part was removed through the middle meatus. Two new instruments were designed to help complete removal of the antral part of the polyp through the maxillary ostium. Some points of controversy concerning the antrochoanal polyp are discussed according to the diagnostic and therapeutic endoscopic findings. Endoscopic follow-up of these cases for periods ranging between 6 and 30 months, with an average of 20 months, showed no recurrence. It was concluded that endoscopic surgery of the antrochoanal polyp through the middle meatus could be performed as an outpatient procedure, and is safe and reliable.

Cytokines and immunoglobulin in rheumatic heart disease: production by blood and tonsillar mononuclear cells

Rheumatic fever and rheumatic heart disease are considered to result from abnormal immune responses after Group A streptococcal pharyngitis. Production of interleukin 1 (IL-1), tumor necrosis factor-alpha (TNF), interleukin 2 (IL-2) and immunoglobulin (Ig) by blood and tonsillar mononuclear cells from rheumatic or healthy children was measured after stimulation in vitro by pokeweed mitogen (PWM) or the streptococcal extracellular product, blastogen A (BLA). Tonsillar cells from patients with rheumatic heart disease produced significantly less IL-1, TNF, IL-2, and Ig than control tonsillar cells. In contrast, blood mononuclear cell cultures from rheumatic children produced more TNF and IL-2 than controls. Our findings suggest that abnormal regulation of cytokine and Ig production may contribute to the pathogenesis of acute rheumatic fever and rheumatic heart disease.

Compartmentalization of cells bearing "rheumatic" cell surface antigens in peripheral blood and tonsils in rheumatic heart disease

Monoclonal antibodies that recognize "rheumatic" antigens of peripheral blood non-T cells were used to study the compartmentalization of such cells in peripheral blood and tonsils of individuals with rheumatic heart disease (RHD) and suitable control subjects. The peripheral blood of most (71%) of the 42 individuals with RHD contained cells reacting with monoclonal antibody 83S19.23 or 256S.10, whereas these cells were present in only 17% of the 41 control subjects (P less than .02). However, none of 21 individuals with RHD had such cells in their tonsils, although they were present in the tonsils of 50% of the 40 control subjects (P less than .03). These results may reflect a failure in RHD or organ-specific homing of cells with the epitopes recognized by the antibodies. The presence of these cells in tonsils may be important in the immune response to streptococcal pharyngeal infection, and their absence in RHD may be involved in the unusual immune responses characteristic of this disease.

Clinical and immunological results of segmental splenectomy in schistosomiasis

We evaluated segmental splenectomy in 51 patients who required splenectomy to relieve the symptoms of schistosomal splenomegaly, and compared their course with that of 44 patients who underwent total splenectomy in an unrandomized study. We describe a minor modification of our initial technique. Patients having segmental splenectomy had a similar postoperative course to those having total splenectomy. Conversion of a segmental to a total splenectomy was required in two cases due to technical faults. No regrowth of the spleen has occurred in up to 4 years of observation. We noted an increased percentage of T lymphocytes with an increased ratio of T helper to T suppressor cells in patients having segmental splenectomy. Our cumulative experience supports adoption and wider evaluation of segmental splenectomy in schistosomiasis.

Stimulation of Schistosoma mansoni oviposition in vitro by animal and human portal serum

Coupled adult pairs of Schistosoma mansoni were incubated in medium containing either peripheral or portal serum from rat, rabbit, hamster or humans. Daily egg production was measured. In all cases egg production was significantly increased for pairs in the presence of portal sera compared with that in the presence of peripheral sera. Fractionation of rabbit portal serum according to molecular weight demonstrated that the most active component(s) were in the range of 2,000 to 50,000. These fractions were as effective in stimulating oviposition as whole portal serum.

CONCLUSIONS

1) portal serum factor(s) that stimulate S. mansoni oviposition are present in susceptible and non-susceptible hosts; 2) the molecular weight range for the active components is larger than would be expected for simple carbohydrates, amino acids or free fatty acids absorbed from the gastrointestinal tract.

Liver collagen-type characterization in human schistosomiasis. A histological, ultrastructural, and immunocytochemical correlation

Liver biopsies of four patients with hepatosplenic schistosomiasis, two patients with schistosomiasis and chronic active hepatitis, two patients with chronic active hepatitis and four control patients with no clinical evidence of either disease, were examined by standard light microscopic techniques, electron microscopy and immunocytochemical staining for collagen type I, III and B. Pure schistosomiasis showed the classical "clay-pipe stem fibrosis" and granulomata composed of eosinophils, macrophages and lymphocytes. In that group, the hepatocellular damage was less conspicuous than in the groups with chronic hepatitis and was usually confined to the granulomatous or fibrotic areas. Destruction of the normal architecture and infiltration by macrophages and lymphocytes with severe damage of hepatocytes was found only in the cases of chronic active hepatitis, with or without associated schistosomiasis. Increased collagen deposits were demonstrated in all three groups. Types I, III and B were found in the enlarged portal triads and fibrotic septa. The intranodular or intralobular collagen stained negatively for type I and strongly positive for types III and B.

Segmental splenectomy in schistosomiasis

Segmental splenectomy was performed in 5 patients with hepatosplenic schistosomiasis mansoni and symptomatic splenomegaly. The aim was to preserve a functional remnant comprising 20-30 per cent of the bulk of a greatly enlarged spleen. The operative technique involved devascularization of anatomic segments and suture of an omental patch to the residual spleen. This procedure was simple, well tolerated and effective in relieving abdominal discomfort and cytopenias. The residual spleens showed normal uptake of 99Tc-sulphur colloid. If long term observation confirms the value of segmental splenectomy in hepatosplenic schistosomiasis, it may become appropriate therapy for those patients with symptomatic splenomegaly who do not require portal decompression.

Suppression splenic T lymphocytes in human hepatosplenic Schistosomiasis mansoni

Splenic suppressor cell activity was evaluated in 10 patients with advanced hepatosplenic Schistosomiasis mansoni undergoing elective splenectomy. We used cell mixing experiments to assess the effect of mitomycin-C-treated spleen cells on antigen and mitogen-induced 3H-thymidine incorporation of responder cells. The suppressor to responder ratio was 1.0. Spleen cells from 7 of 10 patients caused at least 20% suppression of phytohemagglutinin-induced 3H-thymidine incorporation of one or more populations of responder cells (spleen cells, autologous and allogeneic peripheral blood mononuclear cells)Responses of peripheral blood mononuclear cells to streptokinase-streptodornase and schistosome soluble egg and worm antigen preparations also were inhibited by co-cultured spleen cells. An inverse correlation was apparent between the spleen cell response to PHA and the suppressor activity of that spleen cell population (r = -0.74, p less than 0.05). Cell purification procedures showed that the active suppressor splenic cell was non-adherent and rosetted neuraminidase-treated sheep erythrocytes. This splenic suppressor T lymphocyte may modulate splenic and peripheral blood lymphocyte responses in patients with hepatosplenic schistosomiasis.