3D-exoscopic microlaryngoscopy in phonosurgery for glottic insufficiency

PURPOSE

We hypothesized that using a 3D-exoscope (3Dex) in microlaryngoscopic phonosurgery is non-inferior to using a standard operating microscope (OM). To compare the above, we utilized a 3Dex and an OM for microlaryngoscopic vocal fold augmentation with autologous fat in patients with glottic insufficiency and compared the procedure itself and the long-term impact of vocal fold augmentation on subjective and objective voice parameters in both groups.

METHODS

36 patients with glottic insufficiency received microlaryngoscopic laryngeal augmentation with autologous fat. A 3Dex was utilized in 24 cases for visualization and compared to twelve cases in which an OM was used. Voice parameters were evaluated over a period of twelve months.

RESULTS

Comparison of operation time and voice parameters between the 3Dex and OM groups did not reveal significant differences. Significant improvement of mean voice quality in all parameters excluding roughness was observed at 3 and 6 months followed then by a slight decrease of voice quality parameters between the 6 and 12 months interval in both groups.

CONCLUSION

Our findings indicate no difference concerning operation time and outcome between the use of a 3Dex and an OM in phonosurgery. Our results highlight a significant voice improvement after vocal fold augmentation with autologous fat in glottic insufficiency mediated dysphonia. The smaller viewing system, better ergonomics for the primary surgeon and the assistant and a direct view for the entire surgical team make a 3Dex an interesting alternative for visualization in microlaryngoscopic phonosurgery.

Analysis of the Quality of Parotidectomy Videos on YouTube Using the IVORY-Grading-System

OBJECTIVE

The aim of this study was to evaluate the quality and the educational content of YouTube videos showing parotidectomy.

METHODS

We searched for videos displaying parotidectomy on YouTube. To rate parotidectomy videos, we introduced the "Instructional Videos in Otorhinolaryngology by YO-IFOS (IVORY)-grading-system (GS)" derived from the IVORY Guidelines, which pose established consensus recommendations for the production of educational surgical videos in otolaryngology. The videos were rated using the IVORY-GS, and the total score was tested for statistical association with views, likes, likes/dislikes-ratio, age, and length of the videos for validation of the IVORY-GS.

RESULTS

Overall, 50 parotidectomy videos were identified. Sixty-eight (68%) of the videos showed a superficial parotidectomy. The mean IVORY-GS total score was 24.9 (out of a maximum of 44 points). Video education quality was rated as moderate in 22% and high in 4%. There was a statistically significant correlation between the total score and the number of views (p = 0.03), the total score and the number of likes (p < 0.01), and the total score and the likes/dislikes ratio (p < 0.01). A higher total score was a significant predictor of more likes (p = 0.01) and a higher likes/dislikes ratio (p < 0.01).

CONCLUSION

Our modification of the IVORY Guidelines is otolaryngology-specific, suitable, and recommended to evaluate parotidectomy videos. To date, most videos are of poor educational quality. Future efforts in otolaryngology surgical video education could focus on the establishment of an online video platform.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2631-2637, 2023.

The human myotendinous junction: an ultrastructural and 3D analysis study

The myotendinous junction (MTJ) is a specialized structure in the musculotendinous system, where force is transmitted from muscle to tendon. Animal models have shown that the MTJ takes form of tendon finger-like processes merging with muscle tissue. The human MTJ is largely unknown and has never been described in three dimensions (3D). The aim of this study was to describe the ultrastructure of the human MTJ and render 3D reconstructions. Fourteen subjects (age 25 ± 3 years) with isolated injury of the anterior cruciate ligament (ACL), scheduled for reconstruction with a semitendinosus/gracilis graft were included. Semitendinosus and gracilis tendons were stripped as grafts for the ACL reconstruction. The MTJ was isolated from the grafts and prepared for transmission electron microscopy (TEM) and focused ion beam/scanning electron microscopy. It was possible to isolate recognizable MTJ tissue from all 14 patients. TEM images displayed similarities to observations in animals: Sarcolemmal evaginations observed as finger-like processes from the tendon and endomysium surrounding the muscle fibers, with myofilaments extending from the final Z-line of the muscle fiber merging with the tendon tissue. The 3D reconstruction revealed that tendon made ridge-like protrusions, which interdigitiated with groove-like indentations in the muscle cell.

Non-hematopoietic PAR-2 is essential for matriptase-driven pre-malignant progression and potentiation of ras-mediated squamous cell carcinogenesis

The membrane-anchored serine protease, matriptase, is consistently dysregulated in a range of human carcinomas, and high matriptase activity correlates with poor prognosis. Furthermore, matriptase is unique among tumor-associated proteases in that epithelial stem cell expression of the protease suffices to induce malignant transformation. Here, we use genetic epistasis analysis to identify proteinase-activated receptor (PAR)-2-dependent inflammatory signaling as an essential component of matriptase-mediated oncogenesis. In cell-based assays, matriptase was a potent activator of PAR-2, and PAR-2 activation by matriptase caused robust induction of nuclear factor (NF)κB through Gαi. Importantly, genetic elimination of PAR-2 from mice completely prevented matriptase-induced pre-malignant progression, including inflammatory cytokine production, inflammatory cell recruitment, epidermal hyperplasia and dermal fibrosis. Selective ablation of PAR-2 from bone marrow-derived cells did not prevent matriptase-driven pre-malignant progression, indicating that matriptase activates keratinocyte stem cell PAR-2 to elicit its pro-inflammatory and pro-tumorigenic effects. When combined with previous studies, our data suggest that dual induction of PAR-2-NFκB inflammatory signaling and PI3K-Akt-mTor survival/proliferative signaling underlies the transforming potential of matriptase and may contribute to pro-tumorigenic signaling in human epithelial carcinogenesis.

Bacteraemia as a result of Campylobacter species: a population-based study of epidemiology and clinical risk factors

Invasive disease as a result of Campylobacter is rarely reported. We reviewed 46 cases of blood stream infection with Campylobacter in a Danish population with complete follow-up. The incidence was 2.9 per 1 million person-years with a peak incidence in the age group above 80 years. In the population, the ratio of notified bacteraemia/enteritis patients with Campylobacter infection was 0.004. Patients with bacteraemia were older and had higher comorbidity, e.g. alcoholism, immunosuppression, previous gastrointestinal surgery or HIV infection. We found 26% of blood isolates resistant to ciprofloxacin. The length of hospitalization was significantly longer in bacteraemia patients, whereas the outcome was favourable with 28-day mortality of 4% in bacteraemia patients and 1% in enteritis patients. None of the bacteraemia patients relapsed within 365-day follow-up.

Exogenous estrogen boosts circulating estradiol concentrations and calcium uptake by duodenal tissue in heat-stressed hens

In the hen, heat stress (HS) disrupts shell calcification and reproductive processes, including hormone synthesis and egg production. Two studies were conducted to investigate palliative effects of exogenous estrogen or dietary vitamin D3 on Ca homeostasis and reproductive physiology during HS. Study 1: Hy-Line W36 hens were randomly assigned to thermoneutral (TN) or HS treatments and to 1 of 7 estrogen treatments: zero (control) or one Compudose 200 implant given 1, 2, 3, 8, 9, or 10 d before onset of HS. With no implant, HS reduced plasma estradiol (E2) and total Ca absorbed (CaT) by duodenal cells (P < 0.05). In TN hens with implants, plasma E2 tripled within 24 h (P < 0.05) and remained elevated (P < 0.05) through d 9. In HS hens with implants, plasma E2 rose 6-fold (P < 0.05) to equal TN+E2 concentrations and remained elevated through d 10. In TN and HS hens with implants, the rate of Ca absorption (CaTR) and CaT increased dramatically; the responses were quadratic and essentially identical. Study 2: Hy-Line W36 hens were provided diets formulated either according to NRC requirements (NRC, 1994), or with the addition of 22,000 IU/kg vitamin D3 (+VD hens). A 24-h HS episode was imposed 2 wk after initiation of the dietary regimen. Duodenal samples were collected for Ca absorption assays after the 24-h HS episode. Both CaTR and CaT in +VD hens were approximately 3-fold higher than in hens in the NVD group (P = 0.102). The results lead to the conclusion that exogenous estrogen, high levels of dietary vitamin D, or both, before a HS episode, are efficacious in alleviating at least some of the effects of HS and should be further investigated.

Western immunoblotting in avian shell gland sample immunoblotting methods

Avian shell gland tissue was subjected to Western blot analysis using anti-human estrogen receptor-alpha antibody H222. Initial attempts to obtain consistent, high-quality blots were unsuccessful because, as it turned out, excessive lipid in tissue preparations interfered with protein separation. Incremental additions of acetone eventually proved to be the critical step in solubilizing lipids and allowing consistent separation of bands on gels. A detailed description of the methodology is presented.

Role of estrogen in avian osteoporosis

One of the difficulties associated with commercial layer production is the development of osteoporosis in hens late in the production cycle. In light of this fact and because of hens' unique requirements for Ca, many studies have focused on the regulation of Ca and the role of estrogen in this process. The time course of estrogen synthesis over the productive life of hens has been well documented; increased circulating estrogen accompanies the onset of sexual maturity while decreases signal a decline in egg production prior to a molt. Numbers of estrogen receptors decrease with age in numerous tissues. The parallel changes in calcium-regulating proteins, primarily Calbindin D28K, and in the ability of duodenal cells to transport Ca, are thought to occur as a result of the changes in estrogen, and are also reversible by the molt process. In addition to the traditional model of estrogen action, evidence now exists for a possible nongenomic action of estrogen via membrane-bound receptors, demonstrated by extremely rapid surges of ionized Ca in chicken granulosa cells in response to 17beta-estradiol. Estrogen receptors have also been discovered in duodenal tissue, and tamoxifen, which binds to the estrogen receptor, has been shown to cause a rapid increase in Ca transport in the duodenum. In addition, recent evidence also suggests that mineralization of bone per se may not explain entirely the etiology of osteoporosis in the hen but that changes in the collagen matrix may contribute through decreases in bone elasticity. Taken together, these studies suggest that changes in estrogen synthesis and estrogen receptor populations may underlie the age-related changes in avian bone. As with postmenopausal women, dietary Ca and vitamin D are of limited benefit as remedies for osteoporosis in the hen.

Estrogen receptor-alpha populations change with age in commercial laying hens

Older hens in production lay larger but fewer eggs than younger birds, and the incidence of soft and broken shells is greater in older hens than younger. These changes are attributable at least in part to changing hormone profiles and diminished ability of the hen to transport calcium at the duodenum. In further exploration of this relationship, a study was conducted with three ages of Hy-Line W-36 birds: prelay pullets (PL; 19 wk, 0% production), peak-production hens (PP; 29 wk, approximately 93% production), and late-stage hens (LS; 71 wk, approximately 80% production). Hens from the PP and LS groups were palpated for presence of an egg in the shell gland; hens were then euthanized and tissues (kidney, shell gland, hypothalamus) were removed for quantification of estrogen receptor-alpha (ERalpha) populations via immunocytochemical and Western blot analyses. Localization of ERalpha by immunostaining in the shell gland showed differences among age groups; however, no differences were noted in localization of ERalpha between age groups in the kidney and hypothalamus. In both the kidney and the shell gland there was a decrease in the amount of ERalpha, as detected by immunoblotting, in the LS hens compared to PL and PP birds (P < 0.05). The results suggest that failure of calcium regulating mechanisms with age may be mediated at least in part through the reduced populations of estrogen receptors in certain critical tissues.

Small cerebral aneurysms presenting with symptoms other than rupture

BACKGROUND

Recent natural history studies have suggested that unruptured intracranial aneurysms smaller than 1 cm have a low risk of rupture. Symptomatic aneurysms may be underrepresented in natural history studies because they are preferentially treated. The authors compared the number of patients with symptoms caused by unruptured intracranial aneurysms smaller than 1 cm treated surgically at their institution with similar patients enrolled in the International Study of Unruptured Intracranial Aneurysms (ISUIA) from their institution over the same time period.

METHODS

The records of all unruptured aneurysms treated surgically at the Mayo Clinic from 1980 through 1991 were reviewed. There were 97 patients with 117 unruptured aneurysms smaller than 1 cm by angiography. Aneurysms with a history of rupture or larger than 1 cm on cross-sectional imaging were excluded from analysis. The presence and characteristics of symptoms directly attributable to the aneurysm were recorded. Comparison was made with patients from the Mayo Clinic enrolled in the ISUIA retrospective natural history cohort over the same time period.

RESULTS

Of the 97 patients studied, 15 presented with symptoms other than rupture (15.5%). The symptoms were third nerve deficit (seven patients), cerebral ischemia owing to emboli originating from within the aneurysm (five patients), and visual acuity loss (three patients). Eleven other aneurysms had possibly but not definitively caused symptoms; these were considered asymptomatic. No patient from the Mayo Clinic enrolled in the retrospective cohort of the ISUIA had a symptomatic aneurysm smaller than 1 cm on both angiography and cross-sectional imaging.

CONCLUSIONS

Unruptured intracranial aneurysms smaller than 1 cm occasionally present with neurologic symptoms. These symptoms are typically owing to mass effect on the second and third cranial nerves or cerebral ischemia as a result of emboli originating from within the aneurysm. Patients with symptomatic unruptured aneurysms less than 1 cm at the Mayo Clinic were preferentially treated. Although existing natural history data may be applied to most unruptured aneurysms, small symptomatic aneurysms may be underrepresented in natural history studies.

Ischemic complications of surgery for anterior choroidal artery aneurysms

OBJECT

Anterior choroidal artery (AChA) aneurysms account for 4% of all intracranial aneurysms. The surgical approach is similar to that for other supraclinoid carotid artery lesions, but surgery may involve a higher risk of debilitating ischemic complications because of the critical territory supplied by the AChA.

METHODS

Between 1968 and 1999, 51 AChA aneurysms in 50 patients were treated using craniotomy and clipping at the Mayo Clinic. There were 22 men (44%) and 28 women (56%) whose average age was 53 years (range 27-79 years). Twenty-four AChA aneurysms (47%) had hemorrhaged; nine patients (18%) had subarachnoid hemorrhage from another aneurysm. Three AChA aneurysms (6%) were associated with symptoms other than rupture. Forty-one patients (82%) achieved a Glasgow Outcome Scale (GOS) score of 4 or 5 at long-term follow up. The surgical mortality rate was 4%, and major surgical morbidity (GOS < or = 3) was 10%. Eight patients (16%) had clinically and computerized tomography-demonstrated AChA territory infarcts. Five of these strokes manifested in a delayed fashion 6 to 36 hours after the operation, and progressed from mild to complete deficit over hours. In 41 patients the aneurysm arose from the internal carotid artery adjacent to the AChA, and in nine patients the aneurysm arose directly from the origin of the AChA itself; four of these nine patients had postoperative infarction.

CONCLUSIONS

Surgical treatment of AChA aneurysms involves a significant risk of debilitating ischemic complications. Most postoperative strokes occur in a delayed fashion, offering a potential therapeutic window. Patients with aneurysms arising from the AChA itself have an extremely high risk for postoperative stroke.

Folk remedies and child abuse: a review with emphasis on caida de mollera and its relationship to shaken baby syndrome

OBJECTIVE

There were two objectives: first, to make the reader familiar with folk remedies that might be confused with child abuse; second, to challenge the idea existing in the literature that treatment for the Hispanic folk illness caida de mollera can cause the injuries seen in the shaken baby syndrome.

METHOD

Literature review and analysis with case application were used.

RESULTS

A wide variety of folk remedies with potential for confusion with child abuse were found to exist, and were described. Treatment for caida de mollera was found to consist of a number of gentle, nonviolent maneuvers quite different from the violent shaking believed to cause shaken baby syndrome.

CONCLUSIONS

Familiarity with folk remedies will help differentiate them from child abuse. The child protection community would benefit from realizing that treatment for caida de mollera is an improbable cause of shaken baby syndrome injuries.

Rapid detection of cytomegalovirus in bronchoalveolar lavage fluid and serum samples by polymerase chain reaction: correlation of virus isolation and clinical outcome for patients with human immunodeficiency virus infection

Bronchoalveolar lavage (BAL) fluids and serum samples from 153 patients with pulmonary symptoms who were infected with human immunodeficiency virus (HIV) and underwent BAL were examined for the presence of cytomegalovirus (CMV) by conventional culture and by polymerase chain reaction (PCR) for detection of CMV DNA. PCR detected CMV more frequently than did cultures of BAL fluid (PCR of BAL fluid, 53%; PCR of serum, 40%; and culture, 30%). In a multivariate model, development of extrapulmonary CMV disease was predicted by the finding of CMV in BAL fluid by culture (relative risk [RR], 8.0; confidence interval [CI], 3.8-16.8) or the finding of CMV DNA in serum (RR, 7.4; CI, 3.2-17.3) or BAL fluid (RR, 8.0; CI, 3.1-20.7) by PCR. Mortality was found to be similar for patients who did or did not have CMV detected by either culture or PCR. Detection of CMV DNA by PCR was a more rapid and sensitive technique than conventional culture. Detection of CMV DNA in BAL fluid or serum predicted subsequent development of extrapulmonary CMV disease but not death for HIV-infected patients with pulmonary symptoms.

Marginal costs in general acute care hospitals: a comparison among California, New York and Canada

In the present paper we offer a detailed comparison of hospital costs between California and New York and two Canadian provinces (Ontario and British Columbia) in 1981 and 1985. We find that production technologies differ significantly between the two countries and between California and New York. Marginal costs and their distributions also differ across jurisdictions and across different size hospitals. Marginal cost levels were the lowest in Canadian hospitals for almost all outputs in both years and their distribution was also the tightest. Some very mild scale effects were also present in the acute care production. Hospitals in California experienced for the most part increasing marginal costs for acute care, whereas Canadian hospitals showed the reverse pattern. In New York we find a weak negative scale effect in acute care production. Density estimates conditional on hospital output reinforce these results.

Patient-administered sequential spirometry in healthy volunteers and patients with alpha 1-antitrypsin deficiency

The launching of cheap, pocket-sized spirometers, with data storage capability, has made patient-administered sequential spirometry (PASS) an attractive method of monitoring ventilatory capacity. At present, little information is available on the quality of PASS, compared to laboratory spirometry. The aim of this study was to investigate whether patients could perform PASS without loss of reliability and reproducibility as compared with traditional laboratory spirometry. Ten healthy volunteers performed spirometry for 1 month and 10 emphysematous patients with alpha 1-antitrypsin deficiency (type PiZ) performed spirometry twice daily for up to 2 yr. To fulfil Good Clinical Practice criteria on full data documentation, a traditional direct recording spirometer, the Vitalograph R-model, was used. A decompression device was used for calibration and a 3.8% annual drift in volume registration was noted. This drift was largest for the first year. After training, all patients were able to perform unsupervised spirometry, producing technically correct forced expiratory curves. Reproducibility of FEV1 and FVC obtained by PASS was found to be as good as for laboratory spirometry. After adjustment for the diurnal variation, the residual variation of FEV1 was 2.5% (range 1.6-4.2%) for healthy volunteers and 5.6% (range 4.2-7.7%) for emphysematous patients. Forced vital capacity showed the same pattern. In conclusion, PASS is possible in highly motivated individuals without loss of reliability and reproducibility when compared to laboratory spirometry.

Late patency of long saphenous vein bypass grafts to the anterior and posterior cerebral circulation

To evaluate the late results and the natural history of long saphenous vein bypass grafts (SVGs) between the extracranial and intracranial circulation, the authors retrospectively analyzed 202 consecutive SVGs performed at the Mayo Clinic from 1979 to 1992. The distal anastomosis was to the vertebrobasilar system in 98 patients and to the carotid artery system in 103 patients. Surgical indications were advanced cerebroocclusive disease in 63% (127 cases), giant aneurysm in 37% (74 cases), and neoplasm in one patient. In 125 patent SVGs follow-up information was obtained for longer than 1 year and in 23 patent SVGs it was over 10 years (maximum 13 years, median 6.5 years). Most of the graft failures (76%) occurred during the 1st year after surgery, with 42% of all graft failures found during the first 24 hours after operation. Late graft attrition occurred in only 10 patients (8%). Cumulative patency at 1 year was 86% +/- 3%, at 5 years 82% +/- 4%, and at 13 years 73% +/- 19%. Neurological worsening at the time of occlusion developed in 72% of patients with early occlusion, whereas 80% of patients with late graft occlusion had no new neurological symptoms. Long-term patency of SVGs for cerebral revascularization appears to be excellent, with an average failure rate of 1% to 1.5% per year following the 1st year after surgery. To minimize early graft thrombosis, meticulous attention must be paid to technical detail.

Prostate-specific antigen obtained under optimal conditions determines extracapsular adenocarcinoma of the prostate

OBJECTIVE

To assess the relationship of prostate-specific antigen (PSA) obtained under optimal conditions with the presence or absence of organ-confined prostate cancer following radical prostatectomy.

PATIENTS AND METHODS

The medical records of 300 consecutive patients who underwent radical retropubic prostatectomy were retrospectively reviewed. Ninety-three patients were excluded who had a pre-operative PSA level potentially altered by various factors (prostate infection, manipulation or instrumentation).

RESULTS

A pre-operative PSA value < 4 ng/mL accurately predicted pathologically confined disease in 42 of 51 patients (82%) which contrasted with extracapsular disease in 74 of 84 patients (88%) who had a PSA value > 10 ng/mL. One of the 53 patients with a PSA > 15 ng/mL had organ-confined disease at surgery.

CONCLUSION

These data demonstrate that optimal serum PSA values correlate well with pathological stage.

Detection of cytomegalovirus DNA in serum correlates with clinical cytomegalovirus retinitis in AIDS

The high sensitivity of nested polymerase chain reaction (PCR) offers the possibility of rapid detection of cytomegalovirus (CMV) DNA in serum. Five consecutive serum samples were examined from 52 human immunodeficiency virus (HIV)-seropositive patients (19 of whom had clinically presumed diagnosis of CMV chorioretinitis). Presence of CMV DNA in serum was shown to precede development of clinical disease. Eleven patients who developed chorioretinitis were positive for CMV DNA in serum samples obtained 3 months before clinical disease, and 3 retinitis patients who initially were negative for CMV DNA became positive with the onset of clinical retinitis. In contrast, 29 of 33 HIV-seropositive subjects without clinical CMV chorioretinitis and matched with respect to age and CD4 T cell numbers were negative for CMV DNA in all 5 serum samples. Thus, the presence of CMV DNA in serum analyzed by PCR is a good predictive marker of CMV retinitis in HIV-seropositive subjects. A positive PCR results supports the clinical diagnosis and may be useful for monitoring response to antiviral treatment.

Pyoderma gangrenosum in infants and children

Pyoderma gangrenosum is an uncommon ulcerative skin disorder that occurs in all age groups. Approximately 4% of patients are infants and children. There are several notable differences between the childhood and adult manifestations of the disease, including the distribution of lesions and associated disorders. We reviewed the childhood cases (< or = 18 yrs of age) of unequivocal pyoderma gangrenosum in the English literature and tabulated the trends in clinical features, associated disorders, and therapy. We report our 3-week-old patient, the youngest documented case. Of the 46 patients, only 4 were less than 1 year of age. A systemic illness was present in 74% of the older children, most commonly, ulcerative colitis. Only one infant had an associated problem (HIV+) at the time of onset. Infants appear to have an unusual distribution of perianal and genital lesions not often described in other age groups. Our review suggests that pyoderma gangrenosum in children has a similar clinical appearance to that in adults. It is associated with some of the same underlying disorders, but with different frequencies. The distribution of lesions in children is similar, often involving the lower extremities, but pyoderma gangrenosum of the head and face appears to be more common in children. Infants may have ulcers in genital and perianal areas. The most frequently prescribed treatment for children is systemic corticosteroids, which generally are very effective.

High-dose epinephrine results in greater early mortality after resuscitation from prolonged cardiac arrest in pigs: a prospective, randomized study

OBJECTIVE

To determine whether high-dose epinephrine (0.2 mg/kg) during cardiopulmonary resuscitation (CPR) results in improved outcome, compared with standard-dose epinephrine (0.02 mg/kg).

DESIGN

A prospective, randomized, blinded study.

SETTING

Research laboratory of a university medical center.

SUBJECTS AND INTERVENTIONS

Thirty domestic swine were randomized to receive standard- or high-dose epinephrine during CPR after 15 mins of fibrillatory cardiac arrest. Three minutes of CPR were provided, followed by advanced cardiac life support per American Heart Association guidelines. Animals that were successfully resuscitated were supported for 2 hrs in an intensive care unit (ICU) setting, and then observed for 24 hrs.

MEASUREMENTS AND MAIN RESULTS

Electrocardiogram, aortic blood pressure, right atrial blood pressure, and end-tidal CO2 were monitored continuously until the intensive care period ended. Survival and neurologic outcome were determined. Return of spontaneous circulation was attained in 14 of 15 animals in each group. Four of 14 high-dose epinephrine pigs died during the ICU period after return of spontaneous circulation vs. zero of the 14 standard-dose pigs (p < .05). Six standard-dose pigs survived 24 hrs vs. four high-dose pigs. Twenty-four-hour survival rate and neurologic outcome were not significantly different. Within 10 mins of defibrillation, severe hypertension (diastolic pressure > 120 mmHg) occurred in 12 of 14 high-dose pigs vs. two of 14 standard-dose pigs (p < .01). Severe tachycardia (heart rate > 250 beats/min) occurred in seven of 14 high-dose pigs vs. zero of 14 standard-dose pigs (p < .01). All four high-dose epinephrine pigs that died during the ICU period experienced both severe hypertension and tachycardia immediately postresuscitation.

CONCLUSIONS

High-dose epinephrine did not improve 24-hr survival rate or neurologic outcome. Immediately after return of spontaneous circulation, most animals in the high-dose epinephrine group exhibited a hyperadrenergic state that included severe hypertension and tachycardia. High-dose epinephrine resulted in a greater early mortality rate.

Bronchial responsiveness in children and adolescents: a comparison between previously asthmatic, currently asthmatic, and normal subjects

The aim of this study was to examine the degree of bronchial responsiveness in previously asthmatic subjects. Of 253 patients, born within 1964-1974, followed in the pediatric department at the University hospital in Copenhagen, 224 subjects (89%) were successfully contacted by telephone; of these 195 complained of persistent asthma and 29 (13%) had had no asthmatic symptoms for at least 2 years. On the basis of the degree of respiratory symptoms, 58 individuals were examined at the outpatient clinic. Of these, (1) 19 were previously asthmatics, (2) 20 had current mild asthma, and (3) 19 had current severe asthma. Furthermore, 19 healthy individuals, age-matched with the preceding asthmatic subjects, were selected as controls. In all subjects, skin prick tests, lung function tests, and bronchial challenge tests with inhaled histamine and bronchodilator were performed. Furthermore, the subjects measured their peak expiratory flow (PEF) twice daily during a period of 4 weeks. Of the 39 current asthmatic subjects, 82% had a PC20 < or = 8 mg/ml, whereas all previously asthmatic subjects and the controls had a PC20 > 8 mg/ml. The degree of bronchial responsiveness as indicated by the dose-response slope (DRS), the percentage change in forced expiratory volume in 1 sec (FEV1) per inhaled mumol of histamine, was found to be significantly higher in previously asthmatic patients (median logDRS 0.1 delta %FEV1/mumol) than in controls (median logDRS-0.4 delta %FEV1/mumol) (p < 0.001). Furthermore previously asthmatic subjects had significantly increased change in FEV1 after inhalation of bronchodilator and peak expiratory flow variability compared to controls. These findings suggest that apparently asymptomatic previously asthmatic subjects have increased airway variability.

[Allergy and bronchial reactivity in children and adolescents from Copenhagen]

The relationship between bronchial responsiveness and the results of a skin prick test was studied in 527 children and adolescents from Copenhagen. All participants completed a questionnaire concerning birth weight, breastfeeding, month of birth, month of examination, allergic symptoms in themselves or their parents. Furthermore, skin prick test reactivity to nine common aero-allergens, lung function, serum IgE, and bronchial responsiveness to histamine and exercise were measured. A total of 158 (30%) subjects showed signs of allergy (defined as a positive reaction to the skin prick test), of whom 53 (10%) subjects had positive skin reactivity and 105 subjects had moderate skin reactivity; 366 (70%) subjects had no signs of allergic disease as measured by the pride test. The most important marker for the degree of bronchial responsiveness was asthma (p < 0.001), month of examination (p < 0.01) and allergy (skin reactivity to one or more allergens) (p < 0.05). Furthermore, the degree of bronchial responsiveness to inhaled histamine was significantly related to a history of asthma in two first degree relatives (p < 0.01) and the skin reactivity to house-dust mites (p < 0.01), whereas the degree of bronchial responsiveness to exercise was significantly associated with the level of serum IgE (p < 0.05), month of birth (p < 0.001) and birth weight (p < 0.05). In conclusion, allergy is an important risk factor for the presence of increased degree of bronchial responsiveness to inhaled histamine and to exercise.

[Cytomegalovirus infection. A review]

Once considered to be an infrequent cause of human disease, human cytomegalovirus (CMV) is now recognized as being one of the most common congenital infections leading to birth defects, and furthermore, it is a common opportunistic infection associated with serious illness and death in immunocompromised patients. CMV has been assigned to the herpes family of viruses. It is an enveloped DNA virus. About 50%-60% of Danish blood donors have anti-CMV. This figure is dependent on age, race, socioeconomic status, sexual behaviour and geographical area. Patients exhibiting symptoms and signs of primary or reactivated CMV infection should be further evaluated with appropriate laboratory tests, as treatment of CMV disease with antiviral chemotherapy such as ganciclovir or foscarnet, has proven to be effective.

Distribution of serum IgE in children and adolescents aged 7 to 16 years in Copenhagen, in relation to factors of importance

The distribution of total serum-IgE and factors of importance for the level of IgE was studied in a random sample of 508 children and adolescents, aged 7-16 years, from Copenhagen. A detailed history about asthma, rhinitis, dermatitis and urticaria was obtained, and a physical examination, skin prick test with 9 common allergens, lung function test, bronchial challenge with inhaled histamine and exercise, and measurement of IgE (kU/l) were performed. The distribution of IgE among children and adolescents was found to exhibit a log normal distribution and a positive skin prick test, allergic symptoms, a family history of allergic diseases, age and smoking were found to be significantly related to an increased level of IgE. No relationship was found between increased bronchial responsiveness and IgE. The geometric mean of "normal" values of IgE (*1 SD and *2 SD) of the Danish children and adolescents was 18 kU/l (*4.7, *18.2), suggesting that normal IgE values were within 330 kU/l. Measurement of IgE as the only screening for allergic disease is unreliable, as the predictive value of an elevated IgE in population samples was found to be 50%, whereas misclassification (1-specificity) of asymptomatic subjects as allergic because of an increased IgE was low (4%). In conclusion, total IgE is highly influenced by allergen skin reactivity. Further, this study suggests that normal IgE values were within 330 kU/l, although the range was wide.

Atopy and bronchial responsiveness in random population sample of 527 children and adolescents

The relationship between bronchial responsiveness, lung function, and results of skin prick testing was studied in 527 children and adolescents from Copenhagen. All participants completed a questionnaire concerning allergic symptoms (asthma, rhinitis, atopic dermatitis, and urticaria). Furthermore, skin prick test reactivity to nine common aeroallergens, lung function, serum IgE and bronchial responsiveness to histamine and exercise were measured. A total of 53 subjects were atopic, (skin prick 3+), 105 subjects had moderate skin reactivity (1-2+), and 366 subjects had no signs of atopic disease (prick test negative); 58% of the subjects with skin test reactivity (1-3+) were asymptomatic. Increasing degree of atopy was correlated significantly with symptoms such as asthma, rhinitis, dermatitis, and urticaria (P less than .001); increasing level of IgE (P less than .001); month of birth (P = .001); and family history of allergic diseases (P less than .05). The most important markers for the degree of bronchial responsiveness to inhaled histamine were the presence of respiratory symptoms (P less than .001), the degree of atopy (P = .001), a history of asthma in at least two first degree relatives (P less than .01), and the skin reactivity to house dust mites (P = .001), horse epithelium (P = .01), Alternaria iridis, and dog epithelium (P less than .05). In contrast, the degree of bronchial responsiveness to exercise was significantly correlated with asthma (P less than .001), the level of IgE (P less than .05), month of birth (P less than .001), and birth weight (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Epithelioid sarcoma of the penis

A rare case of penile epithelioid sarcoma in a 26-year-old white man is presented. The patient had a firm, slow growing, painless mass associated with penile deviation on erection, which was initially misdiagnosed as Peyronie's disease 5 years previously. With the onset of decreased urinary stream the lesion was biopsied, with a resultant diagnosis of epithelioid sarcoma. The patient underwent radical penectomy and perineal urethrostomy, and received 6,000 cGy. external beam radiotherapy postoperatively. Two years postoperatively the patient remained free of clinical disease. We review the pathophysiology, clinical characteristics and treatment of penile epithelioid sarcoma.

Mycoplasma hyosynoviae in joints with arthritis in abattoir baconers

The occurrence of Mycoplasma hyosynoviae in synovial fluid of baconers with chronic arthritis was studied at an abattoir. Cultural examination of synovial fluid samples from diseased tarsal joints of 50 animals from 42 herds yielded M. hyosynoviae in 10 cases from 8 herds. Streptococci were found in 6 cases from 6 other herds. M. hyosynoviae antigen was found in 1 of 47 of the samples, and antibody to the mycoplasma was found in 14 of 40 of the samples by ELISA test. The presence of M. hyosynoviae in a joint was usually accompanied by the corresponding antibody. In joints with streptococcal infection antibody to M. hyosynoviae could not be found.

Sensitivity and specificity of the histamine challenge test for the diagnosis of asthma in an unselected sample of children and adolescents

The purpose of this investigation was to study factors of importance for the degree of bronchial responsiveness and, furthermore, to evaluate the sensitivity, specificity and predictive value of a bronchial challenge test with histamine for the diagnosis of asthma in 495 randomly selected children and adolescents, aged 7-16 yrs, from Copenhagen, Rigshospitalet. Detailed history about allergic symptoms, physical examination and bronchial histamine challenge tests were performed at the out-patient clinic. Asthma, atopic disease and height were found to be of great importance for the degree of bronchial responsiveness, whereas the age, sex and smoking habits were of no significance. The percentage of asthmatics with bronchial hyperresponsiveness, i.e. sensitivity to the test, increased towards 100% on inhaling increasing concentrations of histamine, but this was accompanied by a decrease in specificity and predictive values of positive test in regard to the diagnosis of asthma. However, lower concentrations of histamine may be preferable in order to distinguish between asthma and non-asthma in population samples, as inhalation of 2.4 mg.ml-1 and provocative concentration producing a 20% fall in forced expiratory volume in one second (FEV1) (PC20) provided an acceptable sensitivity (57%), specificity (98%), and predictive value of a positive test (60%). We conclude that as regards the diagnosis of asthma, a low predictive value confirms that the bronchial challenge test plays only a supplementary, but valuable, role in detecting the disease in population samples.

Sensitivity and specificity of the histamine challenge test for the diagnosis of asthma in an unselected sample of children and adolescents

The purpose of this investigation was to study factors of importance for the degree of bronchial responsiveness and, furthermore, to evaluate the sensitivity, specificity and predictive value of a bronchial challenge test with histamine for the diagnosis of asthma in 495 randomly selected children and adolescents, aged 7-16 yrs, from Copenhagen, Rigshospitalet. Detailed history about allergic symptoms, physical examination and bronchial histamine challenge tests were performed at the out-patient clinic. Asthma, atopic disease and height were found to be of great importance for the degree of bronchial responsiveness, whereas the age, sex and smoking habits were of no significance. The percentage of asthmatics with bronchial hyperresponsiveness, i.e. sensitivity to the test, increased towards 100% on inhaling increasing concentrations of histamine, but this was accompanied by a decrease in specificity and predictive values of positive test in regard to the diagnosis of asthma. However, lower concentrations of histamine may be preferable in order to distinguish between asthma and non-asthma in population samples, as inhalation of 2.4 mg.ml-1 and provocative concentration producing a 20% fall in forced expiratory volume in one second (FEV1) (PC20) provided an acceptable sensitivity (57%), specificity (98%), and predictive value of a positive test (60%). We conclude that as regards the diagnosis of asthma, a low predictive value confirms that the bronchial challenge test plays only a supplementary, but valuable, role in detecting the disease in population samples.

The distribution of bronchial responsiveness to histamine and exercise in 527 children and adolescents

The aim of the study was to describe the bronchial responsiveness to inhaled histamine and exercise in a randomly selected group of 527 children and adolescents from Copenhagen, aged between 7 to 16 years. The distribution of the bronchial responsiveness was described as (1) the provoking concentration that causes a 20% reduction in FEV1 (2) the dose-response slope (DRS), that is, the linear slope of the dose-response curve, and (3) reduction in FEV1 after 6 minutes of exercise on a treadmill. The distribution of the concentration that causes a 20% reduction in FEV1 in the responsive range was not significantly different from a unimodal distribution, although the findings were skewed toward the less responsive end of the range (p greater than 0.05). The subjects with asthma represented a subgroup within the responsive distribution tail rather than a separate distribution peak. In asymptomatic individuals, the values of DRS were distributed symmetrically on a logarithmic scale. The deviation from normal was such that the standard deviation only slightly underestimated the "normal" range. The distribution of the bronchial response to exercise was found to be significantly different from a normal distribution. However, a significant relationship was found between the bronchial response to inhaled histamine and exercise (p less than 0.0001). We conclude that there is a log-normal distribution of the bronchial response to inhaled histamine in a random sample of children and adolescents.

Lipoprotein-cholesterol levels in infertile women with luteal phase deficiency

OBJECTIVE

To determine if reductions in plasma progesterone (P) secretion seen in luteal phase deficiency (LPD) might be because of reduced availability of circulating low-density lipoprotein (LDL) or high-density lipoprotein (HDL), known substrates for corpus luteum P synthesis.

DESIGN

We measured plasma lipoproteins in the luteal phase of the menstrual cycle in 39 infertile women. These women were divided into two groups on the basis of endometrial biopsies; the LPD group had biopsies that were greater than or equal to 3 days out-of-phase.

SETTING

All participants were recruited from the Reproductive Endocrinology and Infertility Clinic at the University of Washington, an institutional tertiary care center.

PATIENTS, PARTICIPANTS

Eighteen women had in-phase and 21 had out-of-phase LPD biopsies.

MAIN OUTCOME MEASURE

Lipoprotein levels were obtained in a fasted state on the day of the luteal phase on which the biopsy was performed.

RESULTS

No difference in covariates that affect lipoprotein levels such as obesity, age, and alcohol use were observed between the two groups. No significant differences between groups were found for triglycerides, total cholesterol, very low density lipoprotein, LDL, HDL, HDL2, and HDL3 concentrations. However, LPD was associated with a reduction in the extent to which: age and obesity are associated with higher triglycerides; obesity is associated with a lower HDL2; and alcohol is associated with a higher HDL3-cholesterol.

CONCLUSIONS

Lipoproteins on average are not different in LPD, suggesting reasons other than a deficient plasma lipoprotein cholesterol source as the explanation for decreased P secretion. A lesser interaction between LDL or HDL and obesity, age, and alcohol in LPD could signify an influence of the altered hormonal milieu of LPD on the way lipoproteins interact with covariates and could lead to differences in lipoproteins between normal and LPD subjects at the extremes of the lipoprotein distribution.

Cutting healthcare costs. Can physicians make a difference?

Information about healthcare "bargains" is easy to obtain. Physicians who take the time to familiarize themselves with costs in their hospitals and clinics can help reduce charges for tests and drugs and can avoid wasteful use of supplies and misuse of staff time that can lead to additional charges. Education is effective in fighting rising healthcare costs, but efforts need to be ongoing if patients and medical institutions are to benefit in the long run.

The effect of astemizole on bronchial hyperresponsiveness and exercise-induced asthma in children

The ability of the new generation H1-receptor antagonist, astemizole, to prevent histamine-induced airway obstruction and exercise-induced asthma (EIA) was studied in 20 children with asthma. The study was a randomised clinically controlled trial of oral astemizole versus placebo in a cross-over study. In each of the two treatment periods the children were tested at days 0, 6, 15 and 22 of therapy. The two treatment periods were separated by a washout period of 50 days, and at each visit a bronchial challenge with increasing concentrations of histamine followed by an exercise test was performed, and peak flow and asthmatic symptom score were recorded daily. The children tolerated significantly higher mean concentrations of histamine when treated with astemizole compared with placebo (P less than 0.001). Astemizole postponed the response to exercise, but no change in the maximal response was found. No differences between the treatment periods were found regarding frequency of asthmatic symptoms or the daily recording of peak flow.