Role of Thymosin Beta 4 in the diagnosis of Nonalcoholic Fatty Liver and its relation to Metabolic Syndrome in Egyptian patients

Nonalcoholic fatty liver disease (NAFLD) is a spectrum of hepatic diseases linked to metabolic and cardiovascular disorders that impair quality of life and increase morbidity and mortality. There has been significant interest in replacing conventional diagnostic tools such as liver biopsy with non-invasive biomarkers for the diagnosis of NAFLD. Thymosin Beta 4 (Tβ4) is a G-actin sequestering peptide involved in many critical biological processes. This study aimed to evaluate the role of Tβ4 in the diagnosis of NAFLD, and its relation to metabolic syndrome. Eighty patients were enrolled in this study, divided into two equal groups of NAFLD cases (n=40) and a control group (n=40). The two groups were subjected to history taking, physical examination, measurement of waist circumference and body mass index (BMI). Laboratory workup included serum Tβ4, insulin resistance (HOMA-IR), fibrosis-4 score (FIB-4), fatty liver index (FLI) and NAFLD fibrosis score (NFL) were calculated for both groups. Serum Tβ4 was significantly lower in NAFLD patients (P <0.001) and there was a significant positive correlation between serum Tβ4 and HDL (P = 0.034). On the other hand, there was a significant negative correlation between serum Tβ4 and waist circumference (P <0.001), total cholesterol level (P <0.001), insulin level (P <0.001), HOMA-IR (P <0.001), serum triglycerides (P= 0.025) and FLI (P = 0.004). Serum Tβ4 at a cut-off value of ≤900 ng/ml had 100 % sensitivity, 100 % specificity, 100% positive predictive value and 100% negative predictive value for the prediction of NAFLD. In conclusion, serum Tβ4 could be used as a biomarker for the diagnosis of NAFLD.

Identifying a nasal gene expression signature associated with hyperinflation and treatment response in severe COPD

Hyperinflation contributes to dyspnea intensity in COPD. Little is known about the molecular mechanisms underlying hyperinflation and how inhaled corticosteroids (ICS) affect this important aspect of COPD pathophysiology. To investigate the effect of ICS/long-acting β₂-agonist (LABA) treatment on both lung function measures of hyperinflation, and the nasal epithelial gene-expression profile in severe COPD. 117 patients were screened and 60 COPD patients entered a 1-month run-in period on low-dose ICS/LABA budesonide/formoterol (BUD/F) 200/6 one inhalation b.i.d. Patients were then randomly assigned to 3-month treatment with either a high dose BDP/F 100/6 two inhalations b.i.d. (n = 31) or BUD/F 200/6 two inhalations b.i.d. (n = 29). Lung function measurements and nasal epithelial gene-expression were assessed before and after 3-month treatment and validated in independent datasets. After 3-month ICS/LABA treatment, residual volume (RV)/total lung capacity (TLC)% predicted was reduced compared to baseline (p < 0.05). We identified a nasal gene-expression signature at screening that associated with higher RV/TLC% predicted values. This signature, decreased by ICS/LABA treatment was enriched for genes associated with increased p53 mediated apoptosis was replicated in bronchial biopsies of COPD patients. Finally, this signature was increased in COPD patients compared to controls in nasal, bronchial and small airways brushings. Short-term ICS/LABA treatment improves RV/TLC% predicted in severe COPD. Furthermore, it decreases the expression of genes involved in the signal transduction by the p53 class mediator, which is a replicable COPD gene expression signature in the upper and lower airways.Trial registration: ClinicalTrials.gov registration number NCT01351792 (registration date May 11, 2011), ClinicalTrials.gov registration number NCT00848406 (registration date February 20, 2009), ClinicalTrials.gov registration number NCT00158847 (registration date September 12, 2005).

Iatrogenic Arterial Perforation During Endovascular Interventions

The use of minimally invasive endovascular procedures has increased, and as such, the frequency of associated vascular complications has also increased. Regardless of the access site location, rarely, arterial perforation can occur, which can be fatal if not properly managed. Interventionalists should be aware of the risk factors for perforation, commonly perforated vessels, and how different sites of perforation are diagnosed and managed. Rapid recognition and endovascular management reduce the need for open surgical repair, and thus reduce the morbidity and mortality of these complications. This review outlines the presentation, diagnosis, and management of iatrogenic perforations of the subclavian artery, thyrocervical trunk (TT), common carotid artery, superficial femoral artery (SFA), and external iliac artery.

The value of prednisolone acetate provocative test before intravitreal triamcinolone acetonide injections

Purpose:

The aim of this study was to investigate the diagnostic value of a topical prednisolone acetate 1% provocative test for steroid-induced ocular hypertension before intravitreal triamcinolone acetonide injection.

Methods:

This is a prospective, single-center, randomized controlled study at Kasr El Aini Hospital, Cairo University. Patients scheduled for intravitreal triamcinolone acetonide were enrolled and randomly allocated in a ratio 2:1 to either Group A: received prednisolone acetate provocative test and those who did not develop SIOH proceeded with intravitreal triamcinolone acetonide or Group B: did not receive prednisolone acetate provocative test and proceeded directly to intravitreal triamcinolone acetonide. Intraocular pressures were measured weekly for 4 weeks following intravitreal triamcinolone acetonide. Steroid-induced ocular hypertension is defined as intraocular pressure increase of 5 mmHg or more from baseline after prednisolone acetate provocative test or intravitreal triamcinolone acetonide.

Results:

A total of 66 eyes (66 patients) were included. Of which, 10 eyes (23.8%) showed prednisolone acetate provocative test steroid-induced ocular hypertension during the 4-week period. Intravitreal triamcinolone acetonide steroid-induced ocular hypertension was less likely to develop in Group A (prednisolone acetate provocative test non-steroid-induced ocular hypertension, n = 32, 31.25%) than in group B (n = 24, 54.2%) (p = 0.006, odds ratio: 0.178, 95% CI: 0.53–0.596). Our test achieved a negative predictive value of 68.75%.

Conclusion:

The topical prednisolone acetate provocative test may be a useful method to predict a steroid-induced ocular hypertension following intravitreal triamcinolone acetonide.

Multidisciplinary Management of Subclavian Artery Perforation and Complications

The radial approach to cardiac catheterization and percutaneous coronary interventions has increased in popularity due to the favorable side effect profile relative to the femoral approach. Mediastinal hematoma after radial access cardiac catheterization has scarcely been reported in the literature and, if present, the exact location of the bleed was rarely identified. In this case presentation, we describe an elective transradial coronary angiography resulting in subclavian artery perforation in close proximity to the vertebral artery, with subsequent mediastinal and cervical hematoma formation. This scenario was managed by immediate imaging of the chest after sudden deterioration raised suspicion of an adverse event during wire navigation. Formation of a mediastinal hematoma is the equivalent of retroperitoneal bleed from the femoral approach and requires rapid recognition, interdisciplinary collaboration, and endovascular management.

Nasal gene expression differentiates COPD from controls and overlaps bronchial gene expression

Background

Nasal gene expression profiling is a promising method to characterize COPD non-invasively. We aimed to identify a nasal gene expression profile to distinguish COPD patients from healthy controls. We investigated whether this COPD-associated gene expression profile in nasal epithelium is comparable with the profile observed in bronchial epithelium.

Methods

Genome wide gene expression analysis was performed on nasal epithelial brushes of 31 severe COPD patients and 22 controls, all current smokers, using Affymetrix Human Gene 1.0 ST Arrays. We repeated the gene expression analysis on bronchial epithelial brushes in 2 independent cohorts of mild-to-moderate COPD patients and controls.

Results

In nasal epithelium, 135 genes were significantly differentially expressed between severe COPD patients and controls, 21 being up- and 114 downregulated in COPD (false discovery rate < 0.01). Gene Set Enrichment Analysis (GSEA) showed significant concordant enrichment of COPD-associated nasal and bronchial gene expression in both independent cohorts (FDR_GSEA < 0.001).

Conclusion

We identified a nasal gene expression profile that differentiates severe COPD patients from controls. Of interest, part of the nasal gene expression changes in COPD mimics differentially expressed genes in the bronchus. These findings indicate that nasal gene expression profiling is potentially useful as a non-invasive biomarker in COPD.

Trial registration

ClinicalTrials.gov registration number NCT01351792 (registration date May 10, 2011), ClinicalTrials.gov registration number NCT00848406 (registration date February 19, 2009), ClinicalTrials.gov registration number NCT00807469 (registration date December 11, 2008).

Electronic supplementary material

The online version of this article (10.1186/s12931-017-0696-5) contains supplementary material, which is available to authorized users.

Diagnostic and prognostic significance of ischemic electrocardiographic changes with regadenoson-stress myocardial perfusion imaging

BACKGROUND

The diagnostic and prognostic value of regadenoson-induced ST-segment depression (ST↓) is not defined. Due to the low incidence of ST↓ ≥1.0 mm with vasodilator stress, a lower threshold to define ischemic ECG response may provide improved clinical utility.

METHODS

We conducted a retrospective cohort study of patients who underwent regadenoson-stress SPECT myocardial perfusion imaging (MPI) followed by coronary angiography within 6 months. Ischemic ST↓ was defined as ≥0.5 mm. The prevalence of angiographically severe coronary artery disease (CAD) and the rates of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, and coronary revascularization were determined.

RESULTS

In a diagnostic cohort of 629 subjects, 117 (18.6%) had ST↓ ≥0.5 mm. Severe CAD was more prevalent in the ST↓ ≥0.5 vs ST <0.5 group (13.7% vs 5.3%, P = .001). Among patients with normal MPI (n = 229), the prevalence of severe CAD was higher in the ST↓ ≥0.5 group (8.2% vs 2.2%, P = .04). Adjusting for clinical and imaging covariates, ST↓ ≥0.5 mm was independently predictive of severe CAD [odds ratio = 3.37, 95% confidence interval (CI) = 1.67-6.83, P = .001], and provided incremental diagnostic value (Chi square increment = 10.3, P = .001). In an outcome cohort of 748 subjects, after adjusting for clinical and imaging covariates, ST↓ ≥0.5 mm was associated with increased MACE rate in the entire cohort [hazard ratio = 1.41, CI 1.01-1.96, P = .04] and in the subgroup of patients with normal MPI [hazard ratio = 2.2, CI 1.11-4.39, P = .02], and provided incremental prognostic value (Chi square increment = 3.9, P = .049). A diagnostic ST↓ threshold of 0.5 mm provided greater discriminatory capacity than a 1.0 mm cutoff (P = .03).

CONCLUSIONS

Among patients selected to undergo coronary angiography, regadenoson-induced ST↓ ≥0.5 mm was associated with higher rates of severe CAD and MACE, irrespective of MPI finding.

Evaluation of the efficacy, safety, and acceptability of an eyelid warming device for the treatment of meibomian gland dysfunction

Meibomian gland dysfunction (MGD) is widespread and has significant impact on patients' quality of life. Eyelid hygiene is the mainstay of treatment but is unstandardized and requires commitment from the patient and encouragement from the ophthalmologist. Blephasteam(®) is an eyelid warming device designed to be an easy-to-use and standardized treatment for MGD. In the present study, 73 patients were treated for 21 days with twice daily Blephasteam(®) sessions. The primary efficacy variable, a symptomatology visual analog scale score, declined from 63.07±21.23 (mean ± standard deviation) on day 0 to 41.90±25.49 on day 21. There were also improvements in a number of secondary efficacy variables including subjective ocular symptoms and clinical signs and symptoms of MGD and dry eye, though tear film breakup time and tear osmolarity were not improved. Global efficacy was assessed as satisfactory or very satisfactory in 83.8% of cases. Patient-reported subjective ocular symptoms declined during the study, and a majority of patients rated the efficacy of Blephasteam(®) as satisfactory or very satisfactory. Most patients found the device comfortable and were able to continue with normal activities (reading, watching TV, using a computer) during the Blephasteam(®) session. No safety or tolerability issues were identified.

The impact of regimented aminophylline use on extracardiac radioisotope activity in patients undergoing regadenoson stress SPECT myocardial perfusion imaging: a substudy of the ASSUAGE trial

BACKGROUND

In patients undergoing regadenoson stress SPECT myocardial perfusion imaging (MPI), the impact of the regimented administration of aminophylline on the cardiac-to-extracardiac photon activity ratio is unknown.

METHODS

This is a substudy of the ASSUAGE trial (NCT01250496); a double-blinded, randomized, placebo-controlled clinical trial which investigated the attenuation of regadenoson-related adverse effects using 75 mg of intravenous aminophylline vs placebo, administered 90 seconds following (99m)Tc-tetrofosmin injection in patients undergoing regadenoson stress SPECT-MPI. In subjects with normal MPI enrolled in the trial, we sampled from the antero-posterior planar projection of the post-stress scintigraphic data the mean photon activity in the myocardium, liver, bowel, and lungs. The mean cardiac-to-extracardiac activity ratios were compared between patients randomized to aminophylline vs placebo.

RESULTS

We studied 158 eligible subjects, randomized to receive aminophylline (n = 86) or placebo (n = 72). The means of photon activity ratios of the heart-to-liver, heart-to-bowel, heart-to-lungs, inferior wall of the heart-to-liver, and inferior wall of the heart-to-bowel were not statistically different between those who received aminophylline vs placebo (P values > .30). Only the time lapse between stress (99m)Tc-tetrofosmin injection and stress SPECT acquisition independently correlated with higher heart-to-liver and heart-to-bowel activity ratios (P values ≤ .01). Patients' body mass index independently correlated with lower heart-to-lung ratio (P = .009).

CONCLUSION

The regimented intravenous aminophylline use following regadenoson stress does not significantly improve the cardiac-to-extracardiac photon activity ratio in patients undergoing regadenoson stress (99m)Tc-tetrofosmin SPECT-MPI.

Disseminated superficial actinic porokeratosis on the face treated with imiquimod 5% cream

Porokeratoses are a group of hereditary or acquired disorders characterized by annular lesions with an atrophic center and a prominent peripheral ridge. Pathologically, porokeratosis is characterized by the presence of abnormal clones of keratinocytes that form a column of parakeratotic cells, called the cornoid lamella. Fifteen percent of patients of disseminated superficial actinic porokeratosis (DSAP) have facial lesions; other regions like the extensor surface of extremities constitute the majority of reported cases. Exclusively facial lesions are probably less frequent. Rarely, actinic porokeratosis is confined to the nose only. Of reported porokeratosis cases, 7.5% have revealed a malignancy arising within the lesion. We present a case of facial sporadic DSAP that was treated with imiquimod 5% cream in conjunction with a regular sunscreen. Follow-up of this case is important to rule out the possibility of malignant transformation of the lesions.

Fatal metastatic cutaneous squamous cell carcinoma evolving from a localized verrucous epidermal nevus

A malignant transformation is known to occur in many nevi such as a sebaceous nevus or a basal cell nevus, but a verrucous epidermal nevus has only rarely been associated with neoplastic changes. Keratoacanthoma, multifocal papillary apocrine adenoma, multiple malignant eccrine poroma, basal cell carcinoma and cutaneous squamous cell carcinoma (CSCC) have all been reported to develop from a verrucous epidermal nevus. CSCC has also been reported to arise from other nevoid lesions like a nevus comedonicus, porokeratosis, a sebaceous nevus, an oral sponge nevus and an ichthyosiform nevus with CHILD syndrome. Here we report a case of progressive poorly differentiated CSCC arising from a localized verrucous epidermal nevus, which caused both spinal cord and brain metastasis.

Polymer Materials Design for Optical Limiting

Phthalocyanines (PC's) containing heavy metal central atoms have recently been recognized as leading candidates for reverse saturable absorption and optical limiting (OL) applications in the visible spectrum. Strong triplet excited state absorption brought about by a large intersystem crossing rate is responsible for the excellent limiting performance of these molecules. Moreover, devices which maximize the excited state population along the light path will demonstrate maximum limiting efficiency. A non-homogeneous distribution of indium tetra(tert-butyl) phthalocyanine chloride (InC1PC) has been shown to be very effective in attenuating 532 nm nanosecond laser pulses. This was accomplished by approximating a hyperbolic distribution of chromophores using discrete elements of fixed dye concentration. Greater OL should be achieved by fabricating materials containing a continuous concentration gradient of chromophore. This paper focuses on issues concerning the preparation of solid polymeric materials that contain such a chromophore gradient. This design is achieved by diffusing chromophore-containing solutions into partially polymerized poly(methyl methacrylate) (PMMA).

Approaches for Optimizing and Tuning the Optical Limiting Response of Phthalocyanine Complexes

Recent progress on the use of molecular engineering approaches for the enhancement and spectral tuning of the optical limiting responses of phthalocyanine complexes is presented. Examples are given involving the use of the heavy-atom approach to enhance the limiting response of naphthalocyanines and of donor substitution of naphthalocyanines to red shift the optical limiting response, as demonstrated for indium and tin octabutoxynaphthalocyanines. These approaches have led to new materials for optical limiting with potential for high performance. An experimental demonstration of the “bottleneck” limiter concept, in which the optical-limiting material is distributed nonhomogeneously to permit strong pumping of excited-state population throughout the interaction region, is presented and shows an order-of-magnitude increase in pulse suppression compared to a homogeneous distribution, without an increase in linear absorbance.

Morbid obesity and metabolic syndrome in Ossabaw miniature swine are associated with increased platelet reactivity

BACKGROUND

Metabolic syndrome (MetS) and type 2 diabetes mellitus in humans are associated with increased platelet activation and hyperreactivity of platelets to various agonists. Ossabaw swine develop all the hallmarks of MetS including obesity, insulin resistance, hypertension, dyslipidemia, endothelial dysfunction, and coronary artery disease when being fed excess calorie atherogenic diet. We hypothesized that Ossabaw swine with MetS would exhibit increased platelet reactivity compared with lean pigs without MetS.

MATERIALS AND METHODS

Ossabaw swine were fed high caloric, atherogenic diet for 44 weeks to induce MetS (n = 10) and were compared with lean controls without MetS that had been fed normal calorie standard diet (n = 10). Light transmittance aggregometry was performed using adenosine diphosphate (ADP), collagen, thrombin, and arachidonic acid (AA) at different concentrations. Dose response curves and EC50 were calculated. Glucose tolerance testing and intravascular ultrasound study of coronary arteries were performed.

RESULTS

MetS pigs compared with lean controls were morbidly obese, showed evidence of arterial hypertension, elevated cholesterol, low-density lipoprotein/high-density lipoprotein, and triglycerides, and insulin resistance. Platelets from MetS pigs were more sensitive to ADP-induced platelet aggregation than leans (EC50: 1.83 ± 1.3 μM vs 3.64 ± 2.2 μM; P = 0.02). MetS pigs demonstrated higher platelet aggregation in response to collagen than lean pigs (area under the curve: 286 ± 74 vs 198 ± 123; P = 0.037) and a trend for heightened response to AA (AUC: 260 ± 151 vs 178 ± 145; P = 0.13). No significant difference was found for platelet aggregation in response to thrombin.

CONCLUSIONS

MetS in Ossabaw swine is associated with increased reactivity of platelets to ADP and collagen. The Ossabaw swine may be a practical, large animal model for the study of certain aspects of platelet pathophysiology and examine vascular devices in a metabolic environment comparable to humans with MetS.

Aspirin resistance

The development of adverse cardiovascular events despite aspirin use has established an interest in a possible resistance to the drug. Several definitions have been set and various laboratory testing modalities are available. This has led to a wide range of prevalence reports in different clinical entities. The etiologic mechanism has been related to clinical, genetic, and other miscellaneous factors. The clinical implications of this phenomenon are significant and warrant concern. Management strategies are currently limited to dosing alteration and introduction of other anitplatelet agents. However, these measures have not met the expected efficacy or safety.

Bronchoalveolar lavage in sarcoidosis

There is no single cell type present in bronchoalveolar lavage (BAL) fluid that appears to be predictive for sarcoidosis. However, BAL fluid analysis can be very helpful in the differential diagnosis. A grouping of features, an elevated total cell count, predominantly lymphocytes, together with a nearly normal percentage of eosinophils and polymorphonuclear neutrophils and the absence of plasma cells, distinguish the most likely diagnosis of sarcoidosis from the most common interstitial lung diseases, extrinsic allergic alveolitis (EAA), nonspecific interstitial pneumonia (NSIP), and idiopathic pulmonary fibrosis (IPF). In sarcoidosis the majority of cases have an increased number of lymphocytes and a normal amount of eosinophils and neutrophils. Disease presentation or activity at the time the BAL is performed as well as the smoking status is crucial for interpretation of individual BAL fluid analysis results. In severe cases the number of neutrophils can be increased as well. For an individual case the CD4:CD8 ratio is of less importance because it can be increased, normal, and even decreased. In the follow-up depicting prognosis and response to treatment, BAL fluid analysis has less clinical relevance.

Lacrimal punctum occlusion in the treatment of severe keratoconjunctivitis Sicca caused by Sjögren syndrome: a uniocular evaluation

PURPOSE

A controlled uniocular study to evaluate the short-term efficacy of lacrimal punctum occlusion in the treatment of severe dry eye caused by Sjögren syndrome.

METHODS

Uniocular punctum occlusion by punctum plug in the upper and lower puncta in 1 eye was performed in 20 patients with severe keratoconjunctivitis Sicca caused by Sjögren syndrome. To overcome possible interindividual variability between patients, the other eye, in the same patient, was not occluded and served as a control eye. The eye to be occluded was randomly selected. The patients were instructed to continue using their dry eye medications. Tear function tests (Schirmer test, rose Bengal test, and debris in de cul-de-sac) were performed in both eyes. Subjective complaints (discomfort) were registered for both eyes. All the above-mentioned data were collected before starting the treatment and at least 6 weeks later. The above-mentioned parameters were compared and statistically analyzed in both eyes.

RESULTS

Of the 20 patients, 7 patients dropped out. The remaining 13 patients completed the final analysis. In the occluded eye, we found a significant improvement in both the subjective complaints and the rose Bengal score, but the Schirmer test and the tear mucus score did not change.

CONCLUSION

Punctum occlusion therapy in a short-term study improved the rose Bengal score and discomfort score in our patients and thus may be helpful in the treatment of severe dry eye caused by Sjögren syndrome.

Scintigraphic evaluation for tear drainage, after dacryocystorhino- stomy, in relation to patient satisfaction

AIM

To measure the degree of physiological patency of the tear drainage system using dacryoscintigraphy before and after external dacryocystorhinostomy (EDCR) in relation to patient complaints.

METHODS

Prospective evaluation of 29 eyes of 24 patients with primary acquired nasolacrimal duct obstruction (PANDO) who underwent EDCR. The epiphora complaints were measured subjectively. Dacryoscintigraphy was performed in all eyes preoperatively, and was repeated 6 months after DCR together with the complaints score. For evaluation of dacryoscintigraphy, we determined T1 (percentage of administered dose still present after 1 min) and linear clearance rate (LCR), defined as: 100%(T1-T15)/T1) from the tracer disappearance curve. Dacryoscintigraphy findings were compared with the results of 20 eyes of normal volunteers without any symptoms. Scintigraphic findings were compared before and after the operation, with the change in patient complaints score as well as with normal values.

RESULTS

Significant improvement occurred after the operation in the complaints score, T1 and LCR. However, despite absence of complaints (score=0) postoperative scintigraphic values were still abnormal as compared to normal individuals.

CONCLUSION

Despite almost complete remission of epiphora complaints, DCR does not result in normalization of the tear drainage system.

Early osteotomy with delayed implant placement: a step further for immediate loading

The commonly used implantation technique involves a 2-stage surgical protocol for load-free and submerged healing to ensure predictable osseointegration. This article presents a new approach that benefits from previous bone and soft tissue protocols. It combines new surgical and insertion techniques to perform immediate loading with delayed implant placement, avoiding the problems of discomfort, inconvenience, and anxiety associated with healing periods. It maintains a similar success rate to the present common technique. After osteotomy, bone healing passes through 3 stages (i.e., inflammation, fibrous tissue, and maturation). In the new approach, implant insertion is performed 2 weeks after drilling (i.e., during the fibrous phase). The insertion timing is so selected because collagen formation and revascularization represent an acceptable implant bed configuration. Flap surgery offers the optimal osteotomy approach, but esthetic outcomes are definitely compromised. Accordingly, adopting the punch technique alleviates several postoperative problems, such as pain, tenderness, and swelling. Moreover, the punch technique avoids the sutures needed to adjust the gingiva around the abutment. It provides both cosmetic and functional properties.

Clinical value of dacryoscintigraphy using a simplified analysis

PURPOSE

To study the discriminatory ability of dacryoscintigraphy in differentiating between patients with epiphora and volunteers using a simple method.

METHODS

Twenty eyes in ten volunteers and 66 eyes in 55 patients with severe epiphora were studied. Dacryoscintigraphy (15 frames of 1 min) was performed after administration of 4 MBq (99m)Tc-pertechnetate (10 mul) in both eyes. By mapping a single region of interest (ROI) over the conjunctival sac we determined T1 (%dose in first minute) and linear clearance rate (LCR, defined as [see text] from the tracer disappearance curve. Reproducibility was determined in volunteers. Conjunctival resorption was determined from completely obstructed systems. Sensitivity and specificity were calculated and receiver operating characteristics (ROC) analysis was conducted.

RESULTS

In volunteers mean T1 was 52.8+/-11.9% (95% CI 47.1-58.4%), and LCR was 74.2+/-11.1% (95% CI 69.0-79.4%). Reproducibility was good (mean difference 4.1+/-13.3% for T1 and 0.7+/-17% for LCR). Epiphora patients had clearly higher T1 (82.1+/-15.2%, P<0.0001) and lower LCR (38.9+/-22.5%, P<0.0001) values. Tracer resorption was 24%. Based on ROC analysis 70% for T1 and 50% for LCR were considered optimal cut-off levels to separate patients from volunteers. Sensitivity/specificity were 77/95% for T1 and 71/100% for LCR. T1 and LCR values did not correlate with symptom scores or Anel test results.

CONCLUSION

Dacryoscintigraphy, using LCR and T1 as parameters, is a reliable and objective method to detect tear-flow abnormalities.

Long-Term Patient Satisfaction of External Dacryocystorhinostomy

PURPOSE

To evaluate patient's opinion on the long-term success of external dacryocystorhinostomy using the same quantitative parameter pre- and postoperatively.

METHODS

A postal questionnaire was sent to 139 patients who had undergone external dacryocystorhinostomy. The only parameter for success of the treatment was the improvement of patient's subjective pre- and postoperative symptoms score. The duration of this follow-up ranged from 1 year up to 5 years postoperatively. Statistical analyses were performed using the Wilcoxon Signed-Ranks test and the chi2 test.

RESULTS

According to the patient's own evaluation, external dacryocystorhinostomy is a successful operation. After 1 year the success percentage was 89%, after 2-3 years it was 79% and after 4-5 years it was 71%.

CONCLUSION

External dacryocystorhinostomy is appreciated by the patients and considered a successful operation. The subjective evaluation of this operation should yield more creditability than objective methods.

Rituximab treatment in patients with primary Sjögren's syndrome: An open-label phase II study

OBJECTIVE

To investigate the safety and efficacy of B cell depletion treatment of patients with active primary Sjögren's syndrome of short duration (early primary SS) and patients with primary SS and mucosa-associated lymphoid tissue (MALT)-type lymphoma (MALT/primary SS).

METHODS

Fifteen patients with primary SS were included in this phase II trial. Inclusion criteria for the early primary SS group were B cell hyperactivity (IgG >15 gm/liter), presence of autoantibodies (IgM rheumatoid factor, anti-SSA/SSB), and short disease duration (<4 years). Inclusion criteria for the MALT/primary SS group were primary SS and an associated MALT-type lymphoma (Ann Arbor stage IE) localized in the parotid gland. Patients were treated with 4 infusions of rituximab (375 mg/m2) given weekly after pretreatment with prednisone (25 mg) and clemastine. Patients were evaluated, using immunologic, salivary/lacrimal function, and subjective parameters, at baseline and at 5 and 12 weeks after the first infusion.

RESULTS

Significant improvement of subjective symptoms and an increase in salivary gland function was observed in patients with residual salivary gland function. Immunologic analysis showed a rapid decrease of peripheral B cells and stable levels of IgG. Human anti-chimeric antibodies (HACAs) developed in 4 of 15 patients (27%), all with early primary SS. Three of these patients developed a serum sickness-like disorder. Of the 7 patients with MALT/primary SS, complete remission was achieved in 3, and disease was stable in 3 and progressive in 1.

CONCLUSION

Findings of this phase II study suggest that rituximab is effective in the treatment of primary SS. The high incidence of HACAs and associated side effects observed in this study needs further evaluation.

Mathematical determination of inspiratory upper airway resistance using a polynomial equation

We have previously shown that the pressure-flow relationship of the upper airway during nonrapid eye movement sleep can be characterized by a polynomial equation: F(P) = AP(3) + BP(2) + CP + D. On the basis of fluid mechanic principles, we hypothesized that we could objectively calculate upper airway resistance (R(UA)) using the polynomial equation. We manually measured RUA (mR(UA)) from the first linear portion of a pressure-flow loop in 544 breaths from 20 subjects and compared the mRUA to the R(UA) calculated from the polynomial equation (cRUA). Bland-Altman analysis showed that the mean difference between mR(UA) and cRUA was 0.0 cm H2O/L/s (95% CI, 0.1 to 0.1 cm H2O/L/s) with an upper limit of agreement of 2.0 cm H (2)O/L/s (95% CI, 1.9 to 2.1 cm H2O/L/s) and a lower limit of agreement -2.0 cm H2O/L/s (95% CI, -2.1 to -1.9 cm H2O/L/s). Additional Bland-Altman analyses showed that the agreement between the two measures was excellent for both inspiratory flow-limited and non-flow-limited breaths. We conclude that R(UA) can be measured in a simple, objective, and reproducible fashion from a polynomial function that characterizes the upper airway pressure-flow relationship.

Comparison of lacrimal and salivary gland involvement in Sjögren's syndrome

OBJECTIVES

To determine the performance of different tear and salivary tests applied in Sjögren's syndrome (SS) and to disclose how these tests relate to common serologic tests in SS.

DESIGN

In addition to the routine ocular and oral tests for diagnosing SS (Schirmer test, rose bengal score, unstimulated whole saliva flow, and parotid sialography), tear breakup time and flow rate of glandular saliva (parotid and submandibular-sublingual [SM/SL]) were evaluated in patients referred for diagnosis of SS. Patients were categorized into primary SS, secondary SS, and non-SS groups according to the revised European classification criteria for SS.

SETTING

Referral center.

PATIENTS

Referred sample of 80 consecutive patients.

MAIN OUTCOME MEASURE

Correlation between ocular and salivary measures.

RESULTS

Breakup time performed insufficiently in diagnosing SS, as opposed to the rose bengal score. In patients with primary and secondary SS, a clear correlation was noted between tear and saliva quality and secretion rate, and between the rose bengal score and parotid sialography. Increased rose bengal scores also correlated significantly with hyperglobulinemia and presence of SS-B antibodies in serum, with duration of subjective eye dryness, and with decreased tear-gland function. With regard to the oral tests, whole, parotid, and SM/SL salivary flow decreased significantly with increasing duration of oral complaints, with the stimulated SM/SL flow rate showing the strongest decrease and being more specific in diagnosing SS. Also, parotid sialography was more specific in excluding patients without SS than the commonly applied diagnostic criterion of secretion of unstimulated whole saliva.

CONCLUSIONS

The rose bengal score remains the eye test of choice, as it has the highest specificity for SS. Hyperglobulinemia and especially positive serologic findings for SS-B may warrant close monitoring of the eyes, since these serum findings appear to relate to the severity of ocular surface damage. Parotid sialography and stimulated secretion of SM/SL saliva are more specific in diagnosing SS than unstimulated secretion of whole saliva.

Isolation and characterization of two types of actinophages infecting Streptomyces scabies MR13

Two types of actinophages, phi S and phi L, were isolated from soil samples by using Streptomyces scabies MR13, a potato scab pathogen, as an indicator strain. The phages were partially characterized according to their physicochemical properties, plaques and particles morphology and their host-range. The host-range of these phages was narrow for phi S and wide for phi L. The adsorption rate constants of the phi S and phi L were 3.44 x 10(-9) and 3.18 x 10(-9) ml/min, and their burst sizes were 1.61 and 3.75 virions, respectively. One-step growth indicated that phi S and phi L have a latent period of 30 min followed by a rise period of 30 min. The temperate character of these phages was tested in other isolates of Streptomyces. Four of the phages (phi SS3, phi SS12, phi SS13 and phi SS17) were identified as temperate phages, since they were able to lysogenize SS3, SS12, SS13 and SS17. phi SS3, phi SS12 and phi SS13 were homoimmune, and they were heteroimmune with respect to phi SS17. The restriction barriers of lysogenic isolates (SS12, SS13 and SS17) interfered with the blockage of plaques formation by phages (phi SS12, phi SS13 or phi SS17) propagated on them, about 75% of lysogenic isolates had restriction systems. The exposure of the lysogenic isolates (SS12, SS13 and SS17) to UV-irradiation prevented the possible restriction barriers of these isolates, and these barriers could be overcome.

Early and late assessment of internal drainage of chronic dacryocystitis

To evaluate the efficacy of internal drainage of a lacrimal abscess, we treated 10 patients with pyocele of the lacrimal sac, who did not want to undergo operative intervention. A temporary nasolacrimal stent was placed in the nasolacrimal duct, and the pussy material was collected for microbiological examination to adjust the preliminary antibiotic treatment which was given systemically and locally. The stents were removed after the infection had subsided clinically. Three years later, there was a recurrence of the infection in only 1 patient. This internal drainage of the lacrimal sac, combined with systemic and local antibiotics, was successful in 90% of the patients.

Isolation and characterization of two types of actinophage infecting Streptomyces scabies

Two types of actinophages, phi S and phi L, were isolated from soil samples by using Streptomyces scabies, a potato scab pathogen, as indicator strain. The phages were partially characterized according to their physicochemical properties, plaques and particles morphology, and their host range; this varied from narrow (for phi S) to wide (for phi L). The adsorption rate constants of the phi S and phi L were 3.44 and 3.18 pL/min, and their burst sizes were 1.61 and 3.75 virions per mL, respectively. One-step growth indicated that phi S and phi L have a latent period of 1/2 h followed by a rise period of 1/2 h. The temperate character of these phages was tested in other isolates of Streptomyces. Four of the phages (phi SS3, phi SS12, phi SS13 and phi SS17) were identified as temperate phages, since they were able to lysogenize SS3, SS12, SS13 and SS17. phi SS3, phi SS12 and phi SS13 were homoimmune, and they were heteroimmune with respect to phi SS17. The restriction barriers of lysogenic isolates (SS12, SS13 and SS17) interfered with the blockage of plaque formation by phages (phi SS12, phi SS13 or phi SS17) propagated on them, about 75% of lysogenic isolates had restriction systems. The exposure of the lysogenic isolates (SS12, SS13 and SS17) to UV-irradiation prevented the possible restriction barriers of these isolates so that these barriers could be overcome.

Oral and ocular manifestations in Sjögren's syndrome

OBJECTIVE

Little is known about the relationship between lachrymal and salivary gland involvement in Sjögren's syndrome (SS). It is also of interest to know which eye test contributes most to the diagnosis of SS. We investigated the performance of different tear tests and how these tests relate to common serologic and salivary tests in SS.

METHODS

In patients suspected of SS, the tear breakup time and the tear mucus score were evaluated in addition to the routine tests. Eighty consecutive patients were included, categorized into primary SS (pSS), secondary SS (sSS), and negative for SS.

RESULTS

The tear breakup time and mucus score both performed insufficiently in diagnosing SS, in contrast to the Rose Bengal score. In pSS and sSS patients, a clear correlation was noted between tear and saliva quality and secretion rate, and between the Rose Bengal score and parotid sialography. Increased Rose Bengal scores also correlated significantly with hyperglobulinemia and presence of SSB antibodies in serum, with duration of subjective eye dryness, and with decreased tear gland function.

CONCLUSION

The Rose Bengal score remains the eye test of choice having the highest specificity for SS. Hyperglobulinemia and especially positive SSB serology may warrant close monitoring of the eyes, since these serum findings appear to relate to the severity of ocular surface damage. Theoretically, a positive evaluation of either the ocular or oral component, in addition to positive serology or histopathology, could be sufficient to diagnose the syndrome for clinical purposes.

Epiphora due to compression of the lacrimal sac by a supernumerary blind sac

A 23-year-old male had suffered from epiphora in the left eye since childhood. There was no history of infection or trauma. A supernumerary punctum was seen in the left lacrimal caruncle on examination. Subsequent dacryocystography and computer tomography showed a blind-ended sac that was connected to the supernumerary punctum, but not to the normally developed nasolacrimal system. When distended with secretion, this blind-ended lacrimal sac caused compression and obstruction of the normal lacrimal drainage pathway, which led to epiphora. The epiphora disappeared after surgical removal of the supernumerary system.

Diameter of the bony lacrimal canal: normal values and values related to nasolacrimal duct obstruction: assessment with CT

BACKGROUND AND PURPOSE

Epiphora, or tearing due to primary acquired nasolacrimal duct obstruction (PANDO), is increasingly being treated with balloon dilatation. The cause of PANDO is unknown, but a small diameter of the bony nasolacrimal canal might be one of the etiologic factors. The purpose of this study was to determine the normal distribution of diameters of the bony canal and to ascertain whether there is an association between the diameter of the bony canal and primary nasolacrimal duct obstruction.

METHODS

Using axial CT, we measured the minimum diameter of the bony nasolacrimal canal in a control group of 50 men and 50 women and in 19 patients with PANDO.

RESULTS

The mean minimum diameter in the control group was 3.5 mm, which was smaller than expected on the basis of published data. The difference between the mean minimum diameter in men (3.70 mm) and that in women (3.35 mm) was significant. The mean minimum diameter in the patient group was 3.0 mm, which was significantly smaller than that in the control group. There was, however, considerable overlap.

CONCLUSION

A small diameter of the bony canal appears to be one of the etiologic factors in PANDO.

Abscess of the lacrimal sac due to chronic or subacute dacryocystitis: treatment with temporary stent placement in the nasolacrimal duct

Stents were placed temporarily in 10 obstructed lacrimal systems in patients with a chronic or subacute lacrimal abscess that did not respond to conventional antibiotic therapy. In all 10 cases, the abscess was treated successfully. Long-term patency of the lacrimal system was restored in five cases. Temporary stent placement appears to be a promising method to treat a chronic or subacute lacrimal abscess.

Chemical substance kinetics in the case of chronobiological variations of elimination rate

This study describes an approach permitting the determination of compartmental concentration and drug kinetics in the case of chronobiological variations of elimination rate.

Obstructed nasolacrimal duct system in epiphora: long-term results of dacryocystoplasty by means of balloon dilation

PURPOSE

To evaluate the long-term results of balloon dacryocystoplasty in the treatment of epiphora due to obstruction of the nasolacrimal ducts.

MATERIALS AND METHODS

One hundred eyes in 84 patients with complete or incomplete obstruction of the lacrimal sac and duct were selected for dacryocystoplasty. A catheter with a balloon diameter of 3 mm was used. Follow-up was 5-48 months. No stents were placed. A Kaplan-Meier analysis was used to evaluate patency.

RESULTS

The long-term primary patency rate was 70% +/- 7 (+/- standard error). Repeat dacryocystoplasty was successful in 10 of the 11 cases with initial failure or reobstruction during follow-up, which yielded a long-term secondary patency rate of 81% +/- 7. There was no association between the length of the obstruction or the duration of symptoms before dacryocystoplasty and the initial and long-term success. Initial and long-term success was statistically significantly higher in dacryocystoplasty for an incomplete obstruction rather than for a complete obstruction.

CONCLUSION

The long-term results of dacryocystoplasty, followed if necessary by repeat dacryocystoplasty, are good. Dacryocystoplasty is a safe and simple procedure and could become the treatment of choice for epiphora due to obstruction of the nasolacrimal ducts. Dacryocystorhinostomy is indicated when dacryocystoplasty or repeat dacryocystoplasty fails or when dacryocystoplasty is contraindicated (e.g., in anatomic malformations in the lacrimal duct or bony canal).

An approach for determination of chronopharmacokinetic parameters of methotrexate

In classical pharmacokinetic studies, the organism is represented by one or several compartments described by a system of linear differential equations with constant coefficients. A system of linear differential equations can not describe the compartmental model in the presence of chronobiological variations. The purpose of this study is to calculate the chronopharmacokinetic parameters of Methotrexate, which presents this type of variation.

Vasopressin and developmental onset of flank marking behavior in golden hamsters

Golden hamsters start displaying flank marking behavior (a form of scent marking) around postnatal day 20 (P-20). Because the behavior is dependent upon the central activity of arginine vasopressin (AVP), the present study was conducted to correlate this activation with changes in the vasopressinergic system. A first set of experiments was performed to compare flank marking activity between P-18 and P-22. A second set of experiments was performed to compare the density of AVP receptors between the age periods and assess responsiveness to AVP microinjection. Finally, a third set of experiments incorporated immunocytochemistry, radioimmunoassay, in situ hybridization, and Northern blot analysis to determine the location and numbers of AVP immunoreactive neurons and the level of mRNA correlating with the developmental onset of flank marking behavior. Our results show that flank marking develops between P-18 and P-22. Male and female hamsters do not display odor-induced flank marking anytime before P-19. However, all animals show odor-induced flank marking by P-22. The onset of flank marking does not appear to be associated with any change in AVP receptor binding in the anterior hypothalamus. Indeed, flank marking can be triggered in hamsters on P-18 by the microinjection of AVP in the anterior hypothalamus. This would suggest that the postsynaptic mechanisms contributing to the transduction of the AVP signal and the motor control of flank marking are intact prior to the onset of odor-induced flank marking. In contrast, AVP levels in the hypothalamus and pituitary increase by two to threefold between P-18 and P-22, suggesting that changes in AVP synthesis and release from presynaptic sites may contribute to the onset of flank marking. Interestingly, there is no change in AVP mRNA between P-18 and P-22, which raises questions about posttranslational processing during this developmental period. These results suggest that heightened synthesis and release of AVP between P-18 and P-22 may contribute to the developmental onset of flank marking.

Case report: haemangiopericytoma of the oesophagus

Haemangiopericytomas are rare, vascular soft tissue sarcomas typically located in the retroperitoneum, pelvis or lower extremities. To our knowledge this neoplasm within the oesophagus has not been reported previously. We present a patient with a haemangiopericytoma of the oesophagus and discuss the radiographic and pathological findings.

Laparoscopic Nissen fundoplication is less expensive than open Belsey Mark IV

Laparoscopic Nissen fundoplication is a relatively new technique used to treat gastroesophageal reflux disease (GERD). The purpose of this study was to compare the cost to the patient and insurer of a laparoscopic Nissen fundoplication (LN) to an open Belsey Mark IV (B4), the previous standard operation for GERD at Emory University Hospital. A retrospective review of 20 consecutive patients undergoing LN or B4 for GERD was performed. Patients were well matched for age, severity of disease, and comorbid illness. The data were analyzed using an unpaired Student's t-test or Wilcoxon signed rank analysis. The results are as follows (mean +/- SD): [table: see text] We conclude that the charges for laparoscopic Nissen fundoplication are significantly less than the charges for Belsey Mark IV. The majority of the savings resulted from a shortened hospital stay.

Dacryocystoplasty: treatment of epiphora by means of balloon dilation of the obstructed nasolacrimal duct system

PURPOSE

To evaluate treatment of epiphora due to acquired stenotic obstruction of the nasolacrimal duct system with dacryocystoplasty (DCP), in which balloon dilation is used to alleviate the obstruction.

MATERIALS AND METHODS

Twenty patients (21 eyes) with epiphora due to obstructing lesions at the saccular or subsaccular level were treated with DCP. The authors used a catheter with a balloon diameter of only 3 mm to prevent damage to the nasolacrimal duct system and a nontraumatizing guide wire. Stent placement was not considered necessary. Follow-up ranged from 14 to 70 weeks.

RESULTS

Cannulation was not possible in one case of complete obstruction. DCP was successfully performed in the other 20 cases. In 18 of these cases (90%), results comparable with those of dacryocystorhinostomy were achieved. No side effects were observed.

CONCLUSION

DCP is potentially the treatment of choice for epiphora due to acquired stenotic obstruction of the nasolacrimal duct system.

Enhanced reverse saturable absorption and optical limiting in heavy-atom-substituted phthalocyanines

The reverse saturable absorption and the optical-limiting response of metal phthalocyanines can be enhanced by use of the heavy-atom effect. Phthalocyanines containing heavy-metal atoms, such as In, Sn, and Pb, show a nearly factor-of-2 enhancement in the ratio of effective excited-state to ground-state absorption cross sections compared with those containing lighter atoms, such as Al and Si. In an f/8 optical geometry, homogeneous solutions of heavy-metal phthalocyanines, at 30% linear transmission, limit 8-ns 532-nm laser pulses to </=3 microJ (the energy for 50% probability of eye damage) for incident energies as high as 800 microJ.

Value of technetium 99m sestamibi iodine 123 imaging in reoperative parathyroid surgery

BACKGROUND

The purpose of this study was to assess the contribution of technetium 99m sestamibi iodine 123 (T/S) imaging to preoperative and intraoperative management of patients with persistent hyperparathyroidism.

METHODS

During a period of 10 months, all patients being prepared for reoperative parathyroid surgery (n = 10), two patients deemed significant operative risks (one patient with severe chronic obstructive pulmonary disease and one patient with severe cervical spine ankylosing spondylitis), and two patients who had undergone prior thyroid operation were studied with T/S imaging. Six patients undergoing reoperative surgery had undergone one, three had undergone two, and one had undergone three prior procedures.

RESULTS

T/S imaging correctly localized 14 of 16 parathyroid tumors. By comparison, only 1 of 6 thallium technetium and 3 of 12 computed tomography (CT) scans (in seven patients) were positive. T/S imaging guided the reoperative surgical approach accurately in 12 of 14 patients, including one case of an undescended left lower gland at the level of the mandible and identification of a third gland on the left in another case. Sternal split was required to remove three lesions localized by T/S imaging, two beneath the aortic arch and one nestled in the aortopulmonary window in a patient who had undergone two prior procedures including a sternal split. In these three cases T/S imaging was particularly useful, because CT scans, thallium technetium scans, magnetic resonance imaging, and arteriography were not diagnostic. The outcome after operation was favorable in all 14 cases, with correction of hypercalcemia and no permanent laryngeal nerve injuries or hypocalcemia.

CONCLUSIONS

We concluded that T/S imaging is more accurate than thallium technetium and CT scans in evaluation of patients with persistent hyperparathyroidism.

Relation Between Bond-Length Alternation and Second Electronic Hyperpolarizability of Conjugated Organic Molecules

The solvent dependence of the second hyperpolarizability, gamma, of a variety of unsaturated organic compounds has been measured by third harmonic generation at 1907 nanometers. It is seen that the measured gamma is a function of solvent polarity. These solvent-dependent hyperpolarizabilities are associated with changes in molecular geometry from a highly bond-length alternated, polyene-like structure for a formyl-substituted compound in non-polar solvents, to a cyanine-like structure, with little bond-length alternation, for a dicyanovinyl-substituted compound in polar solvents. By tuning bond-length alternation, gamma can be optimized in either a positive or negative sense for polymethine dyes of a given conjugation length.

Chronotoxicity of methotrexate in mice after intraperitoneal administration

Methotrexate (MTX), an effective agent in treatment of cancer, is one of the most versatile antineoplastic agents in spite of severe toxicity problems. The purpose of this study was to determine the circadian variation of this toxicity in order to decrease the side effects. The experiments were done in mice given a single i.p. dose. The toxicity of MTX, estimated from the relative weight loss, varied according to the time of administration, with a maximum after administration at 0900 (02 HALO). The dose-effect relationship can be described by a linear function: delta P/P versus log (dose). The slope of this line varies with the time of administration. These variations are correlated with the variations in biochemical [dihydrofolate reductase (DHFR) activity] and pharmacokinetic parameters (AUC) studied in previous works.

A variable reabsorption time-delay model for pharmacokinetics of drugs

A two-compartment model with time delay is proposed to describe the pharmacokinetics of drugs subject to enterohepatic circulation. This model is applicable when the reabsorption is repeated several times at unequal intervals. Sample applications are provided.

The carotid sinus syndrome: a frequently overlooked cause of syncope in the elderly

Exaggerated carotid sinus reflexes may account for alterations in consciousness responsible for significant disability and injury in elderly patients. Nonspecificity of symptoms and concomitant medical conditions frequently delay diagnosis and therapy. During a recent 9-year period, 82 patients were identified as having symptomatic carotid sinus hypersensitivity (CSH). Fifty-nine patients described complete syncope, 73 patients had multiple syncopal or near-syncopal episodes, and 40 patients related cervical pressure or motion as provocative events. Electrophysiologic testing demonstrated that 47% had cardioinhibitory CSH, 26% had vasodepressor CSH, and 27% had combined vasodepressor and cardioinhibitory CSH. The mean follow-up period of all patients was 36 months. Surgical therapy included ventricular demand pacemaker implantation in 33 patients and carotid sinus denervation in seven patients. Medical therapy was used in 32 patients, 11 mildly symptomatic patients were not treated, and 3 patients had carotid sinus irradiation. Pacemaker implantation relieved symptoms in 53%; however, 11 patients (33%) had significant postoperative complications. Carotid sinus denervation relieved symptoms in 86%, medical therapy in 54%, and carotid sinus irradiation in 33% of patients. Because of its demonstrated effectiveness in all variants of CSH and negligible perioperative morbidity, carotid sinus denervation should be offered to acceptable operative candidates when the diagnosis of CSH is confirmed.