Azithromycin for chronic eosinophilic rhinosinusitis with nasal polyp: a placebo-controlled trial.

BACKGROUND: Chronic eosinophilic rhinosinusitis with nasal polyps (CRSwNP eosinophilic) is characterised by the formation of benign and bilateral nasal polyps. We aimed to compare the effectiveness of azithromycin as an immunomodulator with the use of a placebo in patients presenting with CRSwNP concomitant with asthma and aspirin intolerance after 3 months of treatment and at a 1-year follow-up. METHODOLOGY: We performed a randomised, double-blind, placebo-controlled trial. Patients received 500 mg azithromycin orally three times/week for 12 weeks. Improvement was evaluated by staging, the Sino-Nasal Outcome Test (SNOT-22), and nasal polyp biopsy. Data collected at pretreatment and 3 months posttreatment were compared. Quality of life was evaluated at the 1-year follow-up. RESULTS: Twenty-seven and 21 patients were treated with azithromycin and a placebo, respectively. The medication was well tolerated overall. Twenty patients (74%) in the azithromycin group and three patients (14%) in the placebo group were not refer- red for surgery at the end of the 3-month treatment. Regarding subjective improvement, there was a median decrease only in the azithromycin group, and the between-group difference was significant. SNOT-22 improvement was maintained in the azithromy- cin group at the 1-year follow-up. CONCLUSIONS: Azithromycin could be considered a therapeutic option for patients presenting with CRSwNP concomitant with asthma and aspirin intolerance.

Cytokines profile in cystic fibrosis patients with nasal polyps.

UNLABELLED: Nasal polyposis often complicates the progress of patients with cystic fibrosis and there has been little study about the importance of cytokines in the polyps of such individuals. OBJECTIVE: To assess RNAm expression for interleukins 4, 5, 6, 8, GM-CSF and IFN-gamma by RT-PCR in eosinophilic and non-eosinophilic polyps of patients with cystic fibrosis. MATERIAL AND METHOD: A total of 124 persons were evaluated, of which thirteen patients with cystic fibrosis and nasosinusal polyps were selected--three were eosinophilic and ten were non-eosinophilic. The control group was composed of eleven individuals with normal otorhinolaryngological exam and the mean age was 18 years (3-57). The middle turbinate mucosa and nasal polyps were biopsied from the control group and the cystic fibrosis group respectively, and these were analyzed with RT-PCR. The middle turbinate mucosa was biopsied in the control group and in the cystic fibrosis group polyps that was analyzed to RT-PCR. The polyps of cystic fibrosis patients were also further anaylsed for subjected to a second biopsy in order to determine the percentage of eosinophils. IL-4, IL-5, IL-6, IL-8, IFN-gamma and GM-CSF transcriptions were analyzed. RESULTS: There was no difference in IL-5, IL-8 and GM-CSF when compared to the eosinophilic, non-eosinophilic and control groups (p>0.05). When compared to the eosinophilic and non-eosinophilic groups, higher IL-4 and IL-6 values (p=0.01 and p=0.01 respectively) were observed. When analyzed separately with the control group, IL-4 (p=0.01) expression was higher in the eosinophilic group, while IFN-gamma (p=0.03) was lower in the non-eosinophilic group. IL-5, IL-8, GM-CSF are non-specific cytokines present in the nasosinusal sinonasal polyps of cystic fibrosis patients. IL-4 and IL-6 are important mediators in the eosinophilic sinonasal polyps, while low IFN-gamma may be related to lower eosinophils in non-eosinophilic polyps.

Padrão respiratório e movimento toracoabdominal de crianças respiradoras orais / Breathing pattern and thoracoabdominal motion in mouth-breathing children

OBJETIVO: Caracterizar o padrão respiratório e o movimento toracoabdominal de crianças respiradoras orais, na faixa etária entre oito e dez anos, e compará-lo ao de seus pares respiradoras nasais. MÉTODOS: Estudo observacional realizado em laboratório universitário. O número amostral calculado com base em um estudo piloto com dez crianças em cada grupo, perfazendo um total de 20 crianças, foi de 50 para um nível de significância de 0,05 e um poder estatístico de 0,80. Participaram do estudo 26 crianças respiradoras orais e 25 respiradoras nasais. A pletismografia respiratória por indutância calibrada foi o instrumento utilizado para a análise das seguintes variáveis, entre outras: freqüência respiratória (FR), contribuição da caixa torácica para o volume corrente ( por centoCT/Vc), ângulo de fase (Angfase) e a razão entre o tempo para alcançar o pico de fluxo inspiratório e o tempo inspiratório (PifT/Ti). A saturação periférica da hemoglobia em oxigênio (SpO2) foi medida pela oximetria de pulso. A análise estatística foi realizada por meio do teste t de Student para grupos independentes e do teste U de Mann-Whitney, em função da distribuição das variáveis. RESULTADOS: No total, 4.816 ciclos respiratórios foram analisados, sendo 2.455 de respiradores orais e 2.361 de respiradores nasais, com média de 94 ciclos por criança. Não houve diferença significativa entre os grupos nas variáveis estudadas (FR=20,00±2,68 versus 20,73±2,58, p=0,169; por centoCT/Vc=39,30±11,86 versus 38,36±10,93, p=0,769; Angfase=14,53±7,97 versus 13,31±7,74, p=0,583; PifT/Ti=57,40±7,16 versus 58,35±5,99, p=0,610; SpO2=96,42±1,52 por cento versus 96,88±1,01 por cento, p=0,208; respectivamente). CONCLUSÕES: Estes resultados sugerem que as crianças respiradoras orais apresentam padrão respiratório e movimento toracoabdominal semelhantes às de respiradores nasais de mesma faixa etária.

OBJECTIVE: To characterize the breathing pattern and thoracoabdominal motion of mouth-breathing children aged between eight and ten years and to compare these characteristics with those of nose-breathing children of the same ages. METHODS: This observational study was carried out in a university laboratory. The sample size of 50 subjects was estimated based on the results of a pilot study with ten children in each group (total of 20 children) and considering a significance level of 0.05 and statistical power of 0.80. Twenty-six mouth-breathing and 25 nose-breathing children participated. Calibrated respiratory inductive plethysmography was used to analyze the following variables, among others: respiratory frequency (f), rib cage contribution towards tidal volume ( percentRC/Vt), phase angle (PhAng) and the ratio between time taken to reach peak inspiratory flow and total inspiratory time (PifT/Ti). Peripheral oxygen saturation of hemoglobin (SpO2) was measured using pulse oximetry. Statistical analysis was performed using the Student's t test for independent groups or the Mann-Whitney U test, according to the sample distribution of the variables. RESULTS: A total of 4,816 respiratory cycles were analyzed: 2,455 from mouth-breathers and 2,361 from nose-breathers, with a mean of 94 cycles per child. No statistically significant differences were observed between the groups, for the variables studied (f=20.00±2.68 versus 20.73±2.58, p=0.169; percentRC/Vt=39.30±11.86 versus 38.36±10.93, p=0.769; PhAng=14.53±7.97 versus 13.31±7.74, p=0.583; PifT/Ti=57.40±7.16 versus 58.35±5.99, p=0.610; SpO2=96.42±1.52 percent versus 96.88± 1.01 percent, p=0.208; respectively). CONCLUSIONS: These results suggest that mouth-breathing children show breathing patterns and thoracoabdominal motion that are similar to those of nose-breathing children in the same age group.

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis.

OBJECTIVE: in diabetic patients with critical limb ischaemia (CLI) an inferior success rate following infrainguinal bypass surgery is quite often suggested. The aim of this retrospective analysis was, therefore, to evaluate the graft patency and, particularly, the clinical outcome at 1 year in diabetic compared with non-diabetic patients. MATERIAL AND METHODS: two hundred and eleven patients (diabetics 94; non-diabetics 117) with femorodistal reconstruction for CLI were studied. Groups were comparable with regard to the Fontaine classification, the distribution of vascular risk factors, graft material, distal anastomosis site, and the angiographic runoff grading. RESULTS: diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004). CONCLUSIONS: our preliminary results support the view that infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients.

Prevalence and impact of chronic otitis media in school age children in Brazil. First epidemiologic study concerning chronic otitis media in Latin America.

OBJECTIVE: The first epidemiological study carried out in Latin America to investigate the prevalence of otological disease and its impact in a representative random sample of the school children population. METHODS: A cross sectional epidemiological survey to investigate the epidemiology of otitis in a representative random sample of 1119 children and adolescents from a total of 486166 elementary and high-school students, aged 6-18 years, regularly registered in one of the 521 public and private schools of the city of Belo Horizonte, in the state of Minas Gerais, southern Brazil. The interviews were conducted individually, in the school, by an otolaryngologist or a pediatrician. The interview included all of the personal data and also detailed questions regarding otological disorders and hearing. The otological examination was carried out with Mini-Heine otoscopes and the audiometric evaluation with the AudioScope 3 with 25dB intensity. The questionnaire and basic procedures for medical examination had been previously tested through a pilot test in two schools. RESULTS: The prevalence of chronic otitis media was 0.94%. Impacted wax was found in 12.3% of the students. The prevalence of abnormalities (excluding wax) in the otoscopy examination was 10.5%. It was found that 8.3% of students had a past history of otitis and 7.7% had a past history of otorrhea. These two special groups presented statistically significant associations with chronic otitis media, hearing loss and otolaryngological surgeries (when compared with the other school children). Parents and school children seemed significantly able to identify a special group of children with past history of otitis during childhood.

[A young patient with multiple arterial occlusions]. / Junge Patientin mit multiplen arteriellen Verschlüssen.

BACKGROUND: Mild hyperhomocysteinemia due to genetic causes and nutrition factors is well known as an independent strong risk factor for premature arterial occlusive disease. CASE REPORT: A 27-year-old female with a history of two episodes of small bowel ileus due to vascular causes presented with subacute pain in the left lower extremity. Angiography revealed a short segmental occlusion in the P III segment of the popliteal artery with small vessel collateralization and proximal occlusion of the superior mesenteric artery und the coeliac trunk. Vascular risk factors in this patient included smoking over a duration of 10 years, use of oral contraceptives (estrogen and gestagen combination) and elevated levels of homocysteine in the fasting state and after methionin loading. The patient was treated conservatively with intravenous application of prostaglandins, additionally she underwent training to improve her walking capability. After 4 weeks of the fasting state as well as after methionin loading were normalized by an oral substitution with folate and B vitamins. So far it was not possible to prove a genetic defect of the enzymes participating in the metabolism of homocysteine. CONCLUSION: This clinical conference of a young female patient with occlusion of several arteries illustrates the differential diagnosis of premature occlusive vascular disease with special regard to mild hyperhomocysteinemia as an independent risk factor.

[Instrumental diagnosis for therapy decision making--what is possible and desirable, what is essential and what is superfluous--in vascular surgery]. / Apparative Diagnostik zur Therapieentscheidung--was ist möglich und wünschenswert, was unverzichtbar und was überflüssig--in der Gefässchirurgie.

It is impossible to give a paper on the whole of vascular surgery, which represents a broad surgical specialty; so we will concentrate on three typical vascular procedures, namely Carotid surgery, abdominal aortic aneurysm, and varicose veins. Ultrasound examinations in carotid artery disease are inevitable because they are screening examinations. CCT or MRT are necessary, but not angiography, particularly in symptomatic patients. In asymptomatic patients, DSA may be of value for forensic documentation; MR angiography is now better, but is still not so evident as conventional DSA. CBF should be carried out in multiple vessel disease. Intraoperatively, quality control can be assured by Doppler or flowmetry; other techniques like DSA, EEG, SEP or transcranial Doppler are not necessary when a temporary shunt is routinely applied. In AAA, sonography and CT (or MRT) are absolutely necessary; angiography may reveal accessory visceral and renal vessels. In treatment of varicose veins, sonography (color-coded) is indispensible; phlebography can reveal more details, but is not absolutely necessary.

Prevention of cerebral ischaemia under general anaesthesia.

General anaesthesia influences the oxygen supply/demand ratio of the brain and may thus be able to improve neurological outcome after carotid artery surgery. Among the anaesthetic agents, barbiturates and isoflurane produce a marked reduction of the cerebral metabolic rate and activity. But the incidence of neurological deficits in the immediate postoperative period is low, while the possible causes of any neurological deficits are multiple. Consequently, to date, no particular anaesthetic agent or management has been shown to influence the neurological results.

[The migration behavior of human vascular myocytes in culture--the screening potential of anti-arteriosclerosis active endogenous and exogenous substances]. / Migrationsaktivität humaner Gefässwandmyozyten in Kultur--Screening potentiell anti-arteriosklerotisch wirksamer endogener und exogener Substanzen.

Besides proliferation, migration of smooth muscle cells (SMC) is considered to be an essential cellular mechanism involved in plaque formation. Human SMCs were cultured from 14 arteriosclerotic lesions of coronary (n = 5), femoral (n = 7) and aortic (n = 2) arteries. By a semi-automatic standardized video analysis system SMC migratory activity was quantified to be 21.7 +/- 2.1 microns/h (n = 14; x +/- SD). Addition of drugs, such as calcium antagonists (10(-5) - 10(-7) M), heparin (100 micrograms/ml), SIN-1 (10(-5) M) and colchicine (10(-7) M) resulted in a significant decrease of SMC migratory velocity. Exposure to endogenous extracellular matrix proteins (5 micrograms/cm2) showed no effect for collagen I and a significant reduction of SMC migratory activity for fibronectin, respectively. Our results indicate SMC migratory velocity to be a parameter of potential interest to screen various substances for an anti-arteriosclerotic effect.

[Current status of amputation surgery]. / Derzeitiger Stand der Amputationschirurgie.

Limb salvage by revascularisation of occluded arterial pathways is main goal of vascular surgical activities. However, if dying or gangrenous tissue has to be removed, the question of: where to amputate--and the potential rehabilitation has to be answered. Septic amputation being an emergency operation has to be compared with elective one with definitive shaping of the stump. In major amputations knee disarticulation is preferred nowadays as being mostly "atraumatic" and well able for rehabilitation. In minor amputations bunions of the great and the little toes should be preserved especially in case the whole phalangeal and metatarsal forefoot amputation seems to have better results than removal of the first of fifth toe together with their metatarsia. A distal borderline amputation can only be performed in diabetics and after revascularisation of the feeding arterial tree.

[Asymptomatic carotid stenosis: which preoperative diagnosis is necessary and adequate?]. / Asymptomatische Carotisstenose: Welche präoperative Diagnostik ist notwendig bzw. ausreichend?

Operative correction of asymptomatic ICA stenosis requires only CCT and intraarterial DSA of all the common noninvasive procedures. Multiple vessel disease, however, must also be examined by quantitative cerebral blood flow measurements to determine the autoregulation reserve capacity; this can be done by transcranial Doppler plus CO2 provocation or rCBF with carboanhydrase inhibitor. CCT or NMRI seems necessary in any case. Detailed cardiac examination is absolutely necessary in all carotid patients.

[Current state of amputation surgery]. / Derzeitiger Stand der Amputationschirurgie.

Upper extremities: Traumatic amputations should be re-planted whenever possible. Lower extremities: Traumatic amputations must never be replanted! Arterial occlusive diseases cause the majority of amputations (ref. to indication, technique, rehabilitation). Borderline amputations are considered only after arterial reconstruction (profundaplasty) or in diabetics. The major preferential amputation is the knee disarticulation, since it results in less trauma and promotes quick rehabilitation, especially in geriatric patients.