[Dermatofibrosarcoma protuberans: Surgical margins using Slow-Mohs micrographic surgery. A clinical retrospective study about 20 cases]. / Marges d'exérèse des dermatofibrosarcomes cervico-faciaux par technique de Slow-Mohs : étude clinique rétrospective sur 20 cas.

OBJECTIVES: The main objective of this study is to determine the necessary surgical margins to obtain a complete R0 resection for head and neck dermatofibrosarcoma protuberans (DFSP) using Slow-Mohs micrographic surgery. The secondary objective is to study the recurrence rate of these tumors. PATIENTS AND METHODS: Slow-Mohs micrographic surgery was used for patients included between 2005 and 2015 at Bordeaux universitary hospital. For each patient the age, the sex and death occurrence, the initial surgical margins, the surgical margins for complete R0 resection, the occurrence of local or general recurrence during follow-up were reported. Surgery was realized under local anesthesia. The closure of the tumor site was realized secondarily using a skin graft or local flap. RESULTS: Twenty patients were included in the study. Initial surgical margins were 10mm (9 patients) or 15mm (11 patients). Complete resection was obtained from the first surgery for fifteen patients (75%). The average surgical margin for a complete R0 resection was 15,25±5,7mm (10-25). None of the patients presented recurrences during the entire follow-up (38 months) CONCLUSION: A complete R0 resection of head and neck DFSP is obtained from the first surgery in 75% of the cases, with minimum surgical margins (12,75±2,55mm) using the Slow-Mohs micrographic surgery. This allows a reduction of surgical margins and local recurrences. This technique provides a preservation of soft-tissues, which plays a key role for head and neck surgery.

Anatomical landmarks for maxillary nerve block in the pterygopalatine fossa: A radiological study.

INTRODUCTION: The aim of this study was to describe the anatomical landmarks for maxillary nerve block in the pterygopalatine fossa. The risk of injury to the skull base and maxillary artery was assessed. METHODS: This retrospective study was based on the analysis of 61 consecutive computed tomography angiographies obtained from patients suffering from different pathologies. Anatomical relationships between optic canal (OC), foramen rotundum (FR), inferior orbital fissure (IOF) and puncture point (PP) were assessed. A "maxillary section" was virtually carried out on the CTs, following a plane passing through PP, IOF and FR in order to mimic the anaesthesia needle route. RESULTS: No gender difference was observed except for the PP-OC distance that was longer in men. The mean PP-IOF distance was of 31.9 (± 0.7mm). PP-OC (43.9±0.5) and PP-FR (44.2±0.7) distances increased significantly with the patients height (PP-FR=17.25+0.16×height (cm); PP-OC=20.54+0.13×height (cm)). The route to the skull base was curved, with an angle of 168±1.6° at the FR level. The angle to reach the OC was greater than 7°. DISCUSSION: With a 35-mm needle length, the probability to reach the IOF was high (79%), while the risk to injure the skull base (2%) and the optical nerve (0%) was low. Artery injuries were only found in 13% of cases. Therefore, a 35-mm needle length allows for the best efficacy/risk ratio in maxillary nerve block.

[Prisma France: implementation program of an innovation in health and services system for disabled people. Adaptation of a case-management based integration model]. / Prisma France: programme d'implantation d'une innovation dans un système de soins et de services aux personnes en perte d'autonomie. Adaptation d'un modèle d'intégration basé sur la gestion de cas.

BACKGROUND: The French health and services system to maintain at home is characterized by its fragmentation, whereas the need of the people for intervention is generally total. This fragmentation have consequences: delay in services delivery, inadequate transmission of information, redundant evaluation, service conditioned by the entrance point solicited rather than by the need of the person and inappropriate use of expensive resources by ignorance or difficulty of access to the less expensive resources. PRESENTATION OF THE INNOVATION: The purpose of integration is to improve continuity of interventions for people in loss of autonomy. It consists in setting up a whole of organisational, managerial and clinical common tools. Organisational model "Projet et Recherches sur l'Intégration des Services pour le Maintien de l'Autonomie" (Prisma) tested in Quebec showed a strong impact on the prevention of the loss of autonomy in term of public health on a population level. This model rests on six principal elements: partnership, single entry point, case-management, a multidimensional standardized tool for evaluation, an individualized services plan and a system for information transmission. CONTEXTUAL ANALYSIS: Thus, it was decided to try to implement in France this organisational model. The project is entitled Prisma France and is presented here. The analysis of the context of implementation of the innovation which represents integration in the field of health and services for frail older reveals obstacles (in particular because of diversity of professional concerned and a presentiment of complexity of the implementation of the model) and favourable conditions (in particular the great tension towards change in this field). CONCLUSION: The current conditions in France appear mainly favourable to the implementation of integration. The establishment of Prisma model in France requires a partnership work of definition of a common language as well on the diagnoses as on the solutions. The strategic and operational dialogue is thus a key element of the construction of integration. This stage currently occurs in parallel in three areas contrasted in France. The results of associated qualitative research should make it possible to define the factors fostering or hindering the realization of integration according to each site (analyzes contrasted) and in all the sites (related to the particular context of care and French services as a whole).

Bladder leiomyoma: report of two cases and literature review.

Mesenchymal tumors of the urinary bladder are rare and the majority of them are malignant. We report two cases of leiomyoma of the urinary bladder presenting with symptoms of bladder outlet obstruction. The first patient was managed with staged transurethral resections, and the second with holmium laser transurethral inoculation. The outcome was excellent in both cases. A review of the literature is also outlined.

The efficacy and safety of tadalafil: an update.

OBJECTIVE: To provide an update on the efficacy and safety of tadalafil, a phosphodiesterase-5 inhibitor, in the treatment of erectile dysfunction (ED). PATIENTS AND METHODS: In all, 2102 men (mean age 56 years) with mild-to-severe ED of various causes were randomized to placebo or tadalafil, taken as needed with no food restrictions, at fixed 'on-demand' doses of 10 or 20 mg in 11 randomized, double-blind, placebo-controlled trials lasting 12 weeks. The three co-primary outcomes were changes from baseline in the erectile function domain of the International Index of Erectile Function (IIEF) and the proportion of 'yes' responses to questions 2 and 3 of the Sexual Encounter Profile (SEP). Additional efficacy instruments included a Global Assessment Question (GAQ). RESULTS: Compared with placebo, tadalafil gave significantly better outcomes. Patients receiving either dose of tadalafil had a significant mean improvement of 6.5 and 8.6, respectively, in the IIEF erectile function domain score from baseline (P < 0.001 vs placebo). At both doses the mean success rate for intercourse attempts (SEP-Q3) was 58% and 68%, respectively, compared with 31% in the placebo group (P < 0.001), and 71% and 84% reported improved erections at the endpoint (GAQ), vs 33% on placebo (P < 0.001). Tadalafil was effective up to 36 h after dosing and was effective regardless of disease severity and causes, and in patients of all ages. The most frequent adverse events were headache, dyspepsia, back pain and myalgia. CONCLUSION: Tadalafil was an effective and well-tolerated treatment for ED.

Bellini duct carcinoma with ovarian metastasis.

We report a case of collecting duct carcinoma presenting as pyelonephritis with hypercalcemia and metastasis to the ovary. Case management and literature review being presented.

A comparison of the International Index of Erectile Function and erectile dysfunction studies.

OBJECTIVE: To evaluate the ability of the five-item version of the International Index of Erectile Function (IIEF-5) to diagnose the vascular aetiology and severity of erectile dysfunction (ED), and to compare it with pharmacological testing and duplex Doppler ultrasonography, as such questionnaires are widely used by the pharmaceutical industry to categorize the severity of ED and to assess the efficacy of drug therapy. PATIENTS AND METHODS: In all, 80 patients (mean age 45.2 years, sd 14.0; mean duration of ED 3.5 years) were reviewed by an examiner unaware of their IIEF scores during testing. Penile blood flow was assessed in each patient after an intracavernosal injection with prostaglandin-E1 (10 micro g), with self-stimulation in privacy. The peak systolic velocity, end diastolic velocity and resistive index were measured for the vascular diagnosis. Visual ratings of erectile responses were also used for analysis. RESULTS: Of the 80 patients, 30 had a normal vascular response, 38 arterial insufficiency and 12 were diagnosed with venous leakage. There was no significant difference in the IIEF scores among patients with a normal vascular response, arterial insufficiency or venous leakage. Analysis of visual ratings of erections showed no difference in IIEF scores among the different groups of patients. CONCLUSION: The IIEF was designed and developed specifically for assessing and evaluating sexual function in clinical trials. However, as shown here, the IIEF cannot and should not be used as a tool to diagnose or compare specific vascular causes of ED.

Smoking and erectile dysfunction: evidence based analysis.

PURPOSE: We examined available evidence concerning the role of smoking in the development of erectile dysfunction. This task involved a complete review of the smoking literature as it pertained to erectile dysfunction and select endothelial diseases. MATERIALS AND METHODS: We comprehensively reviewed the literature, including PubMed and recent abstract proceedings from national meetings relevant to smoking, erectile dysfunction and endothelial diseases. The quality of the evidence was assessed by methods used to develop clinical practice guidelines. Our review involved an objective evaluation of the basic science literature and clinical studies. When necessary, we examined studies of endothelial diseases other than erectile dysfunction because of obvious gaps in the literature. RESULTS: There are strong parallels and shared risks among smoking, coronary artery disease, atherosclerosis and erectile dysfunction. Clinical and basic science studies provide strong indirect evidence that smoking may affect penile erection by the impairment of endothelium dependent smooth muscle relaxation. The association of erectile dysfunction with risk factors such as coronary artery disease and hypertension appears to be amplified by cigarette smoking. Smoking may increase the likelihood of moderate or complete erectile dysfunction 2-fold. The prevalence of erectile dysfunction in former smokers was no different from that in individuals who had never smoked, implying that smoking cessation may decrease the risk of erectile dysfunction. Case studies and retrospective series have shown an association of smoking with erectile dysfunction. CONCLUSIONS: Available evidence on the association of smoking with erectile dysfunction is not complete insofar as association linking factors are concerned. However, the evidence of such an association is likely due to the consistency of the relationship of smoking and endothelial disease, and the strength of the association of erectile dysfunction with other endothelial diseases.

Penile curvature associated with scleroderma.

We present 2 cases of Peyronie's disease in patients with scleroderma. This association is uncommon, and our patients' symptoms and disease course differed from that typical for Peyronie's disease. We suggest a more conservative approach when treating patients whose penile curvature is associated with a systemic disease such as scleroderma.

Postnatal development of penile NADPH diaphorase in male rats (Rattus norvegicus): an indicator of erectile function.

The aim of this study was to determine the contribution of nitric oxide (NO) to the development of penile erection in rats and was accomplished by evaluating the nicotinamide adenine dinucleotide phosphate diaphorase (NADPH) content of juvenile penile tissues. NADPH is an enzyme involved in the synthesis of NO, a mediator of smooth muscle relaxation in penile tissues. We euthanized 36 rats (age, 1 to 65 days) and obtained penile midshaft specimens for NADPH staining. The number of NADPH-positive granules in the corpus cavernosum and dorsal penile nerve increased significantly (P < 0.001) until animals were 50 days of age. Penile erections in young rats are known to occur around 30-40 days, and penile tissues showed a very significant (P < 0.001) increase of NADPH-positive granules in the corpus cavernosum and the dorsal penile nerve during this period. Therefore, NO seems important for the development of penile erection in juvenile rats.

Ongoing twin pregnancy after ICSI of PESA-retrieved spermatozoa into in-vitro matured oocytes: case report.

The recovery of immature oocytes from unstimulated ovaries followed by in-vitro maturation (IVM) is an attractive alternative to conventional IVF in the treatment of female infertility. Similarly, surgical recovery of spermatozoa from the epididymis by percutaneous sperm aspiration (PESA) has simplified the retrieval of the male gamete in treatment of men with obstructive azoospermia. We report the first ongoing clinical twin pregnancy resulting from intracytoplasmic sperm injection (ICSI) of spermatozoa retrieved by PESA into IVM oocytes. In the treatment of a 24-year old woman, 12 immature oocytes were retrieved. Six oocytes matured (maturation rate 50%) after 24-hour incubation and were inseminated by ICSI. Four oocytes had two pronuclei (fertilization rate 67%) and 3 good quality embryos were transferred. A viable twin pregnancy was confirmed by ultrasound scan. This report illustrates the use of a combination of less invasive assisted reproductive techniques in overcoming barriers to infertility.

The pharmacokinetics and metabolic disposition of tacrolimus: a comparison across ethnic groups.

OBJECTIVE: Our objective was to compare the intravenous and oral pharmacokinetics of tacrolimus among subjects of three different ethnic backgrounds, African American, white, and Latin American. METHODS: Ten African American, 12 white, and 12 Latin American subjects received intravenous and oral tacrolimus in an open-label, two-period, parallel group study. All of the subjects received intravenous tacrolimus (0.015 mg/kg) as a constant infusion over 4 hours and oral tacrolimus capsules (5 mg) as single doses in randomized order. Concentrations of tacrolimus and its metabolites were measured in whole blood with the use of a validated HPLC-mass spectrometry assay. RESULTS: There were no significant differences in pharmacokinetic parameters among the three study groups after intravenous administration of the drugs. After oral administration, the tacrolimus maximum concentration was significantly lower (P < .01) in the African American subjects (20.8 microg/L) than in the white subjects (37.8 microg/L) and Latin American subjects (33.0 microg/L). Absolute bioavailability was significantly lower (P = .01) in the African American subjects (11.9%) and in the Latin American subjects (14.4%) than in the white subjects (18.8%). After the oral dose, the area under the plasma concentration-time curve was lower in the African American subjects (179 microg/L x h, geometric mean) than in the white (293 microg/L x h) and Latin American subjects (239 microg/L x h, differences not statistically significant). Maximum concentration (P < .02) and area under the plasma concentration-time curve (not statistically significant) of the main tacrolimus metabolite 13-O-desmethyl tacrolimus was lower in the African American subjects than in the white and Latin American subjects. CONCLUSIONS: Significant differences in tacrolimus pharmacokinetics exist among the three different ethnic groups. Our results indicate that this may result from differences in intestinal CYP3A or P-glycoprotein activities.

Erectile dysfunction occurs following substantia nigra lesions in the rat.

Erectile function was assessed 6 weeks following uni- and bilateral injections of 6-hydroxydopamine in the substantia nigra nucleus of the brain. Behavioral apomorphine-induced penile erections were reduced (5/8) and increased (3/8) in uni- and bilateral lesioned animals. Intracavernous pressures, following electrical stimulation of the cavernous nerve, decreased in lesioned animals. Lesions of the substantia nigra were confirmed by histology. Concentration of dopamine and its metabolites were decreased in the striatum of substantia nigra lesioned rats. Lesions of the substantia nigra are therefore associated with erectile dysfunction in rats and may serve as a model to study erectile dysfunction in Parkinson's disease.

Increases in intracavernous penile pressure following injections of excitatory amino acid receptor agonists in the hypothalamic paraventricular nucleus of anesthetized rats.

PURPOSE: We examined whether N-methyl-D-aspartate (NMDA), amino-3-hydroxy-5-methyl-isoxazole-4-propionic acid (AMPA) or trans-1-amino-1,3-cyclo-pentadicarboxylic acid (ACPD) increase intracavernous pressures when injected in the paraventricular nucleus of the hypothalamus. MATERIALS AND METHODS: Sprague-Dawley rats weighing 250 to 300 gm. were anesthetized with pentobarbital and placed in a stereotaxic apparatus after catheterization of the carotid artery and insertion of a 25 gauge needle in the corpus cavernosum. Both catheters were coupled to pressure transducer systems. Electrical stimulations with glass tungsten microelectrodes and chemical injections with a 0.5 microl. syringe were done in the paraventricular nucleus. At the end of each experiment rats were perfused with saline and 10% formalin solutions. Brains slices 16 microm. thick were mounted and stained with cresyl violet to identify chemical and electrical stimulation sites. RESULTS: Electrical stimulations of the paraventricular nucleus increased intracavernous pressure from 15.5 +/- 5.7 to 50.02 +/- 20.4 cm. H2O in 10 rats (p <0.001) and decreased central pressure in 10 (p <0. 001). Intracavernous pressure increased from 17.2 +/- 5.26 to 60.6 +/- 14.36 cm. H2O with NMDA, 26.0 +/- 8.9 to 49.6 +/- 12.2 cm. H2O with AMPA and 18.0 +/- 2.3 to 41.0 +/- 22.68 cm. H2O with ACPD when injected in the paraventricular nucleus of 5 rats (analysis of variance 12.18, df 3, p <0.007). Mean delays and durations varied between 3.6 to 4.0 and 5.6 to 7.0, respectively, and were similar for all agonists (analysis of variance not significant). CONCLUSIONS: Glutamate receptor subtypes NMDA, ACPD and AMPA cause an increase in intracavernous pressure when injected in the paraventricular nucleus. Therefore, increases in intracavernous pressure following injection of glutamate must be initiated by the synergistic or additive effects of all of these receptor subtypes.

Increases in clitoral and vaginal blood flow following clitoral and pelvic plexus nerve stimulations in the female rat.

The objective of this present study is to establish a model in the rat for the study of female clitoral and vaginal vascular changes during sexual excitation. A laser Doppler was used to measure blood flow changes following clitoral and pelvic plexus nerve stimulations. Results show an increase in clitoral blood flow following clitoral nerve (df1 = 12, df2 = 108, F = 21.4, P < 0.001) and pelvic plexus nerve stimulations (n = 3). A vaginal blood flow increase is also observed following pelvic plexus nerve stimulations (df1 = 12, df2 = 108, F = 4.75, P < 0.001). The female rat can therefore be used as a model for the study of the physiology, pharmacology and sexual dysfunction relating to blood flow in clitoral and vaginal tissue.

Effect of testosterone on the number of NADPH diaphorase-stained nerve fibers in the rat corpus cavernosum and dorsal nerve.

OBJECTIVES: To elucidate the effect of testosterone on penile nerve supply. METHODS: Three groups of 10 rats each were assessed; two groups were castrated and the third underwent a sham operation (control). After castration, one group received subcutaneous injection of testosterone while the others received sesame oil. At 8 weeks, the rats underwent a functional analysis. The evaluation included a subcutaneous injection with apomorphine to study centrally mediated erection, and cavernous nerve electrostimulation and papaverine injection to study peripherally mediated erection. At death, a penile midshaft specimen was taken for nicotinamide adenine dinucleotide phosphate (NADPH) diaphorase staining. RESULTS: In the apomorphine study, castrated rats had no erections, but the erectile function of those receiving testosterone was restored to the level of the controls. The mean numbers of NADPH-diaphorase-stained nerve fibers in the copora cavernosa and both dorsal nerves of castrated rats, at 165.8 +/- 20.0 and 271.3 +/- 21.1, respectively, were significantly lower than those of the controls, at 271.7 +/- 14.6 and 471.2 +/- 27.6, respectively. Those of the testosterone replacement group, at 290.7 +/- 10.1 and 500.7 +/- 23.9, respectively, recovered to the control level. The intracavernosal pressure decreased significantly in the absence of testosterone, both after electrostimulation and intracavernosal papaverine injection, and recovered to the control level after testosterone replacement. CONCLUSIONS: Our results indicate that testosterone acts on the nervous system to mediate erection. When it is absent, there may be downregulation of both the production and activity of nitric oxide (NO), thereby decreasing the response to peripheral stimulation via the NO pathway. Testosterone replacement may upregulate NO activity to the control level.

Delayed testosterone replacement restores nitric oxide synthase-containing nerve fibres and the erectile response in rat penis.

OBJECTIVE: To elucidate the effect of testosterone on penile innervation. Materials and methods Three groups of six rats each were assessed; two groups (1 and 2) were castrated and the third (group 3) underwent a sham operation (control). Eight weeks after castration, group 2 received a subcutaneous injection with testosterone. At 8 weeks, the rats in group 1 and 3 underwent a final functional analysis while those in group 2 did so at 12 weeks. The evaluation included a subcutaneous injection with apomorphine to study centrally mediated erection, and cavernosal nerve electrostimulation and papaverine injection to study peripherally mediated erection. At death a penile mid-shaft specimen was taken for NADPH-diaphorase staining. RESULTS: In the apomorphine study, castration resulted in significantly fewer yawns and erections than in the control, and those in group 2 significantly better central erectile function than in the controls. The mean (SEM) number of nitric oxide synthase (NOS)-containing nerve fibres in the corpora cavernosa and both dorsal nerves of castrated rats, at 46.2 (9.1) and 203 (32.1), respectively, were significantly lower than in rats in group 2, at 84.1 (11.2) and 300.6 (17.1), and than in the controls, at 88.6 (10.9) and 306.3 (22.9), respectively. The intracavernosal pressure decreased significantly in the absence of testosterone, both after electrostimulation and intracavernosal papaverine injection. However, there was no difference between the control and group 2 rats in either the number of NOS-containing nerve fibres or in the peripheral erectile functional study. CONCLUSIONS: Testosterone acts on the nervous system to mediate erection; when it is absent there may be down-regulation of both the production and activity of NO, thereby decreasing the response to peripheral stimulation via the NO pathway. The restoration of erectile function seen in rats in group 2 supports this phenomenon. Delayed testosterone replacement has no detrimental effect on the restoration of the erectile mechanism after castration.

Demonstration of in vivo bioequivalence of a generic albuterol metered-dose inhaler to Ventolin.

STUDY OBJECTIVE: To use histamine bronchoprovocation and bioassay statistical procedures to evaluate the in vivo bioequivalence of a generic albuterol metered-dose inhaler (MDI). DESIGN: A randomized, double-blind, balanced, crossover design was used to determine the potency of each generic albuterol MDI actuation relative to Ventolin (Glaxo Wellcome; Research Triangle Park, NC) administration. One treatment was administered on each of 4 study days. A histamine bronchoprovocation procedure was initiated 1.25 h before and 15 min after administration of the study treatment. PATIENTS: Twenty-four nonsmoking subjects with mild-to-moderate asthma were studied (18 to 65 years of age; FEV(1), > 60% of predicted; and provocative concentration of histamine causing a 20% fall in FEV(1) [PC(20)], < or = 8 mg/mL at screening). INTERVENTIONS: One and four actuations (90 and 360 microg, respectively) of the generic MDI and of Ventolin MDI. Placebo inhalers were used to maintain blinding of inhaler and doses. MEASUREMENTS AND RESULTS: The primary outcome variable was histamine PC(20) measured after study treatment administration. A significant dose-effect relationship was present (p < 0.0001). Deviation from parallelism of the generic and Ventolin dose-response curves (p = 0.95) and differences in overall mean response between the two formulations (p = 0.68) were not significant. Using Finney 2 x 2 bioassay statistical procedures, we estimated that one actuation of the generic albuterol MDI was equivalent to 1.01 puffs of Ventolin (90% confidence interval, 0.69 to 1.50). CONCLUSION: The generic albuterol MDI delivers a quantity of albuterol to the beta(2)-receptor site in the lung that is the bioequivalent to Ventolin. Further, this study reinforces the validity of this statistical methodology for determining in vivo bioequivalence.

Mitral regurgitation after atrioventricular node catheter ablation for atrial fibrillation and heart failure: acute hemodynamic features.

BACKGROUND: Radiofrequency catheter ablation of the atrioventricular node and pacemaker insertion have been associated with occasional development of mitral regurgitation (MR). Ventricular pacing might result in MR if (1) left ventricular (LV) compliance is decreased and/or (2) mitral valve leaflet apposition is disturbed. We studied acute hemodynamic changes resulting from initiation of ventricular pacing in patients undergoing ablation. METHODS AND RESULTS: Thirteen patients (10 men and 3 women) with a mean age of 73.4 +/- 8. 6 years, with chronic atrial fibrillation and congestive heart failure, had permanent ventricular pacemaker insertion with lead placement at the right ventricular (RV) apex. The following hemodynamic recordings were obtained before ablation (during atrial fibrillation) and then immediately after ablation (during RV pacing): heart rate, mean arterial pressure, LV end-diastolic pressure (LVEDP), mean pulmonary capillary wedge pressure, V-wave amplitude, and cardiac index. Presence of MR was assessed by V-wave amplitude and the results of LV angiography. In patients who had MR, recordings were also obtained during temporary ventricular pacing from the RV outflow tract (RVOT). As a group there were no significant changes in any hemodynamic measurement. Before ablation, mild MR by LV angiogram was present in 5 patients, but none had large V-wave amplitude. After ablation, mild MR was present by LV angiogram in 6 patients, and in 3 of these patients large V-wave amplitude developed (mean amplitude 42.7 +/- 2.2 mm Hg; assigned to group 1). This was associated with a rise in LVEDP in 1 patient (consistent with reduced LV compliance), but LVEDP was unchanged in the other 2 patients (suggesting abnormal mitral valve leaflet apposition). All patients in group 1 exhibited a fall in V-wave amplitude when the pacing site was moved to the RVOT. CONCLUSIONS: Both reduced LV compliance and disturbed mitral valve leaflet apposition contribute to MR after ablation. MR is reduced by pacing from the RVOT.

Time course of the medial olivocochlear efferent effect on otoacoustic emissions in humans.

The time course of the medial olivocochlear efferent system has been studied in humans, using the suppressive effect of a contralateral broad-band noise (CBBN) on 2f1-f2 distortion product otoacoustic emissions (DPOAE) amplitude. DPOAE were recorded with F2 at 1.5 kHz, with a temporal resolution of 2.6 s, in the presence and absence of a 40 dB SL continuous CBBN, whose duration ranged between 30 s and 20 min. The CBBN suppressive effect on DPOAE amplitude was greatest from the first 2.6 s, and was sustained for 20 min. At the CBBN offset, when the CBBN duration was > or = 2 min, DPOAE amplitude continued to increase for > 1 min, showing an efferent effect outlasting CBBN stimulation.