[Bleeding and coagulation disorders in tonsillectomies]. / Nachblutungen und Gerinnungsstörungen bei Tonsillektomien.

BACKGROUND: The aim of our prospective analysis was to show the incidence of bleeding disorders among a tonsillectomy patient population and in case of bleeding disorders. PATIENTS AND METHODS: This study comprised 92 consecutive patients who underwent tonsillectomies from 1 January 2007 to 31 December 2007 at the Department of Otorhinolaryngology, University Medical Center Mainz. In addition to gender, age, date of bleeding, Quick, aPTT and platelet count, the following blood values were determined: vWF:AG, vWF:RCo, vWF:RCo/vWF:AG, factor XIII, factor VIII:C, PFA 100™ ADP and PFA 100™ epinephrine (special coagulation analysis). RESULTS: Twelve of 92 patients (13%) showed evidence of coagulopathy. Four of these 12 patients had a postoperative hemorrhage. In eight patients a factor XIII deficiency was diagnosed, with two of them suffering a hemorrhage. In four patients, von Willebrand disease was diagnosed; two of them bled. No correlation between the presence of a coagulopathy and the bleeding rate could be determined. CONCLUSION: Routine preoperative performance of special coagulation analysis in all patients does not significantly contribute to the detection of increased postoperative hemorrhage risk.

[The significance of bleeding disorders in patients with epistaxis]. / Stellenwert von Gerinnungsstörungen bei Patienten mit Epistaxis.

BACKGROUND: Epistaxis can have a variety of different local or systemic causes. It is the cardinal symptom of von Willebrand disease (VWD), the most frequent congenital bleeding disorder with a prevalence of approximately 1%. The usual routine coagulation screening tests (PT, APTT, platelet count) are not sufficient to diagnose VWD, factor XIII (FXIII)-deficiency or platelet dysfunction. METHOD: A prospective study was conducted implementing enhanced coagulation screening for bleeding disorders in a total of 100 inpatients admitted for epistaxis. RESULTS: A bleeding disorder was found in 13%. In eight patients VWD was diagnosed, in six patients FXIII-deficiency was found, and in one patient both. CONCLUSION: The prevalence of bleeding disorders in patients with epistaxis is higher than in the general population. Epistaxis can be the primary symptom of chronic inflammatory disease or malignant disease. A thorough anamnesis is necessary and in cases of doubt additional testing for underlying disorders is recommended.

Probing arrays of circular magnetic microdots by ferromagnetic resonance.

X-band ferromagnetic resonance (FMR) was used to characterize in-plane magnetic anisotropies in rectangular and square arrays of circular nickel and Permalloy microdots. In the case of a rectangular lattice, as interdot distances in one direction decrease, the in-plane uniaxial anisotropy field increases, in good agreement with a simple theory of magnetostatically interacting uniformly magnetized dots. In the case of a square lattice a four-fold anisotropy of the in-plane FMR field H(r) was found when the interdot distance a gets comparable to the dot diameter D. This anisotropy, not expected in the case of uniformly magnetized dots, was explained by a non-uniform magnetization m(r) in a dot in response to dipolar forces in the patterned magnetic structure. It is well described by an iterative solution of a continuous variation procedure. In the case of perpendicular magnetization multiple sharp resonance peaks were observed below the main FMR peak in all the samples, and the relative positions of these peaks were independent of the interdot separations. Quantitative description of the observed multiresonance FMR spectra was given using the dipole-exchange spin wave dispersion equation for a perpendicularly magnetized film where in-plane wave vector is quantized due to the finite dot radius, and the inhomogenetiy of the intradot static demagnetization field in the nonellipsoidal dot is taken into account. It was demonstrated that ferromagnetic resonance force microscopy (FMRFM) can be used to determine both local and global properties of patterned submicron ferromagnetic samples. Local spectroscopy together with the possibility to vary the tip-sample spacing enables the separation of those two contributions to a FMRFM spectrum. The global FMR properties of circular submicron dots determined using magnetic resonance force microscopy are in a good agreement with results obtained using conventional FMR and with theoretical descriptions.

The effects of short-term immunotherapy using molecular standardized grass and rye allergens compared with symptomatic drug treatment on rhinoconjunctivitis symptoms, skin sensitivity, and specific nasal reactivity.

BACKGROUND: The efficacy and safety of short-term immunotherapy with molecular standardized allergens (STI) has been demonstrated by double-blind placebo-controlled clinical trials. The aim of this study was to compare STI with symptomatic drug treatment. METHODS: Forty-eight patients with rhinoconjunctivitis to grass and/or rye pollen were treated either with STI (ALK(7), n = 24) plus anti-allergic drugs or anti-allergic drugs, alone (n = 24) in a prospective, randomized study. Symptoms and use of drugs were reported in patient diaries and titrated nasal provocation and skin prick tests were performed at baseline, before, and after season. RESULTS: Median overall symptom (P = 0.022, U test) and medication scores (P = 0.003) were significantly lower in the STI group, as was the result for a simultaneous analysis of conjunctival, nasal, and bronchial symptom scores and medication (P = 0.005). Sensitivity in the nasal provocation test decreased in the STI group but not in the drug-treated group. These differences became significant directly after STI (P = 0.027) as well as after the grass pollen season (P < 0.001). Skin sensitivity did not change in the STI group but increased in the drug-treated group after season, with a significant difference between the two groups for the erythema (P < 0.001). CONCLUSIONS: STI reduces grass pollen-induced rhinoconjunctivitis symptoms and drug use, and specific nasal reactivity and skin sensitivity, more efficiently than a standard symptomatic treatment.

Rapid Rhino: A new pneumatic nasal tamponade for posterior epistaxis.

OBJECTIVES: Some of these measures to control posterior epistaxis cause loss of nasal respiration and put the patient on those related risks. STUDY DESIGN AND METHODS: The efficiency of a new pneumatic nasal tamponade (Rapid Rhino) was compared with a choanal balloon tamponade that has been used in our department for years in a prospective randomized study in patients with posterior epistaxis. The new pneumatic tamponade was used on the affected side only and nasal ventilation of the contralateral side was possible. RESULTS: Because of the successful use of the new pneumatic tamponade in most of the patients, epistaxis could be controlled without bilateral obstruction of nasal respiration. The use of the new pneumatic tamponade was evaluated to be less painful by the patients than choanal balloon tamponade. CONCLUSION: In an adapted therapeutic regime, the new pneumatic tamponade seems to have its place before using bilateral nasal respiration obstructing measures.

[Percutaneous dilatative tracheostomy versus conventional surgical tracheostomy: a retrospective trial]. / Vergleich der perkutanen Dilatationstracheotomie versus konventioneller Tracheotomie - Eine retrospektive Studie.

BACKGROUND: In this retrospective study we compared endoscopically controlled percutaneous dilatative tracheostomies (PDT) with conventional surgical tracheostomies as a bedside procedure and in the operating theatre. PATIENTS: Between 1998 and 2000 we performed 360 tracheostomies electively, 152 in PDT-technique (42 %) and 208 (58 %) with the conventional procedure. Referring to the PDT-technique 74 % (n = 112) were performed at the bedside and 26 % in the operating theatre. The conventional tracheostomies took place at bedside in 53 % (n = 110) and in the operating theatre in 47 % (n = 98) of the cases. The complications were divided in 5 groups with special interest if the operation took place in the operating theatre or as a bedside procedure. RESULTS: In general the rate of complications in the PDT group was 33 % (50/152) versus 22 % (46/208) referring to the conventional group. Referring to the PDT group the rate of complications were 35 % (39/112) at the bed site procedure and 28 % (11/40) in the operating theatre. The complication rate for the conventional group was 27 % (30/110) as a bedside procedure versus 16 % (16/98) in the operating theatre. Significant differences were found for the PDT with an increase of tubal obstructions (p = 0.007). For the conventional tracheostomy we found a significant increase of wound infections (p = 0.006). There was significantly higher postoperative hemorrhage if the procedure was done at bed site. CONCLUSION: PDT and conventional tracheostomies have different complications. The higher risk of postoperative hemorrhage for bed site procedure has to be considered.

The effect of short-term immunotherapy with molecular standardized grass and rye allergens on eosinophil cationic protein and tryptase in nasal secretions.

BACKGROUND: Activation of mast cells and eosinophils under pollen exposure can be inhibited by specific immunotherapy. OBJECTIVE: The effect of short-term immunotherapy with 7 preseasonal injections of molecular standardized allergens from grass and rye pollen on eosinophil cationic protein (ECP) and tryptase levels in nasal secretions has been compared with symptomatic drug treatment in an open, randomized study with 48 patients. METHODS: Nasal reactivity and mediator levels in nasal secretions were measured at baseline, before season, in season, and after season. RESULTS: Symptom scores in the immunotherapy group were 134.5 (95% CI, 65 to 336) versus 386. 0 (95% CI, 185 to 563), significantly lower as in the drug-treated group. ECP and tryptase levels increased significantly during natural allergen exposition. The seasonal levels in the immunotherapy group were significantly lower than in the drug-treated group with 272.1 ng/mL (252.0 to 293.9 ng/mL; immunotherapy) versus 470.4 ng/mL (SEM, 435.6 to 508.0 ng/mL; drugs) for ECP and with 8.73 ng/mL (SEM, 8.20 to 9.29 ng/mL) versus 17.47 ng/mL (16.42 to 18.60 ng/mL) for tryptase (all, P <.001). The ECP level induced by nasal provocation was 105.6 ng/mL (99.0 to 112.6 ng/mL) versus 180.4 ng/mL (169.2 to 192.4 ng/mL), significantly lower (P <.001) in the immunotherapy group, as was the tryptase level with 12.12 ng/mL (11.53 to 12.75 ng/mL) versus 8.19 ng/mL (7. 79 to 8.62 ng/mL; P <.001) at the after-season visit. CONCLUSION: Short-term immunotherapy is able to reduce tryptase and ECP in nasal secretions more effectively than drug treatment in patients with allergic rhinitis.

[Function of the eustachian tube in epitympanic retraction pockets]. / Funktion der Tuba auditiva bei epitympanalen Retraktionstaschen.

There are different hypotheses for the development of epitympanic retraction pockets. These can occur as the result of an inflammatory process and negative pressure in the middle ear spaces. Anatomic bottlenecks in the middle ear favor diminished inflation of the epitympanic space. The eustachian tube provides pressure equilibration in the middle ear. Its dysfunction involving tubal opening or closing is thought to be the main reason for a permanent negative pressure in the middle ear. A patulous eustachian tube is now claimed for prolonged negative pressure in the middle ear and is caused by a so-called "sniffing" habit. The purpose of this study was to elucidate objectively the frequency of patulous eustachian tubes in ears with epitympanic retraction pockets. We examined passive tubal function in 41 patients with 50 epitympanic retraction pockets by using dual impedance in a pressure chamber. We identified three stages of epitympanic retraction pockets. Stage 1 involved a mobile and controllable retraction pocket; stage 2 corresponded with a fixed but controllable pocket, whereas stage 3 described a fixed pocket that was developing into a cholesteatoma. Results were compared with the function tests of 100 healthy ears in 50 normal individuals. We found 27 patulous eustachian tubes in patients with epitympanic retraction pockets, 22 of which occurred in affected ears while only 2 patulous tubes were found in the group of the healthy ears. Tubal opening pressure (P < 0.001) and tubal closing pressure (P < 0.01) were significantly lower in ears with epitympanic retraction pockets than in healthy ears.

[Arachnoid cyst of the sphenoid sinus]. / Arachnoidalzyste der Keilbeinhöhle.

BACKGROUND: Arachnoid cysts of the paranasal sinus are rare. They have not been described yet in the sphenoid sinus. PATIENT AND METHOD: Microscopic-endoscopic endonasal surgery of the sphenoid sinus was performed on a 34-year-old female with a history of chronic headaches and a suspected mucocele of the sphenoid sinus in computed tomography (CT) and magnetic resonance imaging (MRI) studies. An extended arachnoid cyst was found in the enlarged sphenoid sinus, which was obliterated with collagen, fibrin glue, and abdominal fat. RESULTS: There were no complications after the operation, and 12 months later the patient is still free of symptoms. CONCLUSION: Arachnoidal cysts present in CT and MRI as fluid dense lesions that can imitate a mucocele.

[Reproducibility and seasonal dependence of specific intranasal provocation tests in birch pollen allergy patients]. / Untersuchungen zur Reproduzierbrakeit und jahreszeitlichen Abhängigkeit von spezifischen intranasalen Provokationstests bei Birkenpollenallergikern.

BACKGROUND: The intranasal allergen Provocation test (INT) is the standard procedure to verify the effect of an allergen when a nasal allergy is suspected. It may be especially useful if results from skin tests or in vitro tests conflict with those from the history. In the clinical and research setting, INT may be used to study the efficacy of different treatment modalities such as pharmacotherapy or immunotherapy. The technique of INT has not been well standardized in the past. Variations exist in planning the optimum time for testing, especially in seasonal allergies. METHODS: We examined influences of different test dates with regard to the pollen season on the result of INT. A total of 19 patients (eight females, 11 males, aged 26.1 +/- 4.8 years) with a history of at least two years of allergic rhinitis to birch pollen, positive skin prick test, and RAST (> or = CAP class II) to birch pollen. INT was performed during the winter-period after approximately six months without natural pollen exposition (V1), during the birch pollen season (V2) and six weeks after the birch pollen season (V3). Allergens were applied using a pump spray (0.1 ml) in concentrations of 10, 50, 100, 500, 1000, 5000, 10,000, 50,000, and 100,000 SQ units per ml (SQ/ml). RESULTS: The threshold concentrations were significantly lower at V2 (100 SQ/ml) and V3 (500 SQ/ml) if compared to V1 (1000 SQ/ ml). CONCLUSIONS: Seasonal influences should be taken into account when performing INT in birch pollen allergy.

Increased in vitro cysteinyl leukotriene release from blood leukocytes in patients with asthma, nasal polyps, and aspirin intolerance.

In vitro cysteinyl leukotriene (cLT) release from blood leukocytes was measured in eight normal individuals (NI), nine patients with nasal polyps (NP) without aspirin intolerance, and eight patients with NP, asthma, and aspirin intolerance (AI). Blood leukocytes were prestimulated with interleukin-3 (IL-3) and incubated with acetylsalicylic acid (ASA) (10 and 100 micrograms/ml) together with C5a (10(-8) mol/l) for 18 h. cLT release (LTC4, LTD4 and LTE4) from blood leukocytes was measured with a competitive enzyme-linked immunoassay. Background cLT release was 259 +/- 66 pg/ml (mean +/- SEM) in the NI group, 185 +/- 33 pg/ml in the NP group, and 578 +/- 136 pg/ml in the AI group (P = 0.1). After incubation with 10 micrograms/ml ASA, cLT concentration was lower in normal subjects (346 +/- 72 pg/ml) and in patients with NP (209 +/- 53) than in patients with AI (686 +/- 75 pg/ml, P = 0.002). After incubation with 100 micrograms/ml ASA, cLT concentrations were 285 +/- 72 pg/ml in the NI group, 313 +/- 77 pg/ml in the NP group, and 654 +/- 121 pg/ml in the AI group (P = 0.04), respectively. Simultaneous incubation with ASA 10 micrograms/ml and C5a (10(-8)mol/l) resulted in a cLT concentration of 751 +/- 171 pg/ml in the NI group, 343 +/- 102 pg/ml in the NP group, and 2196 +/- 480 pg/ml in patients with AI (P = 0.0006), whereas simultaneous incubation with ASA 100 g/ml and C5a (10(-8)mol/l) resulted in 268 +/- 51 pg/ml in the NI group, 412 +/- 97 pg/ml in the NP group, and 1701 +/- 368 pg/ml in the AI group (P = 0.005). In patients with AI, cLT release from blood leukocytes is altered when compared with normals and patients with NP. The presented cLT-release assay could be of potential use in the in vitro diagnosis of AI.

Electrophysiology of ion channels of the heart.

The contribution of Na+, Ca2+, and various K+ currents to the shape of the cardiac action potential is outlined based on the relation between electrophysiological properties and structure of channel molecules. These currents have also been found in human ventricular myocytes, where the most prominent K+ current is a transient outward current that is not influenced by methylsulfonanilide antiarrhythmic drugs. Combined knowledge of electrophysiological and molecular properties of ion channels is likely to form the basis for rational design of future drugs.

L-type calcium currents of human myocytes from ventricle of non-failing and failing hearts and from atrium.

L-type calcium currents were studied in ventricular myocytes isolated from non-failing hearts, i.e. donor hearts not suitable for transplantation, and from severely failing hearts, i.e. explanted hearts of organ recipients, in order to identify possible alterations of the currents in cardiomyopathy. Human atrial myocytes were investigated for comparative purposes. As deficient production of cyclic AMP might contribute to the development of cardiac failure, the responses to forskolin, a direct stimulator of adenylyl cyclase, were also studied. The patch-clamp technique was applied in the single electrode whole-cell mode. Calcium currents were similar in myocytes from non-failing and failing hearts: Maximum current-densities were 3.8 v 3.1 pA/pF, and 2.2 pA/pF in atrial cells. In human ventricular cells, threshold was at -33 mV, maximum at +6 mV and reversal potential at about +50 mV, potentials of half-maximum steady-state inactivation -24 mV and -18 mV. The slopes of steady-state inactivation curves were +4.1 mV in myopathic and +5.5 mV in non-failing cells. In all myocytes the current inactivated with two time constants, a fast one with weak and a slow one with pronounced potential dependency. Ventricular or atrial myocytes from patients pretreated with calcium antagonists and untreated did not differ in current density or steady-state inactivation. Forskolin (0.5 microM) increased calcium currents in myocytes from non-failing and failing hearts to the same extent (by 143 and 150%). While beta-adrenoceptor numbers are reported to decline in severely failing myocardium, our data do not suggest that alterations of the properties of calcium currents contribute to the pathophysiology of heart failure, though the number of investigated hearts is limited due to restricted access to non-failing cardiac tissue. No evidence for impairment of the signal transduction cascade beyond the level of GTP binding proteins was found.

Activation of calcium currents in cardiac myocytes by empty beta-adrenoceptors.

BACKGROUND: The cardiac calcium channel is known to be modulated by catecholamines via beta-adrenoceptors acting through intermediary GTP-binding regulatory proteins (G proteins). In biochemical studies on isolated membranes and reconstituted systems, it has been demonstrated that various G protein-coupled receptors, including beta-adrenoceptors, can activate G proteins and also intracellular second messengers like cyclic AMP (cAMP) even in the absence of an agonist and that antagonists can block this empty receptor action. We examined electrophysiologically whether agonist-free beta-adrenoceptors can modulate L-type calcium currents (ICa) in intact cardiac myocytes. METHODS AND RESULTS: Cardiomyocytes were isolated from ventricles of guinea pig and human hearts and from human right atrial appendage. The patch-clamp technique was applied in the single electrode mode to measure whole-cell ICa. Modulation of calcium currents by beta-adrenoceptor antagonists, without addition of an agonist, was studied in the absence and presence of the direct adenylyl cyclase activator forskolin and the cAMP analog adenosine cyclic 3',5'-monophosphorothioate (Sp-cAMPS). In the presence of forskolin (0.5 mumol/L), an agent known to sensitize the adenylyl cyclase signal transduction system for receptor regulation, addition of the beta 1-selective antagonist atenolol and the nonselective antagonist propranolol (but not of the beta 2-selective antagonist ICI 118,551) caused a marked reduction of ICa in a concentration-dependent and stereoselective manner. The inhibitory effect of atenolol was reversible after washing out and was found to be half maximal and maximal (50% reduction) at about 50 and 300 nmol/L, respectively. In the absence of forskolin, inhibition of ICa by atenolol was markedly less (18% at 10 mumol/L atenolol). Finally, in contrast to forskolin-stimulated currents, atenolol (1 mumol/L) did not reduce calcium currents activated by the protein kinase A activator Sp-cAMPS (0.1 mmol/L), causing by itself a similar increase in calcium currents as forskolin. CONCLUSIONS: In isolated guinea pig and human cardiomyocytes, agonist-free beta-adrenoceptors are functionally active and can stimulate L-type calcium currents, an effect blocked by receptor-specific antagonists.

The Kasabach-Merritt syndrome: severe bleeding disorder caused by celiac arteriography--reversal by heparin treatment.

Studies are presented on a 62-yr-old woman with extreme hepatomegaly due to a giant hemangioma with alterations in the clotting system indicating a consumption coagulopathy. There was a fall of hemoglobin, fibrinogen, antithrombin III, and platelet number after arteriography of the truncus celiacus. Furthermore, there was sustained bleeding in the patient's right thigh caused by puncture of the arteria femoralis. Continuous administration of iv heparin corrected the clotting disorder including a rise in platelets from 95,000/microliters to 148,000/microliters, permitting surgical removement of the hematoma. Celiacography is a useful tool for the diagnosis of hepatic hemangiomata, as well as ultrasound, computed tomography, and magnetic resonance imaging. Being an invasive technique, it requires testing for possible consumption coagulopathy if used in patients with hemangiomatosis. Its application should be restricted to cases in which exact diagnosis cannot be established by other means.