Analysis of taste function in patients before and after cochlear implant surgery.

BACKGROUND: Cochlear implantation (CI), the standard therapy for rehabilitation of severe to profound sensorineural hearing loss, exhibits taste dysfunction as a possible postoperative complication. This study aimed to investigate possible postoperative changes in taste and in addition baseline taste function in CI candidates. METHODOLOGY: We included 61 patients (32 male, 29 female) planned to undergo CI surgery and 23 healthy controls (8 male, 15 female). Gustatory function was measured using a chemosensory quasi-threshold test (taste strips) and electrogustometry (EGM). To exclude possible effects of olfaction on taste, olfactory function was tested by means of the Sniffin Sticks odor identification test. Furthermore, the density of fungiform papillae (fPAP) was analyzed. Measurements were taken pre- and 2-4 weeks postoperative. RESULTS: Preoperative taste function and fPAP density was reduced in CI patients compared to controls. The fPAP density correlated significantly with the total taste score, EGM scores and age. Postoperative taste function decreased significantly, whereas EGM scores and fPAP density did not significantly change. Also baseline olfactory function in CI candidates was decreased, whereas no significant change of olfactory function was found post-surgery. CONCLUSION: CI candidates exhibited taste and olfactory dysfunction already preoperatively. Furthermore, a significant decrease in taste scores after CI surgery was detected.

Pursuing Quality in the Application of Bladder Cancer Quality of Life Research.

Patient-reported outcomes (PRO), including health-related quality of life (HRQOL) measures, represent important means for evaluating patients' health outcomes and for guiding health care decisions made by patients, practitioners, investigators, and policy makers. In spite of the large number of studies examining HRQOL in patients with bladder cancer, very few review articles investigated this topic. Because these review studies report mixed results, incorporating bladder cancer HRQOL measures into standard urological practice is not a viable option. In this non-systematic review of the literature and commentary we note some general concerns regarding PRO research, but our primary focus is on the HRQOL methodology within the context of two types of bladder cancer: muscle invasive and non-muscle invasive bladder cancer. Considering bladder cancer HRQOL as the interaction of four areas of the assessment process (i.e., what model of HRQOL to choose, what instruments are available to fit the choice, how interpretation of the resulting data fits the model, and how to derive some utility from the chosen model) and the two types of disease (i.e., muscle invasive and non-muscle invasive) may move us toward a better understanding of bladder cancer HRQOL. Establishing a useful model of perceived general health or specific symptoms is the first and most important step in developing the responsive bladder cancer HRQOL measures necessitated by clinical settings.

[Blindness in Germany--today and in 2030]. / Erblindung in Deutschland--heute und 2030.

Due to demographic developments in Germany, it is inevitable that the number of age-related diseases will grow. The aim of this survey is to forecast the extent of this development in ophthalmology. How many people will be blind or visually impaired in 25 years from now? According to the German Federation of Blind and Visually Impaired People, the number of blind people in Germany is about 145,000 and the number of the partially sighted people can be estimated at approximately 500,000. These figures are based on the legal definitions of blindness and visual impairment, which are stricter in Germany than in other countries. Due to the ageing population, there will be one third more blind people and about 60% more new cases of blindness in 25 years time. In particular, the incidence rate of blindness due to age-related macular degeneration will rise sharply, but the number of blind people and new cases of blindness are only the top of the "iceberg". The number of people suffering from age related eye diseases in future will be even larger. This large number of future patients already should be part of health economic considerations.

Morphometric relationships between tooth and face shapes.

The shape of a patient's face is commonly used as a reference to select the shape of the maxillary central incisors in edentulous patients. The validity of this relationship has not been proved. The objective of this clinical study was to determine whether a relationship exists between maxillary central incisors and face shapes. Casts were made of the maxillas of 50 men and 50 women. A standardized digital photographic procedure was used to record frontal views of each subject's face and of the maxillary central incisors of the dental casts. The shapes of the maxillary central incisors were compared with the face forms. Shape matches were evaluated according to their Hausdorff distance (HDD). The function h(A,B) is called the directed HDD from shape A to shape B (this function is not a true distance). It reflects the distance of the point of shape A that is farthest from any point of shape B and vice versa. The similarity of both shapes is given as a non-negative number. The value 0.0 indicates that the figures are identical (after scaling and shifting). Higher values indicate that shapes differ more substantially. Significant differences on the 5% level were calculated using the non-parametric Mann-Whitney U and Kruskal-Wallis tests. The face shape from the chin margin to the eyebrow line (superior edges of the eyebrows) produced a better match than the one from the chin to the hairline (P < 0.0001). On average, the maxillary central incisors displayed a variability (0.084 +/- 0.028) that was higher by a factor of 1.9 than the face shapes (chin margin to the eyebrow line, 0.045 +/- 0.015). In the interindividual comparison, the shapes of the maxillary central incisors of women displayed a significantly smaller HDD than the ones of the men (P < 0.0001).

Gastrointestinal tuberculosis: an eighteen-patient experience and review.

The diagnosis of gastrointestinal tuberculosis (GITB) is often delayed, increasing the morbidity associated with this treatable condition. In this case series, the clinical presentations and outcomes of 18 patients with GITB are reviewed. Our aim was to elucidate the presenting signs and symptoms of GITB so as to help physicians improve their ability to make this diagnosis. Cases were gathered retrospectively over an 8-year period from Santa Clara Valley Medical Center, San Jose, California. Sources of information included patient records from our TB clinic and our hospital from 1989 to 1997. Of the 18 patients, 16 had a definitive diagnosis of GITB made from histology and/or culture from an abdominal source. In the remaining two patients, a presumptive diagnosis of GITB was made based on the co-occurrence of abdominal signs and symptoms, response to antituberculous therapy, and Mycobacterium tuberculosis identified at a nonabdominal site. The most common clinical presentation was a triad of abdominal pain, fever, and weight loss. This triad was present in 8 of 18 patients. Seven patients presented with two of these signs and symptoms, two had abdominal pain alone, and one presented with other symptomatology. Time to diagnosis ranged from 2 days to 11 months, with a mean time to diagnosis of 50 days. These findings suggest that the diagnosis of GI and hepatic TB is often delayed. Possible reasons for delay include nonspecific signs and symptoms and failure to consider TB in the initial differential diagnosis. Once diagnosed, the outcome of GITB in this series was favorable.

Anomalous rectifying properties of 'diazepam-insensitive' GABA(A) receptors.

Studies using recombinant systems indicate that 'diazepam-insensitive' GABA(A) receptors in the central nervous system contain alpha4 and alpha6 subunits while 'diazepam-sensitive' GABA(A) receptors contain alpha1, alpha2, alpha3 and alpha5 subunits. Both native and recombinant diazepam-sensitive GABA(A) receptors typically exhibit large, outwardly rectifying currents. For example, in patch clamp studies, Human Embryonic Kidney (HEK) 293 cells transfected with cDNAs encoding alpha1beta2gamma2 subunits exhibit a rectification ratio (I +60 mV/I -60 mV) of 1.95 +/- 0.21. However, anomalous rectification was observed in recombinant diazepam-insensitive GABA(A) receptors composed of either alpha4beta2gamma2 (rectification ratio, 0.74 +/- 0.09) or alpha6beta2gamma2 (rectification ratio, 0.67 +/- 0.11) subunits. Based on sequence differences between diazepam-sensitive and -insensitive GABA(A) receptor alpha subunits in the vicinity of the putative channel lining, a point mutation was introduced at His273 on the alpha4 subunit. The rectification ratio in cells expressing a mutated alpha4(Asn273)beta2gamma2 receptor increased to 1.92 +/- 0.17. Moreover, mutation of the homologous residue in the alpha1 subunit to histidine reduced the rectification ratio of alpha1(His274)beta2gamma2 to 1.02 +/- 0.12. The affinities of benzodiazepine site ligands at diazepam-sensitive and -insensitive GABA(A) receptors were unaffected by these mutations. Thus, the electrophysiological properties of diazepam-sensitive and -insensitive GABA(A) receptors may be as divergent as their pharmacological characteristics.

Distinct structural requirements for the direct and indirect actions of the anaesthetic etomidate at GABA(A) receptors.

1. The intravenous anaesthetic etomidate augments GABA-gated chloride currents (indirect action) and, at higher concentrations, evokes chloride currents in the absence of GABA (direct action). 2. In order to identify amino acid residues essential for these actions, site directed mutagenesis was performed on the beta3 subunit. 3. Mutation of an asparagine to a serine residue at position 290 dramatically reduced both etomidate-induced chloride currents and its ability to enhance [3H]flunitrazepam binding in HEK293 cells expressing alpha1beta3gamma2 recombinant GABA(A) receptors. 4. In contrast, the indirect effect of etomidate was retained, though its potency was reduced. 5. These findings indicate that there are distinct requirements for these dual actions of etomidate at GABA(A) receptors.

Distinct loci mediate the direct and indirect actions of the anesthetic etomidate at GABA(A) receptors.

Most general anesthetics produce two distinct actions at GABA(A) receptors. Thus, these drugs augment GABA-gated chloride currents (referred to as an indirect action) and, at higher concentrations, elicit chloride currents in the absence of GABA (referred to as a direct action). Because a beta subunit appears to be required for the direct action of intravenous anesthetics in recombinant GABA(A) receptors, site-directed mutagenesis of the beta3 subunit was performed to identify amino acid residues that are critical for this action. In HEK293 cells expressing a prototypical GABA(A) receptor composed of alpha1beta3gamma2 subunits, mutation of amino acid 290 from Asn to Ser dramatically reduced both etomidate-induced chloride currents and its ability to stimulate [3H]flunitrazepam binding. By contrast, the ability of etomidate to augment GABA-gated chloride currents and GABA-enhanced [3H]flunitrazepam binding was retained. The demonstration that the direct, but not the indirect, actions of etomidate are dependent on beta3(Asn290) indicates that the dual actions of this intravenous anesthetic at GABA(A) receptors are mediated via distinct loci.

Cardiopulmonary manifestations of schistosomiasis.

Three major schistosome species infect hundreds of millions of people worldwide. The majority of these infections are asymptomatic, but significant morbidity and mortality can occur as a consequence of ongoing egg deposition in host tissues. Acutely, transient chest radiographic abnormalities and nonspecific influenza-like symptoms can occur, including cough. The most common chronic pathological sequelae of schistosomiasis are those of portal hypertension with Schistosoma mansoni or S. japonicum, and genitourinary tract obstruction with S. haematobium. In less than 5% of infections, schistosomal egg obstruction of the lung vasculature results in pulmonary hypertension and cor pulmonale. Limited data suggests that cardiopulmonary schistosomiasis is seen most often in S. mansoni infections. Hepatic fibrosis and portal hypertension appear to be a prerequisite to the development of schistosomal cor pulmonale caused by this species. The premortem diagnosis of cardiopulmonary schistosomiasis depends on the detection of viable schistosomal ova in stool or urine along with evidence of characteristic hepatic fibrosis and pulmonary hypertension. Although treatment with praziquantel can effectively eradicate all schistosomal infections with minimal toxicity, cardiopulmonary manifestations are not likely to be reversible given the chronic fibrotic tissue changes that are present.

Social support and patterns of adjustment to breast cancer.

The effect of marital support and support from other adults on the emotional and physical adjustment of 128 women with breast cancer was examined. Role function and satisfaction with health care also were evaluated as predictors of adjustment. Intact data series were obtained at 7-10 days, at 1, 2, 3, and 6 months, and 1 year postsurgery. Emotional adjustment could be predicted by satisfaction with a spouse's response to interactional and emotional needs and by support from other adults. The relationships were significant at concurrent times, across contiguous times, and predicting from the 7-10 day postsurgical period to both the 6-month and 1-year end points. Physical adjustment was not predicted by support but satisfaction with health care was predictive of perceived overall health status. Functional status in vocational, domestic, and social roles was significantly related to emotional and physical adjustment at all phases with few exceptions.

Gastric bezoar caused by lecithin: an unusual complication of health faddism.

We discovered an unusual bezoar in a previously healthy man who had been ingesting large amounts of a vegetable-derived oil touted to contain lecithin, which he purchased from health food stores in the belief that it had beneficial effects in lowering cholesterol levels and improving memory. The large intragastric mass, composed of fatty acids and lecithin, led to considerable morbidity, including abdominal pain, early satiety, and significant weight loss, and required surgical removal.

Breast cancer rehabilitation.

The Breast Surgery Rehabilitation Group (BSRG), established initially in 1970, assists patients at Memorial Sloan-Kettering Cancer Center (MSKCC) with psychical and emotional recovery from breast cancer surgery and promotes return to preoperative activities. The team includes a physical therapist, social worker, and nurse. Attendance at sessions is prescribed by all physicians on the Breast Service. Problems such as threat to life by cancer and emotional impact of breast loss are addressed, in addition to aid in actual physical recovery from surgery with exercise instruction and interaction with other women in the group who have a similar diagnosis. The information and support provided in this way help the patient to achieve a sense of control in a situation that threatens their emotional and physical world.

Amebic liver abscess: a 15-year experience.

Amebic liver abscess is increasingly common in the United States, particularly in the West and Southwest, due to increased immigration from Southeast Asia, Mexico, and Central America. The presentation, course, and treatment of 50 patients treated for amebic liver abscess at a county-community hospital in San Jose, California, between 1974 and 1988 is reviewed. The typical patient is an immigrant, usually a Hispanic male, 20-40 yr old, who presents with fever, right upper quadrant pain, leukocytosis, abnormal serum transaminases and alkaline phosphatase, and a defect on hepatic imaging study. Available serologic testing (i.e., indirect hemagglutinin antibody) is sensitive and confirms the diagnosis. Most patients respond rapidly and completely to oral metronidazole. The data, compared with other studies, indicate no major change in presentation or management, except for decreasing need to aspirate the abscess for diagnosis.

Pleuropulmonary manifestations of hepatic amebiasis.

Pleuropulmonary manifestations of hepatic amebiasis occurred in 30 patients; 18 (60%) presented with at least 1 pulmonary complaint and 10 (33%) had multiple pulmonary symptoms. In 14 patients (47%), abnormalities were found on examination of the chest. In 16 chest roentgenograms (53%), there was at least 1 abnormality: right-sided pleural effusion (9 patients) and elevated right hemidiaphragm (8 patients) were the most common. All patients were treated with metronidazole (Flagyl) and had resolution of the amebic liver abscess and pulmonary disease. Pleuropulmonary disease is a common complication of amebic liver abscess. The clinical presentation and chest roentgenograms are virtually diagnostic and obviate the need for invasive procedures to confirm the diagnosis. Pleuropulmonary disease resolves with amebicidal treatment of the hepatic abscess.

Pharyngeal/upper esophageal sphincter pressure dynamics in humans. Effects of pharmacologic agents and thermal stimulation.

Extensive physiological studies of swallowing have been carried out in laboratory animals; however, similar studies in humans have been limited by available technology. In this study we describe the use of a solid-state circumferential sphincter transducer to define manometric characteristics of the human pharynx and upper esophageal sphincter (UES). Effects of pharmacologic agents and thermal stimulation are also described. We studied nine normal volunteers on three separate days. All studies were done in the upright position and consisted of a station pull-through of the UES and six wet swallows with the sphincter transducer in the most proximal segment of the UES and a posteriorly oriented single transducer 5 cm proximal in the pharynx. Baseline studies preceded all drug studies. Effects of bethanechol were studied on day 1, cold stimulation and benzonatate on day 2, edrophonium and atropine on day 3. The UES resting pressure showed large intrasubject day-to-day variations; however, mean values did not differ. There were no effects on UES relaxation or swallow coordination with any of the pharmacologic agents, although benzonatate produced multiple pharyngeal contractions.

Axillary lymphadenectomy. A prospective, randomized trial of 13 factors influencing drainage, including early or delayed arm mobilization.

Greater amount and duration of postoperative wound drainage after lymphadenectomy impede healing. We evaluated the influence of early vs delayed initiation of shoulder mobilization on postoperative drainage. Fifty-seven women with clinical stage I or II breast cancer were randomized to either early (postoperative day 2) or delayed (postoperative day 5) shoulder motion. Early vs delayed time of exercise initiation had no effect on total amount or duration of drainage, either as an inpatient or outpatient. The two groups were determined to be homogeneous as to age, breast size, weight, height, obesity, previous biopsy, excision of pectoralis minor, excision of thoracodorsal complex, level of axillary dissection, total number of lymph nodes, number of positive lymph nodes, lymphatic vessel invasion (with negative lymph nodes), and whether the dominant hand was on the side operated on. The two factors predicting greater drainage were large numbers of positive lymph nodes and no previous surgical biopsy (as in one-step procedure).

Marked hypergastrinemia in gastric outlet obstruction.

We report a 45-year-old woman with chronic peptic ulcer disease and multiple episodes of bowel obstruction, who was admitted with gastric outlet obstruction. Because of gastric hypersecretion, a diagnosis of Zollinger-Ellison syndrome was suspected and an initial serum gastrin of 1,251 pg/ml supported this diagnosis. Subsequent evaluation failed to reveal a gastrinoma. A repeat serum gastrin level after 14 days of continuous nasogastric decompression was 43 pg/ml, suggesting that the initial hypergastrinemia was due to antral distention. It is important to consider the possibility of gastric outlet obstruction as a stimulus for serum gastrins in the range previously considered diagnostic for the Zollinger-Ellison syndrome.

Pericarditis: complication of esophageal sclerotherapy. A report of three cases.

Three patients developed acute pericarditis while undergoing esophageal sclerotherapy for bleeding varices. One patient required pericardiocentesis and the other 2 patients had spontaneous resolution of the pericarditis. This previously unreported complication of sclerotherapy must be considered in the differential diagnosis of those patients who develop postsclerotherapy chest pain.