Comparison of furosemide-loading cervical vestibular-evoked myogenic potentials with magnetic resonance imaging for the evaluation of endolymphatic hydrops.

BACKGROUND: Furosemide-loading cervical vestibular-evoked myogenic potential (FVEMP), in which vestibular function is improved via diuretics-induced dehydration, can be used to estimate the presence of endolymphatic hydrops, one characteristic of Menière's disease. Inner ear magnetic resonance imaging (MRI) can also reveal endolymphatic hydrops.Aims/Objective: This study aimed to compare and confirm the usefulness of these two examination methods for the diagnosis of Menière's disease. METHODS: Twenty patients with definite unilateral Menière's disease were included. All subjects underwent both, FVEMP and inner ear MRI examinations. The results were then compared statistically between the affected and contralateral ears and among the methods. RESULTS: FVEMP and inner ear MRI of the cochlea, saccules, and utricles yielded positive results indicative of endolymphatic hydrops in 55.0%, 60.0%, 45.0%, and 45.0% of cases, respectively. The results of FVEMP were more consistent with those of the cochlea (κ = 0.8) than with those of the saccules or utricles by inner ear MRI (κ = 0.6). CONCLUSIONS: FVEMP appears to be a good and minimally invasive option for evaluating endolymphatic hydrops. However, the combination of FVEMP and inner ear MRI may yield even more accurate evaluations of endolymphatic hydrops.

Prevalence of potential candidates for electric-acoustic stimulation implant in a hearing-impaired population.

OBJECTIVE: To estimate the prevalence of potential electric-acoustic stimulation (EAS) implant candidates in a hearing-impaired population through a review of auditory examinations. METHODS: In total, 7356 patients underwent audiometric examination in our department between 2011 and 2014. The prevalence of patients meeting the audiometric criteria for EAS and standard cochlear implant (CI) was assessed. RESULTS: The percentage of EAS implant candidates meeting the pure-tone audiometric criteria was 0.71% (n=34) among the hearing-impaired individuals (n=4758) examined in our department, whereas 2.52% (n=120) met the criteria for standard CI. Among the 34 EAS implant candidates, 2 individuals (5.83%) received EAS implant surgery after approval of the EAS device in Japan. CONCLUSIONS: There was a lower prevalence of EAS implant candidates than standard CI candidates. Nevertheless, healthcare professionals should carefully examine the audiograms of patients with high frequency hearing loss with regard to meeting the indication criteria for EAS implant. This will enable patients to gain access to adequate information relating to further examinations and treatment options.

Recent and Frequent Vertigo Attacks Produce Negative Findings on Furosemide-Loading Vestibular Evoked Myogenic Potential Testing in Meniere's Disease.

Objective: The peak-to-peak amplitude of the p13-n23 wave in cervical vestibular evoked myogenic potential can increase after furosemide administration in patients with Meniere's disease [furosemide-loading VEMP (FVEMP) testing]. The examination is used to test for the presence of endolymphatic hydrops; we investigated factors that may influence the results. Methods: Forty-two subjects (23 males and 19 females, aged 24-70 years) with unilateral definite Meniere's disease who underwent FVEMP testing were retrospectively studied. Possible factors associated with the results of FVEMP testing were studied using logistic regression analysis. Results: Ages, sex, affected side, stage, disease duration, and mean hearing level of pure tone audiometry did not influence the results of FVEMP testing in the univariate analysis (p > 0.05). Number of days since the last vertigo attack [odds ratio (OR): 1.07, p = 0.031] and frequency of vertigo attacks per month (OR: 0.42, p = 0.003) were significantly associated with the results of testing. Multivariate analysis showed that both days since the last vertigo attack < 7 (OR: 0.13, p = 0.04) and frequency of vertigo attacks per month ≥ 2 (OR: 0.06, p = 0.004) were risk factors for negative results on FVEMP testing. Conclusion: This study found that recent and frequent vertigo attacks produced negative findings on FVEMP testing in Meniere's disease. This apparently irrational finding can be explained by the consequences of membranous labyrinth rupture during vertigo attacks, where the altered saccular resonance due to EH cannot be recovered by furosemide administration because of the dissolving dehydration effect that occurs through communication between the endolymphatic and perilymphatic spaces. In addition, the impairment of sensory cells that is caused by endolymph and perilymph mixing upon rupture does not improve upon furosemide administration. FVEMP testing results may provide us with pathophysiological information regarding the membranous labyrinth.

Residual dizziness after successful treatment of idiopathic benign paroxysmal positional vertigo originates from persistent utricular dysfunction.

OBJECTIVE: We used ocular vestibular evoked myogenic potentials to investigate the relationship between residual dizziness and utricular function following the canalith repositioning procedure for benign paroxysmal positional vertigo. METHODS: Ocular vestibular evoked myogenic potentials were measured in 44 patients (40 included in analyses, four excluded) with successful results from the canalith repositioning procedure. The patients were examined before treatment and again one week after treatment. We analyzed how various general factors and ocular vestibular evoked myogenic potentials related to residual dizziness. RESULTS: Residual dizziness was not related to gender, affected side, age, duration of symptoms, recurrence, or the results of the initial ocular vestibular evoked myogenic potential test (p > .05). However, residual dizziness was significantly associated with the results of the second ocular vestibular evoked myogenic potential test (p = .007). CONCLUSIONS: Residual dizziness after a successful canalith repositioning procedure may be caused by persistent utricular dysfunction.

Revision of a furosemide-loading vestibular-evoked myogenic potential protocol for detecting endolymphatic hydrops.

OBJECTIVE: The presence of endolymphatic hydrops can be suggested by improving the amplitude of vestibular-evoked myogenic potential (VEMP) after furosemide administration (furosemide loading VEMP [FVEMP]). The authors aimed to determine a stimulation frequency and judgment criteria to ascertain whether a revised FVEMP protocol can be applied to clinical settings. METHODS: The study included 25 individuals with unilateral Meniere's disease (MD) and 11 normal healthy volunteers. Normalized amplitude of VEMP, using a tone burst sound at 250, 500, 700, 1000, 1500 and 2000 Hz, was measured before and after furosemide administration in the two groups. Improvement ratio (IR) of amplitude was calculated at each frequency. RESULTS: There were no significant differences in IR between the control group and the MD group at each frequency, except at 500 Hz. Receiver operating characteristic curve analysis revealed an IR cut-off value of 14.2% at 500 Hz, with a sensitivity of 0.706 and a specificity of 0.810. CONCLUSIONS: The revised FVEMP protocol using a 500 Hz tone burst stimulus and normalized amplitudes was defined as positive when IR exceeded 14.2% or when a biphasic wave could be detected after furosemide administration in cases without a detectable biphasic wave before administration.

Clinical course of persistent geotropic direction-changing positional nystagmus with neutral position-Light cupula.

CONCLUSION: A short clinical course and frequent recurrence are common features of persistent geotropic direction-changing positional nystagmus with neutral position (positional nystagmus of light cupula: PNLC) and cupulolithiasis of the lateral semicircular canal. It is suggested that PNLC is caused by light debris attached to the cupula of the lateral semicircular canal. OBJECTIVES: PNLC is a sub-type of direction-changing positional nystagmus. It is thought to be caused by anti-gravitational deviation of the cupula of the lateral semicircular canal (light cupula); however, the exact mechanism is yet to be elucidated. To this end, the clinical features of PNLC were studied. METHOD: Clinical charts of 27 patients (13 men and 14 women) with PNLC were reviewed. RESULTS: The nystagmus had resolved within a week in 70% and within 30 days in 89% of the patients. The recurrence rate was 33%. The subjects did not have a history of alcohol intake, head trauma, or vestibular neuritis.

[Promotion of home shifts for terminal cancer patients through intervention of visitor palliative care team].

It has been recommended that terminal cancer patients be shifted from the hospital to their homes. In our hospital, a visitor palliative care team was started for the purpose of the early introduction of palliative care, and home shifts were promoted. The results of home shifts by the visitor palliative care team from 2008 to 2012 were examined. Home shifts were possible for 27 cases out of 108 cases intervened. In 12 cases, there were at-home deaths, and the median at-home period was 55 days. In the group that could not be shifted, the at-home death rate and application rate of nursing care insurance were low. Additionally, the length of stay (median) for patients who died in hospitalization was 8 days for the group that could be shifted and 17 days for the group that could not be shifted. It was felt that effective communication with local health care facilities is important for a successful home shift. Early and adequate preparations for the treatment and care of terminal cancer patients undergoing home shift are important, and in this regard, a review of the current provisions of nursing care insurance is necessary.

[The outpatient palliative care conference for the home palliative care shift (the second report)--the conference was used to look back on the case where the patient's QOL was kept and improved].

The patient was a 30-year-old woman with right tongue cancer and SCC (T4N2bM0). After it had relapsed, the outpatient palliative care conference intervened. The purpose of intervention was as follows: pain control, nutrition management, home recuperation support, and relief of a spiritual pain. We could achieve the patient's desire to recuperate at home as long as possible by sharing a goal and information. The patient was treated for a total of 457 days. Since the relapse, she was treated for 274 days, and was hospitalized for 49 days. By offering necessary home care supports, the patient and family fully demonstrated their potentials what they could do to recuperate and resulted in a long home stay. It was thought that our relationship with the patient and family appeared to have enhanced their self-resistance feelings against the disease. Consequently, we contributed the improvement of QOL.

[The outpatient palliative care conference aimed at "home palliative care shift"].

The association of doctors of Shizuoka City started a conference (S-NET) for cancer diagnosis and treatment in order to enhance a home palliative care for terminal cancer patients. At the same time, we introduced a system called "home palliative care shift" for inpatients. However, we felt that an intervention was necessary at the earliest stage of home palliative care due primarily to difficulties our home palliative team faced in its intervention for inpatients to "home palliative care shift." The outpatient palliative conference started to begin centering in the outpatient chemotherapy room because we thought it was important to have a seamless transition for terminal cancer patients. The primary contents of the conference were mostly centered on how to support the process of decision makings when the cancer treatment for a patient changes and how to choose a location for the patient to have a right medical treatment. The performance status (PS) when intervened was 2.3. The 5 patients who had died spent the final moment at their preferred medical treatment centers. Through the participation of multiple different back ground professionals at the time, the patients were treated well with better understandings. Furthermore, by sharing the patient's objective and information, we could enhance some relationship with the patient as well as going along with patient intensions what they want us to do for them at the final moment of their life. We thought that the system that verifies patient's intentions at the earliest stage of home palliative care was clearly needed most.

[The home palliative care transition manual for the regional cooperation from the general ward at Shizuoka Red Cross Hospital].

Recently, a home palliative care has been recommended for terminal stage cancer patients. However, a few clinics are available providing a home palliative care. As a result of that, there have been many cases of the terminal stage cancer patients who could not receive a peace of mind care and die peacefully at home. Home palliative care has been promoted in Shizuoka City by starting Shizuoka city regional cooperation conference of cancer management with a help from Shizuoka city medical association and the general hospital. It is important to have the knowledge and technique put into practice by clinics and home visiting nurses for a further improvement of the palliative care. In order to transfer patient smoothly, the palliative care team conference is held in the general ward and the homecare transition manual is used at the hospital. An application of homecare insurance, the visiting doctor and nurse are arranged in parallel to management of physical and psychological symptoms of the patient, the visiting doctor and nurse are arranged. Before a patient is discharged from the hospital, the meeting will be held among the ward staff, visiting nurse and the patient's family. We intervened 8 cases from April to July 2007. Six out of 8 cases were transferred to home, and 2 patients were died at home. The home care transition manual will be shared with other hospitals from now on.

Effects of endoscopic transthoracic sympathicotomy on hemodynamic and neurohumoral responses to exercise in humans.

Endoscopic transthoracic sympathicotomy (ETS) is a minimal invasive procedure of thoracic sympathetic block and has been used successfully in the treatment of primary palmar hyperhidrosis. To examine the effect of Th 2-3 ETS on hemodynamic responses to submaximal upright treadmill exercise in humans, cardiac output, plasma noradrenaline and adrenaline at rest and during the last 40s of stage 2 in a modified Bruce protocol were measured before and after ETS in 21 patients with primary palmar hyperhidrosis. Heart rate, mean arterial pressure, rate-pressure product, and noradrenaline decreased at rest and at submaximal exercise after ETS. Cardiac index at rest did not change either before or after ETS, but decreased (8.9 +/- 0.6 vs 6.8 +/- 0.4L x min(-1) m-2; p<0.01, mean +/- SEM) at submaximal exercise after ETS. Stroke index and systemic vascular resistance were similar both at rest and at submaximal exercise before and after ETS. Thus, ETS reduces myocardial oxygen demand and plasma noradrenaline levels both at rest and during exercise without significantly depressing cardiac function in terms of stroke volume.