Biogenic-to-lithogenic handoff of particulate Zn affects the Zn cycle in the Southern Ocean.

Zinc (Zn) is vital to marine organisms. Its active uptake by phytoplankton results in a substantial depletion of dissolved Zn, and Zn bound to particulate organic matter replenishes dissolved Zn in the ocean through remineralization. However, we found that particulate Zn changes from Zn bound to phosphoryls in cells to recalcitrant inorganic pools that include biogenic silica, clays, and iron, manganese, and aluminum oxides in the Southern Ocean water column. The abundances of inorganic pools increase with depth and are the only phases preserved in sediments. Changes in the particulate-Zn speciation influence Zn bioavailability and explain the decoupling of Zn and phosphorus and the correlation of Zn and silicon in the water column. These findings reveal a new dimension to the ocean Zn cycle, implicating an underappreciated role of inorganic Zn particles and their impact on biological productivity.

Post-laryngectomy simplified dysphagia score (SDS) tool: Potential for screening and comparison with the swallowing outcomes after laryngectomy (SOAL) tool.

BACKGROUND: Our understanding of swallowing disorders after laryngectomy remains limited. A literature search found that documentation of swallowing function in the laryngectomee population is lacking. Furthermore, no consensus exists regarding a suitable evaluation tool to assess swallowing function. While conventional questionnaires are time consuming, cost and time constraints make regular objective swallowing investigations impractical. OBJECTIVES: To develop a 2-question simplified dysphagia score (SDS) screening tool for routine documentation of swallowing function at post-laryngectomy follow-up visits, and to test this new tool against an established dysphagia measuring tool for laryngectomees. We also sought to identify risk factors for poor swallowing outcomes. METHODS: Cross-sectional surveys were used to compare results obtained from the validated swallowing outcomes after laryngectomy (SOAL) questionnaire and our novel SDS tool. The components of the SDS were guided by the experience and expertise of surgeons and speech therapists, as well as insights from patients and their families. Sixty laryngectomy patients (females, n=7; males, n=53) were enrolled in the study. All patients were >18 years of age. Each participant was asked to complete the SDS and the SOAL questionnaires. The results of each tool were compared using non-parametric tests, with multiple pairwise comparisons using Bonferroni tests. RESULTS: Both sets of results showed a linear relationship using the Kruskal-Wallis non-parametric analysis of variance (ANOVA) test. The SDS had a specificity of 96% (95% confidence interval (CI) 76 - 100%), a sensitivity of 81% (CI 64 - 91%), a positive predictive value of 97% (CI 81 - 100%) and a negative predictive value of 76% (CI 56 - 89%) against the SOAL scores. The SDS results yielded 7 false-negative and 1 false-positive result for dysphagia compared with the SOAL questionnaire. Outcomes of the secondary objectives did not reach statistical significance. CONCLUSIONS: The SDS is a 2-question, practical grading system that shows a statistically significant correlation with the recognised SOAL questionnaire, making it a useful alternative for everyday use, which provides outcome scores of direct practical value to patient and clinician. Prospective use of the SDS and higher patient numbers may allow a better understanding of dysphagia, its causes and risk factors.

Ventilation tube non-function due to blockage in children: the frequency, course and effect on hearing. A prospective cohort study.

OBJECTIVE: To assess the effect on hearing of non-functioning ventilation tubes due to blockage during the first six months post-operatively, using UK national guidelines. METHOD: A prospective, observational study was conducted on 37 children who underwent bilateral ventilation tube insertion. Air and bone conduction thresholds were measured before and following surgery, and at one, three and six months post-operatively. Tube non-function was assessed by tympanometry supported by otoscopy. RESULTS: Post-operatively, an average of 21 per cent of ventilation tubes were non-functioning. Ears with non-functioning tubes had significantly (p = 0.0001) poorer mean air conduction thresholds than functioning tubes, with a magnitude of 6 dB HL. Ears with otorrhoea were most affected (15 per cent). At any one visit, the air-bone gap was closed to 10 dB or less in 76 per cent of ears. Non-functioning tubes reduced this to 56 per cent. Compared with tympanometry, otoscopy underdiagnosed tube non-function due to blockage by 22 per cent. CONCLUSION: Non-functioning of ventilation tubes occurs frequently and can be missed on otoscopy. Although it is associated with poorer air conduction thresholds, the magnitude of this difference is unlikely to warrant further intervention unless there is otorrhoea or recurrence of bilateral hearing impairment.

[Septic arthritis in adults]. / Septische Arthritis des Erwachsenen.

Septic arthritis is a true rheumatological emergency requiring immediate and thoughtful effort for rapid diagnosis establishment and treatment initiation. Children and elderly persons as well as immunocompromised individuals, patients with pre-existing joint damage and with inflammatory rheumatic joint diseases are preferentially affected. Bacteremia, joint surgery and intra-articular injections pose risk situations for the development of joint infections. The most frequent causative organism is Staphylococcus aureus but other relevant pathogens include coagulase-negative staphylococci, streptococci and mycobacteria. Synovial fluid analysis (e.g. appearance, cell count and microbiological examination) is the most important step to establish the diagnosis. The two main components of therapy consist of joint drainage and antibiotic treatment. The approach to periprosthetic joint infections depends on the duration of symptoms, causative organism and individual factors.

[IgG4-related disease]. / IgG4-assoziierte Erkrankung.

IgG4-related disease is a systemic fibroinflammatory syndrome of unknown etiology characterized by local inflammatory swelling and tumefactive lesions in one or several organs. It unifies several diseases previously thought to be unrelated. Recently, diagnostic criteria for the disease have been formulated and were complemented by an international consensus on histopathological assessment. In general, the disease activity can be rapidly controlled by high doses of prednisolone (0.6 mg/kg body weight); however, relapses, either local or in other regions, are frequent during tapering of the steroid dose. Commonly used steroid-sparing agents are only partially effective. Persistent local inflammatory activity may result in permanent organ damage. In refractory cases rituximab treatment has been used with good success. In the long-term care of affected patients a probable increased risk of malignancies (e.g. solid tumors and lymphoma) requires attention.

Case of acute, resistant fulminant Wegener's granulomatosis successfully treated by rituximab.

BACKGROUND: Wegener's granulomatosis is generally a chronic, indolent, inflammatory condition, treated with cytotoxics (cyclophosphamide) and corticosteroids. OBJECTIVE: This paper reports an unusual case of acute fulminant Wegener's granulomatosis that failed to respond to conventional treatment, but showed a dramatic response to rituximab, which is a relatively new form of treatment for resistant cases. METHOD: As well as describing the case (with photographic illustrations), the current paper provides a review of the literature, focusing on acute Wegener's granulomatosis and frequency of resistance to 'conventional' forms of treatment. There is also an evaluation of the evidence for the effectiveness of rituximab in resistant Wegener's granulomatosis. RESULTS: The patient responded remarkably well to rituximab and had no disease recurrence at 24 months' follow up. CONCLUSION: Clinicians should be aware of the acute fulminant form of Wegener's granulomatosis, as a delay in diagnosis and treatment may have fatal consequences. The paper also highlights the dramatic response to rituximab experienced by the patient.

A randomised controlled trial of active chronic otitis media comparing courses of eardrops versus one-off topical treatments suitable for primary, secondary and tertiary healthcare settings.

OBJECTIVE: Primary: to compare one-off administration of boric acid powder with courses of 1% acetic acid and ciprofloxacin eardrops in treating active chronic otitis media. Secondary: to evaluate the effectiveness of Quadriderm® cream in resistant active chronic otitis media; and to document side effects of these treatments, especially hearing loss. STUDY DESIGN: Randomised controlled trial. SETTING: Outpatient department of a tertiary ENT unit. PARTICIPANTS: Hundred and fifty-nine patients over 6 years old with active chronic mucosal (without cholesteatoma) otitis media randomised to receive one of the three primary agents. METHOD: All techniques employed were suitable for primary healthcare givers as well as specialists. After confirming eligibility, patients were randomly allocated to treatment. All ears underwent toilet with irrigation using clean water, a syringe and ambient light, with or without dry mopping, until the perforation was visible. The randomised solution was flushed through the middle ear and eustachian tube using a 'tragal pump' technique: saline was used as the solution for flushing in the boric acid powder arm. Patients allocated topical ear medication were given a bottle of eardrops to administer (six drops twice daily, 'pumped in') until finished. Those allocated boric acid powder had the external ear canals filled as a one-off treatment. Patients were followed up monthly thereafter. OUTCOME MEASURES: Primary: Dry (inactive) middle ears as assessed by the doctor. Secondary: Patient assessment of success; microbiologic culture and sensitivity; audiologic changes because of treatment; complications of treatment; costs of therapies. RESULTS: Ciprofloxacin eardrops and boric acid powder were statistically superior to 1% acetic acid eardrops in rendering active chronic otitis media inactive (73% dry ears for ciprofloxacin; 67% for boric acid powder; and 24% for acetic acid). There was no difference between the success rates of ciprofloxacin eardrops and boric acid powder. Quadriderm cream was effective in 85% of patients failing first-line therapy. No agent caused significant complications and specifically no hearing loss. CONCLUSIONS: This study showed a single application of boric acid powder following external auditory canal irrigation until the perforation was visible to be as effective as the current best practice of topical quinolone eardrops in active chronic otitis media. Boric acid powder is inexpensive and does not require patient compliance. Boric acid powder is a viable, less costly alternative to topical antibiotic/steroid ear drops in the developing world for active chronic otitis media. Acetic acid eardrops 1% are ineffective. Quadriderm cream, given as a one-off therapy, also appears to be effective.

[Bacterial septic arthritis as rheumatological emergency]. / Bakteriell septische Arthritis als rheumatologischer Notfall.

Septic arthritis has always been a challenge to rheumatologists and surgeons. Treatment according to the current classification needs to be stage-adapted and has to be initiated rapidly as the time factor constitutes the key prognostic criterion. Failure to treat and late treatment initiation result in irreversible joint damage, functional impairment and increasing mortality. Particularly in cases of acute joint infection, clinical findings, laboratory markers of inflammation and synovial analysis lead to a rapid diagnosis of empyema in most cases. However, chronic septic arthritis may be associated with considerable diagnostic problems. In these cases further diagnostic methods, e.g. magnetic resonance imaging (MRI), computed tomography (CT) and skeletal scintigraphy may be needed. Consideration of prior treatment, extent of the infection and of the degree of joint damage is of high clinical relevance. After an optional initial antibiotic pretreatment, definitive surgical treatment is always necessary either arthroscopically or using open techniques, depending on the stage of infection. Both surgical techniques have comparable treatment success rates. Surgical radicality in removing the infected tissue is of high importance. Local and systemic antibiotic treatment is of adjuvant and supportive value. An intensive physical therapy should be initiated early to avoid functional deficits.

[Schnitzler syndrome]. / Schnitzler-Syndrom.

Schnitzler syndrome is a rare systemic inflammatory disease characterized by the presence of chronic urticarial skin rash and a monoclonal immunoglobulin M (IgM) gammopathy, combined with further, variable disease symptoms. The term refers to a young disease entity which has recently gained increasing acknowledgement and attention, also due to the availability of interleukin-1 (IL-1) blockade as an effective therapeutic option. Insights into the pathophysiology of the disease have resulted in the assumption of Schnitzler syndrome being a special form of an autoinflammatory disease with late onset or an acquired genesis. This article provides an overview on the clinical appearance, current knowledge of pathophysiology and available therapeutic options.

Is it oncologically safe to leave the ipsilateral submandibular gland during neck dissection for head and neck squamous cell carcinoma?

AIM: To investigate the incidence of metastasis to the submandibular gland in patients with head and neck squamous cell carcinoma. METHODS: We retrospectively evaluated histological reports of neck dissections for upper respiratory tract carcinoma (performed 2002-2009), recording: primary tumour site, tumour-node-metastasis stage, level Ib involvement, previous radiotherapy, perineural invasion, lymphovascular invasion, extracapsular spread, and the presence of malignant disease in the submandibular gland. RESULTS: We evaluated 107 cases. The most common primary site was the oral cavity (49 per cent) followed by the supraglottis (21 per cent), glottis (14 per cent), oropharynx (9 per cent) and hypopharynx (6 per cent). Forty-eight per cent of patients had advanced local disease, with 21 per cent at tumour stage 3 and 27 per cent at tumour stage 4. Fifty-six per cent had cervical lymph node metastasis, and 8 per cent received pre-operative radiotherapy. Forty-eight per cent had perineural invasion, 46 per cent lymphovascular spread, 27 per cent extracapsular spread and 8 per cent level Ib metastasis. Only one patient had submandibular gland involvement, due to direct spread (a case with prior radiotherapy and macroscopic submandibular gland involvement evident peri-operatively). CONCLUSION: Submandibular gland metastasis from head and neck primary squamous cell carcinoma is extremely rare. Preservation of the ipsilateral submandibular gland during neck dissection is oncologically safe, except in patients with prior surgery or radiotherapy, or a primary tumour in close relation to the gland.

[Current therapeutic options for giant cell arteritis]. / Aktuelle Therapieansätze bei Riesenzellarteriitis.

Giant cell arteritis is the most common systemic vasculitis and affects large and medium-sized vessels. Glucocorticoids are the current standard in the therapy of giant cell arteritis. To reduce the glucocorticoid dose the European League Against Rheumatism (EULAR) suggests the addition of disease-modifying antirheumatic drugs. Of these, methotrexate represents the best investigated drug; possible alternatives include azathioprine, tumor necrosis factor-alpha inhibitors and cyclophosphamide.

Otosyphilis and HIV: therapeutic dilemma and outcome of treatment.

We present a case report and review the world literature concerning otosyphilis, particularly with reference to the HIV positive patient. Our patient received two separate courses of treatment for otosyphilis. A course of intramuscular penicillin and oral prednisone resulted in no improvement in his hearing thresholds. A subsequent course of intravenous penicillin and oral prednisone resulted in an improvement of 79 db in his three frequency pure tone average. Otosyphilis is one of the rare causes of treatable sensorineural hearing loss. HIV has been shown to increase the severity and the progression of luetic ear disease. This case reveals that the optimal treatment remains a 10 day course of intravenous penicillin and oral prednisone.

A randomised controlled trial comparing fresh, dried, and dried-then-rehydrated temporalis fascia in myringoplasty.

OBJECTIVES: To determine whether the way in which temporalis fascia is treated during myringoplasty affects the rate of successful perforation closure. DESIGN: A randomised controlled trial. SETTING: A tertiary ENT Department within the Tygerberg Academic Hospital. PARTICIPANTS: One hundred and fifty patients with perforations between 30% and 70% of the surface area of the eardrum undergoing elective myringoplasty were randomised into three groups by the way in which the temporalis fascia used was treated prior to insertion: fresh fascia; dried fascia; and fascia which was dried and then rehydrated. MAIN OUTCOME MEASURES: The outcome measure was intactness of the tympanic membrane 6 weeks after surgery. Preoperative and follow-up audiometry was obtained, but was not evaluated as an outcome measure. RESULTS: Successful closure of the perforation was achieved in 89% in the dried fascia group (42 of 47 patients), 84% in the fresh fascia group (37 of 44 patients), and 85% in the dried and rehydrated group (39 of 46 patients). The study showed no statistically significant difference between the three groups (P = 0.728). The study would have to had more than 800 patients in each group to have the power to show a 5% difference in take rates. CONCLUSIONS: While the dessication of temporalis fascia prior to use in myringoplasy results in degeneration of cellular and stromal elements histologically, this does not affect the successful closure of perforations. Clinicians should feel free to prepare the fascia in whichever way they find easiest to work with.

Why patients miss follow-up appointments: a prospective control-matched study.

OBJECTIVES: To investigate missed appointments in a South African tertiary hospital. STUDY DESIGN: Prospective, descriptive series with controls. SETTING: The ENT/Oncology clinic at Tygerberg Academic Hospital, South Africa. SUBJECT: 305 patients with a head and neck malignancy who had follow-up appointments over 4 consecutive months between June and September 2006. A control group of 31 patients who attended the clinic was recruited in September 2006. METHOD: Analysis of the clinic attendance statistics to identify patients who missed follow-up appointments followed by a file review and interview of these patients. The results were compared with a control group. OUTCOME MEASURES: 1) Incidence rate of failure to attend follow-up. 2) Causative factors. RESULTS: 51 (17%) booked patients missed their appointments. Non-attenders were most likely to miss their follow-up between 6 and 12 months (17/31) after treatment. No correlations were found between diagnosis, disease stage and missed appointments. Reasons include: transport (19 responses), ill-health (6) and financial constraints (5). State transport was unavailable to almost two-thirds of the responders who cited transport as a problem. CONCLUSIONS: The 17% missed appointment rate is largely due to transport constraints. The commonest time for patients to miss appointments is the 6-12 month follow-up period. The authors seek to identify patients at risk of missed appointments and suggest interventions to decrease this incidence.

Why Patients Miss Follow-Up Neoplasms: a Prospective Control-Matched Study

Objectives: To investigate missed appointments in a South African tertiary hospital. Study Design: Prospective; descriptive series with controls. Setting: T he ENT/Oncology clinic at Tygerberg Academic Hospital; South Africa. Subjects: 305 patients with a head and neck malignancy who had follow-up appointments over 4 consecutive months between June and September 2006. A control group of 31 patients who attended the clinic was recruited in September 2006. Method: Analysis of the clinic attendance statistics to identify patients who missed follow-up appointments followed by a file review and interview of these patients. The results were compared with a control group. Outcome measures: 1) Incidence rate of failure to attend follow-up. 2) Causative factors Results: 51 (17) booked patients missed their appointments. Non-attenders were most likely to miss their follow-up between 6 and 12 months (17/31) after treatment. No correlations were found between diagnosis; disease stage and missed appointments. Reasons include: transport (19 responses); ill-health (6) and financial constraints (5). State transport was unavailable to almost twothirds of the responders who cited transport as a problem. Conclusions: The 17 missed appointment rate is largely due to transport constraints. The commonest time for patients to miss appointments is the 6-12 month follow-up period. The authors seek to identify patients at risk of missed appointments and suggest interventions to decrease this incidence

Quinsy treated by aspiration: the volume of pus at initial aspiration is an accurate predictor of the need for subsequent re-aspiration.

OBJECTIVE: The aim of this study was to determine an accurate indicator of the need for second aspiration of peritonsillar abscesses the day after initial aspiration. SETTING: A tertiary otolaryngology care centre. PARTICIPANTS: Fifty patients aged between 11 and 49 years with suspected peritonsillar abscess. STUDY DESIGN: A prospective case series. OUTCOME MEASURES: The potential indicators investigated included volume of pus at initial aspiration and clinical indicators suggesting persistent pus (dysphagia, odynophagia and trismus). The outcome measure was the presence of pus at subsequent aspiration. RESULTS: A linear correlation was found between volume of first aspirate and presence of pus on re-aspiration (r = 0.9753). A volume of pus <3 mL on initial aspiration accurately predicted <0.5 mL pus on re-aspiration. Sixty-four per cent (32) patients had 3 mL or more pus on initial aspiration and in all there was at least 1 mL or more pus on second aspiration. Clinical indicators correlated less well, with a average coefficient on first aspiration of 0.62 and on second aspiration of 0.35. CONCLUSION: The volume of pus on initial aspiration is a very reliable indicator in assessing the need for re-aspiration of peritonsillar abscesses. If 3 mL or more of pus are aspirated on the first occasion these patients should be seen the next day and have a further aspiration. Clinical symptoms and signs are not useful indicators.

Amino acid dysbalance in liver failure is favourably influenced by recirculating albumin dialysis (MARS).

INTRODUCTION: Dysbalance between branched chain (BCAA) and aromatic amino acids (AAA), which can be quantified by a low Fischer's Index (SigmaBCAA/SigmaAAA), as well as elevated levels of free tryptophan in plasma are common in hepatic failure and may contribute to the development of hepatic encephalopathy. AIM: To evaluate the influence of a new extracorporeal detoxification system for liver failure (Molecular Adsorbents Recirculating System, MARS(R), i.e. dialysis against a recirculating albumin solution cleaned online by charcoal and an anion exchange resin) on plasma tryptophan and Fischer's Index. METHODS: Plasma samples were taken before, during and after MARS treatments (n = 11, mean blood flow 135 ml/min, mean dialysate flow 120 ml/min, high flux polysulfone membrane). Simultaneous to blood sampling, aliquots of the albumin dialysate were taken between the elements of the dialysate circuit. RESULTS: Fischer's Index in systemic blood increased during MARS by 24% (from 1.44 to 1.79, P < 0.001; mean treatment duration, 5.5 h). Systemic tryptophan level was significantly reduced at the same time (-25%, n = 8). Amino acid removal rates from plasma during a single dialyser passage ranged from 10 to 53%. In particular, AAA were preferentially removed (42-44% throughout treatment), while BCAA removal was 28-46% initially and later declined to 24-28%. A maximum concentration gradient between plasma and dialysate was maintained for the AAA throughout treatment through their apparently complete removal by the charcoal adsorber. Conversely, BCAA removal at both adsorbers was only minor. As a result, Fischer's Index showed a significant increase in the processed plasma, which became even more pronounced with increasing treatment duration. CONCLUSIONS: MARS enables an elevation of a pathologically decreased Fischer's Index as well as a reduction of systemic tryptophan levels in patients with liver failure. The effects of MARS on plasma amino acid dysbalance may contribute to an improvement of hepatic encephalopathy.