"Warning card" as a prevention of prolonged apnea in children.

Human butyrylcholinesterase (EC 3.1.1.8) (BChE) is present in serum mainly as "usual UU" form, but it has also been found in variant forms known as "atypical" BChE. The most important predictive value of BChE phenotype is for anesthetist to prevent prolonged apnea. BChE has an important role in the hydrolysis of neuromuscular relaxant succinylcholine (suxamethonium, scoline) used during anesthesia. In order to detect atypical variants of BChE and give these findings to the anesthetists-surgeons before an operation to avoid the prolonged apnea, we phenotyped 542 sera of children before tonsillectomies. Total BChE activity was measured using butyrylthiocholine as substrate and dibucaine, fluoride, urea and dimethylcarbamate Ro 02-0683 were used as inhibitors. The frequencies of phenotypes in 542 children were: UU, UA, US, SS, AS and AA--92.25%, 7.01%, 0.18%, 0.18%, 0.18%, 0.18% respectively. Once established phenotype of BChE does not change during the lifetime. Therefore the carriers of atypical phenotype of BChE received a "Warning card", which is a permanent warning for succinylcholine application, as well as a sign to the members of the families to test their own phenotype of BChE. In our study three "Warning cards" were given: two to the carriers of atypical phenotype and third to a child presented as SS phenotype with low total activity of BChE. The present study is the first clinical evaluation of this genetic abnormality in the Republic of Croatia.

Diagnostic accuracy of transesophageal echocardiography for detection of atrial masses.

The aim of this study was to assess the diagnostic accuracy of transthoracic (TTE) and transesophageal echocardiography (TEE) for the detection of atrial masses. The authors' own experiences with the use of TTE and TEE images in the assessment of atrial masses are reported. These masses included tumors, thrombi, and valvular vegetations. The study groups consisted of 14 consecutive patients (7 women an 7 men), age range 24-72 (mean age 56.6 < +13.4) years. Eleven patients had left atrial tumor, two patients had atrial thrombi, and one patient had vegetation in left atrium detected with TEE. Eight patients had left atrial myoma, two patients had right atrial myxoma, and one patient had right atrial leiomyosarcoma. There was no false negative and no false positive TEE diagnosis, yielding a 100% sensitivity and specificity of TEE in detecting atrial masses. TEE detected atrial masses in six (43%) patients, provided poor images in five (36%) patients, and failed to reveal atrial masses in three (21%) patients. The TEE diagnosis was confirmed by surgery and pathohistology in all patients. The ability of TEE to visualize both atria with great diagnostic accuracy makes it a very valuable procedure in the assessment of atrial masses.

A comparison of surgery and radiotherapy in the management of advanced pyriform fossa carcinoma.

This retrospective study analyses the outcome of treatment of 61 patients with advanced carcinoma of the pyriform fossa. Thirty-two patients (group 1) underwent surgery and postoperative radiotherapy and 29 patients (group 2) had induction chemotherapy followed by radiotherapy. The local recurrence-free survival at 5 years from the completion of therapy for group 1 was 54%, compared to 61% for group 2. The 5-year neck recurrence-free survival for groups 1 and 2 were 54% and 59%, respectively. The 5-year overall survival rates for groups 1 and 2 were 19% and 14%, respectively. Non-surgical therapy for advanced stage pyriform fossa cancer provides survival comparable with that achieved with the standard approach of surgery and postoperative radiotherapy. We advocate radical irradiation as the method of choice because it provides nodal coverage to the bilateral jugular chains and retropharyngeal nodes, all known to be at risk for metastases, and is associated with lower morbidity compared to surgery. But, however, despite the therapy, the outcome is poor.

Osteoma of the internal auditory canal.

Osteomas of the internal auditory canal, inaccesible to clinical examination, are rare lesions. There are only 14 cases of osteomas and exostoses of the internal auditory canal reported in the international medical literature. A patient with an osteoma of the internal auditory canal is presented, along with differential diagnosis and possible etiologic factors for the lesion. The auditory brainsteam evoked response testing showed increased absolute latencies of 1 wave and discrepancy of the wave morphology due to bony compression of the eight nerve in the internal auditory canal. Computed tomography showed a bony growth in the internal auditory canal. Magnetic response showed no abnormalities. No surgery was performed since the symptoms improved by conservative therapy.

Pilocarpine in the prevention of postirradiation xerostomia.

During radiation therapy to the head and neck region, salivary gland hypofunction commonly develops. The aim of our study was to evaluate whether the sialogogue pilocarpine given during radiation therapy may reduce the severity of xerostomia and salivary dysfunction. Our results showed the pilocarpine-treated group to have a lower frequency of oral symptoms during the treatment than the placebo-treated group. Although salivary flow decreased in all patients, the pilocarpine-treated group had smaller flow reductions. No drug effect was observed in the glands that were completely irradiated. Thus, pilocarpine appeared to stimulate salivary tissues outside the radiation field.

Recruitment in the diagnosis of small PCA tumors.

Acoustic brainstem response (ABR) waveforms were preoperatively analyzed in 86 cases of pontocerebellar angle (PCA) tumors. Absolute (APL) and interpeak latencies (IPL) ipsilateral to the tumor and interaural absolute latency differences of wave V (IAAPLD V) were normal in two patients with small intracanalicular tumors. However, results of latency-intensity studies were abnormal. So, if PCA tumor is suspected, and standard ABRs are normal by usual criteria, the latency-intensity functions should be examined before the test result is reported as negative for an acoustic nerve tumor.

Clinical interpretation of brainstem evoked response audiometry abnormalities in cochlear pathology.

This investigation involved 45 patients with sensorineural hearing loss (SNHL): 24 with Meniere's disease, 18 with acoustic trauma, and 3 with SNHL due to ototoxic drugs. They all underwent pure tone audiometry and standard brainstem evoked response audiometry (BERA). In patients without wave I in auditory brainstem response, electrocochelography (ECochG) was performed. The findings are presented showing that cochlear lesions (beside threshold elevation) cause latency prolongation of wave I, III and V relative to normal latencies at the actual click hearing level. At high stimulation levels, this effect is almost completely compensated for by the fact that cochlear recruiting ears exhibit steeper latency-intensity curves than do normal ears. But, at the same time this pathology does not cause latency prolongation of central conduction time (CCT). Beside this, cochlear lesions will cause, in some cases, deterioration of replicability (poor waveform resolution) of waves preceding wave V. In such cases, the authors strongly recommend electrocochleography (ECochG) to make wave I visible, because they think that it is the best way to verify the diagnosis of cochlear lesion using BERA.

Bilateral Bell's palsy in a pregnant woman.

Bell's palsy is a peripheral facial palsy of unknown etiology. During pregnancy, there is an increased incidence of idiopathic facial paralysis (Bell's palsy). Nevertheless, bilateral facial paralysis in pregnant woman is a rare phenomenon with only a few case reports in medical literature. We report on a patient with bilateral facial paralysis in pregnancy, with a review of the literature and possible etiologic factors. The patient was treated conservatively and the left facial palsy resolved completely, whereas on the right side there was a residual lesion of facial function. The etiology, treatment and prognosis of Bell's palsy in pregnancy remain controversial.

Vertigo as a prognostic factor in sudden hearing loss.

A group of 87 patients suffering from unilateral sudden hearing loss were investigated. They were divided into two groups with and without vertigo, and were evaluated according to the severity of initial hearing loss and shape of tonal audiogram. Twenty-five percent of the patients had accompanying vertigo. Vertigo occurred more often in patients with severe hearing loss in high tone frequencies. Hearing recovery of high tone frequencies was poorer in the patients with vertigo than in those without it, although the initial hearing loss was the same.

Serum total, LDL, HDL cholesterol and triglycerides related to age, gender and cigarette smoking in patients with first acute myocardial infarction.

The aim of this study was to examine relationships between total cholesterol, LDL, HDL cholesterol, triglycerides and age, gender, and cigarette smoking in 190 patients (132 men and 58 women) aged 34-87 years with first AMI. The control group included 103 patients (57 men and 46 women) aged 29-90 years without a history of angina pectoris or AMI. High total cholesterol (over 5.2 mmol/L) was observed in 75% of patients with AMI vs. 48% of patients in the control group (p < 0.001). Patients with AMI had significantly higher total cholesterol and LDL cholesterol levels than controls (p < 0.0001). HDL cholesterol levels were significantly lower among patients with AMI than among the control group patients (p < 0.0001). Serum total cholesterol and LDL cholesterol is higher in patients with AMI up to 60 years old, but lower in patients older than 60 years. Women aged less than 50 years had significantly higher HDL cholesterol (p < 0.001), lower LDL cholesterol (p < 0.001), and lower total cholesterol (p < 0.05) than those over 50 years. Smokers with AMI who smoked over 20 cigarettes per day had significantly higher total cholesterol, LDL cholesterol and triglycerides levels than the non-smokers (p < 0.05). These findings suggest important influences of hyperlipoproteinemia and cigarette smoking upon development of myocardial infarction, especially in younger patients.

Prognostic value of Glasgow Coma Scale for tracheotomy in head injured patients.

The Glasgow Coma Scale (GCS), an indicator of the severity of head injury, may help identify the head injured patients who will eventually undergo tracheotomy. Authors' present retrospective study reveals that the likelihood of tracheotomy is significantly greater in patients with a GCS rating < 7 than in those with a GCS rating > 7 (p < 0.01). In order to minimize complications and make tracheotomy patients feeling more comfortable and communicable, this study argues for early tracheotomy in patients with a GCS score < 7, but never before 72 hours after injury, because it is a time necessary for patient stabilization and elimination of any illicit drugs or alcohol used prior to head injury.

Syncope caused by carotid body tumor.

A 71-year-old woman with a syncope and carotid body tumor is described. On palpation of the tumor on the left side of the neck, the patient felt vertiginous and has a syncope, while ECG showed an asystolic pause of 7.6 s. The tumor was completely surgically removed. After the surgery, massage of the left side of the neck provoked neither sinus bradycardia nor asystole, and the pacing electrode was removed. Temporary pacemaker is recommended in patients with syncope caused by carotid body tumor for the safe performance of diagnostic and surgical procedures. This report describes the successful operation of carotid body tumor as a rare cause of syncope. The patient feels well one year after the surgery.

[Complications after prolonged intubation in patients with head trauma]. / Komplikacije nakon prolongirane intubacije kod pacijenata s traumom glave.

In this study, 72 patients with head injury, hospitalized in the Intensive Care Unit (ICU) were analyzed. All of them required prolonged intubation. Every patient was initially intubated. Thirty (41.7%) of them underwent tracheotomy and 56 (77.8%) demanded mechanical ventilation. The patients were divided into three groups with respect to their treatment: 1. Patients intubated up to five days--27 (37.5%); 2. Patients intubated more than five days--45 (62.5%); 3. Tracheotomized patients--30 (41.7%). Tracheotomy was done between the fifth and the twenty-sixth day following the intubation. Laryngotracheal complications occurred in 47% of the patients from the second group and 23% from the third group. The patients in the first group developed no complications. Pulmonary infections prevailed in the second group. We conclude that early postinjury tracheotomy is associated with a lesser incidence of complications than prolonged intubation in neurosurgical patients.

[Bilateral glomus caroticum tumors]. / Bilateralni tumori karotickoga glomusa.

Paragangliomas of the head and neck are tumors which are believed to function as chemosensory reflex receptors that respond to changes in their chemical environment. They may occur in the carotid body, on the vagus nerve, along the jugular vein, in the middle ear, in the orbit, in the larynx and nasopharynx. The incidence of multiple paragangliomas is about 3% of all the patients with this tumor and 26% of the patients with positive family history.

[Auditory evoked potentials: monaural and binaural stimulation in cochlear hearing loss]. / Slusni evocirani potencijali: monoauralna i binauralna stimulacija kod kohlearne nagluhosti.

We have evaluated the auditory brain stem responses of 37 patients with bilateral, symmetrical, cochlear hearing loss, by mono and binaural stimulation. These patients were divided into several groups according to the shape of the pure-tone audiometry curve. It was found that binaural stimulation is better with regard to monoaural, since it results in a significant increase of wave amplitudes (45%) what allows the answers at lower levels of stimulation. Moreover, it was found that patients with uniform hearing loss (relatively good hearing in high frequencies) have a statistically significant shorter latency in contrast to the patients with more severe hearing loss in high frequencies (groups with gradually and perpendicularly decreasing curve of pure-tone audiometry), p < 1%.

Laryngeal cancer and blood selenium levels.

Blood selenium concentrations in 43 patients with laryngeal cancer and 47 normal subjects were determined by atomic absorption spectrophotometry. No significant differences in selenium values were observed in sera from the cancer patients when compared with controls, but there were significant differences between patients with advanced (T4) supraglottic cancers and the normal controls. These results suggest that lower blood selenium levels in this latter group of laryngeal cancer patients may be a consequence of their disease rather than its cause.

Oxalosis associated with aluminum bone disease: a new type of mixed renal osteodystrophy.

An 18-year-old man suffering from uremia was hospitalized because of severe skeletal pain and multiple exostoses. The patient had been treated for 5 years by regular hemodialysis; primary oxalosis was the suspected cause of uremia. Transiliac bone biopsy and subsequent histomorphometric analysis of undecalcified bone specimen as well as specific aluminum staining revealed a picture of oxalosis combined with osteomalacia and a marked accumulation of aluminum at the front of mineralization. This combination of histological features of oxalosis and aluminum bone disease suggests a new type of mixed renal osteodystrophy.

Nasopharyngeal cancer and blood selenium level.

A case-control study of nasopharyngeal carcinoma was performed in Zagreb from 1989 until 1993. Blood selenium concentrations were determined in 34 patients with nasopharyngeal cancer and 47 normal subjects by means of the atomic absorption spectrophotometric method. The sera of nasopharyngeal cancer patients showed no significant differences in selenium values from the sera of normal individuals, but there were significant differences between patients with enlarged cancer (T4 stage) and normal individuals. The results suggest that lower blood selenium levels in this group of nasopharyngeal cancer patients may be a consequence of their disease, rather than the cause of the cancer.

[Summating potentials in the differential diagnosis of cochlear pathology]. / Sumarni potencijali u diferencijalnoj dijagnostici kohlearne patologije.

Three groups of patients with Ménière's disease, sensorineural hearing loss caused by acoustic trauma, and healthy controls were examined by electrocochleography in order to establish the value of absolute summating potential (SP) amplitudes in the differential diagnosis of these entities. A statistically significant increase in absolute SP amplitudes was found in patients with Ménière's disease in comparison to patients with sensorineural hearing loss caused by acoustic trauma (p < 0.01). Besides that, there was also a statistically significant increase in absolute SP amplitude values in healthy persons, as compared to patients with sensorineural hearing loss caused by acoustic trauma (p < 0.05).

[Auditory evoked potentials in alcoholics]. / Slusni evocirani potencijali kod alkoholicara.

In this paper, auditory brain stem potentials in the group of 26 alcoholics were studied and a significantly delayed latencies of the peaks II through V as compared to the healthy control subjects were found. In addition, a statistically significant prolongation of brain stem transmission time (BTT) in alcoholics was observed. The study also suggests the possibility of monitoring the level of pathohistological changes of the central auditory pathway caused by excessive alcohol consumption.