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Thirty patients with ACE-inhibitor–induced angioedema were assigned to receive icatibant or standard therapy with intravenous prednisolone plus clemastine. The median time to complete resolution of edema was 8.0 hours with icatibant and 27.1 hours with standard therapy. Angioedema induced by treatment with angiotensin-converting–enzyme (ACE) inhibitors is estimated to occur in up to 0.68% of patients who receive ACE inhibitors, 1 – 5 although the true incidence is difficult to estimate because symptoms can take years to appear. 6 Although the risk of ACE-inhibitor–induced angioedema is low, the increasing use of ACE inhibitors is resulting in a comparatively large number of patients at risk for this condition, 7 which accounts for one third of all cases of angioedema treated in the emergency room. 8 ACE-inhibitor–induced angioedema affects almost exclusively the upper aerodigestive tract but can, in rare cases, affect the gut. Obstruction of . . .

Reported success rates of endoscopic choanal atresia (CA) surgery vary substantially due to a high heterogeneity in and between study groups. Comprehensive data on the unique patient cohort of newborns with bilateral CA are scarce. Our study aimed to close this gap by using narrow inclusion criteria and standardized surgical outcome parameters. A total of ten neonates who were diagnosed with bilateral complete CA and underwent endoscopic surgery at the Department of Otolaryngology, Head and Neck Surgery in the University Hospital of Munich between 2008 and 2017 were included. Preoperative findings, surgical procedures, outcome, and follow-up were analyzed. Standardized criteria were used to assess surgical outcome. Almost all patients (90%) required at least one revision procedure within the first 6 months after initial surgery because of symptomatic partial or complete restenosis. After that, all surviving patients remained asymptomatic until the end of the follow-up period.Conclusion: Endoscopic bilateral CA repair in neonates is a safe procedure with a high long-term success rate. However, compared to other patient groups with choanal obstruction, restenosis occurs frequently, and revision procedures are required in a large number of cases. This should be considered during preoperative planning and parent counseling.What is Known:• Bilateral complete choanal atresia (CA) is a neonatal emergency that requires surgical intervention.• Reported success rates of endoscopic choanal obstruction repair are highly variable and mostly derived from heterogenous study groups that do not reflect the situation in neonates adequately.What is New:• This study focuses exclusively on newborns with complete bilateral CA who underwent endoscopic surgery within the first 28 days of life and uses standardized criteria to assess outcome.• The long-term success rate of endoscopic bilateral CA repair in neonates is high; however, almost all patients require at least one revision procedure within the first 6 months.

PurposeTo compare free text (FTR) and structured reports (SR) of videofluoroscopic swallowing studies (VFSS) and evaluate satisfaction of referring otolaryngologists and speech therapists.Materials and methodsBoth standard FTR and SR of 26 patients with VFSS were acquired. A dedicated template focusing on oropharyngeal phases was created for SR using online software with clickable decision-trees and concomitant generation of semantically structured reports. All reports were evaluated regarding overall quality and content, information extraction and clinical decision support (10-point Likert scale (0 = I completely disagree, 10 = I completely agree)).ResultsTwo otorhinolaryngologists and two speech therapists evaluated FTR and SR. SR received better ratings than FTR in all items. SR were perceived to contain more details on the swallowing phases (median rating: 10 vs. 5; P < 0.001), penetration and aspiration (10 vs. 5; P < 0.001) and facilitated information extraction compared to FTR (10 vs. 4; P < 0.001). Overall quality was rated significantly higher in SR than FTR (P < 0.001).ConclusionSR of VFSS provide more detailed information and facilitate information extraction. SR better assist in clinical decision-making, might enhance the quality of the report and, thus, are recommended for the evaluation of VFSS.Key Points• Structured reports on videofluoroscopic exams of deglutition lead to improved report quality.• Information extraction is facilitated when using structured reports based on decision trees.• Template-based reports add more value to clinical decision-making than free text reports.• Structured reports receive better ratings by speech therapists and otolaryngologists.• Structured reports on videofluoroscopic exams may improve the comparability between exams.

Background: Patients with nonallergic rhinitis with eosinophilia syndrome (NARES) show typical symptoms of persistent allergic rhinitis (PAR). The aim of the present study was to compare nasal cytokine patterns between NARES and PAR. Methods: Nasal secretions of 31 patients suffering from NARES, 20 patients with PAR to house dust mite and 21 healthy controls were collected using the cotton wool method and analyzed for interleukin (IL)-1β, IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17, granulocyte-macrophage colony-stimulating factor (GM-CSF), granulocyte colony-stimulating factor (G-CSF), interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α), monocyte chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein-1β (MIP-1β) by Bio-Plex Cytokine Assay as well as eosinophil cationic protein (ECP) and tryptase by UniCAP-FEIA. Results: NARES and PAR presented elevated levels of tryptase, while ECP was markedly increased solely in NARES compared to both the controls and PAR. Elevated levels of IL-1β, IL-17, IFN-γ, TNF-α and MCP-1 were found in NARES compared to the controls as well as PAR. MIP-1β was elevated in NARES and PAR, while IL-4, IL-6 and G-CSF showed increased levels in NARES, and IL- 5 was elevated in PAR only. Conclusions: In patients with NARES and PAR, eosinophils and mast cells appear to be the pivotal cells of inflammation, reflected by high levels of tryptase and ECP as well as IL-5 and GM-CSF as factors for eosinophil migration and survival. The elevated levels of proinflammatory cytokines in NARES may indicate the chronic, self-perpetuating process of inflammation in NARES which seems to be more pronounced than in PAR. IL-17 might be a factor for neutrophilic infiltration or be responsible for remodeling processes in NARES.

Background: The contribution of the nasal and paranasal cavities to the vocal tract resonator properties is unclear. Here we investigate these resonance phenomena of the sinonasal tract in isolation in a cadaver and compare the results with those gained in a simplified brass tube model. Methods: The resonance characteristics were measured as the response to sine sweep excitation from an earphone. In the brass model the earphone was placed at the closed end and in the cadaver in the epipharynx. The response was picked up by a microphone placed at the open end of the model and at the nostrils, respectively. A shunting cavity with varied volumes was connected to the model and the effects on the response curve were determined. In the cadaver, different conditions with blocked and unblocked middle meatus and sphenoidal ostium were tested. Additionally, infundibulotomy was performed allowing direct access to and selective occlusion of the maxillary ostium. Results: In both the brass model and the cadaver, a baseline condition with no cavities included produced response curves with clear resonance peaks separated by valleys. Marked dips occurred when shunting cavities were attached to the model. The frequencies of these dips decreased with increasing shunting volume. In the cadaver, a marked dip was observed after removing the unilateral occlusion of the middle meatus and the sphenoidal ostium. Another marked dip was detected at low frequency after removal of the occlusion of the maxillary ostium following infundibulotomy. Conclusion: Combining measurements on a simplified nasal model with measurements in a cadaveric sinonasal tract seems a promising method for shedding light on the acoustic properties of the nasal resonator. © 2014 S. Karger AG, Basel

Doc number: O17

Doc number: P29

Obesity is associated with insulin resistance, particularly when body fat has a central distribution. However, insulin resistance also frequently occurs in apparently lean individuals. It has been proposed that these lean insulin-resistant individuals have greater amounts of body fat than lean insulin-sensitive subjects. Alternatively, their body fat distribution may be different. Obesity is associated with elevated plasma leptin levels, but some studies have suggested that insulin sensitivity is an additional determinant of circulating leptin concentrations. To examine how body fat distribution contributes to insulin sensitivity and how these variables are related to leptin levels, we studied 174 individuals (73 men, 101 women), a priori classified as lean insulin-sensitive (LIS, n = 56), lean insulin-resistant (LIR, n = 61), and obese insulin-resistant (OIR, n = 57) based on their BMI and insulin sensitivity index (S(I)). Whereas the BMI of the two lean groups did not differ, the S(I) of the LIR subjects was less than half that of the LIS group. The subcutaneous and intra-abdominal fat areas, determined by computed tomography, were 45 and 70% greater in the LIR subjects (P < 0.001) and 2.5- and 3-fold greater in the OIR group, as compared with the LIS group. Fasting plasma leptin levels were moderately increased in LIR subjects (10.8 +/- 7.1 vs. 8.1 +/- 6.4 ng/ml in LIS subjects; P < 0.001) and doubled in OIR subjects (21.9 +/- 15.5 ng/ml; P < 0.001). Because of the confounding effect of body fat, we examined the relationships between adiposity, insulin sensitivity, and leptin concentrations by multiple regression analysis. Intra-abdominal fat was the best variable predicting insulin sensitivity in both genders and explained 54% of the variance in S(I). This inverse relationship was nonlinear (r = -0.688). On the other hand, in both genders, fasting leptin levels were strongly associated with subcutaneous fat area (r = 0.760) but not with intra-abdominal fat. In line with these analyses, when LIS and LIR subjects were matched for subcutaneous fat area, age, and gender, they had similar leptin levels, whereas their intra-abdominal fat and insulin sensitivity remained different. Thus, accumulation of intra-abdominal fat correlates with insulin resistance, whereas subcutaneous fat deposition correlates with circulating leptin levels. We conclude that the concurrent increase in these two metabolically distinct fat compartments is a major explanation for the association between insulin resistance and elevated circulating leptin concentrations in lean and obese subjects.

Obesity is associated with insulin resistance, particularly when body fat has a central distribution. However, insulin resistance also frequently occurs in apparently lean individuals. It has been proposed that these lean insulin-resistant individuals have greater amounts of body fat than lean insulin-sensitive subjects. Alternatively, their body fat distribution may be different. Obesity is associated with elevated plasma leptin levels, but some studies have suggested that insulin sensitivity is an additional determinant of circulating leptin concentrations. To examine how body fat distribution contributes to insulin sensitivity and how these variables are related to leptin levels, we studied 174 individuals (73 men, 101 women), a priori classified as lean insulin-sensitive (LIS, n = 56), lean insulin-resistant (LIR, n = 61), and obese insulin-resistant (OIR, n = 57) based on their BMI and insulin sensitivity index (S(I)). Whereas the BMI of the two lean groups did not differ, the S(I) of the LIR subjects was less than half that of the LIS group. The subcutaneous and intra-abdominal fat areas, determined by computed tomography, were 45 and 70% greater in the LIR subjects (P < 0.001) and 2.5- and 3-fold greater in the OIR group, as compared with the LIS group. Fasting plasma leptin levels were moderately increased in LIR subjects (10.8 +/- 7.1 vs. 8.1 +/- 6.4 ng/ml in LIS subjects; P < 0.001) and doubled in OIR subjects (21.9 +/- 15.5 ng/ml; P < 0.001). Because of the confounding effect of body fat, we examined the relationships between adiposity, insulin sensitivity, and leptin concentrations by multiple regression analysis. Intra-abdominal fat was the best variable predicting insulin sensitivity in both genders and explained 54% of the variance in S(I). This inverse relationship was nonlinear (r = -0.688). On the other hand, in both genders, fasting leptin levels were strongly associated with subcutaneous fat area (r = 0.760) but not with intra-abdominal fat. In line with these analyses, when LIS and LIR subjects were matched for subcutaneous fat area, age, and gender, they had similar leptin levels, whereas their intra-abdominal fat and insulin sensitivity remained different. Thus, accumulation of intra-abdominal fat correlates with insulin resistance, whereas subcutaneous fat deposition correlates with circulating leptin levels. We conclude that the concurrent increase in these two metabolically distinct fat compartments is a major explanation for the association between insulin resistance and elevated circulating leptin concentrations in lean and obese subjects.

The Concurrent Accumulation of Intra-Abdominal and Subcutaneous Fat Explains the Association Between Insulin Resistance and Plasma Leptin Concentrations Distinct Metabolic Effects of Two Fat Compartments Miriam Cnop 1 , Melinda J. Landchild 1 , Josep Vidal 1 , Peter J. Havel 3 , Negar G. Knowles 1 , Darcy R. Carr 2 , Feng Wang 1 , Rebecca L. Hull 1 , Edward J. Boyko 1 , Barbara M. Retzlaff 1 , Carolyn E. Walden 4 , Robert H. Knopp 1 and Steven E. Kahn 1 1 Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, VA Puget Sound Health Care System, and Harborview Medical Center, Seattle, Washington 2 Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington 3 Department of Nutrition, University of California, Davis, California 4 College of Medicine Research Office, University of Arizona, Tucson, Arizona Abstract Obesity is associated with insulin resistance, particularly when body fat has a central distribution. However, insulin resistance also frequently occurs in apparently lean individuals. It has been proposed that these lean insulin-resistant individuals have greater amounts of body fat than lean insulin-sensitive subjects. Alternatively, their body fat distribution may be different. Obesity is associated with elevated plasma leptin levels, but some studies have suggested that insulin sensitivity is an additional determinant of circulating leptin concentrations. To examine how body fat distribution contributes to insulin sensitivity and how these variables are related to leptin levels, we studied 174 individuals (73 men, 101 women), a priori classified as lean insulin-sensitive (LIS, n = 56), lean insulin-resistant (LIR, n = 61), and obese insulin-resistant (OIR, n = 57) based on their BMI and insulin sensitivity index ( S I ). Whereas the BMI of the two lean groups did not differ, the S I of the LIR subjects was less than half that of the LIS group. The subcutaneous and intra-abdominal fat areas, determined by computed tomography, were 45 and 70% greater in the LIR subjects ( P < 0.001) and 2.5- and 3-fold greater in the OIR group, as compared with the LIS group. Fasting plasma leptin levels were moderately increased in LIR subjects (10.8 ± 7.1 vs. 8.1 ± 6.4 ng/ml in LIS subjects; P < 0.001) and doubled in OIR subjects (21.9 ± 15.5 ng/ml; P < 0.001). Because of the confounding effect of body fat, we examined the relationships between adiposity, insulin sensitivity, and leptin concentrations by multiple regression analysis. Intra-abdominal fat was the best variable predicting insulin sensitivity in both genders and explained 54% of the variance in S I . This inverse relationship was nonlinear ( r = −0.688). On the other hand, in both genders, fasting leptin levels were strongly associated with subcutaneous fat area ( r = 0.760) but not with intra-abdominal fat. In line with these analyses, when LIS and LIR subjects were matched for subcutaneous fat area, age, and gender, they had similar leptin levels, whereas their intra-abdominal fat and insulin sensitivity remained different. Thus, accumulation of intra-abdominal fat correlates with insulin resistance, whereas subcutaneous fat deposition correlates with circulating leptin levels. We conclude that the concurrent increase in these two metabolically distinct fat compartments is a major explanation for the association between insulin resistance and elevated circulating leptin concentrations in lean and obese subjects. Footnotes Address correspondence and reprint requests to Steven E. Kahn, ChB, VA Puget Sound Health Care System (151), 1660 S. Columbian Way, Seattle, WA 98108. E-mail: skahn{at}u.washington.edu . Received for publication 13 September 2001 and accepted in revised form 17 December 2001. CT, computed tomography; FSIGT, frequently sampled intravenous glucose tolerance test; IAF, intra-abdominal fat; LIR, lean insulin-resistant; LIS, lean insulin-sensitive; log e , natural log; NHANES, National Health and Nutrition Examination Survey; OIR, obese insulin-resistant; SCF, subcutaneous fat; S I , insulin sensitivity index. DIABETES