Objective. To assess potential benefit of a Passy-Muir Speaking Valve (PMV) in decreasing aspiration in patients with a tracheostomy.Background. Many patients with tracheostomy exhibit clinically significant aspiration. It has been previously noted that aspiration can often be reduced or eliminated by plugging or removing the tracheostomy tube. Some patients, however, do not tolerate removal or plugging of their tracheostomy tube, which then leads to persistent aspiration. We postulated that a one-way speaking valve may restore more normal subglottic and glottic air flow and reduce aspiration.Methods. Alert patients with a tracheostomy and clinical evidence of aspiration were eligible for study. Eleven patients with tracheostomy and known aspiration were studied with a modified barium swallow. Radiographic examination was used to evaluate the presence and amount of aspiration while patients swallowed both with and without a PMV in place on their tracheostomy tube.Results. Aspiration was reduced (or eliminated) during swallowing in all 11 patients when they wore a PMV, when compared to swallowing with an open (unvalved) tube. This improvement was achieved with liquids, semisolids, and pureed consistencies.Conclusion. This study demonstrates that a Passy-Muir speaking valve facilitated swallow and reduced aspiration in patients with a tracheostomy and known aspiration.

The nasal septal hemangioma or ''bleeding polyp,'' first reported by Ash and Old(1) in 1950, is an uncommon lesion of the nasal cavity. Histological confirmation of the diagnosis is crucial to make the appropriate diagnosis and institute definitive treatment because these tumors often mimic malignancy. We present an unusual case of a patient with a nasal septal hemangioma that originated on the osseous nasal septum rather than the more commonly described anterior cartilaginous septum. Computed tomography (CT) and early biopsy assisted in definitive treatment planning.

Patients with cystic fibrosis (CF) are host to a plethora of respiratory infections. Chronic colonization with Pseudomonas aeruginosa and other potentially virulent organisms is routine after years of exposure to multiple antibiotics, both prophylactic and therapeutic. The advent of lung transplantation has now offered CF patients the opportunity to overcome the most debilitating and often lethal part of their condition, their pulmonary disease. With transplantation, however, the CF patient faces a whole new host of challenges. In particular, lung transplant recipients require significant doses of immunosuppressive drugs such as prednisone, cyclosporine, and FK 506. These medications predispose the CF patients to severe infections by the same organisms that most frequently colonize their bodies in general and their upper respiratory tract in particular, namely P. aeruginosa, Staphylococcus aureus, and Hemophilus influenza. Another less prevalent but more virulent organism, Pseudomonas cepacia, has emerged as the greatest contributor to morbidity in the double lung transplant patients with CF.l The most prevalent head and neck infection associated with CF is chronic sinusitis, frequently associated with nasal polyposis.' Less frequent, although still common for CF patients, is chronic or serous otitis media. P. aeruginosa remains the most common pathogen isolated from the sinuses and middle ears, although P. cepacia has also been reported. Osteomyelitis of the temporal bone, characteristically seen in elderly diabetics, usually results

Indirect evidence suggests a causative role for intraperitoneal free fatty acids (FFA) in hypocalcemia associated with pancreatitis. We examined the effects of intraperitoneal injection of four naturally occurring FFAs on serum calcium in rats. Two saturated FFAs, stearate and palmitate, induced little or no hypocalcemia. Two unsaturated FFAs, oleate and linoleate, caused dramatic hypocalcemia in treated versus control rats (6.3 +/- 1.4 and 5.3 +/- 0.7 mg/dl, respectively, versus 10.1 +/- 0.6). Dose-response studies demonstrated that minute quantities of oleate (100 mu-l per 250 g rat) caused marked hypocalcemia (7.2 +/- 0.3 mg/dl). Treated versus control rats also revealed a decrease in ionized calcium (3.15 +/- 0.2 versus 5.6 +/- 0.05 mg/dl) and magnesium (1.4 +/- 0.15 versus 2.0 +/- 0.10), an appropriate increase in PTH levels (1670 +/- 451 versus 396 +/- 235 pg/ml), and a fall in calcitonin levels (70.4 +/- 21.3 versus 47.5 +/- 16.4 pg/ml) but no change in albumin or phosphate levels. In vitro, the K(sp) of calcium dioleate was shown to be 5.3 x 10(-8) m3/liter3; thus under physiologic conditions 100 mu-l oleate binds 7.2 mg calcium, or approximately twice the total ECF ionized calcium in the rat.The amounts of intraperitoneal FFA that can easily be achieved in pancreatitis complex pathophysiologically significant amounts of calcium and may lead to severe hypocalcemia.