Analysis of U.S. nationally-representative data revealed significant positive associations between chronic smoking and alterations in the sense of smell. Rates of smell alteration (self-reported problems in the past year, losses with aging, phantom smells) increased from 23% among adults to 33% for chronic smokers and 38% for chronic smokers who also reported heavy drinking. Chronic smoking showed associations with smell alteration that were direct and indirect through exposure to olfactory-related pathologies (naso-sinus problems, dry mouth, head/facial injury). Smell alteration can impact smokers' quality of life by challenging the ability to sense warning odors, food flavor, and olfactory-stimulated emotions and memories.

Background-Homograft valves offer many advantages; however, there is concern about their use in second aortic valve replacement because of the complexity of the procedure and the possibility of accelerated degeneration. Methods and Results-One hundred and forty-four patients underwent a second aortic homograft replacement between 1973 and 1997 (mean follow-up 6.5Ϯ5 years, range 1 to 20 years). Eighty-three were male, and 61 were female, aged 17 to 77 years, mean 49.0 years. All patients had undergone previous aortic valve replacement with a homograft. The indication for reoperation was aortic regurgitation in 75 patients (52.1%), aortic stenosis in 28 (19.4%), and mixed aortic valve disease in 41 (28.5%). Root replacement was performed in 54 patients (38%) and subcoronary in 90 (62.5%). Early mortality was 3.4%. The actuarial survival rate was 93% and 82% at 5 and 10 years, respectively. Freedom from tissue degeneration was 96% and 80% at 5 and 10 years, respectively, and freedom from reoperation was 97% and 82% at 5 and 10 years, respectively. Conclusions-Thisstudy shows that a second aortic valve homograft replacement results in good early and long-term survival. Accelerated degeneration does not occur. Left ventricular performance is improved, and earlier surgery could further improve outcome, indicating that an aortic homograft is a safe, durable option for patients requiring a second aortic valve replacement. (Circulation. 1999;100[suppl II]:II-42-II-47.) Surgical TechniquePatients were cooled to a temperature of 28°C under total cardiopulmonary bypass. Myocardial preservation was achieved by using crystalloid cardioplegia at 4°C (St. Thomas Hospital, No 1), infused through the aortic root or directly into the coronary ostia. The

BACKGROUND: Ventral lesions of the subaxial cervical spine are challenging because approaches must circumvent endodermal and neurovascular structures. OBJECTIVE: To use cadaveric study to describe 4 posterolateral approaches to the ventral subaxial cervical spine with various facilitating techniques and osteotomies. METHODS: Three cadaveric specimens of the cervical spine were sequentially subjected to multilevel laminectomy (Type 1), transfacet (Type 2), transpedicular (Type 3), and extreme lateral transforaminal (Type 4) approaches. Approach working angles and proportion of visualized zones were compared, the former calculated using trigonometric methods. RESULTS: There was a significant stepwise increase in working angle in the ventral space, associated with increasing osteotomy type, from an average of 3.7°in single-level type 1 to 19.47°in the type 4 osteotomy. Regarding anatomic zones, proportional partial and total visualization achieved with Type 2 to 4 approaches were significantly greater than with Type 1. Complex osteotomies allowed superior access to be obtained to contributing and adjacent vessels of the ventral spinal axis. CONCLUSION: Ventral subaxial cervical lesions are difficult to access. We report increased working angles using quantified cadaveric data in increasingly complex posterior and posterolateral approaches graded as type 1 through 4. We advocate continued translational research in such approaches to lesions often considered to lie in surgically inaccessible locations.

Background —Homograft valves offer many advantages; however, there is concern about their use in second aortic valve replacement because of the complexity of the procedure and the possibility of accelerated degeneration. Methods and Results —One hundred and forty-four patients underwent a second aortic homograft replacement between 1973 and 1997 (mean follow-up 6.5±5 years, range 1 to 20 years). Eighty-three were male, and 61 were female, aged 17 to 77 years, mean 49.0 years. All patients had undergone previous aortic valve replacement with a homograft. The indication for reoperation was aortic regurgitation in 75 patients (52.1%), aortic stenosis in 28 (19.4%), and mixed aortic valve disease in 41 (28.5%). Root replacement was performed in 54 patients (38%) and subcoronary in 90 (62.5%). Early mortality was 3.4%. The actuarial survival rate was 93% and 82% at 5 and 10 years, respectively. Freedom from tissue degeneration was 96% and 80% at 5 and 10 years, respectively, and freedom from reoperation was 97% and 82% at 5 and 10 years, respectively. Conclusions —This study shows that a second aortic valve homograft replacement results in good early and long-term survival. Accelerated degeneration does not occur. Left ventricular performance is improved, and earlier surgery could further improve outcome, indicating that an aortic homograft is a safe, durable option for patients requiring a second aortic valve replacement.