Is selective neck dissection sufficient treatment for the N0/Np+ neck?

OBJECTIVE

The purpose of this study was to evaluate the therapeutic role of selective neck dissection performed electively in the N0 patient.

METHOD

Fifty-four patients with squamous cell carcinoma of the oral cavity, pharynx, and larynx, without clinical evidence of lymph node metastases, underwent 72 selective neck dissections over a 6-year period. The preoperative tumour and patient data were recorded in all patients. Mean follow-up was 59 months. Outcome data pertaining to pathologic nodal status, tumour recurrence, and survival were recorded on all patients.

RESULTS

Eighty-one percent of patients were histologically and clinically node negative. Seven percent of N0/Np0 patients failed in the neck compared to 50% of patients with occult nodal metastases (N0/Np+). Salvage treatment following nodal recurrence was successful in only one patient.

CONCLUSION

Selective neck dissection does not compromise survival and may minimize surgical morbidity in the N0/Np+ population.

Ecosystem health as a clinical rotation for senior students in Canadian veterinary schools

We describe 4 years of an experimental rotation in ecosystem health offered to senior veterinary students in Canada. Faculty from the 4 Canadian veterinary colleges collaborated in offering the rotation once annually at 1 of the colleges. The 1st rotation was held in Guelph in 1993, followed in successive years by rotations at Saskatoon, Saint-Hyacinthe, and Charlottetown. The rotation is a predominantly field-based experience that allows students to work with veterinary and other role models who are actively engaged in clinical research related to ecosystem health. Five specific field studies that worked particularly well during the rotations are presented. These studies involved investigating mortality in wildlife due to botulism, designing an environmental surveillance system around herds of beef cattle, using belugas to evaluate the health of the St. Lawrence River, dealing with competition for water use by aquaculture and agriculture, and exploring the role of veterinarians during major coastal oil spills. The experience has resulted in our developing the subject matter, field examples, teaching approach, and confidence necessary to make ecosystem health the focus of a productive clinical rotation for senior year veterinary students.

Surgical salvage after radiotherapy for advanced laryngopharyngeal carcinoma

OBJECTIVE

To comment on the use of surgery after the failure of radiotherapy in patients with advanced laryngeal, oropharyngeal, and hypopharyngeal carcinomas.

DESIGN

Randomized, controlled, clinical trial, with a mean follow-up period of 3.1 years.

SETTING

The Princess Margaret Hospital, Toronto, Ontario.

PATIENTS

Patients with advanced laryngopharyngeal carcinoma (T3 or T4 or N+).

INTERVENTION

Three hundred thirty-six patients who met the eligibility criteria were enrolled in a randomized, controlled, clinical trial and treated with primary radiotherapy using either the standard fractionation regimen or the hyperfractionation regimen. One hundred eight patients with recurrent disease underwent salvage surgery and were observed prospectively, with careful documentation of surgical and tumor data, complications, recurrences, and survival.

MAIN OUTCOME MEASURES

Surgical complication rate and survival.

RESULTS

Of the 108 patients who underwent surgery, 29 (27%) had complications. One third of these had multiple complications. There was no statistical difference between the surgical complication rates of the 2 radiotherapy groups (16 patients [28%] in the standard fractionation radiotherapy group and 13 [25%] in the hyperfractionation radiotherapy group). Survival after surgery was statistically correlated with the TNM system for the stage of the recurrent tumor, the pathologic nodal status, and the surgical margin status. The overall 3-year survival rate, which was calculated from the date of surgery, for the group of patients who underwent surgery was 22%.

CONCLUSIONS

In this patient population, the hyperfractionation regimen was not associated with a higher surgical complication rate. Using the policy of primary radiotherapy and reserving surgery for the management of failures of radiotherapy, 140 patients (71%) at highest risk (laryngeal and hypopharyngeal primary tumor sites) retained an intact larynx until the end of the study or death. Since it is the stage of the recurrent tumor that correlates with survival rather than the stage of the tumor at initial presentation, we suggest that tumors be restaged at the time of recurrence.

Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: psychosocial outcomes

OBJECTIVE

The purpose of this study was to determine the effects of antidepressant pharmacotherapy on mood symptoms and psychosocial outcomes in dysthymia.

METHOD

In a multicenter, double-blind, parallel-group trial, 416 patients with a diagnosis of early-onset primary dysthymia (DSM-III-R) of at least 5 years' duration without concurrent major depression were randomly assigned to 12 weeks of acute-phase therapy with sertraline, imipramine, or placebo. The psychosocial outcome measures used in the study were the Global Assessment of Functioning Scale, the Social Adjustment Scale, the Longitudinal Interval Follow-up Evaluation psychosocial ratings, and the Quality of Life Enjoyment and Satisfaction Questionnaire.

RESULTS

Sertraline and imipramine were significantly better than placebo in improving psychosocial outcomes as measured by the first three instruments. The Quality of Life Enjoyment and Satisfaction Questionnaire scores demonstrated significant improvements from baseline, and both active treatments produced significantly greater improvements than placebo. Significantly fewer patients discontinued sertraline (6.0%) than discontinued imipramine (18.4%) because of adverse events.

CONCLUSIONS

Pharmacotherapy is an effective treatment for dysthymia in terms of psychosocial functioning as well as depressive symptoms, even when the dysthymia is long-standing.

The undertreatment of dysthymia

BACKGROUND

Dysthymia is a chronic depressive condition that is quite prevalent. This condition can exact a significant toll on the general health and quality of life in the affected individual. Despite the frequency and consequences of dysthymia, however, the condition is often not diagnosed or treated. We present data on prior treatment from 410 patients with DSM-III-R dysthymia, primary type, early onset without concurrent major depression.

METHOD

Axis I and II diagnoses were made by using the Structured Clinical Interviews for DSM-III-R, Patient Version (SCID-P) and SCID II for Personality Disorders. The Hamilton Rating Scale for Depression and the Clinical Global Impressions scale were also completed. Prior treatment was assessed, with special attention paid to previous antidepressant drug therapy and psychotherapy.

RESULTS

Although the mean duration of dysthymia was about 30 years and almost half of the patients had previous episodes of major depression, only 41.3% had been treated with antidepressants and 56.1% with psychotherapy. A past history of major depression increased the frequency of prior antidepressant pharmacotherapy (45.7%) and psychotherapy (59.4%) compared with no history of major depression (36.8% and 40.9%, respectively). Comorbid personality disorder increased the likelihood of prior psychotherapy (70.7% vs. 49.6%) while having no effect on past pharmacotherapy. A history of substance abuse did not affect the history of antidepressant or psychotherapy treatment. In this study, dysthymia and psychosocial outcomes improved with sertraline and imipramine treatment.

CONCLUSION

Dysthymic patients in this sample were significantly undertreated. Newer antidepressant agents may alter the potential for pharmacotherapy interventions in this vulnerable population.

Quinine--acute self-poisoning and ocular toxicity

Quinine is widely prescribed as a treatment for nocturnal leg cramps. In acute overdosage, it may lead to significant ocular problems. This study reveals that some 30 patients were discharged from Greater Glasgow Health Board hospitals between 1988 and 1992 following acute self-poisoning with quinine. Six of these subjects had severe visual problems, two being registered as blind and another three as partially sighted. These observations, combined with the doubtful clinical efficacy of quinine, suggest that its continued widespread use should be reappraised.

Safety and Efficacy of Once-Daily Captopril Plus Hydrochlorothiazide versus Nifedipine Gastrointestinal Therapeutic System in Black Patients with Mild to Moderate Hypertension

The safety and efficacy of captopril plus hydrochlorothiazide (HCTZ) were compared to nifedipine gastrointestinal therapeutic system (GITS) in 145 randomly assigned black patients with mild to moderate hypertension. Following a 4-week placebo lead-in, patients received captopril plus HCTZ 25/15 mg or nifedipine GITS 30 mg for up to 12 weeks. Upward dose titration was permitted at weeks 3 and 6. Mean seated systolic and diastolic blood pressures decreased 16.1 ± 13.5 mm Hg and 11.5 ± 7.4 mm Hg, respectively, with captopril plus HCTZ. Statistically similar decreases were observed with nifedipine GITS: systolic, 19.3 ± 12.2 mm Hg; diastolic, 13.8 ± 7.2 mm Hg. There were no clinically significant between-group differences in serum chemistries. Edema was reported in 20.3% of nifedipine GITS patients versus 1.4% of captopril plus HCTZ patients (p = 0.001). The two regimens were equally effective in controlling blood pressure in black patients; however, a higher incidence of edema occurred with nifedipine GITS compared to captopril plus HCTZ.

A placebo-controlled, randomized clinical trial comparing sertraline and imipramine for the treatment of dysthymia

BACKGROUND

Despite the high prevalence of dysthymia and its associated morbidity, few controlled trials have evaluated the efficacy of antidepressant medication for this disorder. A 12-week, double-blind, placebo-controlled, randomized, multicenter trial was performed to evaluate the safety and efficacy of sertraline hydrochloride and imipramine hydrochloride in treating dysthymia.

METHODS

A total of 416 outpatients (271 women and 145 men) aged 25 to 65 years with DSM-III-R-defined, early-onset, primary dysthymia without concurrent major depression were randomized to 12 weeks of treatment with sertraline, imipramine, or placebo.

RESULTS

Both active treatments resulted in significantly reduced scores on the 17-item Hamilton Rating Scale for Depression (P = .04 and P = .01 for sertraline and imipramine vs placebo, respectively), the Montgomery-Asberg Depression Rating Scale (P = .01 and P = .003 vs placebo, respectively), Hopkins Symptom Checklist (P < .05), and the self-rated version of the Inventory of Depressive Symptoms (P < .05). With the use of a Clinical Global impressions improvement score of 1 or 2 (very much or much improved) to define response, response rates were 59% for sertraline, 64% for imipramine, and 44% for placebo (P = .02 for sertraline vs placebo and P < .001 for imipramine vs placebo). A significantly greater proportion of patients receiving imipramine than those receiving sertraline or placebo discontinued treatment because of adverse events (P = .001 and P < .001, respectively).

CONCLUSIONS

Pharmacotherapy provides considerable relief from the symptoms of dysthymia in patients suffering from this chronic affective disorder, with both sertraline and imipramine being more effective than placebo. The greater tolerability of sertraline is an important consideration because of the chronicity of dysthymia, which may require prolonged treatment with antidepressant medication.

Intermediate-dose busulphan before autografting for advanced-phase chronic myeloid leukaemia

Between June 1994 and October 1995 we performed 11 autografts in nine patients with advanced-phase chronic myeloid leukaemia (CML) using an attenuated cytoreductive regimen consisting of busulphan 8 mg/kg given in divided doses over 4 d. Five patients were restored to chronic phase. Four patients survived > 50 weeks and one remains well at 79 weeks. Toxicity was generally mild. Four procedures were managed entirely in the out-patient clinic. Therefore autografting after this 'intermediate' dose busulphan provides good palliation for patients with advanced CML with relatively little toxicity. Attenuated autografting should offer major advantages in terms of quality of life and cost for patients with advanced-phase CML.

Prevention of anaemia in inner city toddlers by an iron supplemented cows' milk formula

There are few data to support the use of follow-on formulas in infants from the age of 6 months. In a prospective trial in a deprived inner city area of Birmingham 100 infants who were already receiving pasteurised cows' milk by 6 months of age were enrolled and randomised either to receive a follow-on formula or to continue on cows' milk from 6 months until 18 months. At 18 months of age the follow-on formula group returned to cows' milk and both groups were followed up until 24 months. Iron status, growth, and nutritional status were analysed at intervals of six months. At enrollment, no differences in haematological status were evident. However, by 12 months of age, 31% of the cows' milk group were anaemic (haemoglobin concentration < 110 g/l) compared with only 3% of those receiving follow-on formulas. At 18 months, 33% of the cows' milk group were anaemic compared with only 2% of the follow-on formula group and by 24 months of age none of the follow-on formula group was anaemic, whereas 26% in the cows' milk group still had a haemoglobin of < 110 g/l. Mean corpuscular volume was significantly smaller and ferritin significantly lower in the cows' milk group at 12, 18, and 24 months. Dietary iron intake was higher in the follow-on formula group at 12 and 18 months but not at 24 months, when both groups were back on cows' milk. Infants and toddlers at high risk of iron deficiency are therefore unlikely to become anaemic if receiving a follow-on formula, although the relative merits of follow-on formula compared with an ordinary infant formula remain uncertain.

The clinically negative neck in patients with early oral cavity carcinoma: a decision-analysis approach to management

Despite improvements in both diagnostic and therapeutic techniques in recent decades, the prognosis for oral cavity squamous cell carcinoma has not improved. Patients presenting with overt regional metastases necessarily undergo therapeutic intervention directed to both the primary site and the neck. However, controversy persists regarding the best management for patients without clinical evidence of nodal disease. Would these patients best be managed with elective treatment of the neck, with no neck treatment unless overt nodal metastases are detected, or would some diagnostic test be beneficial in determining which patients are at highest risk of having occult nodal disease and, therefore, most likely to benefit from elective treatment? We performed a decision analysis to address this question. Baseline probability assumptions were made based on the evidence available in the literature for the parameters of interest. A decision tree was constructed and analyzed. In the final analysis, two options, elective functional neck dissection for all patients and a supraomohyoid neck dissection, were equally beneficial and were significantly better than the remaining options tested. Either of these surgical treatment strategies shifted the survival distribution curve significantly to the right.

Desensitization of gonadotropin-releasing hormone action in the gonadotrope-derived alpha T3-1 cell line

Sustained exposure of gonadotropes to GnRH causes a pronounced desensitization of GnRH-stimulated gonadotropin release, but the mechanisms involved are poorly understood. Recent studies have suggested, however, that GnRH-stimulated phosphoinositidase C (PIC) activity does not undergo rapid ( < 5 min) homologous desensitization in alpha T3-1 cells, and we have, therefore, used this cell line to address the question of whether desensitization occurs distal to PIC activity and/or in an intermediate time frame. We show that GnRH stimulates a rapid increase in inositol 1,4,5-trisphosphate [Ins(1,4,5)P3; maximum at 10-20 sec with a modest reduction thereafter] and that the GnRH-stimulated accumulation of [3H]IPs (in cells stimulated in the presence of LiCl) increases linearly over 5-300 sec. This clearly indicates that desensitization of PIC does not occur within this period and that the dramatic reduction in the rate of Ins(1,4,5)P3 accumulation (10-30 sec) is due to its metabolism, rather than to a reduction in Ins(1,4,5)P3 generation. Pretreatment for 60 min with 10(-7)M GnRH reduced cell surface GnRH receptor number by 48% (without measurably altering Kd). The pretreatment also reduced maximal GnRH-stimulated [3H]IP accumulation (to 66% of the control) and increased the EC50 for GnRH-stimulated [3H]IP accumulation approximately 3-fold, demonstrating that desensitization of GnRH-stimulated [3H]IP accumulation can, indeed, occur within 60 min, but that this may be attributable to receptor loss (without appreciable uncoupling of residual receptors from their immediate effector system). Pretreatment for 60 min with GnRH also caused a dose-dependent reduction in both spike and plateau phases of the GnRH effect on cytosolic Ca2+. This effect could not be overcome by stimulation with high concentrations of GnRH and appears, therefore, to reflect not only receptor loss, but, also, an additional inability of agonist-occupied GnRH receptors to elevate cytosolic Ca2+. The effect of KCl on cytosolic Ca2+ was similarly reduced by GnRH pretreatment, suggesting that desensitization of voltage-operated Ca2+ channels mediates desensitization of the plateau phase Ca2+ response to GnRH. Such a mechanism could not, however, explain desensitization of the spike phase of the Ca2+ response to GnRH seen in normal or Ca2+ -free medium. Accordingly, the data reveal a novel mechanism for homologous desensitization to GnRH in which agonist-occupied GnRH receptors are rendered unable to mobilize intracellular Ca2+ and imply that desensitization of GnRH-stimulated Ins(1,4,5)P3 production and/or action occurs.