Arylcyclopropanecarboxyl guanidines as novel, potent, and selective inhibitors of the sodium hydrogen exchanger isoform-1

A novel series of arylcyclopropanecarboxyl guanidines was synthesized and evaluated for activity against the sodium hydrogen exchanger isoform-1 (NHE-1). In biological assays conducted in an AP1 cell line expressing the human NHE-1 isoform, the starting cyclopropane 3a (IC(50) = 3.5 microM) shows inhibitory activity comparable to cariporide (IC(50) = 3.4 microM). Structure-activity relationships are used to optimize the affinity of various acyl guanidines for NHE-1 by screening the effect of substituents at both aryl and cyclopropyl rings. It is demonstrated that introduction of appropriate hydrophobic groups at the phenyl ring and a gem-dimethyl group at the cyclopropane ring enhances the NHE-1 inhibitory activity by up to 3 orders of magnitude (compound 7f, IC(50) = 0.003 microM). In addition, the gem-dimethyl series of analogues seem to display improved oral bioavailability and longer plasma half-life in rats. Furthermore, the lead benzodihydrofuranyl analogue 1 (BMS-284640) shows over 380-fold increased NHE-1 inhibitory activity as well as improved selectivity for NHE-1 over NHE-2 compared to cariporide.

Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion

OBJECTIVE

Presentation of outcomes of pelvic arterial embolization for hemorrhage after spontaneous or induced abortion.

STUDY DESIGN

We collected case reports of embolization after spontaneous or induced abortion from oral presentations and from members of the National Abortion Federation.

RESULTS

Pelvic arterial embolization was performed for 11 women who had hemorrhage after spontaneous or induced abortion, and it was initially successful for all women. One woman ultimately required a hysterectomy after unsuccessful repeated embolization. Prophylactic embolization was done for 8 women who were at risk for hemorrhage from placenta accreta; 4 of these women had subsequent hysterectomies.

CONCLUSIONS

Selective pelvic arterial embolization may be a successful treatment for hemorrhage associated with spontaneous and induced abortion. Embolization can be considered before hysterectomy is undertaken for control of hemorrhage. There may be a role for prophylactic catheterization or embolization when there is a risk of severe hemorrhage.

The development of breast carcinoma in women with thyroid carcinoma

BACKGROUND

Breast carcinoma and thyroid carcinoma are two malignancies that occur most commonly in women. An association between the incidence rates of thyroid and breast carcinoma in women after a diagnosis of the other malignancy has been suggested in a retrospective analysis of a single institution's tumor registry. In that study, an increased incidence of breast carcinoma in premenopausal women previously treated for thyroid carcinoma was observed.

METHODS

The purpose of this study was to investigate further this relation utilizing a large database, the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) database. The SEER database is maintained by the National Cancer Institute, and it represents 11 population-based cancer registries covering approximately 14% of the United States population. The study was a population-based retrospective cohort analysis using external comparisons. From 1973 to 1994, 365 women in the SEER database were identified as having both thyroid and breast carcinomas. The SEER database from 1973 to 1994 was utilized to calculate age specific and calendar year specific incidence rates for each year for thyroid and breast carcinomas. The expected number of second cancers for each age group, calendar year, and follow-up period were determined by multiplying these incidence rates by the age specific and calendar year specific number of person-years at risk. The risk ratio (RR) was calculated by dividing the observed by the expected number of second cancers. Statistical significance was determined by the Poisson test.

RESULTS

A total of 1,333,115 person-years were available for analysis. One hundred thirteen thyroid carcinoma cases were diagnosed after breast carcinoma cases (RR, 0.99; P = 0.576). Two hundred fifty-two breast carcinoma cases were diagnosed after thyroid carcinoma cases (RR, 1.18; P = 0.007). Premenopausal women (age 20-49 years) with an index thyroid carcinoma have a significantly increased risk of developing subsequent breast carcinoma (RR, 1.42; P = 0.001). Black premenopausal women with an index thyroid carcinoma do not have an increased risk of developing breast carcinoma, but the statistical power is lower due to low numbers. No women with index breast carcinoma have an increased risk of developing thyroid carcinoma.

CONCLUSIONS

Women with a history of thyroid carcinoma have a greater than expected risk of developing breast carcinoma. This risk is most pronounced in premenopausal white women. The implications of this observation with respect to breast carcinoma screening guidelines and thyroid carcinoma treatment guidelines deserve further investigation.

The development and validation of a dysphagia-specific quality-of-life questionnaire for patients with head and neck cancer: the M. D. Anderson dysphagia inventory

OBJECTIVE

To design a reliable and validated self-administered questionnaire whose purpose is to assess dysphagia's effects on the quality of life (QOL) of patients with head and neck cancer.

DESIGN

Cross-sectional survey study.

METHODS

Focus groups were convened for questionnaire development and design. The M. D. Anderson Dysphagia Inventory (MDADI) included global, emotional, functional, and physical subscales. One hundred consecutive adult patients with a neoplasm of the upper aerodigestive tract who underwent evaluation by our Speech Pathology team completed the MDADI and the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). Speech pathologists completed the Performance Status Scale for each patient. Validity and reliability properties were calculated. Analysis of variance was used to assess how well the MDADI discriminated between groups of patients.

RESULTS

The internal consistency reliability of the MDADI was calculated using the Cronbach alpha coefficient. The Cronbach alpha coefficients of the MDADI subscales ranged from 0.85 to 0.93. Test-retest reliability coefficients of the subscales ranged from 0.69 to 0.88. Spearman correlation coefficients between the MDADI subscales and the SF-36 subscales demonstrated construct validity. Patients with primary tumors of the oral cavity and oropharynx had significantly greater swallowing disability with an adverse impact on their QOL compared with patients with primary tumors of the larynx and hypopharynx (P<.001). Patients with a malignant lesion also had significantly greater disability than patients with a benign lesion (P<.001).

CONCLUSIONS

The MDADI is the first validated and reliable self-administered questionnaire designed specifically for evaluating the impact of dysphagia on the QOL of patients with head and neck cancer. Standardized questionnaires that measure patients' QOL offer a means for demonstrating treatment impact and improving medical care. The development and validation of the MDADI and its use in prospective clinical trials allow for better understanding of the impact of treatment of head and neck cancer on swallowing and of swallowing difficulty on patients' QOL.

The significance of comorbidity in advanced laryngeal cancer

INTRODUCTION

Cancer patients often have concurrent diseases and conditions known as comorbidities. The aim of this project is to demonstrate the significance of comorbidity in the treatment and outcomes of advanced laryngeal carcinoma.

METHODS

A retrospective medical record review of 182 patients with previously untreated T3 or T4 squamous carcinomas of the larynx treated at M. D. Anderson between 1990 and 1995 was performed. Demographic, patient-specific, tumor-specific, and outcome measures information were collected. Comorbidity was coded using the Modified Medical Comorbidity Index. Univariate and multivariate analysis with the use of life survival analysis techniques and logistic regression were performed.

RESULTS

The median age at diagnosis was 59.5 years. Most patients were men (69.2%) and Caucasian (73.1%). Laryngeal preservation was performed in 90 patients, and surgical resection was performed in 92 patients. Patients in the two treatment groups had similar comorbidity, locoregional control (65%), and 5-year survival (37.3%). Patients with either moderate or severe comorbidity had significantly worse overall survival (p = .00014) and worse 5-year survival than those with no or mild comorbidity (21.8% vs 46.3%, p = .003).

CONCLUSIONS

This study demonstrates that comorbidity is significantly associated with survival in a group of patients with identical histology, site, and stage. Comorbid status should be incorporated into the assessment of prognosis and outcome to improve and optimize the management of head and neck cancer patients.

Stimulation of topoisomerase II-mediated DNA damage via a mechanism involving protein thiolation

The breakage/reunion reaction of DNA topoisomerase II (TOP2) can be interrupted by DNA intercalators (e.g., doxorubicin), enzyme binders (e.g., etoposide), or DNA lesions (e.g., abasic sites) to produce TOP2-mediated DNA damage. Here, we demonstrate that thiol alkylation of TOP2 can also produce TOP2-mediated DNA damage. This conclusion is supported by the following observations using purified TOP2: (1) Thiol-reactive quinones were shown to induce TOP2-mediated DNA cleavage. (2) Thiol-reactive compounds such as N-ethylmaleimide (NEM), disulfiram, and organic disulfides [e.g., 2,2'-dithiobis(5-nitropyridine)] were also shown to induce TOP2-mediated DNA cleavage with similar reaction characteristics as thiol-reactive quinones. (3) TOP2-mediated DNA cleavage induced by thiol-reactive quinones was completely abolished using mutant yeast TOP2 with all cysteine residues replaced with alanine (cysteineless TOP2). These results suggest the possibility that cellular DNA damage could occur indirectly through thiolation of a nuclear protein, TOP2. The implications of this reaction in carcinogenesis and apoptotic cell death are discussed.

Factors associated with age at operation for children with congenital heart disease

OBJECTIVE

Previous studies have shown that children with congenital heart disease (CHD) who live in nonurban areas or who do not have private insurance are at risk for delayed referral to a pediatric cardiologist. However, the effect of these factors on the age at which cardiac surgery is performed has not been evaluated. This study is designed to evaluate the factors that influence the age at which definitive surgical repair is performed.

METHODS

Data on hospital discharges for 1995 and 1996 in California were obtained from the Office of Statewide Health Planning and Development database. Children <18 years who underwent surgical repair for atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), or atrioventricular canal (AVC) were included in the study. Age at surgery was evaluated using type of CHD, gender, race, type of insurance, surgical centers, urban or rural home location, and distance between home and surgical center as independent variables.

RESULTS

In 1995-1996, 666 children underwent ASD closure (mean age: 5.1 years; median: 4.0 years), 582 VSD closure (mean age: 2.8; median: 1.1 years), 394 TOF repair (mean age: 1.7; median:.9 years), and 177 AVC repair (mean age: 1.1; median:.6 years). Comparing median and mean age at surgery, we found: AVC<TOF<VSD<ASD (< indicates younger than). A consistent trend for all 4 types of CHD was seen indicating that for median age at operation: private insurance<managed care<Medicaid. Gender or race had no effect on age at operation, although Asians tended to be older at surgery for all 4 types of CHD. There is a significant negative correlation between the case volume of surgical centers and median age at operation for ASD (r = -.37), VSD (r = -.49), TOF (r = -.63), and AVC (r = -.17). In addition, significant positive correlation was found between degree of urbanization of home locations (measured by population density) and median age at operation for ASD (r =.50), VSD (r =.77), and TOF (r =.18). No significant correlation was found between distance to surgical center and age at operation.

CONCLUSIONS

Many medical and nonmedical variables play important roles in determining age for definitive repair of CHD in children. Type of insurance, a recognized surrogate for access to care, may play an important role. In addition, centers with higher surgical case volume were more likely to operate at a younger age. Finally, children in urban areas tend to be older at the time of surgery for ASD, VSD, and TOF.

The impact of clinical pathways on the practice of head and neck oncologic surgery: the University of Texas M. D. Anderson Cancer Center Experience

OBJECTIVE

To assess the impact of clinical pathways on the practice of head and neck oncologic surgery in an academic center.

DESIGN

Cross-sectional study.

SETTING

Cancer treatment center.

PATIENTS

The study population consisted of 3 groups of patients who underwent unilateral neck dissection and were treated in the Department of Head and Neck Surgery of the University of Texas M. D. Anderson Cancer Center, Houston. Additional procedures which may have been performed were direct laryngoscopy, rigid esophagoscopy, and/or dental extractions. Ninety-six patients treated during 1993-1994 prior to the implementation of the clinical pathway (historical control group) were compared with 94 patients treated during 1996-1998, 64 who were not (contemporaneous nonpathway group) and 30 who were managed on the clinical pathway (pathway group). Patients from 1995 were excluded since the pathway was in the planning stages then.

MAIN OUTCOME MEASURES

Median length of stay; median total costs of care.

RESULTS

The median length of hospital stay of the historical control, contemporaneous nonpathway, and pathway groups decreased from 4.0 to 2.0 days (P<.001). The total median costs of care were less in the pathway group as compared with the historical control group ($6,227 and $8,459, respectively, P<.001) and also less in the contemporaneous nonpathway group compared with the historical control group (S6885 and $8,459, respectively, P<.001). Mean and median length of hospital stay and costs were lower in the pathway group as compared with the nonpathway group but not significantly (P = .11 and P = .07, respectively) The contemporaneous nonpathway and pathway groups did not differ in complications or readmissions.

CONCLUSIONS

Development and implementation of this clinical pathway played a statistically significant role in decreasing length of hospital stay and total costs of care associated with neck dissection between nonpathway and pathway patients. Thus, a more cost-effective practice environment has resulted for all of our patients.

Generation of T-cell immunity to a murine melanoma using MART-1-engineered dendritic cells

The murine melanoma B16 expresses the murine counterpart of the human MART-1/Melan-A (MART-1) antigen, sharing a 68.6% amino acid sequence identity. In this study, mice were vaccinated with bone marrow-derived murine dendritic cells genetically modified with a replication-incompetent adenoviral vector to express the human MART-1 gene (AdVMART1). This treatment generated a protective response to a lethal tumor challenge of unmodified murine B16 melanoma cells. The response was mediated by major histocompatibility complex class I-restricted cytotoxic T lymphocytes specific for MART-1 antigen, which produced high levels of interferon-gamma when reexposed to MART-1 in vitro and lysed targets in a calcium-dependent mechanism suggestive of perforin/granzyme B lysis. MART-1 was presented by the dendritic cells used for vaccination and not by epitopes cross-presented by host antigen-presenting cells. In conclusion, dendritic cells genetically modified to express the human MART-1 antigen generate potent murine MART-1-specific protective responses to B16 melanoma.

Characterization of antitumor immunization to a defined melanoma antigen using genetically engineered murine dendritic cells

A murine model of dendritic cell (DC)-based genetic immunization to a defined human melanoma antigen (Ag), MART-1/Melan-A (MART-1), was developed. The MART-1 gene was stably transfected into the nonimmunogenic mouse fibrosarcoma cell line NFSA that is syngeneic in C3Hf/Sem/Kam (C3H, H-2k) mice to generate the NFSA(MART1) cell line. In vivo protection from a lethal NFSA(MART1) tumor challenge could be generated by DCs transduced with a recombinant adenovirus (AdV) vector expressing MART-1 (AdVMART1). This model has the following characteristics: (a) immunological specificity and memory, (b) comparable protection for varying transduction multiplicities of infection, cell doses, and sites of DC inoculation but, interestingly, worse protection with increasing numbers of vaccinations, (c) the ability to treat small established tumors, (d) an absolute requirement for CD8 and CD4 T cells, (e) generation of MART-1-specific splenic cytotoxic T lymphocytes, and (f) up-regulation of both T helper type 1 and T helper type 2 cytokines. Genetically engineered DCs presenting defined tumor Ags represent an attractive method to generate effective immune responses.

Drug-radiation interactions in tumor blood vessels

Obliteration of the tumor vasculature is an effective means of achieving tumor regression. Antiangiogenic agents have begun to enter cancer clinical trials. Ionizing radiation activates the inflammatory cascade and increases the procoagulative state within blood vessels of both tumors and normal tissues. These responses are mediated through oxidative injury to the endothelium, leading to induction of cell-adhesion molecules and exocytosis of stored proteins from the endothelial cytoplasm. Agents that activate homeostatic responses in the endothelium can enhance thrombosis and vasculitis of irradiated tumor blood vessels. Proinflammatory and prothrombotic biological response modifiers given concurrently with ionizing radiation are known to induce vascular obliteration and necrosis of tumors. Other mechanisms of interaction between antiangiogenic agents and ionizing radiation include the direct cytotoxic effects of these agents. Interactions between drugs and radiation therapy might therefore occur at the level of the vascular endothelium. The importance of this paradigm is that the endothelium might not develop resistance to drugs or radiation because of lessened potential for mutagenesis and clonogenesis. The future design of clinical trials must consider the effects of radiation therapy on the vascular endothelium.

DNA topoisomerase I-targeting drugs as radiation sensitizers

Combination chemoradiation, alone or as an adjuvant to surgery, has been shown to improve treatment outcomes in a number of human malignancies, but may be limited by normal tissue toxicities. A primary challenge in radiation oncology is the development of drugs that can selectively enhance the cytotoxicity of ionizing radiation against tumor cells. Mammalian DNA topoisomerase I is the major cytotoxic target of a number of newly developed anticancer drugs that have shown efficacy against solid tumors, including colon cancer, ovarian cancer, lung cancer, cancer of the head and neck, and pediatric cancers. Topoisomerase I-targeting drugs exert their cytotoxic effect by producing enzyme-mediated DNA damage, rather than by directly inhibiting enzyme catalytic activity. DNA topoisomerase I recently has been established as a biochemical mediator of radiosensitization in cultured mammalian cells by camptothecin derivatives. Interestingly, this sensitization appears to be schedule-dependent, cell cycle phase-specific, cell line-dependent, and not strictly dependent on drug cytotoxicity. Clinical chemoradiation trials using camptothecin derivatives are currently ongoing. Future studies aimed at better understanding the underlying mechanisms of molecular radiosensitization with topoisomerase I-targeting drugs are pivotal to the clinical application of these agents, as well as in guiding the development of more effective radiosensitizers.

p53 selective and nonselective replication of an E1B-deleted adenovirus in hepatocellular carcinoma

An E1B gene-attenuated adenovirus (dl1520) has been proposed to have a selective cytolytic activity in cancer cells with a mutation or deletion in the p53 tumor suppressor gene (p53-null), a defect present in almost half of human hepatocellular carcinomas (HCCs). In this study, the in vitro and in vivo antitumor activity of dl1520 was investigated focusing on two human HCC cell lines, a p53-wild type (p53-wt) cell line and a p53-null cell line. dl1520 was tested for in vitro cytopathic effects and viral replication in the human HCC cell lines Hep3B (p53-null) and HepG2 (p53-wt). The in vivo antitumor effects of dl1520 were investigated in tumors grown s.c. in a severe combined immunodeficient mouse model. In addition, the combination of dl1520 infection with systemic chemotherapy was assessed in these tumor xenografts. At low multiplicities of infection, dl1520 had an apparent p53-dependent in vitro viral growth in HCC cell lines. At higher multiplicities of infection, dl1520 viral replication was independent of the p53 status of the target cells. In vivo, dl1520 significantly retarded the growth of the p53-null Hep3B xenografts, an effect augmented by the addition of cisplatin. However, complete tumor regressions were rare, and most tumors eventually grew progressively. dl1520 had no effect on the in vivo growth of the p53-wt HepG2 cells, with or without cisplatin treatment. The E1B-deleted adenoviral vector dl1520 has an apparent p53-dependent effect in HCC cell lines. However, this effect is lost at higher viral doses and only induces partial tumor regressions without tumor cures in a human HCC xenograft model.

Activation of topoisomerase II-mediated excision of chromosomal DNA loops during oxidative stress

Hydrogen peroxide (H2O2), a reactive oxygen species (ROS), is known to induce oxidative stress and apoptosis. U937 cells treated with H2O2 were shown to produce high molecular weight (HMW) DNA fragments approximately 50 to 100 kb in size in <1 min. The formation of these HMW DNA fragments is reversible and shown to be mediated by DNA topoisomerase II (TOP2). Following this initial event, formation of irreversible HMW DNA fragments and nucleosomal ladders occurs. Our results thus demonstrate a potential role of TOP2 in oxidative damage of DNA and apoptotic cell death.

Methods for creating and animating a computer model depicting the structure and function of the sarcoplasmic reticulum calcium ATPase enzyme

This paper describes the developmental process used to visualize the calcium ATPase enzyme of the sarcoplasmic reticulum. The steps involved were evaluating scientific information, consulting with scientists, model making, storyboarding, and creating and editing in a computer medium. The product was a computer-generated animation depicting the relationship between the structure and function of the sarcoplasmic reticulum calcium ATPase enzyme.

Cost-effectiveness of the diagnostic evaluation of vertigo

OBJECTIVE

To evaluate the cost-effectiveness of several diagnostic tests used in the evaluation of vertigo.

STUDY DESIGN

Cost-effectiveness analysis, using data from retrospective case review.

METHODS

Charts and test results were reviewed from 192 outpatients seen in an academic tertiary referral center for evaluation of vertigo. Cost-effectiveness analysis was performed using decision analysis software, data from office and hospital charges, and expert-based estimations of the utility of different test outcomes. Sensitivity analysis was performed using standard algorithms and wide variable ranges.

RESULTS

We found that audiologic testing, posturography, and electronystagmography were the most cost-effective tests, and that magnetic resonance imaging and blood tests had the lowest cost-effectiveness. The analysis was sensitive to the effects of financial costs of tests but, with a few exceptions, was typically not sensitive to the utility of test outcomes or the distribution of test results.

CONCLUSIONS

The use of cost-effectiveness analysis, the estimation of utility of test outcomes, and techniques of sensitivity analysis should help guide the clinician's decision making on appropriate testing for patients with vertigo.

Challenges and relevance of problem-based learning in dental education

The rôle of PBL as an innovative approach in medical education has been well documented. There has been an emerging trend of incorporating PBL into the dental curriculum. The potential advantages of PBL as a mode of learning encompass the enhancement of an integrated approach in solving dental-treatment-related problems, the development of critical thinking and problem solving skills and the encouragement of independent life-long learning. PBL was introduced into the dental curriculum as a pilot project in the Faculty of Dentistry, National University of Singapore in summer 1996. An example of a case-based study was illustrated and the learning objectives of the study were highlighted. Initial feedback from students indicated a positive attitude to this mode of learning in terms of cognitive, affective and psychomotor skills. Strategies to enhance learning in the PBL environment include time allocation for self-study, availability of resource materials and use of appropriate assessment methods. Problems that remain to be resolved include the choice of appropriate outcome assessment measures to evaluate the effectiveness of PBL as a mode of learning in undergraduate dental education.

Establishing the etiology of childhood hearing loss

The cause of hearing loss in children is often difficult to identify. We evaluated a cohort of 114 children (47 boys, 67 girls) referred with newly diagnosed hearing loss (non-otitis media) to identify factors predictive of etiology and type of hearing loss. Clinical (history and physical examination), laboratory, and radiographic data were collected. One hundred children (87.7%) had sensorineural hearing loss, and 14 (12.3%) had conductive or mixed hearing loss. The cause of hearing loss was identified in 54 children (48%). Patients with isolated aural atresia (n = 7) or with a known diagnosis of congenital cytomegalovirus infection (n = 21) were excluded from further data analysis. We conducted statistical analysis to identify factors predictive of the cause and type of hearing loss. Clinical factors that aided in identifying a cause included abnormal physical examination findings (p = 0.001) and craniofacial anomalies (p = 0.006). Computed tomography of the temporal bones was the only diagnostic test predictive of cause (p < 0.001). Factors predictive of the type of hearing loss detected (sensorineural vs. conductive or mixed) were abnormal physical examination findings (p = 0.01) and craniofacial anomalies (p = 0.004). An exhaustive laboratory or radiographic workup did not prove beneficial in identifying the etiology of hearing loss in our series.

Effect of temperature on lateral wall mechanics of the guinea pig outer hair cell

The outer hair cell is thought to enhance the sensitivity of mammalian hearing. Its lateral wall consists of 3 concentric layers: an outermost plasma membrane, a cortical lattice, and an innermost collection of flattened membranes called the subsurface cisternae. The cytoplasm requires positive pressure for full expression of the outer hair cell's electromotility. Using micropipette aspiration, we investigated the mechanics of the guinea pig's outer hair cell lateral wall at room temperature (22 degrees C) and at the guinea pig's body temperature (39 degrees C). Although there was a 10% decrease in stiffness parameter with an increase from room to body temperature, the difference was not statistically significant; values ranged from 0.45 to 0.65 dyne/cm. With sufficient negative pressure, the cytoplasmic membrane is separated from the rest of the outer hair cell's lateral wall, a process that leads to vesiculation of the plasma membrane. Vesiculation occurs at a lower pressure than at body temperature. Our results demonstrate that the stiffness parameter of the outer hair cell lateral wall at body temperature is similar to that at room temperature. However, the plasma membrane's attachment to the cortical lattice is greatly altered by temperature. The decrease in strength of membrane attachment at body temperature may result from a change in membrane fluidity, making it more easy for membrane attachment sites to break free and permit vesiculation. Whether the tethering of the plasma membrane to the cortical lattice is lost under clinically pathologic conditions deserves future study.

In search of the transfusion trigger

Red blood cell transfusions are used commonly in orthopaedic surgery and cost billions of dollars annually. The goals of transfusion are to reduce mortality and morbidity and improve functional status that result from anemia and inadequate O2 delivery. Risks of infections from transfusion are low and continue to decline, but evidence is growing that red cell transfusions are immunosuppressive and predispose patients to postoperative infections. However, there actually are very little data on when transfusion is indicated. Observational data suggest that transfusion does not reduce mortality in patients with preoperative or postoperative hemoglobin levels 8 g/dL or greater, although no conclusions could be drawn about the effect of transfusion in patients with hemoglobin 8 g/dL or less. Large, well performed randomized clinical trials are needed to establish the efficacy of transfusion. Until better data are available, orthopaedic surgeons will have to rely on clinical judgement in decisions regarding transfusions. Using a higher transfusion threshold in patients with cardiovascular disease is recommended.

Outcomes analysis of voice and quality of life in patients with laryngeal cancer

OBJECTIVE

To assess relationships between voice satisfaction and global quality of life in patients who have been treated for laryngeal cancer.

DESIGN

Cross-sectional survey study.

SETTING

Veterans Affairs Medical Center.

PATIENTS

Eighty patients who had completed treatment for laryngeal cancer with either total laryngectomy (n=17), radiotherapy (n=24), or both (n=39).

MAIN OUTCOME MEASURES

Subscale scores on a general health status instrument (the Medical Outcomes Study 36-item short-form health survey), and a validated voice-specific functional status instrument (the Voice Handicap Index).

RESULTS

Self-rated global health did not correlate significantly with emotional, functional, or physical voice handicap, although some subscales on the 36-item short-form health survey correlated with voice handicap scores. Global health status scores did not differ between patients who had undergone laryngectomy with a tracheoesophageal puncture and patients treated with radiotherapy only. Physical voice handicap scores did not differ significantly between those who underwent tracheoesophageal puncture and those who had radiotherapy, but emotional (P=.07) and functional (P=.01) handicap scores were lower in patients treated with radiotherapy. However, there was considerable overlap in voice handicap scores, with many patients who had had tracheoesophageal puncture showing less voice handicap than patients treated with radiotherapy.

CONCLUSIONS

These data demonstrate that health status is affected by other factors than voice handicap in patients with laryngeal cancer. In addition, there is a large amount of individual variation in voice handicap after treatment. These findings illustrate the need for prospective studies assessing voice handicap and quality of life after treatment for laryngeal cancer.