Cognitive difficulty in physicians

PURPOSE

Remediation of some incompetent physicians has proven difficult or impossible. The authors sought to determine whether physicians with impaired competency had neuropsychological impairment sufficient to explain their incompetence and their failure to improve with remedial continuing medical education (CME).

METHOD

During a one-year period, 1996-97, all 27 participants in the Physician Review Program (PREP) conducted at McMaster University, a physician competency assessment program, undertook a detailed neuropsychological screening battery.

RESULTS

Nearly all physicians assessed as competent also performed well on the neuropsychological testing. However, a significant number (about one third) of the physicians who performed poorly on the competency assessment had neuropsychological impairments sufficient to explain their poor performances. The difficulties were more marked in elderly physicians.

CONCLUSION

A significant minority of incompetent physicians have cognitive impairments sufficient to explain both their incompetence and, probably, their failure to improve with remedial CME. Testing physicians for these impairments is important: to detect and treat reversible conditions, to manage irreversible conditions that preclude successful educational intervention, and to facilitate compensation in this instance. Serious consideration should be given to the incorporation of neuropsychological screening in all intensive physician review programs.

Intracranial extension of inverted papilloma: An unusual and potentially fatal complication

BACKGROUND

The purpose of this article is to define the outcome of intracranial extension of inverted papilloma and outline a rationale for management of this rare clinical presentation.

METHODS

A review of patients with intracranial extension of inverted papilloma reported in the literature (18 patients), or treated in our institution (3 patients ) was performed. The data of these 21 patients were consolidated with regard to clinical presentation, treatment, and outcome. Nine patients, including 1 of our cases, had coexisting squamous cell carcinoma and therefore were excluded from the analysis. Twelve patients with "pure" inverted papilloma formed the basis of this study.

RESULTS

The majority of patients (83%) with intracranial inverted papilloma had recurrent disease. Patients with extradural disease had a survival rate of 86% with an average follow-up of 4.4 years. Eighty-six percent of these survivors were treated with craniofacial resection. In contrast, 75% of patients with intradural inverted papilloma were dead of disease with an average follow-up of 9.3 months regardless of the treatment modality.

CONCLUSIONS

Intracranial extension of inverted papilloma is mostly associated with recurrent disease. Intracranial extradural inverted papilloma can be effectively controlled with craniofacial resection. Intracranial intradural involvement of inverted papilloma has a poor prognosis regardless of treatment. Aggressive treatment of intranasal inverted papilloma may be the most important factor in preventing intracranial presentation.

Modification of the tracheal flange of the Provox voice prosthesis for easier insertion

Prosthetic voice restoration with tracheoesophageal puncture has become the preferred method of speech rehabilitation of laryngectomized patients. Indwelling prostheses seem more advantageous because they do not necessitate frequent removal, cleansing, and insertion for the maintenance. The Provox system (Atos Medical AB, Horby, Sweden) is one of the most widely used prosthetic systems because it has several technical advantages over the other systems; however, the disproportion between its wide tracheal flange and the narrow puncture can make insertion somewhat difficult. We present a simple modification on the tracheal flange of the Provox voice prosthesis, which facilitates its insertion.

Development and implementation of a clinical pathway for patients undergoing total laryngectomy: impact on cost and quality of care

BACKGROUND

The current health care climate demands the provision of quality patient care in a cost-effective manner. Clinical pathways define the essential components of care that are provided to patients with a specific diagnosis to achieve a desired outcome within a predetermined period. Development and implementation of clinical pathways streamline the provision of quality care in the most cost-effective manner.

OBJECTIVES

To develop a clinical pathway for patients undergoing total laryngectomy and to evaluate its impact on the cost and quality of care provided to these patients.

SETTING

A tertiary care academic medical center.

PATIENTS AND METHODS

A total of 45 patients were included in the study. The clinical pathway was implemented for 15 patients, while the other 30 patients were treated without the implementation of the pathway guidelines.

MAIN OUTCOME MEASURES

Length of hospital stay, readmission rate, and hospital variable costs.

RESULTS

The clinical pathway affected all cost outcome measures. Length of stay decreased by 2.4 days (29%; P=.001), and the average hospital variable cost decreased from $3992 to $3419 per case. This represents a 14.4% reduction in cost associated with pathway implementation (P=.02). The standardization of care eliminated unnecessary variation and repetition in resource usage, resulting in overall cost reduction. Pathway implementation resulted in a lower readmission rate (7% [1/15]) than that of patients treated prior to protocol implementation (23% [7/30]).

CONCLUSION

Implementing a carefully developed clinical pathway may reduce cost without compromising the quality of care for patients undergoing total laryngectomy.

The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract

BACKGROUND

Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated.

METHODS

A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome.

RESULTS

Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months.

CONCLUSIONS

ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens.

Application of skull base techniques to pediatric neurosurgery

Techniques for skull base surgery have become well established over the last 10 years. Most of these techniques are used in adult patients for skull base tumors and neurovascular diseases. There are very few large series of pediatric patients in whom skull base approaches have been used, because of the rarity of these conditions. The authors would like to present a relatively large series of 26 pediatric patients who underwent skull base approaches for tumor resection. These tumors involved the anterior cranial base in 5 patients, the medial cranial skull base in 4 patients, and the posterior cranial base in 12 cases. Five patients had tumors that involved two or more fossae. The overall complication rate was 57%, which included temporary cranial nerve palsies, CSF leak and infection. Patients with permanent complications were 8 in number (37%). There was 1 postoperative death from pneumonia approximately 6 weeks after surgery. Complete tumor removal was achieved in 24 of the 26 patients. Skull base tumors in children are often extensive and present significant surgical challenges. Although complete tumor extirpation is the goal in most pediatric patients, this is often achieved only with some morbidity. This paper demonstrates the effectiveness of skull base approaches for these tumors and underscores the high stakes involved.

Mutations in the activation loop tyrosine of the oncoprotein v-Fps

Mutations were made in the activation loop tyrosine of the kinase domain of the oncoprotein v-Fps to assess the role of autophosphorylation in catalysis. Three mutant proteins, Y1073E, Y1073Q, and Y1073F, were expressed and purified as fusion proteins of glutathione-S-transferase from Escherichia coli and their catalytic properties were evaluated. Y1073E, Y1073Q, and Y1073F have k(cat) values that are reduced by 5-, 35-, and 40-fold relative to the wild-type enzyme, respectively. For all mutant enzymes, the Km values for ATP and a peptide substrate, EAEIYEAIE, are changed by 0.4-2-fold compared to the wild-type enzyme. The slopes for the plots of relative turnover versus solvent viscosity [(k(cat))eta] are 0.71 +/- 0.08, 0.10 +/- 0.06, and approximately 0 for wild type, Y1073Q, and Y1073E, respectively. These results imply that the phosphoryl transfer rate constant is reduced by 19- and 130-fold for Y1073E and Y1073Q compared to the wild-type enzyme. The dissociation constant of the substrate peptide is 1.5-2.5-fold lower for the mutants compared to wild type. The inhibition constant for EAEIFEAIE, a competitive inhibitor, is unaffected for Y1073E and raised 3-fold for Y1073Q compared to wild type. Y1073E and Y1073Q are strongly activated by free magnesium to the same extent and the apparent affinity constant for the metal is similar to that for the wild-type enzyme. The data indicate that the major role of autophosphorylation in the tyrosine kinase domain of v-Fps is to increase the rate of phosphoryl transfer without greatly affecting active-site accessibility or the local environment of the activating metal. Finally, the similar rate enhancements for phosphoryl transfer in v-Fps compared to protein kinase A [Adams et al. (1995) Biochemistry 34, 2447-2454] upon autophosphorylation suggest a conserved mechanism for communication between the activation loop and the catalytic residues of these two enzymes.

Prevention and Treatment of Hypertension Study (PATHS): effects of an alcohol treatment program on blood pressure

OBJECTIVE

To determine whether blood pressure is reduced for at least 6 months with an intervention to lower alcohol intake in moderate to heavy drinkers with above optimal to slightly elevated diastolic blood pressure, and whether reduction of alcohol intake can be maintained for 2 years.

DESIGN

A randomized controlled trial.

METHODS

Six hundred forty-one outpatient veterans with an average intake of 3 or more alcoholic drinks per day in the 6 months before entry into the study and with diastolic blood pressure 80 to 99 mm Hg were randomly assigned to a cognitive-behavioral alcohol reduction intervention program or a control observation group for 15 to 24 months. The goal of the intervention was the lower of 2 or fewer drinks daily or a 50% reduction in intake. A subgroup with hypertension was defined as having a diastolic blood pressure of 90 to 99 mm Hg, or 80 to 99 mm Hg if recently taking medication for hypertension.

RESULTS

Reduction in average weekly self-reported alcohol intake was significantly greater (P<.001) at every assessment from 3 to 24 months in the intervention group vs the control group: levels declined from 432 g/wk at baseline by 202 g/wk in the intervention group and from 445 g/wk by 78 g/wk in the control group in the first 6 months, with similar reductions after 24 months. The intervention group had a 1.2/0.7-mm Hg greater reduction in blood pressure than the control group (for each, P = .17 and P = .18) for the 6-month primary end point; for the hypertensive stratum the difference was 0.9/0.7 mm Hg (for each, P = .58 and P = .44).

CONCLUSIONS

The 1.3 drinks per day average difference between changes in self-reported alcohol intake observed in this trial produced only small nonsignificant effects on blood pressure. The results from the Prevention and Treatment of Hypertension Study (PATHS) do not provide strong support for reducing alcohol consumption in nondependent moderate drinkers as a sole method for the prevention or treatment of hypertension.

Sphenoclival Rathke's cleft cysts: embryology, clinical appearance and management

In summary, Rathke's cleft cysts in the extracranial skull base are rare. Untreated, they can grow to involve structures in the sphenoclival region or the cavernous sinus. Surgical removal via an approach that offers maximal visualization and minimal morbidity affords the best treatment for patients with such lesions.

The effect of positive and negative health behavior during gestation on pregnancy outcome

This study examined the effects of substance use (alcohol, tobacco and/or drugs (cocaine and/or marijuana)) and healthy maternal behavior (prenatal care, prenatal class, vitamins, regular exercise) during gestation on pregnancy outcome. Live births from the nationally representative 1988 National Maternal and Infant Health Survey were analyzed. Pregnancy outcomes (infant birth weight, weeks gestation, one and five minute Apgar scores, whether or not the infant was transferred to another hospital after delivery and whether or not the infant was rehospitalized) were studied in multiple linear regression and logistic regression models. The relationship of the interaction of substance use and healthy behaviors and outcome was studied in all models. It was found that women engaging in substance use while pregnant were less likely to engage in healthy behavior. However, in general, engaging in healthy behaviors had the largest positive effects on outcome for those women who engaged in multiple substance use while pregnant. Significant interactions between healthy and unhealthy behavior were found for birth weight, weeks gestation and five minute Apgar scores, indicating that engaging in positive health behavior may help moderate some of the deleterious consequences of substance use during pregnancy.

Extranodal lymphomas of the head and neck. A 20-year experience

BACKGROUND

Extranodal non-Hodgkin lymphoma (NHL) of the head and neck is a relatively uncommon disease. Over the last 3 decades, a variety of systems, including the Rappaport, Luke-Collins, and Working Formulation classifications, have been used to classify extranodal NHLs of the head and neck. Most studies have included a relatively small number of patients, used different modalities of therapy, and did not include all head and neck sites. These limitations make comparisons between different studies and drawing any conclusions difficult.

OBJECTIVES

To describe in a uniform fashion a relatively large number of patients with extranodal NHL of the head and neck treated at the same institution, using only the most current classification system and to describe the clinical features, behavior, and outcome of this relatively uncommon, but potentially curable disease.

DESIGN

A retrospective study of 98 patients with extranodal NHL of the head and neck. All patients were reclassified according to the Working Formulation system (regardless of the time of diagnosis) in order to uniformly define the clinical course of this disease in the head and neck.

SETTING

A tertiary care referral center.

RESULTS AND CONCLUSIONS

The sinonasal tract was the most commonly involved site (25%). If the nasopharynx (16%), tonsil (12%), and base of tongue (8%) are grouped together, this combined site (Waldeyer ring) becomes the most common site of disease (36%). Patients with tonsillar lymphoma had a 20% incidence of associated gastrointestinal involvement. Approximately 50% of the patients had associated nodal disease, and only 20% had systemic or B symptoms. Three fourths of the patients had stage I or II disease, and approximately two thirds had intermediate-grade lymphoma. Radiation therapy was the primary modality of therapy for localized disease (stages I and II), especially for low-grade lymphomas. Combination chemotherapy with or without radiation was used for more advanced disease and for intermediate- and high-grade lymphomas. Surgery was limited to establishing the diagnosis. Two thirds of the patients had a remission after initial therapy. Two thirds of these patients had no further relapse. Three fourths of the patients with relapse after initial remission died of their disease. The overall and disease-free survival rates for all patients were 60% and 50%, respectively. Outcome of therapy was related to stage and histologic grade. Patients with lymphomas of high histopathologic grade and recurrent and recurrent and disseminated disease had the poorest prognosis.

Defensible assessment of the competency of the practicing physician

When a physician's license to practice is at stake, professional acceptance and legal challenge are concerns for an organization undertaking competency assessments for practicing physicians. In 1995 the Physician Review and Enhancement Program (PREP), a program of McMaster University sponsored by the College of Physicians and Surgeons of Ontario, underwent an external review by evaluation experts. As a result, one of the four assessment tools, the Structured Office Oral, was dropped, as it was insufficiently structured to be reliable and because it did not add significantly to the other tools. The content of all assessment tools was revised based on a PREP-developed blueprint for family practice. The multiple-choice questions (MCQs) were upgraded through collaboration with Canada's physician-accrediting body, the Medical Council of Canada (MCC), by the physician assessors, who chose MCQs according to the blueprint from the MCC question bank. The standardized-patient assessment was also refined by these physicians, who developed scenarios of standardized clinical cases with predefined performance criteria. Finally, through collaboration with the American Board of Emergency Medicine, a chart-stimulated recall test, in which the physician's own patient records are used to assess the physician's practice behavior, was restructured to ensure objectivity in standardization and interpretation. The result of these changes in the assessment tools is a more standardized and structured program of assessing physicians' competencies.

Extradural pneumatocele: an unusual cause of pulsatile tinnitus

Our objective is to heighten the awareness of the clinician to the unusual features of latrogenic, pulsatile, yet nonvascular tinnitus. We present the case of an elderly white male with pulsatile tinnitus immediately following microvascular trigeminal decompression. Computed tomography revealed an extradural air collection and mastoidal fistula. The patient noticed resolution of tinnius with digital pressure over the mastoidal operative site. Treatment included exposure of the aerocele with resection of the lateral wall, fistula obliteration with wax, and abdominal fat graft. The patient noted complete resolution of his tinnitus in the recovery room. The etiology of pulsatile tinnitus can be suspected based on history and can be confirmed with corroborative imaging techniques.

Acute intravaginal misoprostol toxicity with fetal demise

We report a case of an overdose with fetal demise from the intravaginal administration of misoprostol. A 25-yr-old gravid female self-administered 6000 micrograms misoprostol intravaginally and 600 micrograms orally. She rapidly developed shaking chills, abdominal and extremity cramping, emesis, and confusion. Hyperthermia and hypotension developed within 3.5 h after drug administration, with a temperature of 41.4 degrees C (106 degrees F). Ultrasound at 3.5 h after drug administration showed no fetal movement or heart motion. A nonviable fetus was delivered by emergent cesarean section. Treatment of the mother was supportive and included intravaginal decontamination and endotracheal intubation with neuroparalytic therapy to control agitation and hyperthermia. Recovery was complete within 15 h of drug administration.

Endoscopically introduced expandable stents in laryngotracheal stenosis: the jury is still out

A new technique using endoscopically introduced, expandable stents for the management of upper airway stenosis is presented. Evaluation of this technique in the canine model forms the basis of this pilot study. Stenosis was surgically induced in a controlled fashion by resection of cartilage from the anterior cricoid arch and tracheal wall to reduce the airway diameter by approximately 50%. A period of 8 weeks was allowed for complete healing and maturation of the surgical stenosis. This was followed by endoscopic introduction of expandable titanium-mesh stents. The stents were then balloon-inflated to dilate the stenotic region. Airway patency was assessed clinically, radiologically, and endoscopically, before expansion and at 4 and 8 weeks after expansion. This assessment was followed by euthanasia of the animals and gross examination of the expanded stenotic segments. In general, the stents were well tolerated with adequate expansion of the airway. In some instances granulation tissue formation was noted around the stents. This was less pronounced when stents coated with Tecoflex (Advanced Surgical Intervention Co., San Clemente, Calif.) were used. This is probably because of their "inert" nature, which induces less tissue reaction. A literature review of the subject is presented. The significance of this endoscopic modality for management of upper airway stenosis is discussed, and the indications, alternatives, potential pitfalls, and complications are depicted.

Endoscopically Introduced Expandable Stents in Laryngotracheal Stenosis: The Jury is Still Out

A new technique using endoscopically introduced, expandable stents for the management of upper airway stenosis is presented. Evaluation of this technique in the canine model forms the basis of this pilot study. Stenosis was surgically induced in a controlled fashion by resection of cartilage from the anterior cricoid arch and tracheal wall to reduce the airway diameter by approximately 50%. A period of 8 weeks was allowed for complete healing and maturation of the surgical stenosis. This was followed by endoscopic introduction of expandable titanium-mesh stents. The stents were then balloon-inflated to dilate the stenotic region. Airway patency was assessed clinically, radiologically, and endoscopically, before expansion and at 4 and 8 weeks after expansion. This assessment was followed by euthanasia of the animals and gross examination of the expanded stenotic segments. In general, the stents were well tolerated with adequate expansion of the airway. In some instances granulation tissue formation was noted around the stents. This was less pronounced when stents coated with Tecoflex (Advanced Surgical Intervention Co., San Clemente, Calif.) were used. This is probably because of their “inert” nature, which induces less tissue reaction. A literature review of the subject is presented. The significance of this endoscopic modality for management of upper airway stenosis is discussed, and the indications, alternatives, potential pitfalls, and complications are depicted.

Squamous cell carcinoma in a thyroglossal duct cyst (TGDC): clinical presentation, diagnosis, and management

Squamous cell carcinoma arising in a TGDC is a rare event, and a high index of suspicion is therefore needed for reaching a correct preoperative diagnosis to plan adequate therapy. The work-up should include fine needle aspiration cytology and high-resolution CT scan. The recommended therapy is adequate wide resection with frozen section control of the surgical margins. For localized lesions within the TGDC (diagnosed as an incidental histological finding), the Sistrunk operation is adequate. If, however, the tumor invades surrounding structures, wider resections (which may include strap muscles, thyroid, larynx, or base of tongue) are recommended. Neck dissection is reserved for cases with nodal metastasis. There is no role for prophylactic neck dissections except perhaps for the paratracheal nodes. Postoperative radiation therapy is recommended for larger lesions, positive surgical margins, or extensive nodal disease. Strict follow-up is recommended for prolonged periods of time, because local recurrences are common and could occur many years after the initial treatment.

[Correlation between p-53 expression and clinical resistance in testicular cancer]

One of the most common cellular gene which negatively regulates the cell cycle, thus functioning as tumour suppressor gene, is the p-53 gene. The presence of this mutated gene has been correlated with, the aggressiveness of several malignant neoplasmas. Expression of the p-53 gene product protein was screened in 55 untreated human germ cell testicular tumours, furthermore a relationship between p-53 expression and clinical resistance was investigated. Using monoclonal antibody and immunoenzyme staining elevated p-53 level could be demonstrated in nuclei of embryonal carcinoma (84%) and seminoma components (56%). Most of the choriocarcinoma cases showed positive staining. Teratomas expressed this antigen negatively or scarcely. In seminomas the highest level of p-53 was stated in stage I. In contrast the opposite tendency could be demonstrated in embryonal carcinomas where p-53 was ++ positive in stage III. Between the high level of p-53 and clinical resistance a converse correlation could be stated because the resistant tumours expressed no or low, the sensitive tumours high level of p-53 protein (P 0.01). These results suggest that elevated p-53 expression could be a prognostic marker of sensitivity in testis cancer.

[Multidrug resistance of testicular cancers. (Detection of P-glycoprotein and MDR1 gene expression and their clinical connection)]

The most frequently reported alteration of multidrug-resistant cells is overexpression of a 170 kD glycoprotein (P-glycoprotein or P-170) encoding by the MDR1 gene family. Expression of the multidrug-resistance gene product P-glycoprotein was screened in 55 untreated human germ cell testicular tumors using monoclonal antibody (C219) and immunoenzyme staining. In samples out of 17 seminomatous germ cell testicular tumors (SGCT) 2 seminomas, and out of 38 non-seminomatous tumors (NSGCT) 20 carcinomas (15 teratomas, 4 embryonal carcinomas, 1 with Yolk sac differentiation and 1 embryonal rhabdomyosarcoma) showed high expression of P-glycoprotein. NSGCT-s, which are more refractory than seminomas to anticancer chemotherapy, frequently expressed P-glycoprotein. These immunohistochemically detected elevated P-170 expressions were correlated by the overexpression of MDR1 mRNA gene sequences. A relationship between clinical resistance and P-glycoprotein expression seems thus to exist in 4 teratomas 3 embryonal carcinomas, and 1 seminomas. A significant correlation (p < 0.02) between P-170 expression and clinical drug resistance in stage II-III germ cell testicular tumors could be demonstrated. The results suggest that a multidrug resistant phenotype may also occur and P-glycoprotein might contribute to drug resistance in testicular tumors.

Prevention and Treatment of Hypertension Study (PATHS). Rationale and design

Alcohol consumption has been recognized as an important correlate of blood pressure in many epidemiologic studies, but few interventional studies have been conducted to examine the effect of a reduction in alcohol intake on blood pressure. Because these studies have usually included few subjects and been of short duration, the National Heart, Lung, and Blood Institute (NHLBI), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the Veterans Affairs (VA) Cooperative Studies Program have initiated a randomized, controlled, multicenter trial to determine whether blood pressure and left ventricular mass are lowered over 6 months of alcohol moderation in non-dependent moderate to heavy drinkers (three or more drinks per day average but not alcohol dependent) with above-average normal (80 to 89 mm Hg) and mildly hypertensive (90 to 99 mm Hg) levels of diastolic blood pressure, and whether a reduction in alcohol intake can be maintained for 2 years. Eligible veterans are randomized to either an alcohol reduction intervention or a control observation group at seven clinical sites. The projected sample size is 580 participants. Alcohol intake is assessed by self-report using a retrospective diary (Chronological Drinking Record) and by various biochemical markers, including apolipoproteins, HDL cholesterol (and subfractions), and carbohydrate deficient transferrin, analyzed at a central laboratory. The alcohol intervention technique is a cognitive-behavioral program, the intensive phase of which consists of six counseling sessions over 3 months. Echocardiograms are obtained at baseline and 6 months after randomization. This trial has important implications for both the prevention and treatment of hypertension.