Progressive septal and palatal perforation secondary to intranasal cocaine abuse

Septal perforation from intranasal cocaine abuse is well recognised. We present a case of progressive septal as well as palatal perforation. Progression from septal perforation to palatal perforation occurred after cessation of intranasal cocaine abuse. This patient had a weakly positive cytoplasmic antineutrophilic cytoplasmic antibody (C-ANCA) but no histologic evidence of Wegener's Granulomatosis. The differential diagnosis for septal and palatal perforation is reviewed. This case represents the fifth reported case of palatal perforation secondary to cocaine abuse in the literature, and the second associated with positive C-ANCA.

Preoperative, intraoperative, and postoperative management of patients with obstructive sleep apnea syndrome

The patient with untreated, obstructive sleep apnea may present difficult or potentially life-threatening challenges to the surgical team. This is true even if the anticipated surgery is remote to the upper airway. Preoperative recognition of the obstructive apnea is essential as the first step in preventing potential complications. When recognized, intraoperative and postoperative initiative can result in a satisfactory outcome.

A new technique for laparoscopic splenectomy with massively enlarged spleens

Splenectomy is indicated in several hematological disorders and it can be particularly challenging in children with sickle cell disease, splenomegaly, and recurrent sequestration. Over the last 6 months, we have developed a new technique for laparoscopic splenectomy (LS) for hypersplenism and splenomegaly in five children with sickle cell disease. The average age of our patients was 6 years (range, 2-11), and the average weight was 18.7 kg (range, 13.2-30.1). On preoperative ultrasound, spleen size index ranged from 0.42 to 0.76. For the LS, four trochars were placed. One patient, who also underwent a laparoscopic cholecystectomy, had six trochars placed, two of which were used for both cholecystectomy and splenectomy. After laparoscopic mobilization of the spleen and hilar vascular stapling, a Steiner electromechanical morcellator was inserted through the 12-mm port to extract cores of splenic tissue until complete splenectomy was achieved. No patient required conversion to an open procedure or creation of a larger incision to remove the massively enlarged spleen. Operative time averaged 190 minutes; the combined LS and cholecystectomy took 245 minutes. Postoperative length of stay was <2 days for all patients. There were no complications, and no patient required postoperative transfusion. Based on these early findings, we conclude that intracorporeal coring of splenic tissue allows for safe and complete laparoscopic removal of very large spleens in small children. It provides expedient recovery and minimal postoperative pain and scarring. This new technique should enable surgeons to perform LS even in patients with massive splenomegaly, eliminating the need for large and cumbersome intracorporeal bags or the creation of additional incisions to remove the spleen.

Lymphatic mapping with isosulfan blue dye in squamous cell carcinoma of the head and neck

OBJECTIVE

To determine whether intraoperative lymphatic mapping with isosulfan blue dye and sentinel lymph node biopsy accurately demonstrates the pathway of regional metastases from mucosal sites in squamous cell carcinoma of the head and neck.

DESIGN

A prospective clinical study of intraoperative lymphatic mapping.

SETTING

An academic tertiary referral center.

PATIENTS

Patients with previously untreated squamous cell carcinoma of the head and neck whose surgical treatment included neck dissection.

INTERVENTION

Injection of isosulfan blue dye into the mucosa surrounding squamous cell carcinomas of the upper aerodigestive tract during cervical lymphadenectomy.

OUTCOME MEASURES

Correlation of the pathologic findings in the blue sentinel lymph node with those in the remaining cervical lymphatics.

RESULTS

No blue-stained cervical lymphatics were identified after injection of the mucosa surrounding the primary squamous cell carcinoma with isosulfan dye.

CONCLUSION

The technique of intraoperative lymphatic mapping with isosulfan blue dye requires further study before it can be used for the detection of occult cervical metastases in squamous cell carcinoma of the head and neck.

Mechanisms responsible for signaling and functional defects

Lymphocytes recovered from human tumors or peripheral circulation of patients with advanced cancer have abnormalities in signaling via the T cell receptor (TcR) or Fc gamma RIII. Here we show that in comparison with normal T lymphocytes, those isolated from tumor-involved lymph nodes (LNLs) or blood (PBLs) of patients with head and neck carcinoma (HNC) have a variety of defects in expression and function of signaling molecules, including significantly decreased expression of TcR-associated zeta and epsilon chains, decreased Ca2+ flux, as well as impaired kinase activity following triggering with anti-CD3 antibodies and altered expression of downstream protein tyrosine kinase p56lck. Some of these alterations were demonstrable not only in isolated LNLs or PBLs but also in situ in patients' biopsies. Expression of mRNA for the zeta chain in LNLs was comparable with that seen in normal T cells. Significantly, LNLs of patients with HNC were shown to contain numerous apoptotic, TUNEL+ [TdT-mediated dUTP nick-enol labelling] cells in situ. Co-expression of CD3-epsilon+ and TUNEL+ in the same cells in situ was observed. Co-incubation of normal activated T cells or Jurkat cells with HNC cell lines induced apoptosis in a substantial proportion of lymphocytes. HNC cell lines and HNC in situ were shown to express FasL, while LNLs in tumor-involved lymph nodes were Fas+. These data suggest that signaling defects, which are commonly found in lymphocytes of HNC patients, might be a part of the process of apoptosis induced by the tumor in lymphocytes found in its milieu.

Perineural invasion in squamous cell carcinoma of the head and neck

OBJECTIVE

To determine if perineural invasion (PNI) of small nerves affects the outcome of patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract.

DESIGN

Retrospective clinicopathological study of patients with at least 2 years of follow-up and with negative margins and no prior, synchronous, or metachronous SCC.

SETTING

Academic otolaryngology department.

PATIENTS

One hundred forty-two patients who had SCC of the oral cavity, oropharynx and hypopharynx, or larynx resected between 1981 and 1991.

INTERVENTION

Surgery with or without adjuvant therapy.

MAIN OUTCOME MEASURES

Local recurrence was examined with respect to PNI, nerve diameter, and microvascular or microlymphatic invasion. Perineural invasion was correlated with lymph node metastasis, extracapsular spread, and survival.

RESULTS

Perineural invasion of nerves less than 1 mm in diameter was present in 74 patients, lymphatic invasion in 53, and vascular invasion in 9. Perineural invasion was significantly associated with local recurrence (23% for PNI vs 9% for no PNI; P=. 02), and disease-specific mortality (54% mortality for PNI vs 25% for no PNI; P<.001). With extralaryngeal tumors, PNI was associated with nodal metastasis (73% vs 46%; P=.03). Perineural invasion was not associated with extracapsular spread (P=.47). Microvascular invasion, lymphatic invasion, and nerve diameter were not significantly related to local recurrence.

CONCLUSIONS

Perineural invasion of small nerves is associated with an increased risk of local recurrence and cervical metastasis and is, independent of extracapsular spread, a predictor of survival for patients with SCC of the upper aerodigestive tract.

Implications of cartilage invasion in surgically treated laryngeal carcinoma

BACKGROUND

Cartilage invasion adversely affects the outcome of laryngeal carcinoma treated with radiotherapy. The UICC and American Joint Committee on Cancer (AJCC) classify laryngeal carcinoma with cartilage invasion as T4 or stage IV.

METHODS

This study examines the prognostic significance of cartilage involvement in T3,4 N0,1 glottic carcinoma treated with total laryngectomy. Patients with tumor extension to pharynx, tongue, and thyroid gland, extracapsular spread, positive resection margins, and less than 2 years' follow-up were excluded.

RESULTS

Sixty-seven pT3 (cartilage free of tumor) and 37 pT4 (cartilage invaded by tumor) cases were studied. The difference between the pT3 and pT4 groups in terms of local or regional recurrence, distant metastasis, and determinate survival was not significant.

CONCLUSIONS

The results of this study question the use of cartilage invasion as a staging parameter for surgically treated laryngeal carcinoma. However, further studies with larger sample sizes are required to fully elucidate the prognostic significance, if any, of cartilage invasion in surgically treated cancer of the larynx.

Endogenous IL-2 in cancer cells: a marker of cellular proliferation

We have previously demonstrated that interleukin-2 (IL-2) receptors, IL-2 protein, and mRNA for IL-2 are present in human carcinomas in vitro and in vivo. Carcinoma cells synchronized in the G2/M-phase of the cell cycle express significantly more intracytoplasmic IL-2 as well as IL-2R-beta and -gamma than tumor cells in the G0/G1-phase. Here we evaluated immunohistologically the cell cycle-dependent distribution of the proliferation-associated Ki-67 antigen and expression of the cytokine IL-2 in four different carcinoma cell lines. In addition, 34 tissue samples from patients with squamous cell carcinomas of the head and neck were simultaneously analyzed for Ki-67 and IL-2 expression and the data were correlated to the histological grade of the tumors. All tumor cell lines were shown to express IL-2 in the Golgi complex. The strongest IL-2 expression was seen in tumor cells undergoing mitosis, identified by double staining with the antibody to Ki-67. In the tumor tissue, the highest level of co-expression of IL-2 and Ki-67 was observed in poorly differentiated carcinomas, with a labeling index (LI) of 67. 2% for IL-2 and 68.8% for Ki-67. Well-differentiated carcinomas showed a significantly lower expression of both proteins (LI 35.0% for IL-2 and 26.5% for Ki-67). The correlation between the labeling indices was statistically significant (r = 0.747; p<0.001). These results demonstrate that IL-2 expression in human carcinoma tissues is strongly associated with cell proliferation and significantly correlates with the histological tumor grade.

Thyroid gland after total laryngectomy: CT appearance

PURPOSE

To determine the computed tomographic (CT) appearance of the normal thyroid gland after total laryngectomy, because the high attenuation (or heterogeneous attenuation) of thyroid parenchyma was misinterpreted as tumor on several CT studies.

MATERIALS AND METHODS

A search of computerized clinical files compiled from January 1996 through August 1997 yielded data on 24 patients who had undergone laryngectomy and subsequent CT of the neck. From these 24 patients, CT findings were available in 21. Because one patient had undergone total thyroidectomy and was excluded from the study, a retrospective review was performed in the remaining 20 patients.

RESULTS

In 14 patients, unilateral thyroid tissue was present; in the other six there was bilateral thyroid tissue not connected by an isthmus. Thus, there were 26 remaining thyroid lobes, of which six were round and 20 were oval or lobular. Nineteen lobes showed homogeneously high attenuation (including one scanned without use of contrast material), six showed heterogeneous high attenuation or contained areas of hyperlucency, and one was obscured by streak artifact.

CONCLUSION

Thyroid tissue can appear as unilateral or bilateral asymmetric masses on neck CT scans after laryngectomy. Gland tissue can show homogeneously or heterogeneously high attenuation. Familiarity with the varied postoperative appearance of normal thyroid gland can prevent its misdiagnosis as tumor.

Gait and long cane kinematics: a comparison of sighted and visually impaired subjects

Although visually impaired individuals have used the long cane to increase mobility for many years, few empirical studies have examined the effectiveness of this tool. The purposes of this research were to determine if these cane procedures provide adequate protection for visually impaired individuals and to compare sighted and visually impaired gait mechanics. Seven sighted (four females, three males) and five visually impaired subjects (two females, three males) were videotaped at 60 Hz by two cameras situated at opposite 45 degrees angles to the subjects' frontal plane so that three-dimensional coordinates could be calculated via direct linear transformation. One-way analyses of variance were calculated on 17 variables to determine if there was a significant biomechanical difference between sighted and visually impaired gait at an adjusted alpha = .003. The results showed that for both groups the cane tip touched outside where the foot landed and that the only variable significantly different between the two groups was resultant cane velocity. The major conclusion of this research was that present cane techniques may not provide adequate protection for visually impaired individuals since the purpose of mobility training is to have the person touch the ground with the cane tip at the foot contact positions.

QT interval changes following neck dissection. A stratified prospective study

Studies from Europe have suggested that neck dissection, especially right radical neck dissection, causes a dangerous prolongation of the QT interval. Sudden cardiac arrest due to QT prolongation has been reported following right radical neck dissection. We investigated the prevalence of QT interval prolongation following neck dissection. Electrocardiogram tracings from 45 patients who underwent different combinations of neck dissection were studied. Preoperative and postoperative tracings were interpreted by a cardiologist blinded to the patient identification of each tracing. There were 28 unilateral neck dissection patients and 17 bilateral neck dissection patients eligible for analysis. There were 7 patients in the classic right radical neck dissection group, and only 3 of these had no neck dissection on the left. Comparisons of preoperative versus postoperative corrected QT interval for all subjects did not indicate a significant change. Stratification by neck dissection type (radical, modified or selective, and carotid artery resection) or by side dissected (left, right, or both) also showed no significant differences. No malignant arrhythmias were encountered. Thus, in contrast to the European experience, our findings show no significant predictable change in the QT interval after any of the combinations of neck dissection. Head and neck surgeons should be aware of the possibility of postoperative QT interval prolongation following neck dissection, although in the absence of other risk factors it appears to be a rare occurrence.

Effectiveness of selective neck dissection for management of the clinically negative neck

OBJECTIVE

To determine the effectiveness of selective neck dissection for management of the clinically negative neck in head and neck squamous cell carcinoma.

DESIGN

A retrospective comparison of patients treated electively with selective neck dissection and comprehensive neck dissection.

SETTING

Academic tertiary referral center.

PATIENTS

Patients with clinically negative necks and previously untreated head and neck squamous cell carcinoma.

INTERVENTION

Elective neck dissection, surgical treatment of the primary lesion, and postoperative radiotherapy as indicated.

OUTCOME MEASURES

Regional recurrence, distant metastasis, and disease-free survival.

RESULTS

Selective neck dissection was as effective as comprehensive procedures for staging the clinically negative neck. Occult metastases had a statistically significant effect on patient outcome as measured by distant metastasis.

CONCLUSION

Elective neck dissection provides invaluable staging information, which guides the decision for adjuvant therapy.

Development of distant metastasis after treatment of advanced-stage head and neck cancer

BACKGROUND

The recognition of risk factors for the development of distant metastasis is necessary for identifying high-risk patients who may benefit from systemic therapy. Previous investigations studying possible risk factors have been heterogeneous, with patients having varied forms of therapy. This study is designed to evaluate the clinical and histologic risk factors for the development of distant metastasis (DM) in patients with only advanced-stage head and neck squamous cell carcinoma after surgery and radiotherapy.

METHODS

Retrospective analysis of a cohort of potentials with-surgically treated stage III and IV squamous cell carcinoma of the hypopharynx, tongue, and supraglottic larynx between 1988-1992. The cohort consisted of 130 patients of which 30 patients developed DM as the initial site of failure. All patients underwent surgical resection of the primary. Neck dissection was performed in 26 of 30 (87%0 patients who developed distant metastasis. Almost all patients received radiation therapy. Patients who initially developed DM (DM group) were compared with patients who did not initially develop DM (no DM group) with respect to certain clinical and histo-pathological factors.

RESULTS

The majority of patients in the DM group had advanced T stage and clinically palpable cervical lymph nodes (73% and 93% respectively). In the no DM group, most patients had advanced T stage (85%) but 42% of the patients had stage NO necks (p < .05). Eighty-eight percent of patients in the DM group and 60% of patients in the no DM group had histological evidence of extracapsular spread of tumor from cervical lymph nodes (p < .05). Three or more positive lymph nodes were found in 69% of patients who developed DM and in only 35% of patients in the no DM group (p < .05). Age, gender, primary site, history of radiation therapy, perineural invasion and tumor grade were not associated with a higher risk for DM (p > .05).

CONCLUSION

Patients wit clinically palpable neck disease (N1-3), histological evidence of metastatic nodal disease, extracapsular spread, and three or more positive lymph nodes are at greater risk of developing failure at distant sites. This subset of patients should have an extensive evaluation for distant metastatic disease and should be considered for systemic therapy.

Comparison of ampicillin/sulbactam versus clindamycin in the prevention of infection in patients undergoing head and neck surgery

BACKGROUND

Patients requiring major oncologic head and neck surgery are at high risk for postoperative wound infection when the surgical site is contaminated by secretions from the upper aerodigestive tract. Studies to identify agents active in the prevention of postoperative wound infection may serve to reduce patient morbidity.

METHODS

Patients scheduled for a major contaminated head and neck surgical procedure were randomly assigned to receive either ampicillin/sulbactam or clindamycin. Medication was administered 1 to 2 hours prior to surgery and every 6 hours, for a total of five doses. Postoperatively, patients were followed daily for the development of wound infection or other septic complication.

RESULTS

A total of 242 patients were enrolled in the study; 119 received ampicillin/sulbactam, and 123 received clindamycin. A total of 169 patients were considered evaluable. Of the evaluable patients, 14% in each group developed a postoperative wound infection. There were no statistically significant differences between the number of days to onset of wound infection, nor was there a statistically significant difference in the rate of non-wound infections in the two groups. There were no statistically significant differences between the intent to treat group and the evaluable group of patients.

CONCLUSION

It is concluded that ampicillin/sulbactam is as safe and effective as clindamycin in preventing postoperative wound infection following major head and neck surgery.

Salivary gland lymphoid infiltrates associated with lymphoepithelial lesions: a clinicopathologic, immunophenotypic, and genotypic study

The criteria for distinguishing benign lymphoepithelial lesions (BLEL) from low grade B-cell lymphomas of mucosa-associated lymphoid tissue (MALT) type in salivary glands and the significance of genotypically documented clonality in this setting are controversial. In addition, the clinical implications of a neoplastic diagnosis are unclear. The histopathologic features of 68 specimens from 49 patients with at least one salivary gland biopsy with LEL together with available clinical data were, therefore, reviewed. Paraffin section immunohistochemical (IHC) stains for kappa, lambda, CD3, CD20, and CD43; in situ hybridization (ISH) for kappa and lambda; and polymerase chain reaction (PCR) for immunoglobulin (Ig) HC rearrangement were performed. The 61 salivary gland specimens were classified as BLEL-13, BLEL with monocytoid B-cell (MBC) halos (BLEL-halo-8), low grade B-cell lymphoma of MALT type with confluent zones of MBC or other atypical lymphocytes (ML-MALT-24), low grade B-cell lymphoma of MALT type with monoclonal plasma cells (ML-MALT-PC-12), and high grade B-cell lymphoma of MALT type (MALT-high grade-4). Soft tissue and perineural invasion was not observed in BLEL and was most common in the MALT lymphomas. Lymph node involvement was identified in six patients at the time of their salivary gland MALT lymphomas but in none with BLEL. CD43+ B cells were seen most commonly in ML-MALT but were present in all other categories except MALT-high grade. Clonal B cells were identified by PCR in 5 of 12 BLEL, 5 of 8 BLEL-halo, 17 of 22 ML-MALT, 6 of 10 ML-MALT-PC, and 3 of 3 MALT-high grade biopsies. All ML-MALT-PC were clonal by ISH or IHC. Repeat biopsies in 14 patients most commonly showed a BLEL/ML-MALT lesion in an ipsilateral or contralateral salivary gland with one transformation to a MALT-high grade. Although only a few patients are known to have received chemoradiation or radiation therapy, most patients with low-grade lesions have pursued an indolent course. These data show the presence of two types of borderline lesions within the spectrum of lymphoid proliferations associated with salivary gland LEL. One has clonal B cells without histological features of neoplasia and the other nonconfluent MBC extending beyond the confines of LEL ("halos"). They share some features with the infrequent nonneoplastic BLEL and others with the more common low-grade B-cell lymphomas of MALT. A few high-grade B-cell lymphomas of MALT were also identified including a rare example of transformation from a low- to high-grade lesion. The optimal therapeutic approach for the borderline and low-grade lesions and the reason why so many of the lymphoproliferative lesions associated with LEL remain localized to the neck remain to be defined.

Reaction time and assessments of cognitive effort as predictors of eyewitness memory accuracy and confidence

The authors investigate reaction time, subjective assessments of memory processing, and confidence as predictors of memory for the details of a crime. The authors also examine the mediation of a previously identified difference between recognition tasks and recall tasks in the correlation between confidence and accuracy. College undergraduates (n = 111) answered either recognition or recall questions. Reaction time and subjective assessments of cognitive effort were both negatively related to confidence and accuracy. Subjective assessments, however, were superior predictors of confidence, whereas reaction time was a unique predictor of accuracy. The reaction time-confidence and reaction time-accuracy correlations were stronger under recall conditions than under recognition conditions. Multiple regression results suggested a possible explanation for the superior insight of recall participants into memory accuracy.

Impact of rater knowledge on sexually abused and nonabused girls' scores on the Draw-A-Person: Screening Procedure for Emotional Disturbance (DAP:SPED)

Human figure drawings collected from a clinical sample of 20 sexually abused and 20 nonsexually abused girls were randomly assigned to 1 of 2 case descriptions: Actual, in which raters were told the girls' actual abuse status, or Pretend, in which raters were told that drawings were made by girls with the opposite abuse status. Using the Draw-A-Person: Screening Procedure for Emotional Disturbance (DAP:SPED) scoring system developed by Naglieri, McNeish, and Bardos (1991), three raters independently scored 44 randomly ordered protocols, 4 of which were commonly rated as checks for rater accuracy and observer drift. Results revealed no significant effect for girls' abuse status or the case description given to raters, thereby suggesting that the DAP:SPED is sufficiently objective to withstand the confounding influence of varying case descriptions.

Lack of serologic evidence for Helicobacter pylori infection in head and neck cancer

BACKGROUND

Several epidemiologic investigations have established a link between Helicobacter pylori infection and gastric malignancies. Because the stomach is in continuity with the oral cavity and the bacterium has been isolated from dental plaque and saliva, we hypothesized that H. pylori infection of the upper aerodigestive tract might result in mucosal disruption, allowing for subsequent transformation by known carcinogens such as tobacco and alcohol.

METHODS

To test this hypothesis, we assayed for the presence of IgG antibodies to H. pylori in the serum of 21 patients with squamous cell carcinoma of the head and neck (SCCHN) and 21 matched controls without a history of head and neck cancer.

RESULTS

The incidence of seropositivity in the SCCHN patients was 57% and in the controls, 62% (p > 0.05).

CONCLUSIONS

These data do not support an etiologic role for H. pylori infection in head and neck cancer.

Management of tumors of the parapharyngeal space

Benign and malignant tumors can arise from any of the structures contained within the parapharyngeal space. Such tumors are very rare, however. Also, malignant tumors from adjacent areas (eg, the pharynx) can extend into the parapharyngeal space by direct growth, or distant tumors may metastasize to the lymphatics within the space. Although the history and physical examination can provide clues to the site of origin and nature of a parapharyngeal space tumor, imaging studies are more useful for defining the site of origin and extent of the mass, as well as its vascularity and relationship to the great vessels of the neck and other neurovascular structures. Surgery is the mainstay of treatment. The surgical approach chosen should facilitate complete tumor extirpation with minimal morbidity. Irradiation is administered as primary therapy in patients with unresectable tumors, poor surgical candidates, and selected other patients. Radiation therapy is also used after surgery for high-grade malignancies or when wide surgical margins cannot be achieved.

Lack of serologic evidence for Helicobacter pylori infection in head and neck cancer

BACKGROUND

Several epidemiologic investigations have established a link between Helicobacter pylori infection and gastric malignancies. Because the stomach is in continuity with the oral cavity and the bacterium has been isolated from dental plaque and saliva, we hypothesized that H. pylori infection of the upper aerodigestive tract might result in mucosal disruption, allowing for subsequent transformation by known carcinogens such as tobacco and alcohol.

METHODS

To test this hypothesis, we assayed for the presence of IgG antibodies to H. pylori in the serum of 21 patients with squamous cell carcinoma of the head and neck (SCCHN) and 21 matched controls without a history of head and neck cancer.

RESULTS

The incidence of seropositivity in the SCCHN patients was 57% and in the controls, 62% (p > 0.05).

CONCLUSIONS

These data do not support an etiologic role for H. pylori infection in head and neck cancer.

Fine mapping of an imprinted gene for familial nonchromaffin paragangliomas, on chromosome 11q23

Hereditary nonchromaffin paragangliomas (PGL; glomus tumors; MIM 168000) are mostly benign, slow-growing tumors of the head and neck region, inherited from carrier fathers in an autosomal dominant fashion subject to genomic imprinting. Genetic linkage analysis in two large, unrelated Dutch families assigned PGL loci to two regions of chromosome 11, at 11q23 (PGL1) and 11q13.1 (PGL2). We ascertained a total of 11 North American PGL families and confirmed maternal imprinting (inactivation). In three of six families, linkage analysis provided evidence of linkage to the PGL1 locus at 11q23. Recombinants narrowed the critical region to an approximately 4.5-Mb interval flanked by markers D11S1647 and D11S622. Partial allelic loss of strictly maternal origin was detected in 5 of 19 tumors. The greatest degree of imbalance was detected at 11q23, distal to D11S1327 and proximal to CD3D. Age at onset of symptoms was significantly different between fathers and children (Wilcoxon rank-sum test, P < .002). Affected children had an earlier age at onset of symptoms in 39 of 57 father-child pairs (chi2 = 7.74, P < .006). However, a more conservative comparison of the number of pairs in which a child had > or = 5 years earlier age at onset (n = 33) vis-a-vis that of complementary pairs (n = 24) revealed no significant difference (chi2 = 1.42, P > .2). Whether these data represent genetic anticipation or ascertainment bias can be addressed only by analysis of a larger number of father-child pairs.