Impact on Radiation Therapy Recommendation and Treatment Modality for Patients with Ductal Carcinoma In Situ Using the 7Gene Biosignature: Analysis of the PREDICT Study

PURPOSE/OBJECTIVE(S)

Breast conserving surgery (BCS) followed by adjuvant radiotherapy (RT) has been a mainstay in the treatment of DCIS based on multiple randomized trials demonstrating a local recurrence benefit with RT. However, these studies have failed to identify subsets of patients who did or did not benefit from adjuvant RT after BCS, raising concerns regarding both over and undertreatment. Thus, better prognostic and predictive tools are needed to appropriately risk stratify patients and understand their benefit of RT. The 7-gene predictive DCIS biosignature provides a validated score (DS) for women undergoing BCS that assesses their 10-year risk of in-breast and invasive recurrence with and without adjuvant RT. This trail was designed to evaluate the decision impact of the 7-gene predictive biosignature score on DCIS treatment recommendations.

MATERIALS/METHODS

The PREDICT study is a prospective, multi-institutional trial for patients who received DCISionRT testing as part of their routine care. The registry includes females 26 and older who are diagnosed with DCIS, are candidates for BCS, and eligible for RT. Treating physicians completed treatment recommendation forms before and after receiving test reports to capture surgical, radiation and hormonal treatment (HT) recommendations and patient preferences. Analysis was performed in 2,012 patients treated at 63 clinical sites.

RESULTS

Median age was 62 years old with 32% grade 3 and 10% size 2.5 cm or greater. Post-test, RT recommendation changed for 38% of patients (p<0.001), with a net reduction of 20% in patients recommended to receive RT(p<0.001). The DCISionRT test results had the greatest impact (OR 26.2, 95% CI 19.1-36.4, when analyzed categorically using DS>3 cut-off; 2.3 per DS, 95% CI 2.1-2.6, when evaluated continuously) on post-test RT recommendation in multivariable analysis when compared to all other factors including patient preference, patient clinical and tumor pathological factors, patient race/ethnicity, treatment facility, physician specialty. The post-test RT recommendation rate increased with increasing DS (0-2, 2-4, 4-10) on a categorical basis, with odds ratios of 6.8 DS (2-4 vs 0-2), and 35.0 for DS (4-10 vs 0-2). After DCISionRT test result, patient preference was the second most important factor in post-testing RT recommendation. There was also a significant change in the modality of RT recommended to 34% of those patients recommended RT pre-test and post-test by radiation oncologists (n = 937), with intensified RT modality for higher DS (p<0.001) and de-escalation for lower DS (p<0.001).

CONCLUSION

This analysis of over 2,000 patients demonstrates significant changes in recommendations to add or omit RT based on the 7-gene predictive. The integration of DCISionRT into clinical decision processes has substantial impact on recommendations aimed at optimal management to prevent over- or under-treatment.

Limitations in the Application of Clinicopathologic Factors Alone in Predicting Radiation Benefit for Women with Low-Risk DCIS after Breast Conserving Surgery: The Impact of a 7-Gene Biosignature Based on 10-Year Ipsilateral Breast Recurrence (IBR) Rates

PURPOSE/OBJECTIVE(S)

Most women diagnosed with ductal carcinoma in situ (DCIS) receive radiotherapy (RT) after breast conserving surgery (BCS); however, clinical trials show that over 70% of women with BCS alone will not have a recurrence and therefore not benefit from RT. Traditionally, clinicopathologic (CP) factors have been used to select for whom to de-escalate treatment, but prospective trials have failed to identify a low risk CP group that did not benefit from RT with respect to local control. This study assessed the re-classification of patients with low-risk CP into Risk groups defined by the 7-gene biosignature and compared to 10-yr IBR rates.

MATERIALS/METHODS

Women (n = 926) from four international DCIS cohorts treated with BCS had formalin-fixed paraffin embedded tissue samples analyzed at a CLIA lab (Laguna Hills, CA). CP low-risk patients were identified using a) RTOG-9804-like criteria [Nuclear Grade 1 or 2 & Size ≤2.5 cm & non-Palpable & Screen Detected & margin negative (no-ink on tumor)] and b) MSKCC-like criteria [low-risk score<220, determined using nomogram weighted factors (excluding: number of re-excisions and RT treatment), and using no-ink-on-tumor instead of close margin]. The 7-gene DCIS biosignature combined biomarkers with CP factors (age, size, palpability, and margin status) using an algorithm reporting a Decision Score (DS) and Residual Risk subtype (RRt). Women with low-risk CP were classified into biosignature Low Risk (DS≤2.8, no RRt) or High Risk (DS>2.8 +/- RRt) groups. 10yr in-breast event (IBR) rates with and without RT were assessed by Kaplan-Meier rates and Cox proportional hazard analyses.

RESULTS

Overall, 37% of all women were classified into the biosignature Low Risk group, while 51% and 34% were classified into CP low-risk groups (RTOG-9804-like, MSKCC-like, respectively). The biosignature Low Risk group (n = 338) had a 10-yr IBR risk of 5.6% after BCS and no significant RT benefit (absolute RT benefit = 0.8%, p = 0.70), 99% negative predictive value (NPV) for RT benefit. CP low-risk groups had 10-yr IBR rates of 12% and 8% after BCS without RT with absolute 6% (p = 0.04) and 4% (p = 0.1) IBR rate reductions with RT. The biosignature reclassified 51% and 63% of CP low-risk patients into the biosignature High Risk group. Importantly, these patients had higher IBR rates without RT (20% and 12%) and significant 13% (p = 0.005) and 8% (p = 0.01) absolute IBR rate reductions from RT. CP low-risk patients with concordant biosignature Low Risk demonstrated no significant RT benefit.

CONCLUSION

The 7-gene predictive biosignature more reliably identified patients with low 10-yr IBR rates and no significant RT benefit than the traditional CP low-risk criteria (RTOG-9804-like, MSKCC-like). Importantly, those CP low-risk patients who were re-classified as biosignature High Risk had increased 10-year IBR rates and significant RT benefit.

Dosimetric Analysis of Major Wound Complications Following Preoperative Ultra-Hypofractionated Radiation Therapy for Soft Tissue Sarcoma

PURPOSE/OBJECTIVE(S)

Preoperative radiation therapy (RT) for soft tissue sarcomas (STS), delivered with conventional fractionation, has been shown to reduce long-term toxicity at the expense of increased postoperative major wound complications (MWC). Ultra-hypofractionated RT has emerged as a potential alternative preoperative modality with early but comparable outcomes to conventional regimens. However, limited data are available evaluating dosimetric, patient, and treatment specific factors associated with development of MWC in this setting.

MATERIALS/METHODS

This IRB approved review included STS patients treated with preoperative 5 fraction daily RT followed by surgical resection within 7 days. Patients were evaluated for MWCs in association with patient and tumor characteristics, dosimetric parameters, and treatment techniques. MWCs were defined as a return to operating room, readmission for wound care or IV antibiotics, and persistent deep packing for >120 days. Prescription isodose line, PTV mean dose and the PTV volume exposed to 105% and 110% of prescribed dose were recorded. Dose to tissue likely to be involved in wound healing was assessed by creating a 1 cm thick superficial skin strip within 2 cm of the PTV which was then evaluated for volume, mean dose, V15, V21, V27, and V30. Secondary endpoints were locoregional control (LRC), metastasis free survival (MFS), and overall survival (OS).

RESULTS

A total of 31 patients with a median age of 66 years (range 28-87) and a median follow up of 21 months (IQR 8-43) were included. All patients received 30 Gy in 5 fractions using IMRT/VMAT. There were 11 upper limb (36%) and 20 lower limb (65%) tumors included. Median time to resection following RT was 1 day (IQR 0-3). Median tumor size was 8 cm (IQR 5-13). MWC occurred in 13 patients (42%) with 10 patients (32%) requiring additional surgery. Dehiscence and infection requiring IV antibiotics occurred in 12 (39%) and 6 patients (19%), respectively. RT plans were predominately prescribed to the PTV mean (87%) with a median prescription isodose of 97% (IQR 96-97) and PTV mean dose of 3110 cGy (IQR 3089-3142). Median PTV volume, mean dose, and volume of PTV receiving 105% and 110% of the prescribed dose were higher in the MWC cohort although none reached significance. Similarly, for the 1 cm skin strip the median volume, mean dose, V30, V27, V21, and V15 were all higher in the MWC cohort without significant difference. Among patient, treatment, and tumor factors: tumor size, location, grade, margin status, type of wound closure, and prior non-oncologic resection were not associated with MWC. LRC, MFS, and OS at 3-years were 96%, 67%, and 76%, respectively.

CONCLUSION

Although not reaching significance, increased plan homogeneity and reduced dose/volume relationships in proximity to the skin trended to reduced MWC in this limited cohort. Multi-institutional collaboration may be warranted to better identify factors associated with MWC in patients treated with preoperative ultra-hypofractionated RT.

Outcomes with Five Fraction Image-Guided Partial Breast Irradiation to Reduced Target Volumes

PURPOSE/OBJECTIVE(S)

The use of 5-fraction partial breast irradiation has been shown in a randomized trial to provide comparable rates of local control and reduced toxicities as compared to standard fractionation whole breast irradiation. The initial technique utilized a 2 cm expansion on the lumpectomy cavity (1 cm for clinical target volume [CTV], and 1 cm planning target volume [PTV]) without consistent image guidance (ex. cone beam computed tomography [CBCT]) or motion management recommendations. We present clinical outcomes using a 5-fraction image guided PBI technique (IG-PBI) to reduced target volumes for patients with early-stage breast cancer.

MATERIALS/METHODS

A retrospective review of an IRB approved institutional registry was performed to identify patients treated with IG-PBI. A total of 258 patients with early-stage breast cancer (Stage 0-IIA) receiving IG-PBI were identified. Patients received a dose of 30 Gy in 5 fractions delivered daily or every other day. An expansion of 1 cm on the lumpectomy cavity was used for those patients using deep inspiration breath hold (DIBH) while an expansion of 1.5 cm was utilized for those not using DIBH. All patients received daily CBCT. Plans were delivered using intensity-modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) technique; while the prescription isodose line covered the PTV, the 26 Gy line was allowed to expand beyond the PTV. Kaplan-Meier analyses were used to assess rates of local control and survival. Patient demographics, stage, hormone therapy use, recurrence, mortality, and toxicity data were collected. Survival was analyzed with Kaplan-Meier curve.

RESULTS

Median age at diagnosis was 67 years (range 40-87) with a median follow-up of 29 months (IQR 22-40). Forty-six (18%) patients had in situ disease, 200 (78%) patients T1 tumors, and 12 (5%) patients had T2 tumors. Two hundred thirty-four (91%) patients were White, 15 (6%) were Black, and 9 (4%) were other races. One hundred ninety-six (76%) patients received endocrine therapy, and 16 (6%) patients received chemotherapy. Thirty-two (12%) patients developed grade 1 dermatitis and no grade 2 events were observed. One (0.4%) patient had a cardiac event (aortic stenosis) 19 months after breast radiotherapy. At last follow-up, one (0.4%) patient had a local recurrence and one (0.4%) developed a distant metastasis, with no regional nodal failures. Overall, 4 (1.5%) patients had died, all due to other causes. At 3 years, locoregional control was 99.4%.

CONCLUSION

Outcomes with IG-PBI demonstrate low rates of local recurrence and limited toxicity. The use of reduced target volumes is not associated with increased rates of local recurrence.

Meta-Analysis of Five Fraction Preoperative Radiotherapy for Soft Tissue Sarcoma

PURPOSE/OBJECTIVE(S)

There is increasing interest in shorter courses of radiation therapy (RT) in the management of soft tissue sarcoma (STS). Studies investigating preoperative ultra-hypofractionated 5-fraction RT for STS are few and often limited to single institution experiences with less than 50 patients. We therefore performed a meta-analysis to determine the efficacy and safety of preoperative 5-fraction RT for STS based on currently published literature, with an analysis evaluating effects of dose delivered.

MATERIALS/METHODS

This study level meta-analysis was conducted using Bayesian methods. Statistical estimation for risk of outcome rates were conducted by posterior mean and 95% highest posterior density (HPD) intervals. Studies with two-year local control (LC) and description of major wound complications (MWC) per the CAN-NCIC-SR2 study were included in this meta-analysis, and these served as the primary endpoints. Secondary endpoints included rates of acute and late toxicity. A total of ten studies were identified; seven met inclusion criteria (Kalbasi 2020, Kubicek 2021, Leite 2021, Spalek 2021, Gobo Silva 2021, Bedi 2022, Mayo 2022). Three studies (Kosela-Paterczyk 2014, Kosela-Paterczyk 2021, Potkrajcic 2021) did not include adequate information to accurately determine 2-year LC or MWC. Subgroup analyses were performed for ≥30 Gy vs <30 Gy as the EQD2 of 30 Gy in 5 fractions for an α/β of 3-4 is 50-54 Gy, equivalent to standard preoperative RT fractionation.

RESULTS

A total of 208 patients were included from seven studies. Five studies used ≥30 Gy (n = 144) and 2 studies <30 Gy (n = 64). The median follow-up was 29 months (range: 21-57). Primary tumor location was lower extremity in 68%, upper extremity in 22%, and trunk in 10%. In studies with available information, most tumors were intermediate (27%, 46/169) or high grade (67%, 114/169) and 50% (79/158) were >10 cm. Two-year LC for the entire cohort was 96.9% (95% HPD: 0.9374-0.9889) and the rate of MWC was 30.6% (95% HPD: 0.2106-0.4149). Acute grade 2 and 3 dermatitis was seen in 12.7% and 2.2%, respectively. Late grade 2 toxicities included fibrosis (11.1%), stiffness (6.0%), and lymphedema (4.0%) and late grade 3 toxicities included fibrosis (1.8%) and stiffness (0.4%). Grade 4 toxicity was rare and included fibrosis (0.6%) and stiffness (0.6%). There was a trend toward improved LC with ≥ 30 Gy (95% HPD: 0.949-0.997 vs 0.838-0.986). There was no difference in MWC (95% HPD: 0.185-0.420 vs 0.172-0.553) or late toxicity between the two groups. Acute grade 3 dermatitis was seen less frequently with regimens <30 Gy (95% HPD: 0-0 vs 0.009-0.072), however rare overall.

CONCLUSION

Preoperative 5-fraction RT for STS demonstrates excellent 2-year LC with MWC and toxicity similar to standard fractionation preoperative RT. Multi-institutional trials with a universal RT protocol and larger sample size are warranted to assess this novel treatment paradigm.

Five Fraction Accelerated Partial Breast Irradiation vs. Intraoperative Radiation Therapy for Early-Stage Breast Cancer

PURPOSE/OBJECTIVE(S)

Accelerated partial breast irradiation (APBI) represents an alternative to whole breast irradiation (WBI), reducing the target volume and potentially treatment duration. APBI delivered in 5 fractions with intensity modulated radiation therapy (IMRT) has been shown to have comparable outcomes to WBI with reduced toxicity profiles. In contrast, intraoperative radiation therapy (IORT) offers patients the potential to complete adjuvant radiation therapy in a single treatment. While early data were initially promising, concerns regarding long-term rates of local recurrence exist. We present a comparison of 5 fraction APBI versus IORT.

MATERIALS/METHODS

We performed a retrospective review of 473 patients with early-stage breast cancer (Stage 0-IIA) treated at a single institution with 258 receiving APBI and 215 IORT from October 2011 to May 2021. APBI patients received 30 Gy in 5 fractions delivered with IMRT daily or every other day. IORT patients received 20 Gy in 1 fraction prescribed to the applicator surface delivered at the time of surgery. Kaplan-Meier analysis was used to estimate locoregional control rates and overall survival among the 2 groups.

RESULTS

Mean age was 70.7 years old (IQR:67-74) for the IORT patients and 66.6 years old (IQR:62-72) for the APBI patients (p<0.001). Median follow up was 5.7 years for IORT patients and 2.4 years for APBI patients (p<0.001). For IORT patients, 11%/83.5%/5.5% of patients and for APBI 17.8%/77.5%/4.7% of patients had Tis/T1/T2 disease (p = 0.005). With regards to adjuvant therapies, 79%/76% of IORT/APBI patients were offered endocrine therapy (p = 0.50) and 1.4%/6.2% chemotherapy (p = 0.008). Recurrence at any time was seen in 7.9% (n = 17) of patients receiving IORT as compared to 0.8% (n = 2) of patients receiving APBI. APBI was however no differences in recurrence free survival (92.6% vs. 98.5%, p = .079) or overall survival were noted (92.8% vs. 95.1%, p = 0.99).

CONCLUSION

In a series of almost 500 patients with stage 0-IIA breast cancer, IORT was associated with higher rates of locoregional recurrence compared to APBI with no survival difference at 5 years. These outcomes, consistent with other series and current guidelines, suggest a limited role for IORT as monotherapy following breast conserving surgery.

ICT, Gender Inequality, and Income Inequality: A Panel Data Analysis Across Countries

ICT has been long recognized as a driver of sustainable development goals (SDGs). This study examines the relationship between ICT, gender (in)equality (SDG 5), and income inequality (SDG 10). We conceptualize ICT as an institutional actor and use the Capabilities Approach to theorize the relationships between ICT, gender inequality and income inequality. This study uses publicly available archival data to conduct a cross-lagged panel analysis of 86 countries from 2013 to 2016. The key contributions of the study include the establishment of the relationship between (a) ICT and gender inequality and (b) gender inequality and income inequality. We also make methodological contributions to the field by employing cross-lagged panel data analysis to further our understanding of the links between ICT, gender equality, and income inequality over time. Our findings have implications for both research and practice, which are discussed.

A Cross-Country Examination of Internet Penetration and the Economic Participation of Women: The Influence of Social Capital and Gender Equality

One of the most widespread types of digital technology is the Internet which more than 5 billion people or 63.1% of the world’s population use as of April 2022. Previous studies have established that the relationship between digital technologies, such as the Internet, and labour market participation is worth investigating. While it is widely accepted that digital technologies help in women’s social and economic inclusion, the female labour participation force observed across countries remains slow and varied. There remains a limited investigation into the influence of internet penetration on the changes in the labour market outcomes for women. There is also scope for research on how the Internet affects women’s economic participation from a social and gender perspective. Prior research shows that social capital has been linked to labour allocation. Studies also show that variations in ideas on gender roles are significant for women’s decisions to find employment. We, therefore, investigate how widespread penetration of the Internet has influenced the economic participation of women in this study. We also investigate how social capital and gender equality play a role in the above relationship across countries. Our study uses archival data to conduct a panel analysis of 66 countries from 2014 to 2021. The study’s results show that the penetration of internet and the economic participation of women are positively associated. This study also found that the link between the penetration of internet and the economic participation of women is mediated by social capital. Gender equality was also found to moderate the above relationship, such that social capital had a stronger mediation influence on the association between internet penetration and women’s economic engagement in nations with comparatively lower levels of gender equality.

Bone mineral density at femoral neck and lumbar spine in adults with type 1 diabetes: a meta-analysis and review of the literature

We performed a meta-analysis to evaluate the femoral neck and lumbar spine bone mineral density (BMD) in adults with type 1 diabetes (T1D) compared with controls. Adults with T1D have modestly lower BMD at femoral neck and lumbar spine than adults without diabetes.

INTRODUCTION

Fracture risk is four to sixfold higher in adults with T1D. Since BMD is one of the major contributors for fracture risk, we performed a meta-analysis to evaluate differences in femoral neck and lumbar spine BMD between adults with T1D and controls.

METHODS

MEDLINE, Ovid, and the Cochrane library and abstracts from various scientific meetings were searched. Studies reporting the femoral neck and/or lumbar spine BMD in adults (age > 20 years) with T1D in comparison with people without diabetes were selected. General linear mixed models were used to assess differences in BMD at femoral neck and lumbar spine between subjects with T1D and controls adjusting for age, sex, and dual x-ray absorptiometry (DXA) instruments.

RESULTS

Sixteen studies met the inclusion criteria. The femoral neck BMD was modestly lower in adults with T1D compared to controls (-0.055 g/cm²; 95% CI: -0.065, -0.045). There were no differences in lumbar spine BMD between adults with T1D and controls (0.0062 g/cm²; 95% CI -0.04, 0.016). However, in a sensitivity analysis, lumbar spine BMD was modestly lower in adults with T1D compared to controls (-0.035 g/cm²; -0.049, -0.02). Studies using Lunar DXA instruments have reported higher lumbar spine and femoral neck BMD compared to studies using Hologic DXA instruments.

CONCLUSION

Femoral neck and lumbar spine BMD were modestly lower in adults with T1D compared to controls. However, this modest reduction in femoral neck and lumbar spine BMD cannot explain much higher observed fracture risk in adults with T1D.

Development of a computer model to predict aortic rupture due to impact loading

Aortic injuries during blunt thoracic impacts can lead to life threatening hemorrhagic shock and potential exsanguination. Experimental approaches designed to study the mechanism of aortic rupture such as the testing of cadavers is not only expensive and time consuming, but has also been relatively unsuccessful. The objective of this study was to develop a computer model and to use it to predict modes of loading that are most likely to produce aortic ruptures. Previously, a 3D finite element model of the human thorax was developed and validated against data obtained from lateral pendulum tests. The model included a detailed description of the heart, lungs, rib cage, sternum, spine, diaphragm, major blood vessels and intercostal muscles. However, the aorta was modeled as a hollow tube using shell elements with no fluid within, and its material properties were assumed to be linear and isotropic. In this study fluid elements representing blood have been incorporated into the model in order to simulate pressure changes inside the aorta due to impact. The current model was globally validated against experimental data published in the literature for both frontal and lateral pendulum impact tests. Simulations of the validated model for thoracic impacts from a number of directions indicate that the ligamentum arteriosum, subclavian artery, parietal pleura and pressure changes within the aorta are factors that could influence aortic rupture. The model suggests that a right-sided impact to the chest is potentially more hazardous with respect to aortic rupture than any other impact direction simulated in this study. The aortic isthmus was the most likely site of aortic rupture regardless of impact direction. The reader is cautioned that this model could only be validated on a global scale. Validation of the kinematics and dynamics of the aorta at the local level could not be done due to a lack of experimental data. It is hoped that this model will be used to design experiments that can reproduce field relevant aortic ruptures in the laboratory. Only after such experiments have been run, can local validation be examined and the model judged to be acceptable or unacceptable.

Otologic and audiologic evaluation of human immunodeficiency virus-infected patients

PURPOSE

To quantify the incidence of ear disease in patients infected with human immunodeficiency virus (HIV).

MATERIALS AND METHODS

This is a descriptive case series of HIV-positive patients, with data collected using an otologic questionnaire. otologic examination, audiologic evaluation, and chart review. The study was performed at an urban University Hospital's outpatient Infectious Disease and Otolaryngology clinics. A consecutive sample of 50 HIV-infected patients volunteered for this study. Ten subjects refused. Almost all patients received public assistance for medical care. Descriptive results were tabulated. Audiometric data were analyzed for ear, Centers for Disease Control (CDC) group, otologic complaint, and age effects. Data were compared with established norms.

RESULTS

Twenty-three men and 27 women with a mean age of 40 years and mean duration of HIV disease of 3.5 years were studied. Eighteen percent of patients were in category CDC-A, 38% in CDC-B, and 44% in CDC-C. Otologic complaints were more prevalent than expected: 34% of patients reported aural fullness, 32% dizziness, 29% hearing loss, 26% tinnitus, 23% otalgia, and 5% otorrhea. Results of the neuro-otologic examination were abnormal in 33%. Tympanometric examination was abnormal in 21%. A significant degree of high-frequency sensorineural hearing loss was observed. CDC-B and CDC-C patients had worse hearing than CDC-A patients at 3 frequencies. Patients who complained of hearing loss had significantly worse otoacoustic emission results and hearing results than patients who did not, at all frequencies except 1,000 Hz. Patients in their 30s had better hearing in the speech frequencies than did all other patients.

CONCLUSIONS

Ear disease affects up to 33% of HIV-infected patients. Otitis media is a frequent finding. Sensorineural hearing loss is more severe in patients with more severe HIV infection. Patients with ear complaints have demonstrable otopathology. Continuation of this preliminary descriptive work is necessary.

The frequency of cricopharyngeal dysfunction on videofluoroscopic swallowing studies in patients with dysphagia

PURPOSE

Dysphagia associated with cricopharyngeal dysfunction (CPD) is of particular interest to the otolaryngologist because it may respond to cricopharyngeal myotomy. There is a wide variation in the reported incidence of cricopharyngeal dysfunction in patients with dysphagia. This can be attributed to the different populations being studied, the lack of uniform criteria for diagnosis, and to different techniques used to evaluate patients. We have reviewed videofluoroscopic swallowing studies (VSS) conducted on 443 consecutive patients with complaints of dysphagia to identify the incidence of cricopharyngeal dysfunction.

PATIENTS AND METHODS

The patient population consists of 443 veterans with complaints of dysphagia who were evaluated by videofluoroscopic swallowing studies at the Department of Veterans Affairs Medical Center, East Orange, NJ, between November 1988 and March 1993.

RESULTS

Cricopharyngeal dysfunction was diagnosed radiologically as the appearance of a shelf in the posterior column of barium at the level of the cricoid cartilage. It was identified in 10 of 177 (5.7%) patients with neurological disorders, in 7 of 142 (4.9%) patients with head and neck or esophageal tumors, and in 11 of 124 (8.9%) patients with other medical problems.

CONCLUSION

These results do not support the notion that cricopharyngeal dysfunction is an important factor in a significant proportion of patients with dysphagia. It is recognized that videofluoroscopy may not always detect cricopharyngeal dysfunction and that better criteria for identifying this entity are needed.

Constituents of two varieties of Indian dill

Two varieties of Indian dill, Anethum sowa, are available. They differ morphologically and have a different oil composition. They have a low dillapiole content (12–15%) and have a high content of carvone-dihydrocarvone (50–64%).