Validation of a Novel Allergy-Specific Domain for the 22-Item Sino-Nasal Outcomes Test

OBJECTIVES

To develop and assess the validity of a novel allergy-specific domain for the 22-item sino-nasal outcomes test (SNOT-22), to provide a new tool that efficiently quantifies the impact of allergic rhinitis (AR) concurrent with chronic rhinosinusitis.

STUDY DESIGN

Prospective validation study.

SETTING

Tertiary care hospital and community-based clinic.

METHODS

Proposed items were developed based on clinician and patient input, and further assessed via factor analysis and for internal consistency (n = 1987). Items were then additionally assessed for convergent and discriminant validity (n = 415), applying data from concurrent completions of the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE), Mini-Rhinoconjunctivitis Quality-of-Life Questionnaire (MiniRQLQ), and validated global health assessments. Assessments of intra-rater reliability, responsiveness to change, and qualitative input were also performed.

RESULTS

Factor analysis demonstrated that proposed allergy items mapped to a single domain. Items were internally consistent (Cronbach α: 0.80 within domain, 0.91 within all SNOT). In assessments of convergent validity, domain scores were associated with MiniRQLQ (Spearman's ρ: 0.46, 95% confidence interval [CI]: 0.30-0.59) and NOSE scores (0.36, 95% CI: 0.27-0.44). The novel items also discriminated among clinical states: a 1-point increase in domain score was associated with an 8.32 (95% CI: 5.43-12.75) increase in the odds of prompting a visit for allergy-related symptoms and a 1.52 (95% CI: 1.13-2.05) increase in the odds of positive allergy testing. Intra-rater reliability was substantial (Cohen's κ: 0.8, 95% CI: 0.8-0.9), and responsiveness to change was demonstrated (mean difference: -0.6, 95% CI: -0.8 to -0.4).

CONCLUSIONS

This novel domain is a valid, efficient measure of AR alongside rhinosinusitis.

Longitudinal Analysis of Early Hearing Detection and Intervention Program Performance

OBJECTIVES

Early hearing detection and intervention (EHDI) is a newborn hearing screening system created to detect infants with hearing loss (HL) and intervene to reduce language and communication impairment. Early hearing detection (EHD) consists of three sequential stages: identification, screening, and diagnostic testing. This study longitudinally reviews each stage of EHD in each state and proposes a framework to improve utilization of EHD data.

DESIGN

A retrospective public database review was conducted, accessing publicly available data from the Centers for Disease Control and Prevention. Summary descriptive statistics were utilized to generate a descriptive study of EHDI programs in each U.S. state from 2007 to 2016.

RESULTS

Data over 10 years from 50 states as well as Washington, DC were included in this analysis, creating up to 510 data points per analysis. Hundred percent (85 to 105) (median [min to max]) of newborns were identified by and entered EHDI programs. Ninety-eight percent (51 to 100) of identified infants completed screening. Of the infants who screened positive for HL, the proportion that received diagnostic testing was 55% (1 to 100). The overall proportion of infants who failed to complete EHD was 3% (1 to 51). Of the infants who fail to complete EHD 70% (0 to 100) are from missed screenings, 24% (0 to 95) are from missed diagnostic testing, and 0% (0 to 93) are from missed identification. Although there are more infants missed at screening, it was estimated, with limitations, that there is an order of magnitude more infants with HL among those who did not complete diagnostic testing compared with those who did not complete screening.

CONCLUSIONS

Analysis demonstrates high completion rates at both identification and screening stages, whereas the diagnostic testing stage demonstrates low and highly variable completion rates. The low completion rates at diagnostic testing create a bottleneck in the EHD process and the large variability impedes the comparison of HL outcomes across states. Analysis also demonstrates that among all stages of EHD, whereas the largest number of infants are missed at screening, the largest number of children with HL are likely missed at diagnostic testing. Therefore, a focus by individual EHDI programs on addressing causes of low diagnostic testing completion rates would yield the greatest increase in the identification of children with HL. Potential causes of low diagnostic testing completion rates are further discussed. Finally, a new vocabulary framework is proposed to facilitate further study of EHD outcomes.

Precision clinical trials: a framework for getting to precision medicine for neurobehavioural disorders

The goal of precision medicine (individually tailored treatments) is not being achieved for neurobehavioural conditions such as psychiatric disorders. Traditional randomized clinical trial methods are insufficient for advancing precision medicine because of the dynamic complexity of these conditions. We present a pragmatic solution: the precision clinical trial framework, encompassing methods for individually tailored treatments. This framework includes the following: (1) treatment-targeted enrichment, which involves measuring patients' response after a brief bout of an intervention, and then randomizing patients to a full course of treatment, using the acute response to predict long-term outcomes; (2) adaptive treatments, which involve adjusting treatment parameters during the trial to individually optimize the treatment; and (3) precise measurement, which involves measuring predictor and outcome variables with high accuracy and reliability using techniques such as ecological momentary assessment. This review summarizes precision clinical trials and provides a research agenda, including new biomarkers such as precision neuroimaging, transcranial magnetic stimulation-electroencephalogram digital phenotyping and advances in statistical and machine-learning models. Validation of these approaches - and then widespread incorporation of the precision clinical trial framework - could help achieve the vision of precision medicine for neurobehavioural conditions.

Increased IFRD1 Expression in Human Colon Cancers Predicts Reduced Patient Survival

BACKGROUND

Colon cancer (CRC) is the third most common cancer worldwide. CRC develops through combinations of genetic and epigenetic changes. However, there is marked heterogeneity in the "driver gene" mutational profiles within and among colon cancers from individual patients, and these are not sufficient to explain differences in colon cancer behavior and treatment response. Global modulation of the tumor landscape may play a role in cancer behavior. Interferon-related developmental regulator 1 (IFRD1) is a transcriptional co-regulator that modulates expression of large gene cassettes and plays a role in gut epithelial proliferation following massive intestinal resection.

AIMS

We address the hypothesis that increased IFRD1 expression in colon cancers is associated with poorer patient survival.

METHODS

Tumor and normal tissue from colon cancer patient cohorts from the USA, Spain, and China were used for this study. Cancers were scored for the intensity of IFRD1 immunostaining. The primary clinical outcome was overall survival defined as time from diagnosis to death due to cancer. Kaplan-Meier method and log-rank analysis were used to assess the association between IFRD1 expression and survival.

RESULTS

Almost all (98.7%) colon cancers showed readily detectable IFRD1 expression, with immunoreactivity primarily in the tumor cytoplasm. High IFRD1 colon cancer expression was significantly associated with decreased 5-year patient survival. Patients in the American cohort with high IFRD1 expression had a poorer prognosis.

CONCLUSIONS

We have demonstrated that high IFRD1 protein expression in colon cancer is associated with poorer patient prognosis, suggesting a potential role for IFRD1 in modulating tumor behavior.

Annealing Stability Study of Co20Fe60B20\MgO\ Co20Fe60B20 Perpendicular Magnetic Tunnel Junctions

A full Co20Fe60B20\MgO\ Co20Fe60B20 perpendicular magnetic tunnel junction (pMTJ) with (Co\Pt) multilayers as pinning layers and different functional multilayers stacks were made and annealed at different temperatures. The tunneling magnetoresistance ratio (TMR) and MgO barrier resistance-area product (RA) were measured and analyzed as a function of annealing temperature. The TMR of pMTJs dramatically declines with increasing annealing temperatures from 320 °C to 400 °C while the RA increases with temperature from 375 °C to 450 °C. The pMTJs and partial stacks were also measured in a vibrating sample magnetometer (VSM). We found that the (Co\Pt) multilayers are very stable and maintain a magnetization direction perpendicular to the film plane up to 450 °C. However, the magnetization direction of the CoFeB above and below the MgO barrier rotates from perpendicular to in-plane with increasing annealing temperature. Furthermore, the CoFeB layer influences the adjacent (Co\Pt) layers to rotate at the same time. The pMTJs' elemental depth profiles in the as deposited and annealed states were determined by Secondary Ion Mass Spectrometry (SIMS). We found that Boron and Tantalum migrate towards the top of the stack. The other elements (Platinum, Cobalt, Ruthenium, and Magnesium) are very stable and do not interdiffuse during annealing up to 450°C.

The Feasibility of Using Metacognitive Strategy Training to Improve Cognitive Performance and Neural Connectivity in Women with Chemotherapy-Induced Cognitive Impairment

OBJECTIVE

To evaluate the feasibility and preliminary effect of metacognitive strategy training (MCST) on cognitive performance and on neural connectivity in the frontoparietal network in women with chemotherapy-induced cognitive impairment (CICI) following treatment for breast cancer.

METHODS

A single-group pre/post study was conducted. After completing the baseline assessment battery and neuroimaging, the participants completed a 12-session MCST intervention. Following the completion of the intervention, the subjects completed the same assessment battery and neuroimaging as was completed at baseline within 4 weeks after the intervention. The key inclusion/exclusion criteria for this study were: completed chemotherapy for treatment of breast cancer, no other neurological or psychiatric diagnoses, self-reported CICI, and no contraindications to the use of MRI.

RESULTS

MCST had a small-to-large positive effect on all primary (cognitive) and secondary (quality of life and psychosocial) behavioral outcome measures (r = -0.12 to -0.88). There was also a positive change in functional connectivity in a frontoparietal cognitive control network connection in 6 of the 10 subjects, which was correlated to changes in the behavioral measures.

CONCLUSIONS

This study found that MCST was associated with a positive effect on cognitive performance and neural connectivity in women with CICI following treatment for breast cancer.

Abstract CT070: Biomarker and clinical response of oral cavity squamous cell carcinoma to the MEK 1/2 inhibitor trametinib: A phase II neoadjuvant window of opportunity clinical trial

Purpose: Ras/MEK/ERK pathway activation is common in oral cavity squamous cell carcinoma (OCSCC). To determine biomarker and clinical tumor response of MEK inhibition in patients with OCSCC, we performed a neoadjuvant window of opportunity trial in which the MEK inhibitor trametinib was administered before surgery (NCT01553851).

Patients and Methods: Patients with untreated Stage II-IV OCSCC were scheduled to receive trametinib 2 mg/day orally for 7-14 days prior to surgery (last dose 24 hours before surgery). Tumor specimens from the primary site obtained before and after trametinib underwent immunohistochemistry staining for p-ERK1/2 (a marker of Ras/MEK/ERK activation) and CD44 (a protein upregulated by ERK activation), which represented the primary endpoint. Secondary endpoints included comparison of changes in pre- and post-trametinib tumor measurement by clinical examination and in metabolic activity (SUVmax) by FDG-PET/CT (partial response: >25% reduction). Adverse events (AE) and surgical/wound complications were evaluated.

Results: Of the 20 enrolled patients, 17 (85%) completed the study as planned. Three patients withdrew from the study due to AE, two (nausea; duodenal perforation) related to trametinib and one (constipation) related to narcotics. The most common drug-related AE was mild rash (9/20 patients, 45%). Nineteen patients (95%) underwent surgery and neck dissection with no unexpected surgical/wound complications. Fifteen patients (75%) were evaluable for the primary biomarker endpoint. 5 (25%) patients either had insufficient pre- or post-treatment biopsies or did not complete the trial. Reduction in p-ERK1/2 expression occurred in 7/15 evaluable patients (47%), whereas a reduction in CD44 occurred in 3/15 (20%). Reduction in tumor size (median 40%, range -74 to +17%) assessed by clinical examination was observed in 12/17 (71%) evaluable patients, and partial metabolic tumor response assessed by FDG-PET/CT was observed in 5/13 (38%) patients.

Conclusions: Trametinib was safe to administer as a neoadjuvant treatment in patients with OCSCC and several patients displayed significant reduction in Ras/MEK/ERK pathway activation, and in clinical and metabolic tumor responses. Further exploration of trametinib response in OCSCC patients is warranted.

Citation Format: Ravindra Uppaluri, Ashley Winkler, Tianxiang Lin, Jonathan Law, Bruce Haughey, Brian Nussenbaum, Randal Paniello, Jason Rich, Jason Diaz, Loren Michel, Tanya Wildes, Gavin Dunn, Dorina Kallogjeri, Paul Zolkind, Farrokh Dehdashti, Barry Siegel, Rebecca Chernock, James S. Lewis, Jay Piccirillo, Douglas Adkins. Biomarker and clinical response of oral cavity squamous cell carcinoma to the MEK 1/2 inhibitor trametinib: A phase II neoadjuvant window of opportunity clinical trial. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT070.

Psychometric evaluation of the Sinonasal Outcome Test-16 and activity impairment assessment in acute bacterial sinusitis

OBJECTIVE

To validate the Sinonasal Outcome Test-16 and Activity Impairment Assessment in patients with acute bacterial sinusitis.

STUDY DESIGN

Data were used from a phase III clinical trial designed to evaluate the efficacy and safety of moxifloxacin 400 mg once daily for 5 consecutive days in the treatment of acute bacterial sinusitis. The psychometric properties and factor structure of the 2 measures were assessed.

SETTING

Participants were given the measures to self-complete using either a telephone voice response system or a paper-and-pencil format.

SUBJECTS AND METHODS

Three hundred seventy-four patients with acute bacterial sinusitis were used in the analysis. Patients received either a placebo or 400 mg moxifloxacin once daily. Patients were then reviewed at test of cure and follow-up. All analyses were conducted on a combined sample of placebo and active treatment patients.

RESULTS

The Sinonasal Outcome Test-16 was associated with minimal missing data at baseline but a higher proportion by test of cure. There was no evidence of floor or ceiling effects and no significant skew. The Activity Impairment Assessment also had low missing data at baseline and no obvious floor or ceiling effects, but the data were not normally distributed. Both measures had good internal consistency. Convergent and divergent validity as well as sensitivity and the minimally important difference are also reported.

CONCLUSION

The measures both have good psychometric properties and are suitable for use with patients with acute bacterial sinusitis. Both instruments are sensitive. The minimal important difference estimates for the Sinonasal Outcome Test-16 are quite high but are similar to estimates reported previously.

Methodological aspects of clinical trials in tinnitus: a proposal for an international standard

Chronic tinnitus is a common condition with a high burden of disease. While many different treatments are used in clinical practice, the evidence for the efficacy of these treatments is low and the variance of treatment response between individuals is high. This is most likely due to the great heterogeneity of tinnitus with respect to clinical features as well as underlying pathophysiological mechanisms. There is a clear need to find effective treatment options in tinnitus, however, clinical trials differ substantially with respect to methodological quality and design. Consequently, the conclusions that can be derived from these studies are limited and jeopardize comparison between studies. Here, we discuss our view of the most important aspects of trial design in clinical studies in tinnitus and make suggestions for an international methodological standard in tinnitus trials. We hope that the proposed methodological standard will stimulate scientific discussion and will help to improve the quality of trials in tinnitus.

Functional Connectivity Networks in Nonbothersome Tinnitus

Objective: To capture resting state functional connectivity in a group of nonbothered tinnitus patients in order to assess the impact of tinnitus in cortical neuroplasticity.

Method: Cross-sectional study to examine differences in functional connectivity (FC) in a nonbothered tinnitus group compared to a healthy control group. Enrollment ranged from October 2010 to April 2011. Tinnitus participants were recruited from Washington University. FC differences between the 2 groups were studied by examing 58 seed regions of interest.

Results: The median age for the 18 subjects was 54 years (interquartile range [IQR] 52 to 57), 66% were men, 90% were white, median Tinnitus Handicap Inventory (THI) score was 8 (IQR 4 to 14), and a median Beck Depression Index score of 1 (IQR 0 to 5). The median age for the control group was 46 (IQR 39 to 54) and 52% were men. Of the 58 seeds analyzed, no regions were significantly different in functional connectivity among the nonbothered tinnitus group when compared to the control group.

Conclusion: Among non-bothered tinnitus patients, the tinnitus percept does not appear to alter the functional connectivity of the auditory corte or other key cortical regions.

Functional connectivity networks in nonbothersome tinnitus

OBJECTIVE

To assess functional connectivity in cortical networks in patients with nonbothersome tinnitus compared with a normal healthy nontinnitus control group by measuring low-frequency (<0.1 Hz) spontaneous blood oxygenation level-dependent (BOLD) signals at rest.

DESIGN

Case-control.

SETTING

Academic medical center.

PARTICIPANTS

Nonbothersome, idiopathic subjective tinnitus for at least 6 months (n = 18) and a normal healthy nontinnitus control group (n = 23).

MAIN OUTCOME MEASURE

Functional connectivity differences in 58 a priori selected seed regions of interest encompassing cortical loci in the default mode, attention, auditory, visual, somatosensory, and cognitive networks.

RESULTS

The median age of the 18 subjects was 54 years (interquartile range [IQR], 52-57), 66% were male, 90% were white, median Tinnitus Handicap Inventory (THI) score was 8 (IQR, 4-14), and a median Beck Depression Index score was 1 (IQR, 0-5). The median age for the control group was 46 years (IQR, 39-54), and 52% were male. Of the 58 seeds analyzed, no regions had significantly different functional connectivity among the nonbothersome tinnitus group when compared with the control group.

CONCLUSION

Among nonbothersome tinnitus patients, the tinnitus percept does not appear to alter the functional connectivity of the auditory cortex or other key cortical regions. Trial Registration ClinicalTrials.gov Identifier: NCT01049828.

Use of the modified SNOT-16 in primary care patients with clinically diagnosed acute rhinosinusitis

OBJECTIVE

To determine the reliability, validity, responsiveness, and the minimal important difference (MID) for the Sinonasal Outcome Test-16 (SNOT-16) in the measurement of disease-specific quality of life (QOL) in adults with acute rhinosinusitis.

STUDY DESIGN

Randomized controlled trial to evaluate antibiotic treatment for acute rhinosinusitis.

SETTING

Ten community practices in St Louis, Missouri.

METHODS

The modified SNOT-16 was completed at baseline (by both face-to-face and telephone interviews) and by telephone interview at 3, 7, and 10 days by 166 adults with acute rhinosinusitis diagnosed clinically using standardized criteria (36% were male, 78% were white). Considering severity and frequency, patients rated how much they were bothered by each item using a 4-point scale. The mean SNOT-16 score (ranging from 0 [no problem] to 3 [large problem]) was compared with the patients' global assessment of change to evaluate responsiveness and the MID.

RESULTS

The instrument was easy to use and took less than 5 minutes to complete. The SNOT-16 score identified statistically significant differences in the hypothesized direction for those reporting more or less severe symptoms (P = .02) and more or less bother (P < .001) demonstrating construct-related validity. The Cronbach α ranged from 0.82 to 0.91, demonstrating high internal consistency. There was a statistically significant decrease in scores with time (multivariate analysis of variance, P < .001). The effect sizes at days 3, 7, and 10 were 1.45, 2.34, and 2.90, respectively, indicating high sensitivity to clinical change. The MID was 0.5 units.

CONCLUSION

The modified SNOT-16 is a valid instrument to assess effectiveness of interventions to improve disease-specific QOL in adults with acute rhinosinusitis.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00377403.

Evaluation of clinical research training programs using the clinical research appraisal inventory

The purpose of this study was to measure change in clinical research self-efficacy after participating in KL2, postdoctoral and predoctoral clinical research training programs at Washington University School of Medicine. We surveyed program participants using a 76-item version of the Clinical Research Appraisal Inventory (CRAI). Principal components analysis (PCA) examined the CRAI’s underlying factor structure; Cronbach alpha measured the internal consistency of items on each subscale and the overall CRAI. CRAI score changes from baseline to 1-year follow-up were assessed using repeated-measures analysis of variance. All 29 KL2, 47 postdoctoral, and 31 TL1 scholars enrolled 2006-2009 (mean age 31.6 years, range 22-44; 59.6% female; 65.4% white) completed baseline surveys. Of these participants, 22 KL2, 17 postdoctoral, and 21 TL1 scholars completed the 1-year follow-up assessment. PCA resulted in a seven-factor solution with 69 items (alphas > 0.849 for each subscale and 69-item CRAI). Significant improvements at 1-year follow-up were observed across all programs for Study Design/Data Analysis ( p = .016), Interpreting/Reporting/Presenting ( p = .034), and overall CRAI ( p = .050). Differences between programs were observed for all but one subscale (each p < .05). Clinical research self-efficacy increased 1 year after clinical research training. Whether this short-term outcome correlates with long-term clinical research productivity, requires further study.

Distinctive characteristics of non-small cell lung cancer in the young: A SEER analysis of patients under 40 years old

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Background: Non-small cell lung cancer (NSCLC) is diagnosed at a median age of 65 and is rare in younger people. The presentation and natural history of the disease in younger patients (age < 40) may not be the same as in typical, or older patients (age > 40). Methods: We identified in the SEER (Suveillance Epidemiology and End Results) registry, all patients diagnosed with NSCLC from 1990 to 2005. Patients were grouped by age at diagnosis, < 40 or = 40. Data on gender, cell type, extent of disease, overall survival, and cause of death were obtained from the SEER database. Cancer-specific survival was defined as time to death from cancer, in which case deaths from other causes are counted as censoring events. Results: In the SEER registry, 3,421 patients with NSCLC diagnosed at an age < 40 were identified, along with 323,566 patients age > 40. Younger patients were more likely to be women, 48% vs 43% (p < 0.0001), and more likely to present with distant disease 53% vs 49% (p < 0.0001). Adenocarcinoma and other, or non-specified types of NSCLC were more common in younger patients, 38% and 44% respectively, vs. 35% and 32% in the older patients. Squamous cell carcinoma was far less common in younger patients, 8.5% vs 23.5% in older patients (p<0.0001 for all comparisons). Overall and cancer specific survivals were higher for the younger cohort within each stage group. For example, 3 year overall survival for patients with distant (metastatic) disease was 8.8% in the younger patients and 4.7% in the older patients. For local disease, 5 year cancer specific suvivals were 92% in the younger patients and 62% in the older patients. Conclusions: Patients with NSCLC who are < 40 years old at diagnosis are more likely to be women and have adenocarcinoma and far less likely to have squamous cell carcinoma. Overall and cancer-specific survivals are better in these younger patients.

No significant financial relationships to disclose.

Developing core sets for patients with head and neck cancer based on the International Classification of Functioning, Disability and Health (ICF)

Problems in functioning are frequently seen in survivors of head and neck cancer (HNC) and proof to have increasing impact on their quality of life. With the approval of the International Classification of Functioning, Disability and Health (ICF) by the World Health Assembly in May 2001, we can now rely on a globally accepted framework and classification system based on a bio-psycho-social mode to assess and compare functional outcome. To make the ICF-classification with more than 1.400 categories applicable to every-day clinical practice, ICF core sets are established. The objective of this paper is to outline the proposed development process for the ICF core set for HNC and to invite international experts to participate in this process. The ICF core set will be defined at a Consensus conference, which will integrate evidence from preparatory studies, namely: (a) a systematic literature review regarding the outcome measures of clinical trails and observational studies, (b) semi-structured patient interviews, (c) international experts participating in a internet-based survey and (d) cross-sectional, multi-center studies for clinical applicability. To validate the ICF core set field-testing will follow. The ICF provides useful standards of clinical rehabilitation practice, research and teaching. Its application stimulates comparability of outcome parameters, eventually improving understanding of functioning and disability. The ICF can function as a new language, simplifying communication and cooperation between various professional backgrounds and between health professionals and their patients eventually leading to a more effective and economic rehabilitation. The ICF core set for HNC is designed to translate the benefits of the ICF into clinical routine. The development of ICF core sets is an inclusive and open process. Anyone who wishes to actively participate is invited to contact the project coordinator (Uta.Tschiesner@med.uni-muenchen.de). Individuals, institutions and associations can be formally associated as partners of the project.

Prophylactic and therapeutic functions of T-type calcium blockers against noise-induced hearing loss

Cochlear noise injury is the second most frequent cause of sensorineural hearing loss, after aging. Because calcium dysregulation is a widely recognized contributor to noise injury, we examined the potential of calcium channel blockers to reduce noise-induced hearing loss (NIHL) in mice. We focused on two T-type calcium blockers, trimethadione and ethosuximide, which are anti-epileptics approved by the Food and Drug Administration. Young C57BL/6 mice of either gender were divided into three groups: a 'prevention' group receiving the blocker via drinking water before noise exposure; a 'treatment' group receiving the blocker via drinking water after noise exposure; and controls receiving noise alone. Trimethadione significantly reduced NIHL when applied before noise exposure, as determined by auditory brainstem recording. Both ethosuximide and trimethadione were effective in reducing NIHL when applied after noise exposure. Results were influenced by gender, with males generally receiving greater benefit than females. Quantitation of hair cell and neuronal density suggested that preservation of outer hair cells could account for the observed protection. Immunocytochemistry and RT-PCR suggested that this protection involves direct action of T-type blockers on alpha1 subunits comprising one or more Ca(v)3 calcium channel types in the cochlea. Our findings provide a basis for clinical studies testing T-type calcium blockers both to prevent and treat NIHL.

Long-Term Follow-Up for Children Treated With Surgical Intervention for Chronic Rhinosinusitis

OBJECTIVES/HYPOTHESIS

The goal of this study is to retrospectively compare the long-term, 10 year, outcomes of surgical versus medical management of young children with chronic rhinosinusitis.

STUDY DESIGN

This is a retrospective, age-matched, cohort outcome study performed at a tertiary-care hospital.

METHODS

Two groups of young children (2-5 yr old) with chronic rhinosinusitis were treated with endoscopic sinus surgery or medically managed and evaluated 10 years after their initial therapy. Of the 131 eligible patients, 67 could be located and consented to participate in the study. Six symptoms (day cough, night cough, irritability or crankiness, headaches, nasal airway obstruction, and purulent rhinorrhea) were used to assess the outcome of their treatment.

RESULTS

Children undergoing endoscopic sinus surgery had more significant disease as noted on the computed tomography (CT) scans. Their symptom severity, however, was similar. When individual symptoms were compared, there were no statistically significant differences between the surgically and medically managed groups. When the mean was controlled for baseline symptom severity and CT severity, there was statistical improvement in nasal airway obstruction and decreased rhinorrhea. There was a trend toward improvement in cough, but this was not statistically significant. Parenteral assessment of improvement (change) in symptoms (P = .001) and their degree of satisfaction with treatment (P = .005) was significantly higher in the surgically managed group.

CONCLUSIONS

Children who have chronic rhinosinusitis improve in their symptoms of nasal airway obstruction and purulent discharge if they undergo surgery. Parents of young children with chronic rhinosinusitis appear to be more satisfied with the outcome of surgical management than medical management when assessed 10 years later.

Changing epidemiology of small-cell lung cancer in the United States over the last 30 years: analysis of the surveillance, epidemiologic, and end results database

PURPOSE

Small-cell lung cancer (SCLC) is a histologic subtype of lung cancer with a distinct biology and clinical course. It has been observed that the incidence of SCLC has been decreasing over the last several years.

METHODS

We used the Surveillance, Epidemiologic, and End Results (SEER) database to determine the incidence of SCLC over the last 30 years. In addition, we sought to determine sex- and stage-based differences in the incidence and survival of SCLC among a proportion of reported cases of lung cancer over the last 30 years (1973 to 2002). Joinpoint analyses were applied to test the trends in annual percentage change for statistical significance.

RESULTS

The proportion of SCLC (among all lung cancer histologic types) decreased from 17.26% in 1986 to 12.95% in 2002. Of all patients with SCLC, the proportion of women with SCLC increased from 28% in 1973% to 50% in 2002. A modest but statistically significant improvement in 2- and 5-year survival was noted among both limited-stage SCLC and extensive-stage SCLC cohorts during the study period.

CONCLUSION

Our analysis indicates that the incidence of SCLC is decreasing in the United States, and only modest improvements have been seen in survival over the last 30 years. Possible explanations for the decreasing incidence include the decrease in the percentage of smokers and the change to low-tar filter cigarettes. Despite trends toward modest improvement in survival, the outcome remains very poor.

Multivariate analyses to assess treatment effectiveness in advanced head and neck cancer

OBJECTIVE

To assess relative benefit of combined radiotherapy and surgery over single-modality treatment for advanced-stage squamous cell carcinoma of the aerodigestive tract by means of several multivariable analyses to control for patient variables.

DESIGN

Medical chart review.

SETTING

University medical center.

PATIENTS AND METHODS

The study included 532 patients receiving initial therapy between January 1, 1980, and December 31, 1989. Three multivariate techniques (multiple logistic regression, propensity score stratification, and conjunctive consolidation) were used to compare outcomes for treatment groups.

MAIN OUTCOME MEASURE

Five-year survival.

RESULTS

Survival for radiation, surgery, and combined treatment groups were 24%, 40%, and 46%, respectively. With the use of multiple logistic regression to control patient variables, the radiation group had a significantly lower survival than the combined therapy group (risk ratio, 2.24; 95% confidence interval, 1.32-3.80), while there was no statistical difference for the surgery group compared with the combined therapy group (risk ratio, 1.26; 95% confidence interval, 0.78-2.03). When analyzed by propensity score, 5-year survival was higher in each quintile for the combined therapy group than for the group who received radiation alone (P =.002). There was no significant difference in survival between the surgery and combined treatment groups (P =.25). Conjunctive consolidation was used to create a clinical staging system to compare outcomes across treatment groups. In each clinical severity stage, radiation alone had a lower survival than combined therapy (P =.001), while no statistical difference was noted between surgery and combined therapy (P =.50).

CONCLUSIONS

All 3 statistical techniques showed a significantly lower survival for patients treated with radiation alone vs combined therapy. No significant difference was noted between surgery and combined therapy. Propensity score analysis and conjunctive consolidation are useful techniques to control prognostic variables in cancer database studies and should be used in future outcome studies that address more current treatment dilemmas in head and neck oncology.

Learning, memory, and executive control in individuals with obstructive sleep apnea syndrome

A range of neuropsychological deficits have been identified in individuals with obstructive sleep apnea syndrome (OSAS) and have been related to disruptions in function of the frontal cortex of the brain. We hypothesized that impairments in the use of strategic, frontally-mediated processes that facilitate learning and memory would be associated with deficits in the long-term episodic memory of verbal material (i.e., word lists). We evaluated 28 adults with OSAS and 24 controls (ranging from 28 to 60 years of age) using the California Verbal Learning Test. General executive abilities were assessed using the Wisconsin Card Sorting Test, Letter fluency, and Category fluency. Individuals with OSAS exhibited poorer recall across learning trials, less efficient use of semantic clustering, and poorer use of semantic cues. Retention of previously encoded information and recognition, however, were intact. With the exception of letter fluency, deficits were not observed in general executive control. Results are discussed within the context of disruptions in the interactions between long-term memory and executive abilities that are subserved by frontal and distal brain regions.

Free flap reconstruction of the head and neck: analysis of 241 cases

OBJECTIVE

We undertook this study of free flap reconstruction of the head and neck to stratify patients and procedures, to determine how donor site preference changed over time, to assess medical and surgical outcomes, and to identify variables associated with complications.

METHODS

We analyzed computerized medical records from 236 patients who underwent a total of 241 reconstructions at a tertiary academic medical center in St. Louis between 1989 and 1998. We created a more detailed retrospective database of 141 of those patients by using 48 perioperative variables and 7 adverse outcome measures. Multivariate statistical models were used to analyze associations between variables and outcomes.

RESULTS

The fibula became the preferred donor site for mandibular reconstruction, and the radial forearm became the preferred donor site for pharyngoesophageal reconstruction. For the 241 procedures, the mortality rate was 2.1%, the median length of stay was 11 days, and the flap survival rate was 95%. Administration of more than 7 L of crystalloid during surgery and age over 55 were associated with major medical complications. Blood transfusion, prognostic comorbidity, and number of surgeons correlated with length of stay. Cigarette smoking and receipt of more than 7 L of crystalloid during surgery were associated with overall flap complications, and weight loss of more than 10% before surgery, more than one operating surgeon, and cigarette smoking were associated with major flap complications.

CONCLUSIONS

Risk to patients and transferred tissue is low in free flap head and neck reconstruction. Age, smoking history, and weight loss should be considered during patient selection. Fluid balance should be considered during and after surgery. Division of labor for patient care should be carefully delineated among surgeons in a teaching setting.

Relationship between patient-based descriptions of sinusitis and paranasal sinus computed tomographic findings

OBJECTIVE

To evaluate the relationship of paranasal sinus symptoms with coronal computed tomographic (CT) findings.

DESIGN

Prospective comparison of patient-based symptoms with imaging findings.

SETTING

Primary care and referral center office and hospital practices.

PATIENTS

Of 586 consecutive patients referred by otolaryngologists and primary care physicians for CT of the paranasal sinuses, 221 (151 women and 70 men; age range, 13-82 years; mean age, 44 years) participated by completing the Sino-Nasal Outcome Test-20 (SNOT-20) clinical questionnaire immediately before undergoing CT.

MAIN OUTCOME MEASURES

Radiologists blinded to the patients' responses scored the degree of mucosal thickening at each of 12 sites on CT scans using a staged scale of severity (0-2 points). Bivariate analysis was performed to assess the relationship between patients' symptoms and CT findings.

RESULTS

The SNOT-20 scores ranged from 0 (normal) to 78 (mean, 34). The most commonly reported symptom was fatigue. The CT scores ranged from 0 (normal) to 24 (mean, 4.07). Seventy-five patients (34%) had normal findings on the CT scan. The maxillary sinus was the most commonly involved site (96 patients, or 43%). The SNOT-20 and CT scores failed to significantly correlate (r = 0.11, P < or = .09). When the subset of patients with "positive" or "very positive" CT scans were considered, no significant correlation was observed (r = 0.12, P < or = .16). For the 132 patients reporting facial pain, the mean CT score was lower than for patients without facial pain (3.78 vs 4.78, P = .21).

CONCLUSION

Patient-based reports of paranasal sinus symptoms failed to correlate with findings on CT scans; therefore, CT should be reserved for delineating the anatomy and pattern of inflammatory paranasal disease prior to surgical intervention.