Consensus criteria for chronic rhinosinusitis disease control: an international Delphi Study

BACKGROUND

Chronic rhinosinusitis (CRS) disease control is a global metric of disease status for CRS. While there is broad acceptance that it is an important treatment goal, there has been inconsistency in the criteria used to define CRS control. The objective of this study was to identify and develop consensus around essential criteria for assessment of CRS disease control.

METHODS

Modified Delphi methodology consisting of three rounds to review a list of 24 possible CRS control criteria developed by a 12-person steering committee. The core authorship of the multidisciplinary EPOS 2020 guidelines was invited to participate.

RESULTS

Thirty-two individuals accepted the invitation to participate and there was no dropout of participants throughout the entire study (3 rounds). Consensus essential criteria for assessment of CRS control were: overall symptom severity, need for CRS-related systemic corticosteroids in the prior 6 months, severity of nasal obstruction, and patient-reported CRS control. Near-consensus items were: nasal endoscopy findings, severity of smell loss, overall quality of life, impairment of normal activities and severity of nasal discharge. Participants’ comments provided insights into caveats of, and disagreements related to, near-consensus items.

CONCLUSIONS

Overall symptom severity, use of CRS-related systemic corticosteroids, severity of nasal obstruction, and patient-reported CRS control are widely agreed upon essential criteria for assessment of CRS disease control. Consideration of near-consensus items to assess CRS control should be implemented with their intrinsic caveats in mind. These identified consensus CRS control criteria, together with evidence-based support, will provide a foundation upon which CRS control criteria with wide-spread acceptance can be developed.

The Olfactory Cleft Endoscopy Scale: a multi-institutional validation study in chronic rhinosinusitis

BACKGROUND

Olfactory dysfunction (OD) associated with chronic rhinosinusitis (CRS) remains quite challenging. Instruments to precisely assess olfactory cleft anatomy and their association with olfaction are needed.

METHODS

The olfactory cleft endoscopy scale (OCES) was used to assess the olfactory cleft in healthy control subjects and a cohort of patients with CRS. Psychophysical and psychosocial olfactory function were assessed and correlations with OCES scores were measured.

RESULTS

Control subjects and subjects with CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP) were enrol- led. OCES correlated with both psychophysical and psychosocial olfaction, as measured by threshold, discrimination and identi- fication (TDI) scores and Questionnaire on Olfactory Disorders (QOD-NS) scores for all case and control subjects combined. OCES improved in both CRS groups postoperatively with the highest correlation seen in postoperative olfaction in CRSwNP patients. CRS patients who achieve near perfect OCES and sinus endoscopy scores after surgery have olfactory metrics that are indistin- guishable from controls regardless of polyp status.

CONCLUSIONS

The OCES is a valid olfactory-specific measure that demonstrates strong validity and provides complimentary infor- mation to traditional sinus endoscopy to aid in our understanding of OD associated with CRS.

Lack of impact of radiologic septal measurements upon patient symptoms and performance of septoplasty during endoscopic sinus surgery

BACKGROUND

Recent literature suggests that concurrent septoplasty during endoscopic sinus surgery (ESS) improves patient outcomes, however, the underlying indications for performing concurrent septoplasty are unknown. The objective of this study was to investigate the relationship between objective radiologic measures of nasal septal deviation with preoperative patient symptomatology and measures of CRS disease severity. We also sought to understand the association of objective radiologic measurements with surgeon performance of concurrent septoplasty during ESS.

METHODOLOGY

Seventy-four patients with CRS undergoing ESS were prospectively enrolled. Angles of septal deviation, intranasal areas and volumes were assessed on preoperative computed tomography (CT) scans and correlated with a robust battery of patient reported outcomes measures (PROMs), objective measures of CRS severity including olfaction scores, radiologic and endoscopic staging, and performance of septoplasty.

RESULTS

Intranasal areas and volumes demonstrated only weak linear associations with patient-reported nasal congestion, however, angles of septal deviation alone did not correlate with congestion or any other PROM measure. Meanwhile, radiologic septal-related measurements did not correlate with objective measures of CRS disease severity or the performance of a concurrent septoplasty.

CONCLUSIONS

Though prior studies demonstrate improved patient outcomes in the setting of concurrent septoplasty during ESS, this study failed to establish an association between preoperative radiologic septal-related measurements and patient symptomatology or surgeon decision to perform septoplasty. Although objective factors to identify patients most likely to benefit from concurrent septoplasty remain unidentified, the potential improvement of surgical recommendations and patient outcomes makes this an important area of continued investigation.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

Therapeutic targeting of membrane-associated GRP78 in leukemia and lymphoma: preclinical efficacy in vitro and formal toxicity study of BMTP-78 in rodents and primates

Translation of drug candidates into clinical settings requires demonstration of preclinical efficacy and formal toxicology analysis for filling an Investigational New Drug (IND) application with the US Food and Drug Administration (FDA). Here, we investigate the membrane-associated glucose response protein 78 (GRP78) as a therapeutic target in leukemia and lymphoma. We evaluated the efficacy of the GRP78-targeted proapoptotic drug bone metastasis targeting peptidomimetic 78 (BMTP-78), a member of the D(KLAKLAK)2-containing class of agents. BMTP-78 was validated in cells from patients with acute myeloid leukemia and in a panel of human leukemia and lymphoma cell lines, where it induced dose-dependent cytotoxicity in all samples tested. Based on the in vitro efficacy of BMTP-78, we performed formal good laboratory practice toxicology studies in both rodents (mice and rats) and nonhuman primates (cynomolgus and rhesus monkeys). These analyses represent required steps towards an IND application of BMTP-78 for theranostic first-in-human clinical trials.

Abstract P1-10-13: Can the risk of radiation-induced cardiac disease in breast cancer be mitigated with cardiac-sparing techniques?

Introduction: Data suggest that long-term survivors of breast cancer treated with radiation therapy (RT) have an increased risk of cardiac events despite an overall survival benefit, particularly women with left-sided breast cancers. We hypothesized that with cardiac-sparing radiation techniques there would be no difference in long-term cardiac risks between women with right- and left-sided breast cancers.

Materials and Methods: The outcomes of 775 consecutive women treated between 1984 and 1999 with breast-conserving therapy (BCT) (n=424) and post-mastectomy radiation therapy (PMRT) (n=351) for stage 0-3 breast cancer were assessed retrospectively through a review of medical records and contact with living patients. The choice of BCT vs PMRT was based on tumor board disposition and patient preference; mastectomy was recommended for multicentric or T3 breast cancers. Ninety-six percent of all node-positive patients received treatment to all nodal regions, including the internal mammary (IM), axillary (AX), and supraclavicular (SC) nodes. BCT patients had computed tomography-planned tangential breast radiation with photons with IM nodes treated within the tangent fields or with a separate en face electron field to minimize cardiac exposure. PMRT patients were treated with en face electron fields for the chest wall and IM for sparing of the lung and heart. The AX and SC nodes were treated with a matched anterior photon field with a posterior-anterior boost field (PAB) when necessary to achieve adequate dose in the AX with both BCT and PMRT. Overall, 411 patients were node-negative and 353 were node-positive. All patients have a minimum potential follow-up of 16.4 years; median actual follow-up for the BCT group was 15 years (range, 0.1-31.2) and for the PMRT group it was 9.5 years (range, 0.1-30.5).

Results: Overall survival (OS), cause-specific survival (CSS), and freedom from local-regional recurrence (FFLR) rates for the cohort at 15 years were 58.2%, 72.0%, and 90.8%, respectively. Rates of freedom from cardiac events (FFCE), pulmonary events, and second malignancy were 87.6%, 93.6%, and 86.3%, respectively. On multivariate analysis, OS was correlated with stage (p=.045), number of positive nodes (p=.002), age (p<.0001), diabetes (p =.0021), and modality (p=.0017). Not surprisingly, 15-year survival for patients treated with BCT was better than for patients treated with PMRT (70.9% vs 59.7%; p<.0001). CSS was associated with stage (p=.0207), number of positive nodes (p=.0409), and modality (p=.0003). FFLR was associated with number of positive nodes (p=.0484). FFCE was associated with pretreatment cardiac disease (p<.0001), stage (p=.0461), and age (p=.0056), but not with either breast cancer laterality (p=.1906) or modality (BCT vs PMRT; p=.7487).

Discussion: Long-term disease control and survival outcomes were better in BCT than PMRT patients, likely due to selection criteria. Cardiac events were associated with pretreatment heart disease, older age, and stage, suggesting that this population may benefit from advanced radiation techniques that can further limit cardiac dose. Neither breast cancer laterality nor treatment modality was associated with cardiac events.

Citation Format: Smith TL, Mokhtech M, Bradley JA, Lightsey JL, Morris CG, Mendenhall NP. Can the risk of radiation-induced cardiac disease in breast cancer be mitigated with cardiac-sparing techniques? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-13.

Midline Radiofrequency Tissue Reduction of the Palate for Bothersome Snoring and Sleep-Disordered Breathing: A Clinical Trial

This study is a prospective, nonrandomized clinical trial initiated to assess the safety and efficacy of radiofrequency tissue reduction of the palate for the treatment of bothersome snoring and sleep-disordered breathing. Twelve healthy volunteers with socially disruptive snoring underwent a baseline polysomnogram along with a battery of visual analog scales (VASs) to measure daytime sleepiness, snoring level, pain, and disturbances of speech and swallowing. After radiofrequency tissue reduction of the palate, they were re-evaluated with a mean follow-up after the final procedure of 15.7 ± 5.1 (mean ± SD) weeks. As rated by the bed partner, a significant reduction in the level of snoring occurred in all 12 patients, with a mean pretreatment snoring level of 8.3 ± 2.1 to a mean posttreatment snoring level of 2.1 ± 1.4. (Student t test, P < 0.0001) These patients required an average of 2.3 treatment sessions each. Nine of 12 had a reduction in snoring from a bothersome level (VAS range 5–10) to a nonbothersome level (VAS range 0–3). Daytime sleepiness as measured by the Epworth Sleepiness Scale (0–24) decreased from 10.8 ± 4.4 to 8.3 ± 4.1 ( P = 0.011). Posttreatment pain was considered absent or minimal in 11 of 12 patients and was managed with acetaminophen. No significant adverse events or complications were reported.

Predicting spasticity after stroke in those surviving to 12 months

Objective: To measure muscle tone in a cohort of patients 12 months after stroke and develop a preliminary model, using data recorded routinely after stroke, to predict who will develop spasticity.

Design: A cohort study.

Setting: Initially hospitalized but subsequently community-dwelling stroke survivors in Liverpool, United Kingdom.

Subjects: One hundred and six consecutively presenting stroke patients surviving to 12 months.

Main outcome measures: Spasticity measured at a range of joints using the Tone Assessment Scale.

Results: The Tone Assessment Scale revealed spasticity in 38 (36%) patients and more severe spasticity in 21 (20%) of the 106 patients. Logistic regression analysis revealed that lower day 7 Barthel Index score and early arm or leg weakness were significant predictors of abnormal muscle tone; and lower day 7 Barthel Index score, left-sided weakness and ever smoked to be significant predictors of more severe muscle tone.

Conclusions: Using the models, it may be possible to predict whether or not spasticity will develop in patients 12 months after stroke. The utility of the models is aided by their use of predictor variables that are routinely collected as part of stroke care in hospital and which are easy to measure. The models need testing prospectively in a new cohort of patients in order to test their validity, reliability and utility and to determine if other data could improve their efficiency.

A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa

BACKGROUND

The purpose of this investigation was to compare a new psychotherapy for bulimia nervosa (BN), integrative cognitive-affective therapy (ICAT), with an established treatment, 'enhanced' cognitive-behavioral therapy (CBT-E).

METHOD

Eighty adults with symptoms of BN were randomized to ICAT or CBT-E for 21 sessions over 19 weeks. Bulimic symptoms, measured by the Eating Disorder Examination (EDE), were assessed at baseline, at the end of treatment (EOT) and at the 4-month follow-up. Treatment outcome, measured by binge eating frequency, purging frequency, global eating disorder severity, emotion regulation, self-oriented cognition, depression, anxiety and self-esteem, was determined using generalized estimating equations (GEEs), logistic regression and a general linear model (intent-to-treat).

RESULTS

Both treatments were associated with significant improvement in bulimic symptoms and in all measures of outcome, and no statistically significant differences were observed between the two conditions at EOT or follow-up. Intent-to-treat abstinence rates for ICAT (37.5% at EOT, 32.5% at follow-up) and CBT-E (22.5% at both EOT and follow-up) were not significantly different.

CONCLUSIONS

ICAT was associated with significant improvements in bulimic and associated symptoms that did not differ from those obtained with CBT-E. This initial randomized controlled trial of a new individual psychotherapy for BN suggests that targeting emotion and self-oriented cognition in the context of nutritional rehabilitation may be efficacious and worthy of further study.

A 90-day adaptation to a high glycaemic diet alters postprandial lipid metabolism in non-obese horses without affecting peripheral insulin sensitivity

High glycaemic feeds are associated with the development of insulin resistance in horses. However, studies that evaluated the effect of high glycaemic feeds used horses that either ranged in body condition from lean to obese or were fed to increase body condition over a period of months; thus, the ability of high glycaemic feeds to induce insulin resistance in lean horses has not been determined. This study evaluated the insulin sensitivity of 18 lean horses fed a 10% (LO; n = 6), 20% (MED; n = 6) or 60% (HI; n = 6) non-structural carbohydrate complementary feed for 90 days. Although both the MED and HI diets increased insulinaemic responses to concentrate feeding in relation to the LO diet (p > 0.05), neither induced insulin resistance, as assessed by glucose tolerance test, following the 90-day feeding trial. Interestingly, the post-feeding suppression of plasma non-esterified fatty acids was less pronounced in HI-fed horses (p = 0.054) on days 30 and 90 of the study, potentially indicating that insulin-induced suppression of adipose tissue lipolysis was reduced. As insulin-resistant animals often have elevated plasma lipid concentrations, it is possible that altered lipid metabolism is an early event in the development of insulin resistance. The effects of high glycaemic feeds that are fed for a longer duration of time, on glucose and lipid metabolism, should be investigated further.

Dietary supplementation with short-chain fructo-oligosaccharides improves insulin sensitivity in obese horses

Obesity and insulin resistance are risk factors for laminitis in horses and ponies, and diet can play an important role in modulating these risk factors. Dietary supplementation with prebiotic fibers, such as short-chain fructo-oligosaccharides (scFOS), has resulted in improvement of insulin sensitivity in obese dogs and rodents. Thus, we hypothesized that scFOS may reduce insulin resistance in obese horses and designed a study to evaluate the effect of dietary supplementation with scFOS on insulin sensitivity. Eight mature Arabian geldings (BW = 523.0 ± 56.5 kg) with an average BCS of 8 were included in a crossover study. In each period, 4 horses were provided 45 g/d per horse of maltodextrin (control) and 4 horses received the same amount of scFOS for 6 wk, with a 3-wk washout between periods. Resting plasma concentrations of glucose, insulin, triglycerides, and leptin were measured. Minimal model analysis of a frequently sampled intravenous glucose tolerance test was used to evaluate insulin sensitivity, glucose effectiveness, acute insulin response to glucose, and disposition index. Without affecting BW and BCS, dietary supplementation with scFOS increased (P < 0.05) insulin sensitivity and reduced (P < 0.05) acute insulin response to glucose in comparison with maltodextrin but did not alter (P > 0.05) glucose effectiveness and disposition index. Resting serum insulin concentration also was reduced (P < 0.05) by scFOS supplementation but not by maltodextrin (P > 0.05). There was no effect (P > 0.05) of scFOS supplementation on plasma glucose or serum triglyceride and leptin concentrations. This study demonstrated that scFOS can moderately improve insulin sensitivity of obese horses, a finding that has potential relevance to the dietary management of obese, insulin-resistant horses at increased risk for laminitis.

Effect of Butanol Challenge and Temperature on Lipid Composition and Membrane Fluidity of Butanol-Tolerant Clostridium acetobutylicum

The effect of butanol challenge (0, 1.0, 1.5% [vol/vol]) and growth temperature (22, 37, 42 degrees C) on the membrane composition and fluidity of Clostridium acetobutylicum ATCC 824 and a butanol-tolerant mutant, SA-2, was examined in chemically defined medium. Growth of strain ATCC 824 into the stationary phase coincided with a gradual increase in the percent saturated to percent unsaturated (SU) fatty acid ratio. When challenged with butanol at 22 and 37 degrees C, ATCC 824 demonstrated an immediate (within 30 min) dose-response increase in the SU ratio. This strain showed little additional change over a 48-h fermentation. Compared with ATCC 824, growth of SA-2 into the late stationary phase at 22 or 37 degrees C resulted in an overall greater increase in the SU ratio for both unchallenged and challenged cells. This effect was minimized when SA-2 was challenged at 42 degrees C, probably due to the combination of the membrane fluidizing effect of butanol and the elevated temperature. Growth at 42 degrees C resulted in an increase in longer acyl chain fatty acids at the expense of shorter acyl chains for both strains. The membrane fluidity exhibited by SA-2 remained essentially constant at various butanol challenge and temperature combinations, while that for the ATCC 824 strain increased with increasing butanol challenge. By synthesizing an increased amount of saturated fatty acids, the butanol-tolerant SA-2 strain has apparently developed a mechanism for maintaining a more stable membrane environment. Growth of the microorganism is necessary for butanol to fluidize the membrane. Incorporation of exogenous fatty acids (18:1) did not significantly improve the butanol tolerance of either strain. Since SA-2 was able to produce only trace amounts of either butanol or acetone, increased tolerance to butanol does not necessarily coincide with greater solvent yields in this strain.

Inactivation of the p16 cyclin-dependent kinase inhibitor in high-grade canine non-Hodgkin's T-cell lymphoma

The significance of p16/Rb tumor suppressor pathway inactivation in T-cell non-Hodgkin's lymphoma (NHL) remains incompletely understood. We used naturally occurring canine NHL to test the hypothesis that p16 inactivation has specific pathologic correlates. Forty-eight samples (22 T-cell NHL and 26 B-cell NHL) were included. As applicable, metaphase- or array-based comparative genomic hybridization, Southern blotting, promoter methylation, and Rb phosphorylation were used to determine the presence, expression, and activity of p16. Fisher's exact test was used to test for significance. Deletion of p16 (or loss of dog chromosome 11) was restricted to high-grade T-cell NHL (lymphoblastic T-cell lymphoma and peripheral T-cell lymphoma, not otherwise specified). These were characterized by a concomitant increase of tumor cells with Rb phosphorylation at canonical CDK4 sites. Rb phosphorylation also was seen in high-grade B-cell NHL (diffuse large B-cell lymphoma and Burkitt-type lymphoma), but in those cases, it appeared to be associated with c-Myc overexpression. The data show that p16 deletion or inactivation occurs almost exclusively in high-grade T-cell NHL; however, alternative pathways can generate functional phenotypes of Rb deficiency in low-grade T-cell NHL and in high-grade B-cell NHL. Both morphologic classification according to World Health Organization criteria and assessment of Rb phosphorylation are prognostically valuable parameters for canine NHL.

Survey of the migration of melamine and formaldehyde from melamine food contact articles available on the UK market

The migration of melamine and formaldehyde, monomers used in the production of melamine-ware food contact articles, has been determined from 50 retail articles purchased in the UK. The food simulant 3% aqueous acetic acid was used as this is the most aggressive simulant towards melamine plastics. The test conditions used were repeated exposure to the simulant for 2 hours at 70 degrees C, since the articles were all intended for general use including contact with hot foods and beverages. Melamine migrated from 43 of the 50 samples tested and formaldehyde migrated from all 50 samples. Directive 2002/72/EC specifies migration limits for both of these monomers in foods and food simulants. Melamine is restricted by a specific migration limit (SML) of 30 mg/kg (equivalent to 5 mg/dm(2)) and formaldehyde, along with hexamethylenetetramine expressed as formaldehyde, is restricted by a total (T) SML(T) of 15 mg/kg (equivalent to 2.5 mg/dm(2)). In all cases the migration of melamine was much lower than the SML for this monomer. The migration of formaldehyde exceeded the SML(T) for 5 of the 50 samples tested. The failure to comply with the SML(T) was accompanied by a number of visible surface effects including discolouration and/or pitting of the simulant contact surface and cracking of the articles. Similar surface effects were observed when one of the samples was exposed to fruit juice which confirmed the suitability of the exposure conditions and 3% acetic acid as a simulant for the articles tested. The ratio of specific migration to overall migration was consistent with, but did not prove, the hypothesis that high formaldehyde migration could be due to the use of excessive hexamethylenetetramine in the polymer formulation. All illegal products were voluntarily removed from the market by the product suppliers.

Expression of sigma 1 receptor in human breast cancer

The sigma 1 receptor (S1R) represents a unique drug-binding site that is distinct from any other receptors. We examined S1R expression in human breast cancer and assessed the activity of S1R ligands in breast cancer cell lines. One-hundred nine breast specimens from normal breast, benign breast disease and cancer were examined with immunohistochemistry or RT-PCR and six different cell lines were also evaluated. S1R mRNA overexpression was detected in 64% of breast cancers compared to normal breast tissue. Immunohistochemistry showed positive epithelial cell staining in 60% of invasive and 41% of in situ cancers, 75% of ductal hyperplasia and in 33% of normal breast. The pattern of expression was more diffuse in invasive breast carcinoma compared to other conditions (p = 0.02). S1R expression was neither a prognostic nor a predictive factor for efficacy of adjuvant chemotherapy but the study only included 58 cancer patients and therefore the statistical power is limited. MDA-MB-361, MDA-MB-435, BT20 and MCF7 cells all expressed S1R protein by Western blot. The non-specific S1R ligands haloperidol, reduced haloperidol and progesterone produced a dose-dependent inhibition of the growth at high (>10 microM) concentrations. Reduced haloperidol also showed additive cytotoxic effects when combined with doxorubicin, vinorelbine , paclitaxel and docetaxel in vitro. The S1R-specific ligand, SKF 10047 demonstrated the least growth inhibitory activity and showed no interaction with chemotherapy. These results demonstrate that some normal and most neoplastic breast epithelial cells and cell lines commonly express S1R. High concentrations of haloperidol inhibit the growth of these cells and potentiate the effect of chemotherapy in vitro.

A 5-year prospective evaluation of DSM-IV alcohol dependence with and without a physiological component

BACKGROUND

The DSM-III-R removed tolerance and withdrawal as required elements for a diagnosis of alcohol dependence. Although this practice was continued in DSM-IV, the more recent manual asked clinicians to note whether physiological aspects of withdrawal (tolerance and withdrawal) had ever been experienced. Few studies have determined the prognostic meaning of a history of a physiological component to DSM-IV alcohol dependence.

METHODS

Face-to-face structured interviews were used to evaluate the course of alcohol, drug, and psychiatric problems during the subsequent 5 years for 1094 alcohol-dependent men and women. These subjects had been classified into subgroups at the time of initial interview regarding evidence of tolerance or withdrawal, and all evaluations were based on DSM-IV criteria. At baseline, the application of DSM-IV diagnostic guidelines resulted in 649 (59.3%) individuals having a history of an alcohol withdrawal syndrome, with or without tolerance (group 1); 391 (35.7%) with histories of tolerance but not withdrawal (group 2); and 54 (4.9%) with no lifetime histories of tolerance or withdrawal (group 3).

RESULTS

During the 5-year follow-up, both the broad (group 1 plus 2 versus group 3) and narrow (group 1 versus group 2 plus group 3) definitions of physiological dependence were associated with more alcohol and drug problems. However, for most items, this differential primarily reflected differences between groups 1 and 3, with a less impressive effect by group 2. Although no group differences were noted for the rate of independent major depressive episodes, substance-induced depressions did differentiate among groups, a finding also most closely related to the distinction between groups 1 and 3.

CONCLUSIONS

These data support the prognostic importance of noting the presence of a physiological component in alcohol dependence and indicate the potential relevance of limiting the definition of a physiological component to withdrawal.

A five-year prospective study of diagnostic orphans for alcohol use disorders

OBJECTIVE

One consequence of the DSM-IV diagnostic system for substance abuse and dependence is that there are individuals who might endorse one or two of the criterion items for dependence but not meet criteria for abuse. These persons have been referred to as "diagnostic orphans." The aim of the analyses presented here is to further understanding about this potentially important group.

METHOD

The DSM-IV categorical approach was used to determine alcohol-related diagnoses for 439 young adult men. Structured face-to-face follow-up interviews were administered 5 years later.

RESULTS

At the beginning of the evaluation period, 14.6% (n = 64) of the men were alcohol dependent, 18.2% (n = 80) fulfilled criteria for alcohol abuse, 16.4% (n = 72) did not meet criteria for an alcohol use disorder but endorsed one or two of the dependence criteria and 50.8% (n = 223) reported none of the dependence items. At the initial interview, and again 5 years later, the diagnostic orphans reported alcohol and drug use histories that fell between the histories of those with dependence and those with no alcohol-related difficulties. The orphans were most similar to the men with abuse, although they had lower quantities and frequencies of alcohol use, endorsed fewer additional alcohol-related problems and reported less involvement with drugs compared with that group.

CONCLUSIONS

Although the diagnostic orphans were more similar to the subjects with alcohol abuse than they were to those with dependence or no diagnosis, the data do not necessarily support combining the orphans with those with abuse. These diagnostic orphans do, however, constitute an important group that carries an enhanced risk for alcohol use disorders and should be closely followed.

Mood and anxiety symptoms among 140 children from alcoholic and control families

OBJECTIVE

Children of alcoholics have been reported to have elevated levels of internalizing symptoms, including anxiety and depression. However, many studies have not adequately controlled for the influence of independent (i.e. not substance-induced) parental mood or anxiety disorders and other factors. The present evaluations assess the relationships of the family histories of alcohol use disorders and independent mood and anxiety disorders to internalizing symptoms in children of alcoholic and nonalcoholic subjects.

METHOD

A behavioral checklist and a structured interview were administered to the parents of 140 children aged 7-18 years. The fathers of these offspring had been recruited 15 years previously from a university population to participate in a prospective study of 453 men from alcoholic and nonalcoholic families.

RESULTS

While a higher score for one of four measures of internalizing symptoms in the children was found to relate to a higher density of alcoholic relatives, this pattern was more robust in children of parents with mood or anxiety disorders. In a hierarchical regression, the family history of alcohol use disorders did not add significantly to the prediction of any of the four internalizing scores in the children after considering the impact of a family history of independent mood and anxiety disorders.

CONCLUSIONS

The results indicate that internalizing symptoms in children of alcoholics were more strongly influenced by a positive family history of mood and anxiety disorders than the family history of alcohol use disorders.

Prevalence of spasticity post stroke

OBJECTIVES

To establish the prevalence of spasticity 12 months after stroke and examine its relationship with functional ability.

DESIGN

A cohort study of prevalence of spasticity at 12 months post stroke.

SETTING

Initially hospitalized but subsequently community-dwelling stroke survivors in Liverpool, UK.

SUBJECTS

One hundred and six consecutively presenting stroke patients surviving to 12 months.

MAIN OUTCOME MEASURES

Muscle tone measured at the elbow using the Modified Ashworth Scale and at several joints, in the arms and legs, using the Tone Assessment Scale; functional ability using the modified Barthel Index.

RESULTS

Increased muscle tone (spasticity) was present in 29 (27%) and 38 (36%) of the 106 patients when measured using the Modified Ashworth Scale and Tone Assessment Scale respectively. Combining the results from both scales produced a prevalence of 40 (38%). Those with spasticity had significantly lower Barthel scores at 12 months (p < 0.0001).

CONCLUSION

When estimating the prevalence of spasticity it is essential to assess both arms and legs, using both scales. Despite measuring tone at several joints, spasticity was demonstrated in only 40 (38%) patients, lower than previous estimates.

A comparison of alcohol-induced and independent depression in alcoholics with histories of suicide attempts

OBJECTIVE

Alcohol-dependent men and women are at high risk for two types of major depressive episodes and for suicide attempts. The aim of this study is to compare the characteristics of two groups: (1) alcohol-dependent subjects with histories of suicide attempts and independent mood disorders and (2) a similar population of alcoholics with histories of self harm but who have only experienced alcohol-induced depressions.

METHOD

As part of the Collaborative Study on the Genetics of Alcoholism (COGA), semistructured detailed interviews were administered to 371 alcohol-dependent individuals (62% women) with histories of suicide attempts and major mood disorders. Of the total, 145 (39.1%) had ever had an independent depressive episode and 226 (60.9%) had experienced only alcohol-induced depressions. Information was obtained about socioeconomic characteristics, suicidal behavior, independent and induced psychiatric conditions, and aspects of alcohol dependence.

RESULTS

Univariate and multivariate comparisons revealed that alcohol-dependent individuals with a history of suicide attempts and independent depression had a higher number of suicide attempts, were less likely to have been drinking during their most severe attempt, and were more likely to have an independent panic disorder. Univariate analyses indicated that these subjects reported a less severe history of alcohol dependence.

CONCLUSIONS

The results indicate that a distinction between independent and alcohol-induced mood disorders in alcoholics with a history of suicide attempts may be useful.

Comparison of 3190 alcohol-dependent individuals with and without suicide attempts

INTRODUCTION

Suicidal behaviors are often seen in alcohol-dependent individuals. The aim of this study is to identify and confirm risk factors for suicide attempts in a large, family-based sample of alcoholics.

METHODS

Semistructured, detailed interviews were administered to 3190 alcohol-dependent individuals as part of the Collaborative Study on the Genetics of Alcoholism (COGA). Information about suicidal behavior, socioeconomic characteristics, psychiatric comorbidity, substance use disorders, and characteristics of alcohol dependence were obtained from alcohol-dependent probands, controls, and their relatives.

RESULTS

As determined by both univariate comparison and multivariate logistic regression analysis, alcohol-dependent individuals with a history of suicide attempts were found to have a significantly more severe course of alcohol dependence and a higher prevalence of both independent and substance-induced psychiatric disorders and other substance dependence. First-degree relatives of subjects with suicide attempts showed a significantly higher rate of suicide attempts, even after controlling for additional relevant diagnoses.

CONCLUSION

These results support the hypothesis that alcohol-dependent individuals with a history of suicide attempts are more severely impaired. Screening and subsequent treatment of alcohol use disorder, psychiatric comorbidity, and substance use disorders among alcoholics may be crucial in preventing suicide attempts and completions.

Recommendations for sentinel lymph node processing in breast cancer

The status of the sentinel lymph node (SLN) has been shown to accurately reflect the presence or absence of metastases in the axilla in patients with breast cancer. This study was designed to determine the optimal protocol for SLN processing. A total of 173 SLNs from 96 breast cancer patients who had successful SLN localization and underwent completion axillary node dissection were identified. All SLNs were negative for metastases by initial routine histologic evaluation. The nodes were submitted in a total of 300 blocks. Each block was serially sectioned to produce 10 levels. Pan-cytokeratin stain was performed on levels 3 and 8. All other levels were stained with hematoxylin and eosin. Metastases were identified in 22 SLNs from 19 patients by examining all 10 levels. The first two hematoxylin and eosin- or the first cytokeratin-stained levels were positive for metastases in 21 (95.5%) of the 22 positive SLNs. Two additional hematoxylin and eosin-stained and one cytokeratin-stained levels of each SLN correctly identified the status of the node in 94 (97.9%) of 96 patients. Therefore, we recommend that after an initial hematoxylin and eosin-stained section, two additional hematoxylin and eosin-stained sections and one cytokeratin-stained section should be evaluated.

Is there an increased rate of additional malignancies in patients with mantle cell lymphoma?

PURPOSE

To examine the frequency of additional neoplasms preceding and following the diagnosis of mantle cell lymphoma (MCL).

PATIENTS AND METHODS

A total of 156 patients with MCL treated on the hyperfractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone alternated with methotrexate and cytosine arabinoside (Hyper-CVAD/M-A) program with or without rituximab from 1994 to 2000 were the subjects of this report.

RESULTS

These patients were followed for a median time of 26 months, and a total of 32 (21%) additional neoplasms were diagnosed, 21 preceding the diagnosis of MCL and 11 following MCL. After excluding certain types of non-invasive neoplasms, including basal cell carcinoma, meningioma and cervical intraepithelial neoplasia, we observed seven second malignancies after the diagnosis of MCL, and the 5-year cumulative incidence rate of second malignancy was 11%. The observed-to-expected (O/E) ratio was 7/0.07 = 100 [95% confidence interval (CI) 49.3 to 186.6; P <0.0001]. Of the 21 malignancies diagnosed prior to MCL, 16 were invasive and five non-invasive. There were a total of 10 urologic malignancies occurring before or after the diagnosis of MCL was established.

CONCLUSIONS

Our findings suggest that there is an increased incidence of second malignancies in patients with MCL. In addition, the high number of cases with urinary tract cancer in our series may substantiate prior reports describing a possible association between lymphoma and urologic malignancies.

Expression of erbB/HER receptors, heregulin and P38 in primary breast cancer using quantitative immunohistochemistry

The purpose of this study was to investigate the frequency of expression of the erbB/HER family of growth factor receptors, their ligand heregulin, and the two different signaling pathways p38 and mitogen-activated protein kinase (MAPK), as well as the status of HER-2 phosphorylation in tumor specimens from patients with primary breast cancer. The level of expression of these proteins was measured by quantitative immunohistochemistry combined with microscope-based image analysis in paraffin-embedded breast cancer tissue from 35 patients. The frequency of expression was: EGFR (51%), HER-2 (54%), P-HER-2 (48%), HER-3 (48%), HER-4 (57%), heregulin (48%), p38 (17%), MAPK (48%). There was evidence of associations among the coexpression of heregulin, EGFR, HER-2, and HER-3. Also, there was evidence of a positive association between P-MAPK and HER-4. HER-3 was expressed at high levels in patients younger than 50 years of age. There was a trend for expression of higher levels of HER-4 in tumors larger than 2 cm. The expression of EGFR, HER-2, heregulin, p38 and MAPK was independent of age, tumor size, number of lymph nodes involved or hormone receptor status. The HER family of growth factor receptors appear to be regulated independently in invasive breast cancer. Assessing the expression of multiple tumor markers by quantitative immuno-histochemistry is feasible. Further research is needed to determine the prognostic and predictive roles of the various associations between HER receptors, their ligands and signal transduction molecules in patients with early-stage breast cancer.

Inflammatory and granulomatous lesions of the larynx and pharynx

A number of inflammatory and granulomatous lesions can involve the larynx and pharynx. These conditions are generally difficult to diagnose because of the range of symptoms. This article reviews the following conditions: supraesophageal complications of reflux disease, relapsing polychondritis, Wegener granulomatosis, sarcoidosis, tuberculous laryngitis, Teflon (polytetrafluoroethylene fluoropolymer resin; DuPont, Wilmington, DE) granuloma, amyloidosis, rheumatoid arthritis, and systemic lupus erythematosus. The purpose is to provide a brief review of each disease and its manifestations, symptoms, diagnosis, and treatment.

HER-2/neu overexpression as a poor prognostic factor for patients with metastatic breast cancer undergoing high-dose chemotherapy with autologous stem cell transplantation

PURPOSE

High-dose chemotherapy with autologous stem cell transplantation (HDCT) produces a high tumor response rate for patients with metastatic breast cancer and have 20% long-term progression-free survival. Overexpression of HER-2/neu oncoprotein predicts outcome in patients with breast cancer given standard-dose chemotherapy. Therefore, we evaluated whether the HER-2/neu overexpression in the primary tumor predicts clinical outcome in patients with metastatic breast cancer given HDCT.

EXPERIMENTAL DESIGN

A total of 236 patients were given standard-dose induction chemotherapy followed by stem cell collection; high-dose chemotherapy with cyclophosphamide, thiotepa, and carmustine; and stem cell infusion. HER-2/neu expression was assessed by immunostaining with anti-HER-2/neu e2-4001 monoclonal antibody in 63 patients.

RESULTS

Clinical characteristics and survival were similar for patients with known and unknown HER-2/neu status. HER-2/neu was overexpressed in 22 of 63 tumors (35%). There was some tendency for HER-2/neu overexpression to be associated with the absence of estrogen or progesterone receptors. In considering the association of HER-2/neu expression with patient outcomes, HER-2/neu overexpression was associated with generally shorter overall survival (P = 0.02) and progression-free survival (P < 0.01), and this association persisted to a lesser extent after adjustment for differences in important prognostic factors between the two groups.

CONCLUSION

We conclude that HER-2/neu overexpression may represent an additional prognostic factor for patients with metastatic breast cancer who undergo HDCT.

Female patients with breast carcinoma age 30 years and younger have a poor prognosis: the M.D. Anderson Cancer Center experience

BACKGROUND

The objective of this study was to analyze the outcome of treatment in young women with breast carcinoma who were treated at a single institution and to develop a clearer understanding of the natural history of the disease in these women.

METHODS

One hundred eighty-five women age < or = 30 years in whom a diagnosis of invasive breast carcinoma was made between October 1985 and September 1995 were identified in the Tumor Registry data base. Patient data were obtained by chart review. All female patients with breast carcinoma who were age > 30 years and who were identified in the same data base and received treatment during the same period served as the control population. The stage-stratified overall survival (OS) rate for the study patients was compared with the OS rate for both the control population and patients in the National Cancer Data Base (NCDB).

RESULTS

Of 185 patients, 11% presented with Stage I disease, 45% presented with Stage II disease, 38% presented with Stage III disease, and 6% presented with Stage IV disease. Twenty-nine percent of patients with Stage I disease received adjuvant therapy, and 84% of patients with Stage II disease and 96% of patients with Stage III disease received either adjuvant or neoadjuvant chemotherapy. Among patients with Stage I disease, 8 patients underwent mastectomy and 13 patients underwent breast-conserving surgery (BCS). Among patients with Stage II disease, 66 patients underwent mastectomy and 17 patients underwent BCS. Among patients with Stage III disease, 65 patients underwent mastectomy and 5 patients underwent BCS. The 5-year OS rate was 87% for patients with Stage I disease, 60% for patients with Stage II disease, 42% for patients with Stage III disease, and 16% for patients with Stage IV disease. Compared with the control patients and those in the NCDB, there was a trend toward worse OS rates in women age < or = 30 years.

CONCLUSIONS

Women who are diagnosed with breast carcinoma at an age < or = 30 years appear to have a poorer prognosis compared with that for their older counterparts.

Integrated therapy for locally advanced bladder cancer: final report of a randomized trial of cystectomy plus adjuvant M-VAC versus cystectomy with both preoperative and postoperative M-VAC

PURPOSE

We conducted a phase III trial to investigate the timing of chemotherapy with respect to surgery for patients with resectable but high-risk urothelial cancer. The trial was also designed to evaluate the accuracy of clinical staging in patients with locally advanced cancer and the prognostic significance of chemotherapy-induced downstaging.

PATIENTS AND METHODS

A total of 140 uniformly evaluated patients with locally advanced urothelial cancer were studied. Planned treatment was five cycles of chemotherapy (M-VAC: methotrexate, vinblastine, doxorubicin, and cisplatin) plus radical cystectomy and pelvic lymph node dissection. Patients were randomly assigned to receive either two courses of neoadjuvant M-VAC followed by surgery plus three additional cycles of chemotherapy, or, alternatively, to have initial cystectomy followed by five cycles of adjuvant chemotherapy.

RESULTS

There were no significant differences in outcome between the two groups. By intent-to-treat, 81 patients (58%) remain disease-free, with median follow-up of 6.8 years. We confirmed a high rate of clinical understaging in this cohort, especially among patients showing lymphovascular invasion on biopsy. Patients with no residual muscle-invasive disease at cystectomy after neoadjuvant chemotherapy were likely to be cured.

CONCLUSION

These results lend further support to the impression from small randomized trials that, in a high-risk cohort, there is an improved cure fraction by the combination of multiagent chemotherapy and surgery, although we found no preferred sequence. Importantly, it is possible to select appropriate patients for such therapy on the basis of clinical staging information. These results establish a benchmark of outcome for this cohort.

Physician preferences for continuing medical education with a focus on the topic of antimicrobial resistance: Society for Healthcare Epidemiology of America

OBJECTIVE

To determine the type of media preferred for continuing medical education (CME) and to assess the factors that affect physician preferences for CME in general and on the special topic of antimicrobial resistance.

DESIGN

A voluntary survey of the membership of the Society for Healthcare Epidemiology of America, Inc. (SHEA).

METHODS

SHEA, in collaboration with other medical societies and with technical assistance from the Centers for Disease Control and Prevention, designed and mailed the survey to its membership. The survey included questions about media used, preferred, and of interest to try for CME delivery in general and on the topic of antimicrobial resistance in specific. The survey also included demographic and general questions, such as work environment, percentage of time in direct patient care, and experience treating patients with antimicrobial-resistant pathogens.

RESULTS

225 SHEA members completed the survey. The majority of physicians were in clinical practice (59%) and worked in a hospital (57%). The median year of graduation from medical school was 1979 (range, 1951-1999). CME subject matter (46%) was ranked as the most important factor affecting media preference. Journal articles (52%) were the most frequently used educational medium; local grand rounds (53%) and regional meetings (53%) were the most preferred media. CD-ROM (56%) and the Internet (46%) were selected as media of greatest interest to try. On the topic of antimicrobial resistance, the most frequently used and the preferred medium was journal articles (67% and 87%, respectively). Most (94%) had received an educational update on current antimicrobial resistance issues within the past year. Stratification of the data by graduation date revealed no significant differences in the medical education media used most (F=0.59, degrees of freedom [dfl=4, P=.6715) or preferred by SHEA members in general or on the topic of antimicrobial resistance (F=1.99, df=4, P=.0982).

CONCLUSIONS

This study provides an understanding of how physicians learn, prefer to learn, and implement best practices for optimal patient outcomes in decreasing the spread of antimicrobial resistance.

Temperature-controlled radiofrequency tissue volume reduction in the human soft palate

OBJECTIVE

To validate the use of temperature-controlled radiofrequency energy applied to the soft palate in a multicenter setting for reduction of snoring in a minimally morbid manner.

METHODS

Prospective, nonrandomized multicenter study of 113 patients who had a respiratory disturbance index less than 15 and minimum oxygen saturation not less than 85% and who were seeking treatment for habitual disruptive snoring. Patients were given either single or multiple lesions to the soft palate during each treatment session.

RESULTS

Patients received 1978 J on average with an overall average of 2.4 treatments. Snoring scores went from an average of 7.8 (visual analog scale (VAS), 0-10) pretreatment to 3.2 posttreatment. Pain was minimal, averaging 1.7 (VAS 0-10) on days 1 to 6. Complications were few and transient, and mild.

CONCLUSIONS

The multiple lesion protocol was the most successful; reducing snoring from 7.6 to 2.7, on a VAS with an average of 1232 J delivered over 1.6 treatments. Temperature-controlled radiofrequency was found to be a minimally invasive, well-tolerated procedure that was safe and efficacious in this study group.

Vaccination prevents latent HSV1 infection of mouse brain

Herpes simplex encephalitis (HSE) is a rare but very serious disorder caused by herpes simplex type 1 virus (HSV-1). Treatment with acyclovir decreases mortality but many patients still suffer cognitive impairment subsequently. A vaccine against HSV1 would therefore be of great value. HSV-1 has been implicated also in Alzheimer's disease (AD): we established that HSV1 resides in the brain of about two thirds of AD patients and aged normal people, and that in carriers of the type 4 allele of the apolipoprotein E gene, it is a strong risk factor for AD. Thus a vaccine against HSV-1 might prevent development of AD in some cases. To find whether a vaccine of mixed HSV-1 glycoproteins (ISCOMs), which protects mice from latent HSV-1 infection of sensory ganglia, prevents HSV1 latency in the CNS, ISCOM-vaccinated or unvaccinated animals were infected with HSV-1. Using polymerase chain reaction (PCR) we detected HSV-1 in brain from 16 of 39 unvaccinated mice (41%), but only 3 of 41 vaccinated mice (7%) (P < 0.001). Thus, ISCOMs protect the CNS also, suggesting their possible future usage in humans.

Radiofrequency tissue volume reduction: multilesion vs single-lesion treatments for snoring

OBJECTIVE

To compare the safety and efficacy of single-lesion and multilesion radiofrequency tissue reduction (RFTR) of the soft palate for the treatment of snoring.

DESIGN

Prospective, nonrandomized clinical trial.

SETTING

University hospital outpatient clinic.

PATIENTS

Nonrandomized patients undergoing RFTR to treat socially unacceptable snoring. Of 47 patients, 16 received single-lesion treatments and 31 received multilesion treatments.

INTERVENTION

Soft-palate RFTR was performed using a radiofrequency generator. Patients required 1 to 3 treatments based on improvement or withdrawal from the study, and each received 1, 3, or 4 lesions per treatment. Patients who received single-lesion therapy did not cross over into the multilesion group; however, 5 patients in the multilesion group received 4-lesion therapy after a treatment with 3 lesions.

MAIN OUTCOME MEASURES

Outcome measures were determined using visual analog scale questionnaires assessing level of snoring (snoring index) and level of pain (pain index) associated with the procedure. Adverse events and complications during treatment were cataloged. Data were collected before the procedure, 6 weeks after each treatment, and an average of 16 months after the last procedure.

RESULTS

Single-lesion and multilesion groups showed significant improvement in snoring after RFTR treatments (P<.01 for both). However, compared with the single-lesion group, the multilesion group required fewer treatments (1.94 vs 2.38; P =.05) and was more than twice as likely to be cured after 2 treatments (61% vs 25%; P =.02). A trend toward improved clinical outcomes with increased number of lesions and total energy per treatment was observed when patients treated with 1, 3, or 4 lesions were compared. The 4-lesion group had the most pronounced improvement in snoring index score per treatment, the lowest number of treatments required for cure, and the greatest percentage of patients cured after 2 treatment sessions. Follow-up demonstrated minimal relapse of snoring in the multilesion group at a mean of 16 months. Although there was a statistically significant increase in pain in the multilesion group vs the single-lesion group, this increase did not increase narcotic use or time off work and was considered minimal by reporting patients.

CONCLUSION

Multilesion RFTR using higher energy levels per treatment is safe and has increased efficacy without increased complications relative to single-lesion therapy.

Quality-of-life assessment in patients with unilateral vocal cord paralysis

OBJECTIVE

Our objective was to identify the impact of unilateral vocal cord paralysis (UVCP) on an individual's quality of life both before and after thyroplasty.

STUDY DESIGN AND SETTING

This was a prospective observational outcome study of consecutive patients presenting to a laryngology clinic with UVCP. Participants received The Medical Outcomes Study Short Form 36-Item Health Survey (SF-36), the Voice Handicap Index (VHI), and the Voice Outcome Survey (VOS). Patients underwent medialization laryngoplasty with silastic, with or without arytenoid adduction. Outcome measures were repeated after surgery.

RESULTS

A review of 45 patients at presentation revealed statistically significant reductions in quality of life as measured by each survey. Marked improvements were noted after surgery.

CONCLUSIONS

Our preoperative data support a profile of significant general health-related and voice-related limitations caused by UVCP. Patient perceptions improved significantly after the surgical treatment of glottal insufficiency.

SIGNIFICANCE

The SF-36, VHI, and VOS provide an important complement to traditional endpoints in the analysis of patients with UVCP.

An evolution in the management of sinonasal inverting papilloma

OBJECTIVE

We reviewed the 15-year experience of our institution (Medical College of Wisconsin, Milwaukee, WI) in managing sinonasal inverting papilloma, examining trends in diagnosis and treatment.

STUDY DESIGN

Retrospective.

METHODS

Thirty-seven patients with inverting papilloma were treated from 1986 to 1999. Demographic data, clinical presentations, pathological findings, surgical approaches and procedures, and recurrence rates were collected retrospectively. Each lesion was categorized into one of four groups based on computed tomography scans and endoscopic findings. This categorization was developed to compare various surgical approaches for tumors in each group.

RESULTS

Thirty-one patients had complete information for inclusion in our study. Nineteen patients were treated endoscopically with an average follow-up of 50 months. Eight patients were in group I, five were in group II, six were in group III, and no patients were in group IV. The recurrence rate for the endoscopic group was 10%. Twelve patients underwent lateral rhinotomy or sublabial degloving approach with an average follow-up of 58 months. Five patients were in group I, three patients were in group II, 1 patient was in group III, and three patients were in group IV. The recurrence rate for the external group was 8%. Difference in recurrence rates (P =.85) was not observed between the endoscopic and external approach groups. Regardless of approach, patients who had primary resection had a recurrence of 0%, whereas those with secondary resection had a recurrence of 17% (P =.10).

CONCLUSIONS

Technological advancements have led to a trend of detecting sinonasal inverting papilloma before extension beyond the sinonasal region. Difference in recurrence rates was not observed between the endoscopic and the external approach groups. Recurrence rates are lower for primary resection versus secondary resection, regardless of surgical approach.

Five-year clinical course associated with DSM-IV alcohol abuse or dependence in a large group of men and women

OBJECTIVE

The prognostic validity of the DSM-IV diagnoses of alcohol abuse and alcohol dependence was evaluated by examining the 5-year clinical course associated with those diagnoses in a large group of predominantly blue-collar men and women.

METHOD

Personal semistructured interviews were carried out 5 years after an initial evaluation with 1,346 (75%) of the approximately 1,800 men and women participating in the Collaborative Study on the Genetics of Alcoholism who were eligible for follow-up.

RESULTS

About two-thirds of the 298 subjects with DSM-IV alcohol dependence at baseline maintained that diagnosis during the 5-year study period. Fifty-five percent of the 288 subjects with DSM-IV alcohol abuse at baseline continued to meet one or more of the 11 DSM-IV abuse/dependence criteria, and 3.5% went on to meet the criteria for dependence at follow-up. Among the 760 subjects with no alcohol diagnosis at baseline, 2.5% met the criteria for alcohol dependence and 12.8% for alcohol abuse at follow-up. Baseline characteristics that predicted the occurrence of any of the 11 DSM-IV abuse/dependence criteria during the 5-year interval included male gender, lack of marital stability, presence of several of the criteria for dependence, and history of illicit drug use.

CONCLUSIONS

The data suggest that over 5 years the DSM-IV diagnosis of alcohol dependence predicts a chronic disorder with a relatively severe course, while DSM-IV alcohol abuse predicts a less persistent, milder disorder that does not usually progress to dependence.

Correlates of unpredicted outcomes in sons of alcoholics and controls

OBJECTIVE

Several risk factors for alcohol abuse and dependence have been identified, including a family history of the disorder and a low response to alcohol. However, not everyone with these attributes develops an alcohol use disorder and some alcoholics have neither characteristic. This article evaluates factors that might have contributed to unexpected outcomes, in a prospective study of sons of alcoholics and controls.

METHOD

411 men with complete data at baseline (Time 1 or T1) and at 15-year (Time 15 or T15) follow-ups were studied using the level of response (LR) to alcohol, the family history (FH) of alcoholism, and additional alcohol and drug-related experiences at T1. T15 data included the development of alcohol abuse or dependence, along with the 15-year functioning in six domains for the subject, as well as the characteristics of his spouse. The men were divided into groups based on the presence of two major risk factors, low LR and FH, after controlling for several other characteristics, including antisocial personality disorder.

RESULTS

Rates of alcohol use disorders increased across Group 1 (family history negative [FHN] and no low LR), Group 2 (either family history positive [FHP] or low LR, but not both) and Group 3 (both FHP and low LR). After controlling for FH and LR for Group 1, only T1 drinking quantity and T15 positive alcohol expectancies related to a diagnosis, but explained only 12% of the variance. The results improved to R2's of 0.26 and 0.36 for Groups 2 and 3, with additional predictors including the T1 history of alcohol problems and T15 measures of poor coping mechanisms, higher drinking in the environment and less nurturance in the social support system.

CONCLUSIONS

Procedures aimed at discouraging earlier heavier drinking, altering attitudes toward alcohol early in life, teaching appropriate coping methods and developing support systems might help individuals carrying multiple risk factors to become more resilient.

FHIT RNA and protein expression in oral squamous cell carcinomas

BACKGROUND

To investigate the possible role of FHIT, a possible tumour suppressor gene, in oral carcinogenesis, we examined 17 oral squamous cell carcinomas (OSCCs) for genetic alterations.

MATERIALS AND METHODS

Fresh tissue was obtained during surgery, snap-frozen in liquid nitrogen and stored at -70 degrees C. Nested PCR amplification to examine the integrity of FHIT mRNA was performed on the reverse transcribed complementary DNA obtained from the frozen normal and tumour tissue. Immunohistochemistry was done on formal in-fixed paraffin-embedded tissue protein from the same cases using a polyclonal antiserum against the full length Fhit.

RESULTS

Twelve out 17 (71%) OSCCs showed reduced or absent Fhit protein and half of the cases with reduced Fhit protein exhibited aberrant RT-PCR products.

CONCLUSION

Immunohistochemical detection of Fhit protein expression in OSCCs is the more sensitive method to determine the status of Fhit in these tumours, in agreement with previous studies of other tumour types.

Gemcitabine modulation of alkylator therapy: a phase I trial of escalating gemcitabine added to fixed doses of ifosfamide and doxorubicin

BACKGROUND

The authors investigated the maximum tolerated dose (MTD) and dose limiting toxicity (DLT) associated with the addition of a biomodulating dose of gemcitabine to an established regimen of ifosfamide and doxorubicin as part of a program to explore the potential of low-dose gemcitabine to modulate the activity of alkylating agents.

METHODS

A Phase I trial was carried out in a population of patients with bladder or pelvic carcinoma for whom no standard therapy was available. Doses of ifosfamide and doxorubicin were held fixed at 2 g/m(2) for 4 days and 20 mg/m(2) for 3 days, respectively. Gemcitabine was given on Day 2 and Day 4 at doses of 90 mg/m(2), 150 mg/m(2), and 200 mg/m(2) per dose.

RESULTS

A total of 18 patients received 53 courses of therapy. Myelosuppression was dose limiting. Nonhematologic toxicity also was significant, with 10 of 18 patients experiencing toxicity of Grade 3 or greater. For previously untreated patients with an intact performance status, the MTD for gemcitabine in this context was at least 150 mg/m(2) per dose. According to an intent-to-treat analysis, 11 of 18 patients demonstrated a clinically significant response to this regimen.

CONCLUSIONS

The regimen of ifosfamide and doxorubicin with the addition of gemcitabine was significantly toxic but has promising activity. Based on the observed activity and the generally reversible nature of the toxicity, the authors have initiated a Phase II trial of this regimen in patients with untreated, metastatic urothelial carcinoma.

Controlled trial of filgrastim for acceleration of neutrophil recovery after allogeneic blood stem cell transplantation from human leukocyte antigen–matched related donors

The rapid recovery of hematopoiesis after allogeneic blood stem cell transplantation has been attributed to the quality and quantity of hematopoietic progenitors in the blood stem cell grafts from filgrastim-stimulated donors. To determine whether further stimulation with filgrastim after transplantation would affect hematopoietic recovery, a prospective, randomized, controlled study was performed. Forty-two adult recipients of allogeneic blood stem cells from human leukocyte antigen-matched related donors were randomized to receive 10 μg/kg per day filgrastim subcutaneously from day 1 through neutrophil recovery or no growth factor support after transplantation. There was no significant difference between the 2 groups in the number of CD34+ cells infused (median, 4.8 vs 4.3 × 106/kg). Graft-versus-host (GVHD) disease prophylaxis consisted of tacrolimus and steroids for 9 patients and tacrolimus and minimethotrexate for 33 patients. The group receiving filgrastim had a shorter time to neutrophil levels greater than 0.5 × 109/L (day 12 vs day 15, P = .002) and to neutrophil levels greater than 1.0 × 109/L (day 12 vs day 16, P = .01). The filgrastim group also had a trend for earlier discharge (day 16 vs 20, P = .05). There was no significant difference between the groups in time to platelet recovery, number of transfusions, regimen-related toxicity, infection, incidence of GVHD, relapse, survival, or hospital charges. It can be concluded that the administration of filgrastim after allogeneic blood stem cell transplantation shortens the time to neutrophil recovery.

The silent sinus syndrome: a case series and literature review

PURPOSE

The purpose of this study is to describe the clinical and pathologic features of a form of chronic maxillary atelectasis referred to as the silent sinus syndrome, which is characterized by progressive enophthalmos secondary to maxillary collapse resulting from maxillary sinus hypoventilation.

METHODS

A retrospective medical record analysis was carried out to identify patients with enophthalmos secondary to maxillary collapse. Clinical records, including ophthalmology and otolaryngology evaluations as well as computed tomography scans and operative reports, were carefully examined. A complete literature review for relevant studies was performed to examine possible pathophysiology and similar cases.

RESULTS

Four patients with enophthalmos and asymptomatic maxillary sinus disease were identified. On computed tomography, all four of the patients had opacified, partially collapsed maxillary sinuses with osteopenia of the sinus walls and orbital floor displacement resulting in enophthalmos. All four underwent successful functional endoscopic sinus surgery and transconjunctival orbital floor repair.

CONCLUSION

In some instances, chronic maxillary atelectasis can present with enophthalmos secondary to collapse of the maxillary sinus. For reasons that are unclear, the sinus component of the disease remains asymptomatic and is discovered only after thorough evaluation of the enophthalmos.

The clinical course of alcohol dependence associated with a low level of response to alcohol

AIMS

To evaluate the clinical course of specific alcohol-related life problems and the risk for dependence on illicit drugs in individuals with relatively low and high levels of response (LR) to alcohol earlier in life.

SUBJECTS

From among 439 men who were part of the 15-year follow-up of sons of alcoholics and controls, 108 were identified as having fulfilled criteria for DSM-III-R alcohol dependence.

MEASURES

The LR to alcohol was originally evaluated following the consumption of 0.61 g/kg of ethanol at age 20 by determining the levels of change in subjective feelings of intoxication, body sway and several hormones such as cortisol. From the 453 original subjects, 450 completed a face-to-face 10-year follow-up evaluation, and 439 completed the 15-year protocol.

FINDINGS

A comparison of the clinical course of 50 alcohol-dependent men with clearly low LR values at age 20 with that for 42 individuals whose LR scores were above the median revealed few differences. Those with a low LR had a slightly earlier age of onset of alcohol dependence (24.8 +/- 3.41 vs. 26.6 +/- 4.48 years), and this finding was unrelated to the presence of an alcohol-dependent father. Otherwise the members of the two groups demonstrated a similar course of alcohol dependence. There was no relationship between a low LR at age 20 and either the pattern of substances used or the rate of dependence on illicit drugs.

CONCLUSIONS

The results indicate that for this sample a low LR to alcohol, while associated with a high risk for alcohol dependence, was not related to most aspects of the course of alcohol problems once dependence developed.

Electrosurgery in Otolaryngology???Head and Neck Surgery: Principles, Advances, and Complications

OBJECTIVES/HYPOTHESIS

Electrosurgical instruments are routinely used in many applications by otolaryngologist-head and neck surgeons; and a complete description of their historical development, physics of operation, histological effects, and technological advancements is necessary for our specialty to take full advantage of this instrumentation. Because of the electrical current, heat production, and common use associated with these instruments, compounded by the complex environments in which they are used, potential complications must be considered and are likely underreported in the literature. This thesis describes the important aspects of electrosurgery along with a study of complications so otolaryngologists can use these instruments to their fullest potential while limiting complications.

STUDY DESIGN

National survey of electrosurgical complications.

METHODS

A survey addressing potential complications of electrosurgery was developed based on a review of the electrosurgical and complications literature. The electrosurgical complications were organized in the following categories: 1) unanticipated direct burns as a result of the active electrode contacting some tissue unintentionally; 2) unintentional burns as a result of capacitive coupling where radiofrequency (RF) current passes through a metallic instrument (such as forceps) and burns tissue in contact with that metallic instrument; 3) fires occurring as a result of electrosurgical instruments; 4) electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device; and 5) other complications not included in the previous categories. The survey was mailed to the 620 members of the Society of University of Otolaryngologists.

RESULTS

Of the 620 surveys mailed, 35 were returned by the post office for lack of a forwarding address and 296 were returned completed for a response rate of 49.7%. The respondents performed a total of 99,664 cases in the previous year. During that year, 324 complications related to electrosurgical instruments were reported. These included 219 unanticipated direct burns, 48 burns as a result current flow through a metallic retractor or instrument (capacitative coupling), 13 grounding pad burns, 11 fires, 32 cases of electromagnetic interference, and 1 hair loss at an incision site as a result of a cutting electrosurgical instrument. Information regarding the circumstances surrounding these complications and outcome are presented.

CONCLUSIONS

Electrosurgery has proliferated since its original application by William T. Bovie and Harvey Cushing in the 1920s. Because surgeons use this technology frequently, a thorough understanding of these instruments and their potential complications is critical to their safe and successful use. Electrosurgical units operate on basic fundamental principles of physics and involve the passage of electrical current through tissue to create the desired tissue effect. With knowledge of the history, physics, techniques, histological effects, and safety issues of electrosurgery, the field will continue to proliferate and electrosurgery will continue to assist surgeons in alleviating human suffering.

Sinonasal disease in patients with sarcoidosis

Sarcoidosis is a chronic granulomatous disease of unclear etiology with a propensity to involve the lower respiratory tract, but may also involve the upper respiratory tract. Histologically, it is characterized by non-caseating granulomas of various organ systems. Although nasal and sinus involvement is uncommon, patients with sarcoidosis presenting with nasal and sinus complaints may have sinonasal sarcoidosis or simply rhinosinusitis. We reviewed the cases of six patients with pulmonary sarcoidosis who developed chronic sinonasal disease. All six patients had intranasal findings consistent with sinonasal sarcoidosis, but only four had histologic evidence of sinonasal sarcoidosis. These four patients continue to require extensive therapy including topical steroids, systemic steroids, intralesional steroid injections, and nasal irrigations. We conclude that patients with histologically proven sinonasal sarcoidosis present a significant therapeutic challenge because their symptoms and physical findings are often persistent despite aggressive medical and surgical therapy. Their recalcitrant sinonasal disease is thought to result from the destruction of cilia and mucus-producing glands by the granulomatous process.

Measurement of fatigue in HIV-positive adults: reliability and validity of the Global Fatigue Index

Fatigue is among the most common and distressing symptoms in patients with HIV/AIDS. Little is known about the clinical assessment of fatigue, especially in patients using highly active antiretroviral regimens. The purpose of this study was to evaluate the psychometric properties of the Global Fatigue Index (GFI) in a community-based sample of 209 patients with HIV/AIDS. The GFI is a measure that quantifies five dimensions of fatigue from the Multidimensional Assessment of Fatigue instrument into one score. To assess construct validity, the study included measures of depression, perceived stress, activities of daily living (ADLs), health behaviors, and clinical markers. Cronbach's alpha was calculated for internal consistency reliability, and factor analysis and bivariate correlations were conducted. The GFI was found to be easily self-administered, reliable, and a valid measure of overall fatigue burden in an HIV population. This instrument may be used by clinicians and researchers for assessing fatigue.

Health-related quality-of-life measure enhances acute treatment response prediction in depressed inpatients

BACKGROUND

Many nonbiological variables are reported to predict treatment response for major depression; however, there is little agreement about which variables are most predictive.

METHOD

Inpatient subjects (N = 59) diagnosed with current DSM-IV major depressive disorder completed weekly depressive symptom ratings with the Hamilton Rating Scale for Depression (HAM-D-17) and Beck Depression Inventory (BDI), and weekly health-related quality-of-life (HRQL) ratings with the Quality of Well-Being Scale (QWB). Acute responders were identified by a 50% decrease in HAM-D-17 score from baseline within 4 weeks of medication treatment. Predictor variables were initially chosen from a literature review and then tested for their association with acute treatment response.

RESULTS

An initial predictive model including age at first depression, admission BDI score, and melancholia predicted acute treatment response with 69% accuracy and was designated as the benchmark model. Adding the admission QWB index score to the benchmark model did not improve the prediction rate; however, adding the admission QWB subscales for physical and social activity to the benchmark model significantly improved acute treatment response prediction to 86% accuracy (p = .001).

CONCLUSION

In addition to being designed for use in cost-effectiveness analyses, the QWB subscales appear to be useful HRQL variables for predicting acute inpatient depression treatment response.

Thiotepa, busulfan, cyclophosphamide (TBC) and autologous hematopoietic transplantation: an intensive regimen for the treatment of multiple myeloma

The study was designed to evaluate the efficacy and safety of an intensive, tri-alkylator conditioning regimen, consisting of thiotepa, busulfan and cyclophosphamide (TBC), prior to autologous hematopoietic cell transplantation in patients with multiple myeloma (MM) and to analyze factors associated with outcome. One hundred and twenty patients with MM received high-dose chemotherapy with TBC followed by autologous bone marrow (n = 24) or peripheral blood stem cell (PBSC) transplantation (n = 96). Fifty-four patients had chemosensitive disease and 66 had refractory disease at the time of transplantation. The overall response rate was 81% and the complete remission (CR) rate was 26%. Patients with chemosensitive disease had a CR rate of 52% vs 5% for patients with refractory disease. Multivariable analysis determined disease status at transplant as the factor most likely associated with long survival. Estimated median survival was 48, 35 and 9 months for patients with chemosensitive, primary refractory or disease in refractory relapse, respectively. Short interval from diagnosis to transplant among patients with primary refractory disease and younger age were also favorable prognostic factors for survival. Patients with refractory disease pre-transplant who achieved remission criteria rapidly after treatment had a worse outcome than the slow responders. Treatment-related mortality with the introduction of PBSC and better supportive care was 4.8%. In conclusion, TBC is an effective and relatively well-tolerated intensive conditioning regimen in patients with MM. A more favorable outcome was observed in patients with chemosensitive disease and with early treatment for primary refractory disease. TBC merits further study in these subgroups and comparison with alternative regimens in prospective studies is warranted.

A genome-wide search for genes that relate to a low level of response to alcohol

BACKGROUND

The low level of response (LR) to alcohol is genetically influenced in both humans and animals, and a low LR is a characteristic of offspring of alcoholics that has been reported to predict alcoholism 10 and 15 years later. The genes that contribute to a low LR have not yet been identified.

METHODS

A 12-item questionnaire that measures LR, the Self Rating of the Effects of Alcohol (SRE) instrument, was filled out by 745 individuals from the Collaborative Study on the Genetics of Alcoholism (COGA) for whom genetic material was available. These subjects were genotyped by using 336 markers with an average heterozygosity of 0.74 and an average intermarker distance of 10.5 cM. Both quantitative and qualitative nonparametric, sib-pair analyses were carried out for the SRE measure related to early drinking experiences.

RESULTS

Correlations of SRE scores across related individuals were significant and between 0.16 and 0.22 for most values, compared with nonsignificant correlations of 0.03 or less among unrelated individuals. Linkage analyses performed by using the FIRST 5 variables (first five times alcohol is consumed) identified four chromosomal regions with lod scores > or = 2.0 whose maximum was also near a marker. One of these chromosomal regions previously was linked to alcohol dependence in the COGA sample.

CONCLUSIONS

These data document the familial nature of a low LR to alcohol as measured by the SRE and suggest several chromosomal regions that might contribute to the phenomenon.