[Oral cancer--not only a disease of elder patients with risk factors]

Head and neck cancer is currently the 7th most common malignancy worldwide with more than 600,000 new cases diagnosed each year; oral cancer alone comprises about half of these cases. Tobacco and alcohol are the main etiologic factors for oral cancer. The mean age of patients is 60 years. However, in the recent years, an alarming increase in the incidence of oral cancer among patients younger than 60 years of age with seemingly no relation to the classical etiologic factors, has been reported from several regions, mainly from Western countries. In line with this, we report the case of a non-smoker, non-alcohol user, 26-year old patient who was diagnosed with cancer of the tongue (anterior two-thirds). The tumor mimicked a traumatic ulcer, however immediate biopsy procedure enabled an accurate diagnosis and referral of the patient to treatment without delay.

Association between season and temperature and unstimulated parotid and submandibular/sublingual secretion rates

OBJECTIVE

The purpose of the present study was to evaluate parotid and submandibular/sublingual (SM/SL) unstimulated salivary secretion rate in a group of healthy individuals in winter and summer, and to observe the effect of room-adjusted temperature (air-conditioning) on salivary flow-rate in those seasons.

DESIGN

Unstimulated salivary secretion rates of the right parotid and the SM/SL glands were measured in 50 healthy Israeli volunteers. Each volunteer was evaluated four times during the study: twice in winter (February-March) and twice in summer (July-August).

RESULTS

Parotid and SM/SL salivary mean secretion rate in winter was significantly higher than in summer (p<0.02 and p<0.05, respectively). Room heating in winter lowered significantly the mean parotid flow. Air-conditioning cancelled almost completely the seasonal effects on parotid and SM/SL secretions.

CONCLUSIONS

The results of this study suggest that room temperature is an important factor in measurement of salivary secretion rate. Hence, temperature should ideally be recorded and reported when assessing salivary flow-rates.

[Evaluation of unstimulated and stimulated parotid salivary flow rate in Israeli healthy subjects aged 60 years and older]

Saliva plays a critical role in the maintenance oral health. Clinical studies showed that 25% of the elderly population suffers from oral dryness and its related complaints. Studies that measured parotid gland salivary flow rate, both unstimulated and stimulated, in healthy older individuals did not find age-related functional changes. However, histological studies have revealed an age-dependent reduction in the parotid acinar tissue component. To our knowledge there are still no reports of the parotid salivary flow rate in the elderly population in Israel. The goal of this study was to evaluate the rate of the parotid unstimulated and stimulated salivary flow rate among healthy Israeli people aged over 60 years old--the findings may serve as basic standard values to be compared to data collected from patients with complaints of xerostomia and to data reported in other studies. Thirty healthy volunteers aged 60 to 77 years (average 64.7), 23 females and 7 males, were evaluated. Twenty five of the subjects used to live in kibbutzim and 5 lived in a city. The mean unstimulated parotid salivary secretion rate was 0.044+/-0.063 ml/min and the mean stimulated secretion was 0.163+/-0.291 ml/min. Those rates were found to be lower than the unstimulated and stimulated parotid salivary flow rates reported in most other studies. Fourteen (43.3) of the subjects had zero flow rate at rest. This figure was higher then the 20% zero flow at rest that was reported by others among persons with a broader age range. No significant differences were recorded in the parotid salivary flow, both unstimulated and stimulated, between subjects living in the kibbutzim compared to those living in the city. Similar to other studies the differences in the secretion rates between men and women were non significant. The low mean unstimulated and stimulated salivary flow rates, and the high prevalence of no flow at rest can be explained by the fact that saliva collections were done during the very warm Israeli summer and it is speculated that the subjects might be dehydrated. General dehydration can be observed in warm climate areas. No significant differences were found in the parotid salivary flow rates, (unstimulated and stimulated), between the city subjects compared to those from the kibbutzim. Further similar studies in different weather conditions (winter-summer) are needed to establish data of the normal parotid salivary secretion in the over 60 years old Israeli population.

Nosocomial colonization, septicemia, and Hickman/Broviac catheter-related infections in bone marrow transplant recipients. A 5-year prospective study

In this 5-year prospective study of 242 bone marrow transplantation (BMT) recipients from whom daily blood cultures via the indwelling Broviac/Hickman catheter were obtained, there was a median of 35 catheter-days during hospitalization, mean of 40 days, and total of 9,667 catheter-days which were divided almost equally between neutropenic (4,771) and non-neutropenic (4,896) days. One hundred twenty (50%) patients had a total of 161 episodes of nosocomial bacterial or candidal infections. Overall, 81 (33%) patients experienced 100 episodes of catheter-related infections and 90 (37%) patients experienced 112 episodes of septicemia, including 51 episodes of catheter-related septicemia. There was an incidence of 11.59 septicemia episodes, including 5.28 catheter-related septicemia episodes, 2.48 colonization only (without subsequent septicemia), and 2.59 exit site infections only, per 1,000 catheter-days. Over a period of a total of 6,593 afebrile days, 34 (14%) patients developed 40 episodes of colonization, a rate of 6.07 per 1,000 afebrile days, of which 16 developed into septicemia. Twenty-five patients had 1 episode each of exit site infection without bacteremia. There were 10 (4%) septicemia-related deaths, 4 of which were catheter-related; 50% of all deaths involved Pseudomonas aeruginosa. The mortality due to catheter-related septicemic episodes was not greater than that of the non-catheter-related episodes. Neutropenia was found to be a significant risk factor in our study: 76% of the septicemia episodes (85/112) and 65% of the catheter-related infectious episodes (65/100) occurred during neutropenia. There was a higher incidence of septicemic episodes during neutropenia than during non-neutropenic periods, 17.82 versus 5.51 per 1,000 days (p < 0.0001), and a higher rate of catheter-related infections during the neutropenic period, 13.62 versus 7.15 during non-neutropenic days per 1,000 days (0.001). Fourteen of 16 colonization episodes developed into septicemia during neutropenia versus 2/24 during non-neutropenic periods, a rate of 5.47 versus 0.47 per 1,000 afebrile days, respectively (p < 0.0001), and 9/10 deaths occurred during neutropenia.

Orofacial pain with vascular-type features

OBJECTIVE

To examine whether a classifiable primary vascular-type craniofacial pain subgroup exists that predominantly affects intraoral structures.

STUDY DESIGN

Fifty-five patients were chosen prospectively according to the following inclusion criteria; periodic craniofacial pain that was unilateral, pulsatile, severe, and that may wake the patient from sleep. Accompanying phenomena could include local autonomic and/or systemic signs. Twenty-six cases could be further classified into one of the categories of vascular craniofacial pain. The remaining 29, all with predominantly intraoral pain, were not readily classifiable.

RESULTS

Of the 29 patients 70% were women, with an average onset-age of 42.6 years. All reported severe, episodic pain that was usually unilateral and lasted minutes to hours. In all, 55% of patients had autonomic or systemic signs, 48% had pulsatile pain, and 35.4% of patients were awakened by the pain.

CONCLUSION

Although clinical similarities were observed within these patients, further studies are needed to confirm vascular orofacial pain as a clear diagnostic category.

Nosocomial coagulase-negative staphylococcal infections in bone marrow transplantation recipients with central vein catheter. A 5-year prospective study

The purpose of this study was to examine coagulase-negative staphylococcal infections in bone marrow transplantation (BMT) patients with central vein catheters by investigating incidence, clinical relevance, risk factors, methicillin resistance, clinical impact of initial empiric antimicrobial therapy without vancomycin, and management of documented catheter-related infections. A 5-year prospective study was conducted with daily evaluation of 242 BMT patients during hospitalization, including clinical assessment and blood culture via the Hickman/Broviac catheter. If fever or infected appearance occurred, peripheral blood cultures or exit site cultures, respectively, were done. Results showed a septicemia incidence of 7.0%, including in 6 patients following colonization, in 1 patient with tunnel infection, in 1 patient with thrombophlebitis, in 1 patient with exit site infection, and in 8 patients with septicemia of unknown origin. Total colonization incidence was 7%, with colonization only in 11 patients who had 16 episodes; incidence of exit site infection was 3.7%. Age > or = 18 years was the only identified risk factor for developing staphylococcal infection (P = 0.03). Despite a methicillin resistance rate of 45% and omission of vancomycin from the routine initial empiric antimicrobial regimen, the clinical course of coagulase-negative staphylococcal infections was relatively benign. A single patient, who experienced marrow rejection, died on day +31 with septicemia and only one patient experienced microbiological failure with recurrent colonization. Bacteria grown in both aerobic and anaerobic bottles were more likely true bacteremia than contaminant (P = 0.03). We conclude that the hazard of coagulase-negative staphylococcal infection does not mandate inclusion of a glycopeptide in the initial empiric antimicrobial regimen in BMT patients, even during febrile neutropenia. Hickman/Broviac-related staphylococcal infections, except for tunnel infection or thrombophlebitis, can usually be treated successfully without removing the catheter.

Bacterial pneumonia in recipients of bone marrow transplantation. A five-year prospective study

Bacterial pneumonia as an important complication of bone marrow transplantation (BMT) has not been subjected to comprehensive analysis. Two hundred fifty-five consecutive allogeneic and autologous BMT recipients, ranging in age from 1 month to 53 years, were prospectively followed for 3 days to 3 years (median, 108 days) for development of bacterial pneumonia. Etiology, place acquired, chest radiography, and outcome were recorded and the association between bacterial pneumonia and demographic and clinical variables was analyzed. Thirty-seven (15%) patients experienced 52 episodes of bacterial pneumonia: onset of 13 episodes occurred within 30 days after transplantation, 10 episodes occurred on days +31 to +100, and 29 episodes occurred thereafter. Bacterial pneumonia was the terminal event or contributed to fatal outcome in 8 patients (22% of bacterial pneumonia cases, 3% total study population). Mortality due to hospital-acquired pneumonia (6/21) was significantly higher than (P = 0.03). Bacterial pathogens were identified in 27 (52%) episodes. During the first 100 days after BMT, hospital-acquired Gram-negative bacteria predominated, caused mainly by Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter lwoffi, and Enterobacter cloacae. After day +100, community-acquired, Gram-positive bacteria predominated, particularly Streptococcus pneumoniae. Haemophilus influenzae occurred periodically. Considering all episodes, significant association was found between bacterial pneumonia and veno-occlusive disease (VOD) (P < 0.01) and chronic graft-versus-host disease (GVHD) (P < 0.02). For culture-positive episodes, the association between bacterial pneumonia and VOD was significant (P < 0.001) and borderline for acute GVHD (P = 0.07). It is concluded that VOD and GVHD are positively associated with post-BMT bacterial pneumonia. Its incidence, etiology, risk factors, and outcome are important considerations in its prevention and treatment.

Cytosine arabinoside as a major risk factor for Streptococcus viridans septicemia following bone marrow transplantation: a 5-year prospective study

The incidence and clinical course of nosocomial septicemia with Streptococcus viridans was evaluated prospectively in 242 consecutive bone marrow transplant (BMT) recipients throughout their 15-213 days' (median 47) hospitalization, including 4-58 days (median 18) of neutropenia. Initial empiric therapy for febrile neutropenia consisted of mezlocillin, gentamicin and cefazolin; glycopeptide was excluded. S. viridans septicemia occurred in 23/209 (11%) subjects with underlying malignant disease, and only during neutropenia with concomitant mucositis: in 20 subjects (four with ampicillin-resistant strains), S. viridans septicemia occurred at onset of febrile neutropenia, 1-5 days (median 4.5) post-BMT. All survived with an uncomplicated clinical course. Thus, glycopeptide seems unnecessary in the initial empiric antibiotic regimen. The other three subjects demonstrated S. viridans septicemia (two with ampicillin-resistant strains) on day 11 post-BMT; two died. The major risk identified was cytosine arabinoside administration in the conditioning regimen (P < 0.01).

Diagnosis and treatment of persistent pain after trauma to the head and neck

PURPOSE

A retrospective and prospective study on 22 cases of persistent pain after trauma to the head and neck is presented. According to the predominant symptoms and signs, pain patterns could be divided into musculoskeletal, vascular, and neuropathic, facilitating treatment decisions. Most cases were musculoskeletal in origin, with many demonstrating a combination of two or three pain states.

RESULTS

The variety of pain complaints and their underlying pathophysiology are discussed and treatments for specific pain states are examined.

CONCLUSION

Amitriptyline was the most useful drug in that it provided pain relief in musculoskeletal, vascular, and some neuropathic pain conditions. Multidrug therapy may be indicated in some recalcitrant cases, and drug alternatives are discussed.

Cytomegalovirus pneumonia prior to engraftment following T-cell depleted bone marrow transplantation

CMV pneumonia is a frequent complication of allogeneic bone marrow transplantation (BMT). It usually appears 23 months following transplantation and is associated with a high mortality rate. The incidence of CMV pneumonia in our T-lymphocyte depleted allogeneic BMT recipients, transplanted between 1987-1991, was 18 out of 197 (9.2%) patients. In 3 patients (1.5% of allogenic BMT recipients), pneumonia occurred prior to marrow engraftment, on days 12-16 post BMT. These patients did not develop acute GVHD in contrast to 9/11 patients who had acute GVHD in addition to developing CMV pneumonia between engraftment and day +100 (p < 0.03). Furthermore, these three patients did not receive steroid therapy as opposed to 14/15 patients who were treated with steroids and eventually contracted CMV pneumonia post-engraftment (p < 0.01). The three patients did not have two additional risk factors known for the development of CMV pneumonia: increasing age and a diagnosis of acute myeloblastic leukemia (AML) as the primary disease. Despite prompt diagnosis and therapy with ganciclovir and high doses of intravenous immunoglobulin (IVIG), two of the patients died. Tcell depleted BMT may be a risk factor for development of CMV pneumonia occurring prior to engraftment. In the era of post-BMT anti CMV prophylaxis, one should be aware that life-threatening CMV pneumonia may appear prior to engraftment and consider aggressive CMV prophylaxis.