CAPABLE: A Scoring System Utilizing Patient-Reported Measures to Evaluate Patient Experience After Mohs Surgery

BACKGROUND

Patient experience metrics are gaining prominence in health care. We introduce the CAPABLE survey to assess postoperative experiences of Mohs surgery patients.

OBJECTIVE

We sought to determine whether CAPABLE scores aligned with overall patient satisfaction in Mohs surgery.

METHODS

This was a cross-sectional, survey-based study of patients presenting for their first postoperative visit after Mohs surgery. The CAPABLE survey included questions on postoperative instructions, activity limitations, pain control, provider accessibility, and bleeding, followed by 2 overall satisfaction questions taken from the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems survey. The pilot study took place at the University of Texas Dell Medical School (DMS), followed by a validation study ( n = 206) at DMS and Oregon Health and Science University (OHSU). We assessed for correlations between CAPABLE scores and overall satisfaction.

RESULTS

In the pilot study ( n = 137), overall CAPABLE scores and scores of individual CAPABLE components correlated positively with overall satisfaction.In the multisite validation study ( n = 206) spanning DMS and OHSU, CAPABLE scores correlated positively with overall satisfaction.

CONCLUSION

The CAPABLE survey is a concise tool for assessing specific, actionable components of the postoperative patient experience in Mohs surgery, while correlating with overall patient satisfaction.

Deep learning on reflectance confocal microscopy improves Raman spectral diagnosis of basal cell carcinoma

SIGNIFICANCE

Raman spectroscopy (RS) provides an automated approach for assisting Mohs micrographic surgery for skin cancer diagnosis; however, the specificity of RS is limited by the high spectral similarity between tumors and normal tissues structures. Reflectance confocal microscopy (RCM) provides morphological and cytological details by which many features of epidermis and hair follicles can be readily identified. Combining RS with deep-learning-aided RCM has the potential to improve the diagnostic accuracy of RS in an automated fashion, without requiring additional input from the clinician.

AIM

The aim of this study is to improve the specificity of RS for detecting basal cell carcinoma (BCC) using an artificial neural network trained on RCM images to identify false positive normal skin structures (hair follicles and epidermis).

APPROACH

Our approach was to build a two-step classification model. In the first step, a Raman biophysical model that was used in prior work classified BCC tumors from normal tissue structures with high sensitivity. In the second step, 191 RCM images were collected from the same site as the Raman data and served as inputs for two ResNet50 networks. The networks selected the hair structure and epidermis images, respectively, within all images corresponding to the positive predictions of the Raman biophysical model with high specificity. The specificity of the BCC biophysical model was improved by moving the Raman spectra corresponding to these selected images from false positive to true negative.

RESULTS

Deep-learning trained on RCM images removed 52% of false positive predictions from the Raman biophysical model result while maintaining a sensitivity of 100%. The specificity was improved from 84.2% using Raman spectra alone to 92.4% by integrating Raman spectra with RCM images.

CONCLUSIONS

Combining RS with deep-learning-aided RCM imaging is a promising tool for guiding tumor resection surgery.

Association of Tumor Characteristics With Insurance Type Among Patients Undergoing Mohs Micrographic Surgery for Nonmelanoma Skin Cancer

Importance

Little is known about the association between insurance type and tumor or treatment characteristics among patients undergoing Mohs micrographic surgery (MMS) for nonmelanoma skin cancer (NMSC).

Objective

To investigate whether there are differences in tumor and treatment characteristics among patients undergoing MMS for NMSC by insurance type.

Design, Setting, and Participants

This retrospective cohort study included patients with NMSC who presented for surgery at an academic MMS practice between May 2017 and May 2019.

Main Outcomes and Measures

Preoperative and postoperative tumor diameters, number of MMS stages, type of closure, and number of high-risk tumors were compared based on insurance type among uninsured and underinsured patients and those with private insurance, Medicare, and Veterans Affairs (VA) insurance.

Results

A total of 1397 patients with NMSC (978 [70%] male; mean [SD] age, 68.5 [12.4] years) underwent 1916 MMS procedures. Of these patients, 868 (45%) had Medicare, 570 (30%) had private insurance, 299 (16%) had VA insurance, and 179 (9%) were treated at a safety net clinic or were uninsured. Compared with patients with private insurance, uninsured and underinsured patients had significantly larger preoperative tumor bed diameters (difference, 28%; 95% CI, 14%-43%; P < .001) and postoperative defect sizes (difference, 28%, 95% CI, 16%-41%; P < .001). Patients with Medicare and VA insurance did not have significantly different preoperative tumor bed diameters compared with patients with private insurance. Patients with VA insurance had larger postoperative defect sizes than patients with private insurance (difference, 12%; 95% CI, 2%-23%; P = .02). The number of MMS stages and type of closure did not significantly differ based on insurance type.

Conclusions and Relevance

In this cohort study of patients undergoing MMS for NMSC, larger preoperative tumor and postoperative defect sizes were associated with being uninsured or underinsured compared with privately insured. Future studies are required to determine why these differences exist to deliver optimal care to all patients.

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement

IMPORTANCE

There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs).

OBJECTIVE

To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs.

EVIDENCE REVIEW

Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses.

FINDINGS

The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC.

CONCLUSIONS AND RELEVANCE

Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Imaging sub-diffuse optical properties of cancerous and normal skin tissue using machine learning-aided spatial frequency domain imaging

SIGNIFICANCE

Sub-diffuse optical properties may serve as useful cancer biomarkers, and wide-field heatmaps of these properties could aid physicians in identifying cancerous tissue. Sub-diffuse spatial frequency domain imaging (sd-SFDI) can reveal such wide-field maps, but the current time cost of experimentally validated methods for rendering these heatmaps precludes this technology from potential real-time applications.

AIM

Our study renders heatmaps of sub-diffuse optical properties from experimental sd-SFDI images in real time and reports these properties for cancerous and normal skin tissue subtypes.

APPROACH

A phase function sampling method was used to simulate sd-SFDI spectra over a wide range of optical properties. A machine learning model trained on these simulations and tested on tissue phantoms was used to render sub-diffuse optical property heatmaps from sd-SFDI images of cancerous and normal skin tissue.

RESULTS

The model accurately rendered heatmaps from experimental sd-SFDI images in real time. In addition, heatmaps of a small number of tissue samples are presented to inform hypotheses on sub-diffuse optical property differences across skin tissue subtypes.

CONCLUSION

These results bring the overall process of sd-SFDI a fundamental step closer to real-time speeds and set a foundation for future real-time medical applications of sd-SFDI such as image guided surgery.

Toward automated assessment of mole similarity on dermoscopic images

Purpose: Current skin cancer detection relies on dermatologists' visual assessments of moles directly or dermoscopically. Our goal is to show that our similarity assessment algorithm on dermoscopic images can perform as well as a dermatologist's assessment. Approach: Given one target mole and two other moles from the same patient, our model determines which mole is more similar to the target mole. Similarity was quantified as the Euclidean distance in a feature space designed to capture mole properties such as size, shape, and color. We tested our model on 18 patients, each of whom had at least five moles, and compared the model assessments of mole similarity with that of three dermatologists. Fleiss' Kappa agreement coefficients and iteration tests were used to evaluate the agreement in similarity assessment among dermatologists and our model. Results: With the selected features of size, entropy (color variation), and cluster prominence (asymmetry), our algorithm's similarity assessments agreed moderately with the similarity assessments of dermatologists. The mean Kappa of 1000 iteration tests was 0.49 ( confidence interval   ( CI ) = [ 0.23 , 0.74 ] ) when comparing three dermatologists and our model, which is comparable to the agreement in similarity assessment among the dermatologists themselves (the mean Kappa of 1000 iteration tests for three dermatologists was 0.48, CI = [ 0.19 , 0.77 ] .) By contrast, the mean Kappa was 0.22 ( CI = [ - 0.00 , 0.43 ] ) when comparing the similarity assessments of three dermatologists and random guesses. Conclusions: Our study showed that our image feature-engineering-based algorithm can effectively assess the similarity of moles as dermatologists do. Such a similarity assessment could serve as the foundation for computer-assisted intra-patient evaluation of moles.

Successful treatment of recurrent advanced cutaneous squamous cell carcinoma with cemiplimab

A 90-year-old man presented for evaluation of an incompletely excised squamous cell carcinoma above the right brow, with pathology demonstrating tumor extending to resection margins with perineural invasion. A cord of tumor was noted to extend past the orbital rim and towards the posterior orbit. Mohs excision versus coordinated resection and reconstruction with colleagues in the head and neck surgery and craniofacial plastic surgery departments were considered. Multidisciplinary consensus was to proceed with radical resection in the operating room followed by adjuvant radiation therapy. One year later, the patient presented to our Mohs unit with a 3cm eroded multinodular plaque. Following an in-depth discussion regarding the options of further surgery versus systemic treatment, the patient and his family opted to pursue consultation with a medical oncology consultant to discuss restaging and potential systemic therapy. A PET scan with concurrent CT revealed a hypermetabolic right temporal scalp mass without evidence of bony invasion or extension into the nodal basin. Immunotherapy with cemiplimab was started at a dose of 350mg IV every three weeks. After 7 cycles, the patient demonstrated complete clinical resolution with a repeat PET scan showing interval near resolution of abnormal metabolic activity.

Superpixel Raman spectroscopy for rapid skin cancer margin assessment

Spontaneous Raman micro-spectroscopy has been demonstrated great potential in delineating tumor margins; however, it is limited by slow acquisition speed. We describe a superpixel acquisition approach that can expedite acquisition between ~×100 and ×10 000, as compared to point-by-point scanning by trading off spatial resolution. We present the first demonstration of superpixel acquisition on rapid discrimination of basal cell carcinoma tumor from eight patients undergoing Mohs micrographic surgery. Results have been demonstrated high discriminant power for tumor vs normal skin based on the biochemical differences between nucleus, collagen, keratin and ceramide. We further perform raster-scanned superpixel Raman imaging on positive and negative margin samples. Our results indicate superpixel acquisition can facilitate the use of Raman microspectroscopy as a rapid and specific tool for tumor margin assessment.

Biophysical basis of skin cancer margin assessment using Raman spectroscopy

Achieving adequate margins during tumor margin resection is critical to minimize the recurrence rate and maximize positive patient outcomes during skin cancer surgery. Although Mohs micrographic surgery is by far the most effective method to treat nonmelanoma skin cancer, it can be limited by its inherent required infrastructure, including time-consuming and expensive on-site histopathology. Previous studies have demonstrated that Raman spectroscopy can accurately detect basal cell carcinoma (BCC) from surrounding normal tissue; however, the biophysical basis of the detection remained unclear. Therefore, we aim to explore the relevant Raman biomarkers to guide BCC margin resection. Raman imaging was performed on skin tissue samples from 30 patients undergoing Mohs surgery. High correlations were found between the histopathology and Raman images for BCC and primary normal structures (including epidermis, dermis, inflamed dermis, hair follicle, hair shaft, sebaceous gland and fat). A previously developed model was used to extract the biochemical changes associated with malignancy. Our results showed that BCC had a significantly different concentration of nucleus, keratin, collagen, triolein and ceramide compared to normal structures. The nucleus accounted for most of the discriminant power (90% sensitivity, 92% specificity - balanced approach). Our findings suggest that Raman spectroscopy is a promising surgical guidance tool for identifying tumors in the resection margins.

Raman biophysical markers in skin cancer diagnosis

Raman spectroscopy (RS) has demonstrated great potential for in vivo cancer screening; however, the biophysical changes that occur for specific diagnoses remain unclear. We recently developed an inverse biophysical skin cancer model to address this issue. Here, we presented the first demonstration of in vivo melanoma and nonmelanoma skin cancer (NMSC) detection based on this model. We fit the model to our previous clinical dataset and extracted the concentration of eight Raman active components in 100 lesions in 65 patients diagnosed with malignant melanoma (MM), dysplastic nevi (DN), basal cell carcinoma, squamous cell carcinoma, and actinic keratosis. We then used logistic regression and leave-one-lesion-out cross validation to determine the diagnostically relevant model components. Our results showed that the biophysical model captures the diagnostic power of the previously used statistical classification model while also providing the skin's biophysical composition. In addition, collagen and triolein were the most relevant biomarkers to represent the spectral variances between MM and DN, and between NMSC and normal tissue. Our work demonstrates the ability of RS to reveal the biophysical basis for accurate diagnosis of different skin cancers, which may eventually lead to a reduction in the number of unnecessary excisional skin biopsies performed.

Raman active components of skin cancer

Raman spectroscopy (RS) has shown great potential in noninvasive cancer screening. Statistically based algorithms, such as principal component analysis, are commonly employed to provide tissue classification; however, they are difficult to relate to the chemical and morphological basis of the spectroscopic features and underlying disease. As a result, we propose the first Raman biophysical model applied to in vivo skin cancer screening data. We expand upon previous models by utilizing in situ skin constituents as the building blocks, and validate the model using previous clinical screening data collected from a Raman optical fiber probe. We built an 830nm confocal Raman microscope integrated with a confocal laser-scanning microscope. Raman imaging was performed on skin sections spanning various disease states, and multivariate curve resolution (MCR) analysis was used to resolve the Raman spectra of individual in situ skin constituents. The basis spectra of the most relevant skin constituents were combined linearly to fit in vivo human skin spectra. Our results suggest collagen, elastin, keratin, cell nucleus, triolein, ceramide, melanin and water are the most important model components. We make available for download (see supplemental information) a database of Raman spectra for these eight components for others to use as a reference. Our model reveals the biochemical and structural makeup of normal, nonmelanoma and melanoma skin cancers, and precancers and paves the way for future development of this approach to noninvasive skin cancer diagnosis.

Malignant melanoma arising in the setting of epidermolysis bullosa simplex: an important distinction from epidermolysis bullosa nevus

IMPORTANCE

Patients with epidermolysis bullosa (EB) do not carry a significantly increased risk of melanoma but are prone to developing large, markedly atypical melanocytic nevi (EB nevi), which may mimic melanoma clinically and histologically. Many authors now favor a conservative approach in managing atypical pigmented lesions in patients with EB.

OBSERVATIONS

We present the case of a 30-year-old woman with severe EB simplex who sought care for a large red and black ulcerated plaque. The clinical differential diagnosis included EB nevus and melanoma. An incisional punch biopsy specimen revealed an atypical melanocytic proliferation with focal florid pagetoid spread and involving elongated rete ridges, consistent with invasive acral lentiginous melanoma. The subsequent amputation was confirmatory. Micrometastasis was detected in 1 of 5 sentinel lymph nodes.

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the first reported case of melanoma arising in EB simplex-affected skin. It highlights the difficulty in differentiating melanoma from an EB nevus. Despite the increasing awareness of EB nevi, a high index of suspicion for melanoma should be maintained, and early biopsy is recommended when evaluating large pigmented lesions in patients with EB.

Management options for metastatic melanoma in the era of novel therapies: a primer for the practicing dermatologist: part II: Management of stage IV disease

Part II of this continuing medical education article will discuss the treatment options for stage IV melanoma, including novel therapies, such as ipilimumab and vemurafenib; established therapies, including high-dose interleukin-2, conventional chemotherapy, and biochemotherapy; and additional therapies currently under investigation in the form of clinical trials. The approach to patients with brain metastases will be discussed, as will recommendations for distress screening and defining aspects of palliative care.

Psoriasiform pemphigus foliaceus: a report of two cases

Pemphigus foliaceus (PF) represents an autoimmune blistering disease characterized by the disruption of epidermal intercellular adhesion proteins. Clinical findings include superficial crusted erosions in a seborrheic distribution; however, the disease can rarely present as an exfoliative erythroderma. Histopathologic findings include acantholysis with cleavage within the granular layer. Direct immunofluorescence studies show intercellular IgG and complement deposition. We present two patients, to our dermatology department, with a previous diagnosis of psoriasis, with an exfoliative erythroderma, which ultimately proved to be because of PF based on histopathological features, direct immunofluorescence results and levels of antibodies against desmoglein 1. Both patients responded well to oral prednisone and rituximab. This variant of PF should be entertained in both the clinical differential diagnosis of psoriasiform erythroderma and in the microscopic differential diagnosis of psoriasiform epidermal hyperplasia with focal acantholysis, particularly in patients for whom the clinical history is not classic for psoriasis or for whom conventional psoriasis therapies have not proven beneficial.

Endometrial thickness following medical abortion is not predictive of subsequent surgical intervention

OBJECTIVES

To evaluate the ability of endometrial thickness after medical abortion to predict the need for subsequent dilatation and curettage (D&C).

METHODS

We pooled data from two multicenter medical abortion trials involving 2208 women who received mifepristone orally followed by misoprostol vaginally. Women returned for transvaginal ultrasonography approximately 7 days later. The endometrial thickness was measured if no gestational sac was present. Final status was confirmed by a phone interview at 5 weeks. The area under the receiver-operating characteristics (ROC) curve was calculated to assess the overall ability of endometrial thickness to predict the need for subsequent D&C. Endometrial thickness was dichotomized using threshold values at 5-mm increments from 10 to 30 mm. The sensitivity, specificity, negative predictive value and positive predictive value were calculated to evaluate the ability of each endometrial thickness threshold value to predict subsequent D&C. Multivariable regression analysis was performed to adjust endometrial thickness values for study, treatment group, and study site.

RESULTS

At 7 days after misoprostol treatment, 1870 women (84.7%) had endometrial thickness assessed. Thirty of these women (1.6%) subsequently underwent D&C. The mean endometrial thickness was 14.5 mm for women who underwent D&C and 10.9 mm for those who did not (difference 3.5 mm (95% CI, 1.8-5.3 mm)). Endometrial thickness was poorly predictive of the need for D&C, with an area under the ROC curve of 0.65. All endometrial thickness thresholds had positive predictive values of 25% or less. The results were unchanged by adjustment of endometrial thickness values by multivariable modeling.

CONCLUSIONS

Although endometrial thickness following successful expulsion of the gestational sac is thicker in women who will eventually require surgical intervention after medical abortion, endometrial thickness is not a clinically useful predictor of the subsequent need for D&C.

Adult Henoch-schönlein purpura in a patient with myelodysplastic syndrome and a history of follicular lymphoma

GOAL

To understand Henoch-Schönlein purpura (HSP) to better manage patients with the condition.

OBJECTIVES

Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Describe the criteria for diagnosing HSP. 2. Explain the association of malignancy and HSP. 3. Discuss the prevalence of HSP in adults. Henoch-Schönlein purpura (HSP) is a systemic leukocytoclastic vasculitis involving arterioles and venules most commonly in the skin, glomeruli, and gastrointestinal tract. In skin, it is associated with IgA deposition around dermal blood vessels. While an exact cause of HSP has not been elucidated, several processes have been implicated in its development, including infections; drugs; and allergic, rheumatologic, and neoplastic diseases. We present a 57-year-old woman with a history of follicular lymphoma who developed HSP likely associated with myelodysplastic syndrome. This case is clinically significant because the patient was thought to be in remission of her hematologic disease until her skin findings prompted further evaluation. Her diagnosis of HSP was based on clinical presentation with palpable purpura and abdominal pain, and was confirmed with biopsy and immunohistochemical analyses of purpuric papules demonstrating leukocytoclastic vasculitis and strong anti-IgA labeling in the dermal endothelial cells consistent with immunocomplex deposition. The occurrence of vasculitis and malignant disease in the same patient often is difficult to interpret, as some patients may exhibit both diseases independently and by chance, while others may have vasculitis as a paraneoplastic syndrome. We review cases of adult HSP associated with malignancy in the literature.

Endometrial thickness after misoprostol use for early pregnancy failure

OBJECTIVES

To assess if there was any potential relationship between endometrial thickness and final treatment outcome in women successfully treated with misoprostol for a first trimester anembryonic gestation, embryonic demise or fetal demise.

METHODS

Eighty women were treated with up to two doses of misoprostol 800 microg vaginally for early pregnancy failure. Subjects were scheduled to return 2 (range 1-4), 7 (range 5-9) and 14 (range 12-17) days after treatment. Transvaginal ultrasonography was performed at each follow-up visit.

RESULTS

The median endometrial thickness at each of the follow-up visits for women who had expelled the gestational sac was 14 mm, 10 mm, and 7 mm, respectively. The endometrial thickness at the first follow-up visit exceeded 15 mm in 20 subjects (36%) and 30 mm in four subjects (7%). Only three women had a suction aspiration for bleeding after documented expulsion. The endometrial thickness for these women was 11, 13, and 14 mm at the first follow-up visit.

CONCLUSIONS

There is no obvious relationship between increasing endometrial thickness and the need for surgical intervention in women treated with misoprostol for early pregnancy failure.

Interleukin-1 receptor antagonist as an adjunct in the treatment of Haemophilus influenzae otitis media in the chinchilla

OBJECTIVES

This purpose of this study was to investigate the effect of blockade of the inflammatory cytokine pathway on experimentally induced otitis media in the chinchilla model.

STUDY DESIGN

Pilot, randomized placebo-controlled trial.

METHODS

Ampicillin-sensitive Haemophilus influenzae otitis media was induced in 45 adult chinchillas. The animals were randomly assigned to the following treatment groups: 1) transbullar injections (TBI) of interleukin-1 receptor antagonist (IL-1ra) and intramuscular ampicillin, 2) TBI of saline and intramuscular ampicillin, 3) TBI of IL-1ra and intramuscular sa-1 line or 4) TBI of saline and intramuscular saline. Blinded investigators measured resolution of otitis media by otomicroscopy, tympanogram, and culture results.

RESULTS

Comparisons were made between the treatment groups to assess the ability of IL-1ra to assist with resolution of otitis media using exact two-group binomial tests with the StatXact statistical program. The group with TBI of IL-1ra and intramuscular ampicillin as a treatment demonstrated trends suggesting more rapid resolution of positive cultures and more rapid and complete return to normal results on tympanograms and otomicroscopic findings compared with the group treated with TBI of saline and intramuscular ampicillin. These trends did not achieve statistical significance with the relatively small sample sizes used in this pilot study.

CONCLUSIONS

This investigation provides further evidence that the inflammatory cytokine cascade plays a significant role in the pathophysiology of otitis media and that modulation of this inflammatory pathway may provide novel and efficacious treatments for otitis media Further studies with larger groups of animals are warranted to determine whether the trends identified in this pilot study are reproducible and achieve statistical significance.

Relevant issues in revision canal-wall-down mastoidectomy

The role of canal-wall-down (CWD) versus intact-canal-wall (ICW) mastoidectomy in the treatment of chronic otitis media with or without cholesteatoma remains a debated issue. Although past conventional wisdom has held that CWD mastoid surgery leads to a "safe" ear and is technically less demanding than the more controversial ICW mastoidectomy, this is often not the case. Although our preference is an ICW technique when possible, 47 of 109 (43%) mastoid procedures for chronic otitis media performed between January 1993 and June 1996 involved a CWD mastoid cavity. More than two thirds of these procedures (32 of 47) represented revision surgery, the most common indication being a poorly contoured, preexisting CWD mastoidectomy with persistent otorrhea. A dry, well-epithelialized ear was obtained in 90% of cases. Our preferred method of ossicular reconstruction (double cartilage block ossiculoplasty) is detailed, and hearing results according to American Academy of Otolaryngology Head and Neck Surgery guidelines are reported.

Antisense oligonucleotide inhibition of hepatitis C virus (HCV) gene expression in livers of mice infected with an HCV-vaccinia virus recombinant

Hepatitis C virus (HCV) is the major cause of non-A, non-B hepatitis worldwide. Current treatments are not curative for most infected individuals, and there is an urgent need for both novel therapeutic agents and small-animal models which can be used to evaluate candidate drugs. A small-animal model of HCV gene expression was developed with recombinant vaccinia virus vectors. VHCV-IRES (internal ribosome entry site) is a recombinant vaccinia viral vector containing the HCV 5' nontranslated region (5'-NTR) and a portion of the HCV core coding region fused to the firefly luciferase gene. Intraperitoneal injection of VHCV-IRES produced high levels of luciferase activity in the livers of BALB/c mice. Antisense oligonucleotides complementary to the HCV 5'-NTR and translation initiation codon regions were then evaluated for their effects on the expression of these target HCV sequences in BALB/c mice infected with the vaccinia virus vector. Treatment of VHCV-IRES-infected mice with 20-base phosphorothioate oligonucleotides complementary to the sequence surrounding the HCV initiation codon (nucleotides 330 to 349) specifically reduced luciferase expression in the livers in a dose-dependent manner. Inhibition of HCV reporter gene expression in this small-animal model suggests that antisense oligonucleotides may provide a novel therapy for treatment of chronic HCV infection.

Doramectin efficacy against the kidney worm, Stephanurus dentatus in sows

Sixteen sows passing Stephanurus dentatus eggs in their urine were bought on the local market and placed in individual pens with solid concrete floors in an open-sided bam. Water was supplied by nipple waterers and sows were fed individually 1.8 kg feed daily. First, urine samples were taken at dawn on days -8 and -7 and weights were taken on day 0. Sows were assigned to one of two groups on the basis of average urine egg counts and weights. Group T1 sows were each injected IM in the neck with sterile saline at the rate of 1.5 ml per 50 kg and group T2 sows were each injected IM with doramectin at the rate of 300 micrograms kg-1 on day 0. Urine samples were again taken on days 56 and 57 and the sows were necropsied on day 57. Urine of all doramectin treated sows were test negative for kidney work eggs on days 56 and 57 as was one control sow, whereas the average count for controls was 3762 eggs ml-1. No worms were found in doramectin treated sows and a total of 499 were found in the controls for an average of 62 per sow. The majority of worms were in the perirenal area and kidneys, a few were scattered in liver, lungs, abdominal muscles and peritoneal cavity. The efficacy of doramectin against Stephanurus dentatus in sows was 100% (P < 0.0001).

Doramectin efficacy against gastrointestinal nematodes in pigs

Four controlled trials with growing pigs were performed to determine efficacy of doramectin against natural and induced populations of nematodes. In Trial 1 (T1), 20 pigs with natural infections were assigned to one of two like groups on the basis of weight, sex and worm egg counts. In Trial 2 (T2), 20 pigs with negative worm egg counts were assigned to one of two groups on the basis of weight and sex. Each pig was subsequently given (per os) 3000 Trichuris suis embryonated eggs; 2000 Ascaris suum embryonated eggs; 10000 Oesophagostomum spp. infective larvae and 10,000 Strongyloides ransomi infective larvae (SC injection). In Trial 3 (T3), 20 pigs with negative worm egg counts were assigned as in T2, and each pig was subsequently given (per os) 2000 A. suum embryonated eggs, 15000 Oesophagostomum quadrispinulatum infective larvae, and 2891 Hyostrongylus rubidus infective larvae. In Trial 4 (T4), 16 pigs with negative worm egg counts were each assigned to one of two groups as in T2 and were given (per os) 2670 T. suis embryonated eggs. On Day 0 of each trial, each pig of the control group was injected IM in the neck with sterile saline at the rate of 1.5 ml 50 kg-1. Each pig in the treated group of each trial was similarly injected with doramectin at the rate of 300 micrograms kg-1. All pigs were necropsied 14 or 15 days post-treatment and parasites recovered by standard parasitological procedures. Efficacies against natural infections were: A. suum, 100%; Oesophagostomum spp. 100%; H. rubidus, 99.4%; and Strongyloides ransomi, 99.9%. Efficacies against induced infections were: 4th stage A. suum, 100%; 4th stage O.dentatum, 99.9%; 4th stage O.quadrispinulatum, 97.1 and 99.6%; 4th stage H. rubidus, 100%; adult S. ransomi, 100%; adult Trichuris suis in mixed infection, 54.1%; and in pure infection, 95.3%.

Inhibition of human cytomegalovirus immediate-early gene expression by an antisense oligonucleotide complementary to immediate-early RNA

ISIS 2922 is a phosphorothioate oligonucleotide that is complementary to human cytomegalovirus (CMV) immediate-early (IE) RNA and that exhibits potent and specific antiviral activity against CMV in cell culture assays. Specific assay systems were developed to separately characterize the antisense and nonantisense components of the antiviral activity mediated by ISIS 2922. In U373 cells transformed with cDNA encoding the CMV IE 55-kDa (IE55) protein, expression was inhibited at nanomolar concentrations comparable to effective concentrations in antiviral assays. The specificity of inhibition was demonstrated by using control oligonucleotides incorporating progressive base changes to destabilize oligonucleotide-RNA base pairing and by showing a lack of inhibition of the CMV IE72 product expressed from the same promoter. Inhibition of IE55 protein expression correlated with a reduction in mRNA levels consistent with an RNase H-mediated termination event. Studies with virus-infected cells demonstrated that antisense and nonantisense mechanisms contribute to the antiviral activity of ISIS 2922. Base complementarity to target RNA was important for optimal activity in antiviral assays, but base changes affecting parameters other than hybridization affinity also influenced antiviral activity. Sequence-independent inhibition of virus adsorption to host cells by phosphorothioate oligonucleotides was also observed at high concentrations. Therefore, at least three different mechanisms may contribute to the antiviral activity of ISIS 2922 in cell culture: antisense-mediated inhibition of target gene expression; nonantisense, sequence-dependent inhibition of virus replication; and sequence-independent inhibition of virus adsorption to host cells.

Antisense oligonucleotide inhibition of hepatitis C virus gene expression in transformed hepatocytes

Genetic and biochemical studies have provided convincing evidence that the 5' noncoding region (5' NCR) of hepatitis C virus (HCV) is highly conserved among viral isolates worldwide and that translation of HCV is directed by an internal ribosome entry site (IRES) located within the 5' NCR. We have investigated inhibition of HCV gene expression using antisense oligonucleotides complementary to the 5' NCR, translation initiation codon, and core protein coding sequences. Oligonucleotides were evaluated for activity after treatment of a human hepatocyte cell line expressing the HCV 5' NCR, core protein coding sequences, and the majority of the envelope gene (E1). More than 50 oligonucleotides were evaluated for inhibition of HCV RNA and protein expression. Two oligonucleotides, ISIS 6095, targeted to a stem-loop structure within the 5' NCR known to be important for IRES function, and ISIS 6547, targeted to sequences spanning the AUG used for initiation of HCV polyprotein translation, were found to be the most effective at inhibiting HCV gene expression. ISIS 6095 and 6547 caused concentration-dependent reductions in HCV RNA and protein levels, with 50% inhibitory concentrations of 0.1 to 0.2 microM. Reduction of RNA levels, and subsequently protein levels, by these phosphorothioate oligonucleotides was consistent with RNase H cleavage of RNA at the site of oligonucleotide hybridization. Chemically modified HCV antisense phosphodiester oligonucleotides were designed and evaluated for inhibition of core protein expression to identify oligonucleotides and HCV target sequences that do not require RNase H activity to inhibit expression. A uniformly modified 2'-methoxyethoxy phosphodiester antisense oligonucleotide complementary to the initiator AUG reduced HCV core protein levels as effectively as phosphorothioate oligonucleotide ISIS 6095 but without reducing HCV RNA levels. Results of our studies show that HCV gene expression is reduced by antisense oligonucleotides and demonstrate that it is feasible to design antisense oligonucleotide inhibitors of translation that do not require RNase H activation. The data demonstrate that chemically modified antisense oligonucleotides can be used as tools to identify important regulatory sequences and/or structures important for efficient translation of HCV.

In vitro evaluation of phosphorothioate oligonucleotides targeted to the E2 mRNA of papillomavirus: potential treatment for genital warts

Papillomaviruses induce benign proliferative lesions, such as genital warts, in humans. The E2 gene product is thought to play a major role in the regulation of viral transcription and DNA replication and may represent a rational target for an antisense oligonucleotide drug action. Phosphorothioate oligonucleotides complementary to E2 mRNAs were synthesized and tested in a series of in vitro bovine papillomavirus (BPV) and human papillomavirus (HPV) models for the ability to inhibit E2 transactivation and virus-induced focus formation. The most active BPV-specific compounds were complementary to the mRNA cap region (ISIS 1751), the translation initiation region for the full-length E2 transactivator (ISIS 1753), and the translation initiation region for the E2 transrepressor mRNA (ISIS 1755). ISIS 1751 and ISIS 1753 were found to reduce E2-dependent transactivation and viral focus formation in a sequence-specific and concentration-dependent manner. ISIS 1755 increased E2 transactivation in a dose-dependent manner but had no effect on focus formation. Oligonucleotides with a chain length of 20 residues had optimal activity in the E2 transactivation assay. On the basis of the above observations, ISIS 2105, a 20-residue phosphorothioate oligonucleotide targeted to the translation initiation of both HPV type 6 (HPV-6) and HPV-11 E2 mRNA, was designed and shown to inhibit E2-dependent transactivation by HPV-11 E2 expressed from a surrogate promoter. These observations support the rationale of E2 as a target for antiviral therapy against papillomavirus infections and specifically identify ISIS 2105 as a candidate antisense oligonucleotide for the treatment of genital warts induced by HPV-6 and HPV-11.

Performance of pigs with mixed nematode infections before and after ivermectin treatment

Ninety crossbred parasitized pigs were used in two controlled experiments to compare performance before and after ivermectin treatment. Four groups of 15 pigs were sequentially infected with 2000 Ascaris suum, 10,000 Oesophagostomum spp. and 10,000 Strongyloides ransomi beginning at average pig weights of either 38 kg (Experiment I) or 14 kg (Experiment II). Two infected groups of pigs were treated with ivermectin on Day 34 (Experiment I) or 37 (Experiment II) of the experiments and all pigs were fed to slaughter weights of approximately 100 kg. Average daily gain (ADG) of heavier ivermectin-treated pigs was greater than that of infected non-treated pigs (P less than 0.03) and feed conversion was numerically greater by 5% (P greater than 0.10). ADG was not different between lighter treated or non-treated pigs, but feed conversion was numerically 4% greater in ivermectin-treated compared to non-treated pigs (P greater than 0.10). No differences existed in carcass dressing percentage among the three groups of heavier pigs, but among the lighter groups ivermectin-treated pigs had a higher dressing percentage (P less than 0.03) than infected non-treated or control pigs. Results of the calculation of production costs based on combined data from the two experiments for the post-treatment period, including feed, drug and maintenance costs, indicate that the production cost for ivermectin-treated pigs was $1.53 per pig less than that for infected non-treated pigs when the cost for each group to attain control pig weights is compared with the actual cost for control pigs.

Effect of diaphragmatic respiration with end-tidal CO2 biofeedback on respiration, EEG, and seizure frequency in idiopathic epilepsy

Breathing rate (RR), end-tidal percent CO2, and EEG were obtained in three groups: psychiatric referral subjects presenting with anxiety, panic phobia, depression and migraine; a group of idiopathic seizure sufferers; and a group of asymptomatic controls. Virtually all the noncontrol subjects were found to show moderate to severe hyperventilation and the accompanying EEG dysrhythmia. The seizure group subjects were taught diaphragmatic respiration with end-tidal percent CO2 biofeedback. The training normalized their respiration and altered their EEGs and seizure frequency.

Excess crude protein for nongravid gilts

Twenty-five nongravid crossbred gilts (avg initial wt, 126 kg) were placed on either a high (38%) or a low (13%) crude protein (CP) diet and fed either at the rate of 1.82 kg/d or had ad libitum access to feed. In addition, a fifth group was pair-fed the 13% CP diet to the average intake of the gilts fed high CP ad libitum. The experimental period lasted 30 d. Corn-soybean meal diets were used and CP levels were varied by altering the corn:soybean meal ratio. Gain and gain/feed were reduced (P less than .01) in gilts fed 1.82 kg/d compared with the gilts fed ad libitum or pair-fed gilts. Gain (P less than .03) and feed intake (P less than .01) of gilts with ad libitum access to the 13% CP diet were higher than those of gilts with ad libitum access to the 38% CP diet. Gain/feed was not different (P greater than .10) between the two groups, however. Rate of gain and feed efficiency of gilts pair-fed the 13% CP diet were similar (P greater than .10) to those of gilts with ad libitum access to the 38% CP diet. Plasma total free amino acids, NH3 and total protein were not (P greater than .10) affected by treatment. Plasma urea-N and urinary total N, urea-N and orotic acid were increased (P less than .01) in gilts fed the high CP diet regardless of feed intake level. However, urinary NH3 was higher (P less than .01) in gilts fed the low-protein diet. These results indicate that excess dietary CP for nongravid gilts decreases gain and feed intake and has no effect on efficiency of feed utilization, but it increases plasma urea-N and urinary total N, urea-N and orotic acid.

Effect of ammonium chloride ingestion on Eimeria acervulina-infected chicks fed excess copper

Four experiments were conducted with broiler chicks to investigate the effect of dietary NH4Cl on gain, feed efficiency, duodenal pH, and liver Cu concentration of Eimeria acervulina-infected chicks. Experimental coccidial infection reduced chick gain, feed efficiency, and duodenal pH, but it increased liver Cu concentration in chicks fed excess Cu. Ammonium chloride had no effect on gain, feed efficiency, liver Cu concentration, or on duodenal pH.

Effect of dietary buffer additions on gain, efficiency, duodenal pH, and copper concentration in liver of Eimeria acervulina-infected chicks

Three experiments were conducted with broiler chicks to investigate the effect of dietary additions of NaHCO3(1%), A1(OH)3(.5%), kaolin(1%), A1(OH)2NaCO3(.23%), CaCO3(.37%), and MgO(1%) on gain, efficiency, duodenal pH, and liver Cu concentration of Eimeria acervulina-infected chicks. Experimental coccidial infection consistently reduced chick gain, efficiency, and duodenal pH, but it increased liver Cu concentration of chicks fed excess Cu. Sodium bicarbonate addition improved chick gain and efficiency slightly, whereas the MgO addition reduced these performance criteria. Sodium bicarbonate improved gain more in coccidiosis-infected chicks than in uninfected chicks, but it failed to alleviate, to any extent, the coccidiosis-induced liver Cu increase of the duodenal pH decrease.

Excess supplemental choline for swine

Seven experiments were conducted with 280 crossbred pigs to investigate the effect of excess choline on rate and efficiency of gain of weanling, growing and finishing swine Choline additions were made to a conventional corn-soybean meal diet. Daily gain of weanling pigs was reduced slightly by 6,000 ppm excess choline compared with 0, 500, 1,000, 2,000 or 4,000 ppm excess choline. Excess supplemental choline (2,000 ppm) fed throughout the weanling, growing and finishing (121 to 126 d) phases of growth reduced (P less than .08) daily gain but it did not affect (P greater than .10) feed utilization. The 2,000-ppm choline addition, however, did not affect (P less than .10) pig gain when fed only during the growing and finishing stages of growth (68 to 86 d). Excess choline should be avoided in swine diets if maximum rate of gain is to be achieved.

Behavioral control of intractable idiopathic seizures: I. Self-regulation of end-tidal carbon dioxide

Eleven women and seven men with moderate to severe chronic hyperventilation and idiopathic seizures refractory to therapeutic serum levels of anticonvulsant medication were given diaphragmatic respiration training with percent end-tidal CO2 biofeedback. The training had a rapid correcting effect on their respiration, making it comparable to that of 18 asymptomatic control subjects. Ten of the seizure-group subjects were in the study at least 7 months and following treatment, 8 showed EEG power spectrum "normalization", restoration of cardio-respiratory synchrony (RSA), and their seizure frequency and severity were significantly reduced.