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J F Piccirillo

Publications and source records attributed to J F Piccirillo.

At least 19 recordsLinked to original sources
PubMed2001

Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis.

CONTEXT: Studies suggest little benefit in relief of acute sinusitis symptoms from the use of newer and more expensive (second-line) antibiotics instead of older and less expensive (first-line) antibiotics. However, researchers have failed to include development of complications and cost of care in their analyses. OBJECTIVE: To compare the effectiveness and cost of first-line with second-line antibiotics for the treatment of acute uncomplicated sinusitis in adults. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study using a pharmaceutical database containing demographic, clinical (International Classification of Diseases, Ninth Revision), treatment, and charge information for 29 102 adults with a diagnosis of acute sinusitis receiving initial antibiotic treatment between July 1, 1996, and June 30, 1997. MAIN OUTCOME MEASURES: Absence of additional claim for an antibiotic in the 28 days after the initial antibiotic, presence of a claim for a second antibiotic, serious complications of sinusitis, and direct charges and use for the acute sinusitis treatment. RESULTS: There were 17 different antibiotics prescribed in this study. The majority (59.5%) of patients received 1 of the first-line antibiotics. The overall success rate was 90.4% (95% confidence interval [CI], 90.0%-90.8%). The success rate for the 17 329 patients who received a first-line antibiotic was 90.1% and for the 11 773 patients who received a second-line antibiotic was 90.8%, a difference of 0.7% (95% CI, 0.01%-1.40%; P<.05). There were 2 cases of periorbital cellulitis, one in each treatment group. The average total direct charge for patients receiving a first-line antibiotic was $68.98 and a second-line antibiotic was $135.17, a difference of $66.19 (95% CI, $64.95-$67.43; P<.001). This difference was due entirely to the difference in charge of antibiotics and not other charges, such as professional fees, laboratory tests, or emergency department visits. CONCLUSIONS: Patients treated with a first-line antibiotic for acute uncomplicated sinusitis did not have clinically significant differences in outcomes vs those treated with a second-line antibiotic. However, cost of care was significantly higher for patients treated with a second-line antibiotic.

Acute Disease↗
PubMed2000

Head and neck squamous cell carcinoma: better to be young.

Most head and neck squamous cell carcinoma patients are elderly, with few younger than 40 years. Controversy exists in the literature regarding outcomes for younger patients. The goal of this research project was to compare baseline features and outcomes for young patients (</=40 years), middle-aged patients (41-64 years), and old patients (>/=65 years). To investigate the relationship between age and important presenting features and outcomes, 1160 recently diagnosed patients first treated at Washington University between 1980 and 1991 were identified from an existing database. Full 5-year survival information was available for 1030 patients (89%). Overall, the 5-year survival rate was 46% (478/1030); young patients (65%, 26/40) had a significantly better survival rate than middle-aged (52%, 292/566) or old patients (38%, 160/424) (chi(2) = 24.5; P = 0. 001). Survival was also related to smoking, comorbidity, primary site, TNM stage, and nodal disease. Age remained a significant factor even after we controlled for these other factors. Young patients developed fewer recurrent and new primary tumors. We conclude that young patients have a much better overall prognosis than older patients. The reasons for this difference are unclear, but it appears that the impact of age goes beyond an actuarial effect.

Adult↗
PubMed2000

Factors related to outcome of salvage therapy for isolated cervical recurrence of squamous cell carcinoma in the previously treated neck: a multi-institutional study.

OBJECTIVE: The goal was to identify factors associated with the outcome of salvage therapy for patients with isolated cervical recurrences of squamous cell carcinoma in the previously treated neck (ICR-PTN). STUDY DESIGN AND SETTINGS: A tumor registry search for ICR-PTN patients was performed at 7 participating institutions, and the charts were reviewed. Kaplan-Meier plots for survival and time until re-recurrence were used to evaluate the significance of associated variables. RESULTS: Median survival and time until re-recurrence were both 11 months. Survival was better in patients with the following characteristics: nonsurgical initial neck treatment, negative initial disease resection margins, no history of prior recurrence, ipsilateral location of the ICR-PTN relative to the primary, and use of surgical salvage. CONCLUSIONS: By pooling the experience of 7 US tertiary care medical centers, we have identified 5 factors that are associated with outcome of salvage therapy for ICR-PTN. SIGNIFICANCE: Consideration of these factors, as well as the reviewed literature, should facilitate patient selection for salvage protocols.

Adult↗
PubMed2000

Student Research Award 1999: comparative contrast of voice measurements.

Currently, a variety of objective and subjective measures are available to describe voice and voice function. Despite these various tools, there is no standard measure of voice function that incorporates both objective and subjective measures. The goal of this research was to study the relationship between objective, subjective, and patient-based measures of voice function. Objective voice function was measured with 4 laboratory-based parameters (subglottic pressure, airflow at the lips, maximum phonation time, and vocal efficiency), subjective function with the GRBAS (grade, rough, breathy, asthenic, strained) scale, and patient-based function according to an overall global rating of quality. The objective and subjective measures were significantly related to each other (P < 0.05); the objective and patient-based measures were also related (P = 0.019), but the subjective and patient-based measures were not related. We demonstrate a significant relationship between some but not all measures of voice function. We believe that subjective measures provide additional valuable information not obtained from objective measures alone.

Adult↗
PubMed2000

Outcomes research and obstructive sleep apnea.

Sleep disorders in general and obstructive sleep apnea syndrome in particular are prevalent health problems. This report describe the methodology and findings from a prospective multicenter outcomes research study on obstructive sleep apnea syndrome that was conducted by the American Academy of Otolaryngology-Head and Neck Surgery. Other outcome measures available for outcomes research in obstructive sleep apnea syndrome are also summarized.

Attitude to Health↗
PubMed2000

Importance of comorbidity in head and neck cancer.

OBJECTIVES/HYPOTHESIS: Patients with head and neck cancer are staged according to the morphology of the tumor with little or no attention given to the importance of the other diseases, illnesses, or conditions. These other conditions are generally referred to as comorbidities. Although not a feature of the cancer itself, comorbidity is an important attribute of the patient with cancer. Comorbidity has direct impact on the care of patients, selection of initial treatment, and evaluation of treatment effectiveness. The objective of this thesis is to demonstrate the importance of comorbidity in head and neck cancer. Specifically, the aims are 1) to demonstrate the burden of comorbidity among head and neck cancer patients by comparing the incidence of none, mild, moderate, and severe comorbidity among patients with head and neck cancer to patients with cancers of the colorectum, lung, breast, gynecological sites, or prostate, 2) to demonstrate the independent impact of comorbidity on overall survival, and 3) to demonstrate the importance of comorbidity in the assessment of initial treatment effectiveness. STUDY DESIGN: This was a prospective cohort study of the impact of comorbidity on head and neck cancer patients presenting for treatment between January 1995 and December 1996. METHODS: In 1994, the author trained cancer registrars at an academic teaching hospital to code comorbidity from the medical record of new patients using a standard comorbidity index. Standard statistical techniques, including multivariable analysis, were used to compare and contrast the burden of comorbidity for patients with different cancers. Life survival techniques and multivariable logistic regression analysis were used to assess the independent prognostic impact of comorbidity. Further, the technique of conjunctive consolidation was used to augment the TNM system with comorbidity information, to more completely assess the impact of different initial treatments for patients with head and neck cancers. RESULTS: The cohort consisted of 3,378 patients with cancers of the head and neck (341), colorectum (307), lung (655), breast (483), gynecological sites (482), and prostate (1,110). The percentage of head and neck cancer patients with moderate to severe comorbidity was 21%; this degree of comorbidity burden was second only to patients with lung (40%) and colorectal (25%) cancer. There was a significant relationship between severity of comorbidity and overall survival (log-rank test, chi2 = 15.75; P < .0013). For cancers of the head and neck, lung, breast, and prostate the prognostic significance of comorbidity remained even after controlling for other factors, such as age and TNM stage. CONCLUSIONS: The results of this study show that comorbidity is an important feature of patients with head and neck cancer. Valid instruments exist to measure and classify the overall severity of comorbidity. The scientific evaluation of treatment and the care of patients are impeded by a rigid adherence to a staging system based solely on morphological descriptions of the cancer while ignoring suitable descriptions of the patient. The author believes that the addition of comorbidity information will improve the value of cancer statistics and the care of cancer patients.

Adult↗
PubMed1999

Development of a new staging system for recurrent oral cavity and oropharyngeal squamous cell carcinoma.

BACKGROUND: Approximately 33% of patients with squamous cell carcinoma of the oral cavity and oropharynx develop a recurrence. The management of recurrent tumors can be challenging to both physician and patient, at least in part due to the lack of an accurate and clinically applicable staging system for these patients. The purposes of this study were to examine the survival patterns of patients presenting with recurrent oral cavity and oropharyngeal tumors, to identify key factors affecting prognosis, and to combine these factors to create a new staging system to predict survival and aid in planning therapy. METHODS: The methods included a retrospective chart review of 641 patients with oral cavity and oropharyngeal squamous cell carcinoma who underwent their initial treatment at Washington University between 1980 and 1992. From this population, 249 patients (39%) developed a recurrence. RESULTS: The overall 2-year survival rate was 20% (50 of 249 patients). Six variables affected survival significantly: histologic differentiation, initial (prior to first therapy) TNM stage, initial treatment, time to recurrence, extent of recurrence, and treatment of recurrence. These six variables were entered into a logistic model to determine the individual prognostic significance of each variable. Two variables were found to be statistically significant: initial TNM stage (chi-square test = 7.67; P = 0.0056) and extent of recurrence (chi-square test = 11.75; P = 0.0006). Using the process of conjunctive consolidation, these two variables were combined to create a new staging system for recurrent tumors of the oral cavity and oropharynx. CONCLUSIONS: This staging system provides accurate estimates of prognosis, involves no new technology to implement, demonstrates statistically significant differences in survival by stage, and may aid both the physician and the patient in planning therapy.

Adult↗
PubMed1999

Conscious sedation: a new approach for peritonsillar abscess drainage in the pediatric population.

OBJECTIVE: To assess the safety and efficacy of conscious sedation (CS) in children undergoing emergency department incision and drainage (I&D) of peritonsillar abscesses (PTAs). DESIGN: A 33-month retrospective chart review of all children presenting to the emergency department with the diagnosis of a PTA or peritonsillar cellulitis. Children who underwent CS prior to I&D were compared with children without CS for complications and efficacy. SETTING: St Louis Children's Hospital, an academic tertiary care pediatric hospital. PATIENTS: Fifty-two children were enrolled; 30 PTAs were drained with CS in 27 children (3 underwent I&D twice), and 25 PTAs were drained in 25 children without CS. INTERVENTIONS: The CS team included an otolaryngologist, a pediatric emergency department physician, and a registered nurse. A standardized CS protocol assessing vital signs and level of consciousness was employed during each procedure. A combination of midazolam, ketamine hydrochloride, and glycopyrrolate was used in appropriately weighted calculated doses. Patients were assessed for major and minor airway complications. MAIN OUTCOME MEASURES: Airway complications related to CS were reviewed. Patients who underwent I&D with and without CS were compared with regard to purulent drainage. RESULTS: There were no major airway complications in patients undergoing I&D with CS. There was 1 minor complication in this group, oxygen desaturation to 88%, which resolved with stimulation. Of the 55 procedures, 45 (82%) yielded purulence: 29 (97%) of 30 in the CS group and 16 (64%) of 25 in the non-CS group (chi2 = 9.8; P = .002). Of those children undergoing CS, 3 (10%) of 30 were admitted to the hospital from the emergency department as compared with 6 (24%) of 25 without CS (chi2 = 1.95; P = .16). In the CS group, PTAs had a low recurrence rate of 1 (3.3%) of 30 compared with 2 (8%) of 25 in the non-CS group (chi2 = 0.57; P = .45). No one in the CS group required a secondary procedure under general anesthesia. CONCLUSIONS: This preliminary study demonstrates CS to be a potentially safe and efficacious approach to drainage of PTAs in children. Given its efficacy and its associated lower levels of anxiety and pain for the patient, CS seems to be a promising new approach to caring for children with PTAs.

Adolescent↗
PubMed1999

Symptoms as an index of biologic behavior in head and neck cancer.

The TNM staging system for head and neck cancer is based on the morphologic description of the tumor and disregards the clinical condition of the patient. Cancer symptoms were evaluated as a biologic index of disease to improve survival estimates. The medical records of 1010 patients receiving initial cancer treatment between 1980 and 1991 were retrospectively reviewed. The mean survival duration was 62 months for the entire population. By use of SAS statistical software (SAS Institute, Cary, NC), 48 symptom variables were screened by univariate analysis, and 23 of these variables were selected for entry into a Cox proportional hazards model on the basis of survival duration. Dysphagia, otalgia, neck lump, and weight loss were identified as independent predictors of survival duration (P < 0.01). A composite symptom-severity staging system was created on the basis of the 4 symptoms. Mean survival duration (95% CI) by symptom-severity stage was as follows: none, 74 months (70 to 79 months); mild, 56 months (51 to 61 months); moderate, 40 months (33 to 47 months); and severe, 31 months (22 to 41 months) (chi 2 = 30.8, P = 0.0001). Survival duration by TNM stage was as follows: I, 89 months (82 to 95 months); II, 71 months (65 to 78 months); III, 53 months (47 to 59 months); and IV, 42 months (37 to 47 months) (chi 2 = 56.2, P = 0.0001). When symptom-severity stage was entered in a proportional-hazards model along with TNM stage, comorbidity, age, and alcohol use, all 5 variables were independently predictive of survival duration (risk ratio: symptom severity 1.28, TNM 1.33, comorbidity 1.80, age 1.47, alcohol use 1.09). Appropriately defined symptom variables contain important prognostic information, which is independent of the TNM system. Therefore symptoms provide an index of biologic behavior in head and neck cancer.

Adolescent↗
PubMed1999

Clinical-severity staging system for oral cavity cancer: five-year survival rates.

The objective of this research is to improve the classification and survival estimates for patients with oral cavity cancer by combining cancer symptom severity and comorbidity with the current TNM staging system. The study design is a retrospective medical record review that uses explicit coding criteria. The medical records of 277 patients receiving initial treatment at the Washington University Medical Center between 1980 and 1989 were reviewed. Multivariate analysis identified patient factors that significantly affected 5-year survival. These patient factors, symptom severity and comorbidity, were combined with TNM to create a composite clinical-severity staging system. The overall 5-year survival rate was 46% (128/277). Survival rates by TNM stage were as follows: stage I, 72% (36/50); II, 54% (45/84); III, 37% (24/65); and IV, 29% (23/78) (chi2 = 25.27, P = 0.001). When patients were grouped according to the clinical-severity staging system, survival rates were as follows: stage I, 77% (33/43); II, 56% (45/80); III, 42% (43/103); and IV, 14% (7/51) (chi2 = 40.62, P = 0.001). Survival estimates can be improved by adding carefully studied and suitably defined patient variables to the TNM system. The current TNM staging system for oral cavity cancer is based solely on the morphologic description of the tumor and disregards the clinical condition of the patient. Patient factors, such as cancer symptom severity and comorbidity, have a significant impact on survival. Continued exclusion of patient factors leads to imprecision in prognostic estimates and hinders interpretation of clinical studies.

Aged↗
PubMed1998

Development of a new staging system for patients with recurrent laryngeal squamous cell carcinoma.

BACKGROUND: The management of recurrent head and neck squamous cell carcinoma can be challenging to both physician and patient. This is due at least in part to the lack of an accurate and clinically applicable staging system for these patients. The purposes of this study were to examine the survival patterns of patients presenting with recurrent laryngeal tumors, identify key factors affecting prognosis, and combine these factors to create a new staging system to predict survival. METHODS: The methods included a retrospective chart review of 473 patients with laryngeal squamous cell carcinoma who received their initial treatment at Washington University between 1980 and 1992. From this population, 126 patients (27%) who developed recurrence were identified. RESULTS: The overall 2-year survival rate was 40% (50 of 124 patients). Four variables affected survival: initial TNM stage, initial treatment, morphologic extent of recurrence, and treatment of recurrence. These variables were entered into a multivariate analysis to determine independent prognostic significance. Three variables were found to be statistically significant: TNM stage (chi-square = 4.6; P = 0.03), initial treatment (chi-square 14.3; P = 0.0002), and extent of recurrence (chi-square = 19.4; P = 0.0001). The process of conjunctive consolidation was used to combine significant variables to create a new staging system for laryngeal recurrence. CONCLUSIONS: This staging system provides accurate estimates of prognosis, involves no new technology to implement, can aid both the patient and physician in planning treatment, and can be used in observational studies to assess the relative effectiveness of competing therapies.

Adult↗
PubMed1998

Obstructive sleep apnea treatment outcomes pilot study.

Approximately 40 million Americans have chronic sleep disorders, the most serious of which is obstructive sleep apnea. The goals of this research were to serve as a demonstration project for a multicenter treatment outcomes research project for patients with obstructive sleep apnea. A clinical-severity staging system was created to control for important differences in the severity of sleep apnea among the enrolled patients. A disease-specific quality-of-life measure was used in this project to measure, from the patient's perspective, important pretreatment and posttreatment physical, functional, and emotional aspects of obstructive sleep apnea. Adults with apnea indexes greater than 5 who had not previously undergone uvulopalatoplasty were eligible. In total 142 patients were enrolled from eight otolaryngology practices. The mean age was 48 years, 112 were men, and 114 were white. The mean pretreatment apnea index was 40.0, and the mean respiratory distress index was 60.5. Seventy-one patients received continuous positive airway pressure, and 48 patients received surgery. Outcomes were assessed from scores on patient-based general and disease-specific health status measures 4 months after enrollment. The short duration of follow-up and limited number of patients undergoing posttreatment polysomnograms prohibit any analysis of treatment effectiveness. Nevertheless, this research represents a step forward for the support of future outcomes research projects by organized otolaryngology.

Adult↗
PubMed1998

Clinical correlations with allelotype in supraglottic squamous cancer.

Frequent allelic loss at a genetically polymorphic locus in tumors is an established marker for the presence of a tumor suppressor gene in the neighboring chromosomal region. This technique can be used to identify novel tumor suppressor genes and to monitor their status before the cloning of the gene itself. We have used the polymerase chain reaction and microsatellite loci on all 39 nonacrocentric autosomal chromosomal arms to identify sites of frequent allelic loss in squamous cell carcinomas of the supraglottic larynx. Our allelotype identified seven chromosomal arms (3p, 5q, 8p, 9p, 9q, 13q, and 17p) likely to contain tumor suppressor genes frequently inactivated during squamous tumorigenesis in the larynx. We tested for associations between allelic losses on these chromosomal arms and the clinical and histopathologic features of these tumors. There were no correlations with either T or N classifications. Allelic loss on chromosomal arm 13q is significantly associated with a number of histopathologic features characteristic of poorly differentiated or histologically aggressive tumors. Allelic loss on this arm also exhibits statistical trends toward association with early tumor recurrence and poor survival. The association with survival was substantiated by a multivariate Cox proportional hazards model.

Alleles↗
PubMed1998

Postanesthesia care unit length of stay: quantifying and assessing dependent factors.

UNLABELLED: Postanesthesia care unit (PACU) monitoring reduces morbidity and is the standard of care for postsurgical patients. PACUs require large nurse to patient ratios, which contributes to the cost of care. Despite the importance and cost of PACU length of stay (LOS), no standards have been established. We performed an observational study of 340 PACU patients to measure actual and medically appropriate PACU LOS (the time required to achieve a medically stable condition for safe PACU discharge), to identify factors related to LOS, and to create a LOS prediction index. Mean (+/- SD) actual LOS was 95+/-43 min, and appropriate PACU LOS was 71+/-37 min. Appropriate PACU LOS predictors were anesthetic time, anesthetic technique, and amount of intraoperative fluids. Actual LOS was >30 min longer than the medically appropriate LOS for 20% (68 of 340) of the patients. Frequent causes of excessive LOS were waiting for physician release or laboratory or radiographic results. Appropriate LOS may be related primarily to anesthetic factors, and nonmedical issues account for a significant amount of PACU LOS. IMPLICATIONS: Most patients are stabilized immediately after surgery in a postanesthesia care unit (PACU) until their discharge to a hospital ward. However, there are no standards for appropriate PACU length of stay (LOS). In this study, we measured actual and appropriate PACU LOSs and evaluated clinical factors that may influence PACU LOS.

Adolescent↗