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PubMed2006

Risk factors for hypopharyngeal/upper esophageal stricture formation after concurrent chemoradiation.

BACKGROUND: Concurrent chemoradiation therapy has been demonstrated to be effective as an organ-sparing treatment for select advanced head and neck squamous cell carcinoma (HNSCC). However, this treatment modality is not without side effects. One side effect is the formation of upper esophageal strictures. As concurrent chemoradiation treatment is used more frequently, it is important to identify risk factors associated with stricture formation. METHODS: A retrospective chart review of all patients who had undergone definitive concurrent chemoradiation treatment between 1989 and 2002 was performed. Exclusion criteria included death within 1 year or persistent/recurrent disease that required surgical salvage at the primary site. The outcome measure was stricture formation as determined by both objective findings (barium swallow or endoscopy) and the need for dilation after treatment. RESULTS: Of the 222 patients in this cohort, there were enough data for 199 patients to assess for stricture formation. Strictures developed in a total of 41 patients (21%). Significant predictive factors were a twice-daily (BID) radiation fractionation (p = .007), female sex (p = .015), and a hypopharyngeal primary site (p = .01). Age and tumor extent were not significant factors in stricture formation (p = .15 and p = .23, respectively). CONCLUSIONS: Symptomatic strictures occur in 21% of patients undergoing concurrent chemoradiation for HNSCC. Female sex, BID radiation fractionation, and a hypopharyngeal primary site are significant predictive factors for stricture formation.

Carcinoma, Squamous Cell↗
PubMed2000

Borderline tumors of the ovary: correlation of frozen and permanent histopathologic diagnosis.

OBJECTIVE: To evaluate the correlation between the diagnosis of borderline tumor of the ovary by frozen and permanent pathology. METHODS: All pathology reports with diagnoses of borderline tumor of the ovary between 1980 and 1998 at Massachusetts General Hospital were reviewed. Univariate and multivariable logistic regression models were constructed for patient age, tumor size, histology, presence of bilateral or extraovarian disease, and concurrent diagnosis of endometriosis or endosalpingiosis. RESULTS: We reviewed 140 cases. The average age of patients was 52.3 years. Eighty tumors were serous, 47 mucinous, 11 mixed, and two endometrioid. The mean diameter overall was 13.7 cm (range 1-70 cm), 10.2 cm for serous, and 20.1 cm for mucinous. Diagnoses of borderline tumors by frozen and permanent pathology were consistent in 60% of cases. Frozen section interpreted a benign lesion as malignant (overdiagnosed) in 10.7% of cases, and interpreted a malignant lesion as benign (underdiagnosed) in 29.3%. No variable was a significant predicator of overdiagnosis. In univariate analysis, underdiagnosis was more likely for other types of tumors than serous (P <.001), tumors larger than 20 cm (P =.039), and tumors confined to the ovaries (P =. 009). When all variables were included in a multiple regression model, only histology was a significant predictor of underdiagnosis (P =.039). CONCLUSION: Frozen or permanent pathology reports of diagnoses of borderline tumor were consistent 60% of the time, whereas the positive predictive value of borderline by frozen section was 89.3%. Tumors other than serous are more likely to be misinterpreted.

Adenocarcinoma↗
PubMed2003

Flow cytometry as an adjunct to cytomorphologic analysis of serous effusions.

The role of flow cytometry (FC) in the diagnosis of lymphoid lesions by fine-needle aspiration (FNA) is well established. However, studies evaluating the usefulness of FC in serous cavity effusions (SCE) are few. We performed a retrospective review of 115 consecutive SCE with concurrent FC analysis, comparing the provisional cytopathologic diagnosis (PCD), i.e., before the FC results were added, with final diagnoses as modified by subsequent FC immunophenotyping. The predominant clinical indication for the FC analysis was the presence of a spontaneous SCE in a patient with a history of malignant lymphoma. Three- or four-color analysis was performed using antibodies against CD45, CD71, CD33, CD22, CD19, CD20, kappa, lambda, CD5, CD3, and CD56. The PCD was benign in 47%, atypical in 16%, and malignant in 37% of cases. The latter category consisted mostly of malignant lymphoma (n = 32), but also included acute lymphoblastic leukemia (1 case), T-cell lymphoma/leukemia (2 cases), acute myelogenous leukemia (1 case), multiple myeloma (1 case), Hodgkin's lymphoma (1 case), sarcoma (1 case), and adenocarcinoma (4 cases). In 18 cases (16%), the PCD was later modified by the FC results from atypical/suspicious to benign (8) and from benign or atypical/suspicious to malignant (10 cases). The latter group included acute natural killer (NK) cell leukemia (1 case), chronic lymphocytic leukemia (1 case), mantle cell lymphoma (2 cases), follicular lymphoma (3 cases), angioimmunoblastic lymphoma (1 case), large cell lymphoma (1 case), and multiple myeloma (1 case). As expected, FC was noncontributory in cases of Hodgkin's lymphoma and nonlymphoid malignancies. In summary, immunophenotyping by FC modified the PCD significantly in 16% of SCE, permitting appropriate cancer staging and management. The above data underscore the importance of FC as an adjunct to cytomorphology in SCE.

Ascitic Fluid↗
PubMed2002

Improving the analysis of arteriovenous passage times.

PURPOSE: This study evaluated the effect of two techniques, time-based correction (TBC) and de-interlacing, on the quality of an image sequence from a scanning laser ophthalmoscope (SLO), and their impact on subsequent analysis for the determination of arteriovenous passage (AVP) times. METHODS: Fluorescein angiograms obtained from one patient participating in a concurrent study approved by an institutional review board (IRB) were analyzed before and after the serial connection of a TBC, and before and after de-interlacing of the images. Informed consent was obtained, and all tenets of the Declaration of Helsinki were followed. AVP times were determined and the variance in time per 100 frames was calculated. RESULTS: The average error in the determination of AVP times was significantly less after the application of these techniques ( p<0.05). Also, the coefficient of variance in the time elapsed per 100 frames was reduced after TBC and de-interlacing of the video sequence. CONCLUSION: The study showed that in addition to the subjective improvement in image quality after de-interlacing and TBC, quantitative parameters are improved. This leads to a more accurate analysis of the angiogram.

Arteries↗
PubMed2005

Steroid-induced alterations of mood and behavior in children during treatment for acute lymphoblastic leukemia.

Despite their therapeutic utility, children may experience emotional and behavioral side effects from steroids during treatment for leukemia. However, clinical manifestations and treatment options have rarely been described in the pediatric literature. The aim of this current paper is to address this knowledge gap via four brief case examples and a review of the literature. In addition, we review recent data to indicate how concurrent use of antifolates may place these children at particular risk for adverse psychological reactions.

Affect↗
PubMed1980

Gaucher's disease associated with Hodgkin's disease.

A patient with chronic adult-onset Gaucher's disease is described. The diagnosis was based on the finding of typical Gaucher cells in the spleen, liver and bone marrow associated with deficiency of glucocerebrosidase. The patient also had Hodgkin's disease, nodular sclerosis type, stage III. The patient is alive and relatively well six years after presentation, having been treated with a combination of chemotherapeutic regimens. Previously reported cases of Gaucher's disease concurrent with Hodgkin's disease are reviewed.

Adult↗
PubMed2006

Bullet, bite, and burn wounds in dogs and cats.

Veterinarians are frequently presented with bullet, bite, or burn trauma patients. Injuries can vary from simple minor penetrating skin wounds to major life-threatening soft and hard tissue damage with concurrent complex metabolic ramifications. This article reviews the diagnostic and therapeutic options for each type of injury.

Animals↗
PubMed2006

The role of radiation therapy in the palliation of gastrointestinal malignancies.

Radiation therapy can provide significant palliation in many patients who have unresectable, metastatic, or incurable malignancies of the gastrointestinal tract and is a modality that can be used in many clinical situations. In considering radiation therapy, the radiation oncologist should be mindful of the actual expectation of palliation, the potential degree of relief of symptoms, and the time involved for the patient and those involved in his or her care and transport. When a course of radiation is planned, the dose per fraction, total number of fractions, and total dose delivered should all be taken into account. The use of concurrent systemic chemotherapy needs to be reviewed with respect to chances for augmentation of palliation as well as morbidity. Although long-term disease control is often not achieved, there are reasonable expectations for control of symptoms of bleeding and pain. The side effects associated with radiation are generally well tolerated and, if they occur, usually can be controlled with conservative measures. Significant late effects, although uncommon, are generally a function of the volume of the organ treated, the total dose used, and whether systemic therapy is used in conjunction with radiation. When considering the options for palliation in these situations, multidisciplinary collaboration among all those involved in a patient's care, surgeon, radiation oncologist, medical oncologist, primary care provider, and palliative care specialist, is ideal to address each situation in each patient, for whom there may be a variety of options for palliative treatment. Generally, combinations of interventions are needed to optimize the palliation of a patient's various problems. The goal of providing relief to the patient in the least amount of time with the least amount of morbidity and the greatest expectation for durability of response is paramount.

Gastrointestinal Neoplasms↗
PubMed2005

Statins' dosage in patients with renal failure and cyclosporine drug-drug interactions in transplant recipient patients.

Dyslipidemia is frequent in patients with renal failure and in transplant recipient patients. This lead to a wide use of 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) in patients with impaired renal function or in patients treated with cyclosporine as post-transplantation immunosuppressive therapy. As a result, it is crucial for those patients' physicians to be aware of how to handle these drugs when renal function is impaired and/or when cyclosporine is co-administered. Most statins have an extensive hepatic elimination and the renal route is usually a minor elimination pathway. However, pharmacokinetic alterations have been described for some of these drugs in patients with renal insufficiency. Cyclosporine is a widely used immunosuppresive therapy in solid organ transplant patients and drug-drug interactions are likely to occur when statins and cyclosporine are administered together. Those interactions may theoretically result in increased statins and/or cyclosporine serum levels with potential muscle and/or renal toxicity. As a result, caution is warranted if concurrent administration is performed. In this review, we synthesized the data from the literature on (1) the pharmacokinetics and dosage adjustment of atorvastatin, fluvastatin, pravastatin, rosuvastatin, and simvastatin in patients with renal failure and (2) the potential drug-drug interactions between these drugs and cyclosporine in transplant recipient patients.

Cyclosporine↗
PubMed2006

The influence of the surgeon's and the hospital's caseload on survival and local recurrence after colorectal cancer surgery.

BACKGROUND: Past studies have identified surgeon- and institution- related characteristics as prognostic factors in colorectal cancer surgery. The present work assesses the influence of the surgeon's and the hospital's caseload on long-term results of colorectal cancer surgery. METHODS: The data on 2706 patients from 2, randomized, colorectal cancer trials (Swiss Group for Clinical Cancer Research [SAKK] 40/81, SAKK 40/87) investigating adjuvant intraportal and systemic chemotherapy and 1 concurrent registration study (SAKK 40/88) were reviewed. A first analysis included 1809 eligible, nonmetastatic patients from all 3 studies. A subsequent subgroup analysis included 915 eligible patients from both randomized trials. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) were analyzed in multivariate models taking into account the possible effect of clustering. The main potential covariates were surgeon's annual caseload (>5 operations/year vs < or =5 operations/year), hospital's annual caseload (>26 operations/year vs < or =26 operations/year), tumor site, T stage, and nodal status. RESULTS: Primary analysis of all 3 studies combined found a high surgeon's caseload to be positively associated with OS (P = .025) and marginally with DFS (P = .058). Separate analysis for each trial, however, showed that a high surgeon's caseload was beneficial for outcome in both randomized trials but not in the registration study. A subgroup analysis of 915 patients with 376 rectal and 539 colonic primaries from both randomized trials, therefore, was performed. Neither age, gender, year of operation, adjuvant chemotherapy (intraportal vs systemic vs operation alone), hospital academic status (university vs non-university), training status of the surgeon (certified surgeon vs surgeon-in-training), nor inclusion in 1 of the 2 randomized trials (SAKK 40/81 vs SAKK 40/87) was a significant predictor of outcome. However, both high surgeon's and high hospital's annual caseloads were independent, beneficial prognostic factors for OS (P = .0003, P = .044) and DFS (P = .0008, P = .020), and marginally significant factors for LR (P = .057, P = .055). CONCLUSIONS: High surgeon's and hospital's annual caseloads are strong, independent prognostic factors for extending overall and disease-free survival and reducing the rate of local recurrence in 2 randomized colorectal cancer trials.

Chemotherapy, Adjuvant↗
PubMed1978

Bilateral Wilms tumors.

The current management of bilateral Wilms tumor is reviewed and the high incidence of concurrent anomalies with bilateral Wilms tumor is demonstrated in 4 of 5 children. Standardization of management has not been established. Of the 5 patients 3 survived 30 months to 11 years without recurrent tumor. Two had unilateral nephrectomy and partial nephrectomy, while 1 had bilateral nephrectomy and allotransplant. All survivors have had adjunctive chemotherapy and radiotherapy.

Female↗
PubMed1997

Trends in squamous cell carcinoma of the vulva: the influence of vulvar intraepithelial neoplasia.

OBJECTIVE: To determine trends in the clinicopathology of vulvar squamous cell carcinoma over the past 2 decades, with particular reference to the possible effects of the increasing incidence of vulvar intraepithelial neoplasia (VIN) during this time. METHODS: Two cohorts of 56 and 57 women with squamous cell carcinoma of the vulva and separated by at least 2 decades were reviewed retrospectively. Pathologic specimens were analyzed concurrently. RESULTS: In the 1965-1974 cohort, only one of 56 patients was younger than 50 years of age at the time of presentation, whereas in the 1990-1994 cohort, 12 of 57 (21%) were younger than 50 years of age (P = .001). Ten of 13 women younger than 50 years of age, compared with 13 of 100 of women 50 years of age or older, had warty or basaloid VIN associated with their invasive carcinoma (P < .001). Cigarette smoking and multiple lower genital tract neoplasia were both significantly more common in women younger than 50 years of age (P < .001). CONCLUSION: Over the past 2 decades, a subset of women younger than 50 years of age with squamous cell carcinoma of the vulva has emerged. Most of these carcinomas appear to arise in a field of warty or basaloid VIN. This suggests that the increasing incidence of VIN seen in young women during the past 2 decades is being reflected now in VIN-associated squamous cell carcinoma of the vulva in younger women.

Adult↗
PubMed2001

Pars plana tube insertion of glaucoma drainage implants and penetrating keratoplasty in patients with coexisting glaucoma and corneal disease.

PURPOSE: To determine the efficacy and associated complications of glaucoma drainage implant (GDI) surgery with pars plana tube insertion and penetrating keratoplasty (PK) in eyes with glaucoma and corneal disease. DESIGN: Retrospective, interventional case series. PARTICIPANTS: All patients who underwent both GDI surgery with pars plana tube insertion and PK before September 1997 were included. METHODS: The medical records of 34 consecutive patients (34 eyes) who had undergone GDI (Baerveldt, Pharmacia & Upjohn, Kalamazoo, MI; Molteno, IOP INC:, Costa Mesa, CA; Krupin, Hood Laboratories, Pembroke, MA; or Ahmed, New World Medical, Rancho Cucamonga, CA) insertion before, concurrent with, or after PK were reviewed retrospectively. All corneal grafts were clear before GDI surgery for patients who underwent glaucoma surgery after PK. Outcomes were evaluated using Kaplan-Meier life-table analysis. MAIN OUTCOME MEASURES: Clinical outcome assessment included corneal graft clarity, intraocular pressure (IOP), visual acuity, and identification of complications. RESULTS: Mean follow-up after completion of both GDI surgery and PK was 12.1 +/- 8.4 months (range, 0-31.8 months). Twelve- and 24-month life-table rates for complete success after both GDI and PK were 63% and 33%, respectively. Twelve- and 24-month life-table success rates for IOP control and corneal graft clarity were 85% and 62%, and 64% and 41%, respectively. Final postoperative visual acuity was the same as or better than (> or =2 Snellen lines) the preoperative level in 29 patients (85%). One or more posterior segment complications occurred in 15 (44%) patients. CONCLUSIONS: Pars plana tube insertion of GDIs is a reasonable option for patients who have undergone PK or in whom PK is anticipated, despite the need for a complete pars plana vitrectomy. Although complications related to limbal tube placement are avoided, the incidence of posterior segment complications may be higher for pars plana insertion. The potential for enhanced corneal graft survival with pars plana versus anterior segment tube placement warrants further investigation.

Adult↗
PubMed1998

Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases.

STUDY OBJECTIVE: To determine the safety of intramuscular ketamine when administered by emergency physicians for pediatric procedures in accordance with a defined protocol. METHODS: We assembled a consecutive case series of children aged 15 years or younger who were given ketamine in the emergency departments of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine use (4 mg/kg, intramuscularly) was followed. Treating physicians were instructed to complete data forms recording complications and adequacy of sedation concurrent with patient care. Subsequent chart review was used to determine indications, adjunctive drugs, time to discharge, and adverse reactions for all patients. RESULTS: Intramuscular ketamine was administered 1,022 times, mainly for laceration repair and fracture reduction. Physicians completed data forms for 431 of treated children (42%). Transient airway complications occurred in 1.4%: airway malalignment (n = 7), laryngospasm (n = 4), apnea (n = 2), and respiratory depression (n = 1). All were quickly identified and treated without intubation or sequelae. Emesis occurred in 6.7%, without evidence of aspiration. Mild recovery agitation occurred in 17.6%, moderate to severe agitation in 1.6%. No child required hospitalization for complications caused by ketamine. Ketamine produced acceptable sedation in 98% of patients. The median time from injection to emergency department discharge was 110 minutes for children given a single dose of ketamine. CONCLUSION: Intramuscular ketamine may be administered safely by emergency physicians to facilitate pediatric procedures in accordance with a defined protocol and with appropriate monitoring. Ketamine is highly effective, has a wide margin of safety, does not require intravenous access, and uniquely preserves protective airway reflexes.

Adolescent↗
PubMedDate not supplied

The effect of bright light on sleep and behavior in dementia: an analytic review.

The purpose of this study was to examine bright light as a means of intervention in sleep-wakefulness and behavior disorder among patients with dementia through a review of the relevant literature. Fourteen articles were reviewed in depth for study design, intervention protocols, concurrent control groups, subject characteristics, and outcome measures of behavior and sleep. Previous studies found that behavior disorders improved, although not all the studies reviewed reported a quantitative measure of improvement. The effects on sleep disorders were controversial. As a result of limitations in past studies, the effect of bright light on dementia patients is inconclusive. The current review has revealed areas of weakness in previous research that might profitably be explored in the future.

Aged↗
PubMed2003

Clostridium difficile infection and concurrent vancomycin-resistant Enterococcus stool colonization in a health care worker: case report and review of the literature.

Clostridium Difficile diarrhea was noted in a previously healthy health care worker from the study institution after receiving oral clindamycin therapy; the worker also had vancomycin-resistant Enterococcus stool colonization. Health care workers should be aware that antibiotic therapy may place them at increased risk for colonization and infection with nosocomial pathogens such as Clostridium difficile and vancomycin-resistant Enterococcus.

Adult↗