Sinonasal adenocarcinoma: Population-based analysis of demographic and socioeconomic disparities

BACKGROUND

Sinonasal adenocarcinoma (SNAC) is a rare tumor. The impact of health disparities on survival, stage at presentation, and utilization of surgery is not well understood in patients with SNAC.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for cases of SNAC from 1973 to 2015. Cases were analyzed to assess for disparities in presentation, treatment, and survival.

RESULTS

SNAC was identified in 630 patients. In a multivariate model of overall survival, an age increase of 10 years (Hazard Ratio (HR) = 1.37, p < 0.001), male sex (HR = 1.26, p = 0.045), and more recent decade of diagnosis (HR = 0.74, p < 0.001) were significantly related to time-to-death. There is a higher rate of SNAC-related death in counties with more rural populations (p = 0.027).

CONCLUSION

Future interventions targeting rural and less well-educated populations may improve care with the goal of increasing the span of healthy life and reducing survival disparities related to SNAC.

Presentation and outcomes of chronic rhinosinusitis following liver and kidney transplant

Objective

This study aims to describe presenting characteristics of patients diagnosed with non-invasive chronic rhinosinusitis (CRS) following liver or kidney transplant and determine factors associated with disease-related complications, selection of endoscopic sinus surgery (ESS), and disease resolution in this population.

Study design

Retrospective chart review.

Setting

An academic tertiary care center (Mayo Clinic, Rochester, Minnesota).

Subjects and methods

Liver and kidney transplant recipients evaluated by Mayo Clinic otolaryngologists for CRS between 1998 and 2018 were identified. Univariate and multivariate logistic regression analyses were used to determine patient factors and treatment modalities associated with developing complications, selection of ESS, and disease resolution.

Results

Fifty-seven patients met inclusion criteria. No patients developed intraorbital or intracranial complications of their CRS. Multivariate modeling demonstrated that the presence of polyps (P = 0.036) was associated with undergoing ESS within one year of presentation. A higher Lund–Mackay (LM) computed tomography score (P = 0.023) and older age (P = 0.018) were significantly associated with decreased disease resolution. No other factors were significantly associated with the use of endoscopic sinus surgery within one year of otolaryngology presentation or resolution of CRS in this cohort.

Conclusion

The risk of developing CRS-related intraorbital or intracranial complications in this immunecompromised patient cohort may be lower than originally thought. For liver- and kidney-recipients stable on immunosuppressive medication for many years, prognostic factors for CRS may mirror those for immunocompetent patients.

Chronic rhinosinusitis in eosinophilic granulomatosis with polyangiitis: clinical presentation and antineutrophil cytoplasmic antibodies

BACKGROUND

In this study we aim to describe presenting characteristics and identify prognostic factors for disease resolution in patients with chronic rhinosinusitis (CRS) in the setting of eosinophilic granulomatosis with polyangiitis (EGPA).

METHODS

Patients evaluated at a tertiary care center with diagnoses of EGPA and CRS were identified. Descriptive statistics were obtained. Univariate analysis was used to search for prognostic factors associated with higher Lund-Mackay score at presentation and disease resolution.

RESULTS

Forty-four patients were included with a mean age of 52.7 (standard deviation, 14) years. Twenty-one patients (47.7%) were female, all had a diagnosis of asthma, and 36 (83.7%) had eosinophils >10%. Common presenting symptoms for CRS included nasal discharge (87.9%) followed by nasal congestion (83.9%) and facial pain and pressure (83.8%). Medical management of CRS included systemic corticosteroids (93.2%) and systemic antibiotics (75%). Surgical intervention occurred in 29 patients (67%). Nine patients (20.5%) had resolution of sinus symptoms, including 4 with imaging confirmation. Fourteen patients (31.8%) had continued CRS, but with improved symptoms, whereas 9 patients (20.5%) had continued CRS with no improvement in symptoms. Eleven patients (25%) were lost to follow-up and 4 (9.1%) died. Univariate analysis did not show antineutrophil cytoplasmic antibody positivity, presence of peripheral eosinophilia, gender, age, or absence of systemic therapy to be predictive of higher Lund-Mackay score at presentation or predictive of disease resolution.

CONCLUSION

CRS in patients with EGPA is often refractory to medical and surgical management. Treatment of these patients should occur in a multidisciplinary setting.

Prevalence and predictors of airflow obstruction in an HIV tertiary care clinic in Montreal, Canada: a cross-sectional study

Objectives

The reported prevalence of chronic obstructive pulmonary disease (COPD) in people living with HIV (PLWHIV) varies widely. Our objective was to estimate the prevalence of airflow obstruction and COPD in unselected PLWHIV and identify characteristics that increase the risk of nonreversible airflow obstruction in order to guide case finding strategies for COPD.

Methods

All adults attending the Chronic Viral Illness Service were invited to participate in the study, regardless of smoking status or history of known COPD/asthma. Individuals underwent spirometric testing both before and after use of a salbutamol bronchodilator. Airflow obstruction was defined as forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) < 0.7 post‐bronchodilation, whereas COPD was defined as FEV₁/FVC < 0.7 post‐bronchodilation and Medical Research Council (MRC) score > 2. Multivariate logistic regression was used to evaluate risk factors associated with airflow obstruction, reported as adjusted odds ratios (aORs).

Results

Five hundred and three participants successfully completed spirometry testing. The median (Q1; Q3) age was 52 (44; 58) years. The median (Q1; Q3) CD4 count was 598 (438; 784) cells/μL and the median (Q1; Q3) nadir CD4 count was 224 (121; 351) cells/μL. There were 119 (24%) current smokers and 145 (29%) former smokers. Among those screened, 54 (11%) had airflow obstruction whereas three (1%) of the participants had COPD. Factors that were associated with airflow obstruction included a history of smoking [aOR 2.2; 95% confidence interval (CI) 1.1; 4.7], older age (aOR 1.6; 95% CI 1.2; 2.2), and lower CD4 count (aOR 0.8; 95% CI 0.7; 1.0).

Conclusions

Airflow obstruction was relatively uncommon. Our findings suggest that PLWHIV who are ≥50 years old, smokers and those with nadir CD4 counts ≤ 200 cells/μL could be targeted to undergo spirometry to diagnose chronic airflow obstruction.

Implementing a declination form programme to improve influenza vaccine uptake by staff in Department of Veterans Affairs spinal cord injury centres: a pilot study

BACKGROUND

Individuals with spinal cord injuries and disorders are at high risk for respiratory and influenza-related complications after developing influenza. These individuals often have frequent contact with the healthcare system. Vaccination rates in healthcare workers at Department of Veterans Affairs (VA) spinal cord injury (SCI) centres have been approximately 50% for several years. Efforts are needed to increase vaccination uptake among SCI HCWs. Declination form programmes (DFPs) in combination with other strategies have resulted in significant increases in influenza vaccination uptake in HCWs.

AIM

Use of external and internal facilitation including local teams and consensus processes to pilot a DFP in two VA SCI centres and evaluate factors influencing implementation.

METHODS

Implementation meetings and a consensus-building process with leadership and implementation team members were conducted, along with semi-structured post-implementation interviews with members of each implementation team (N = 7).

FINDINGS

The DFP was well accepted and easy to use. Leadership was a key facilitator for DFP implementation. Barriers included difficulty communicating with HCWs working during early/late shifts. Participation was 100% at Site 1 and 48% at Site 2.

CONCLUSION

Use of local teams and consensus to identify strategies to implement a DFP is feasible and effective for achieving moderate-to-high levels of participation in the programme.

Effect of HPMC on the quality of wheat-free bread made from carob germ flour-starch mixtures

Carob germ proteins have been shown to have functional properties similar to wheat gluten enabling formulation and production of yeast leavened gluten-free baked goods from a true dough rather than a stiff batter. The purpose of this research was to optimize the production of wheat-free bread containing carob germ flour, corn starch, NaCl, sucrose, hydroxypropyl methylcellulose (HPMC), and H₂O. A key criterion was to formulate viscoelastic dough similar to wheat dough. To that end, response surface methodology (RSM) was used to determine optimal levels of carob germ flour, H₂O, and HPMC. Components varied as follows: 4.94%-15.05% for carob germ flour, 0.05%-3.75% HPMC, and 65.25%-83.75% H₂O (percents are on a flour basis, where carob germ flour in combination with maize starch equals 100%). Sucrose, NaCl, and yeast were held constant at 2%. Bread parameters evaluated were specific volume and crumb hardness, where the largest specific volume and the lowest value for crumb hardness were considered most desirable. The optimum formula as determined by RSM consisted of 7% carob germ flour, 93% maize starch, 2% HPMC, and 80% H₂O with predicted crumb hardness of ~200 g of force and a specific volume of ~3.5 cm³/g. When proof time was optimized, a specific volume of ~5.6 ml/g and crumb hardness value of ~156 g of force was observed. Carob germ flour may be used as an alternative to wheat flour in formulating viscoelastic dough and high quality gluten-free bread.

PRACTICAL APPLICATION

Celiac disease affects approximately 1% of the world's population. Sufferers of the disease must consume a gluten-free diet. Currently, gluten-free baked products are made from batters and lack the ability to be made from dough based systems which limits the overall processability and product variety. This research is aimed at the utilization of carob germ protein and its ability to form dough to produce an optimal gluten-free bread formulation. This will help to alleviate problems in processability and product variety associated with gluten-free baked goods.

Standardization of the immunocytochemical detection of cancer cells in BM and blood: I. establishment of objective criteria for the evaluation of immunostained cells

BACKGROUND

Detection of isolated tumor cells (TC) in BM from carcinoma patients can predict future relapse. Various molecular and immunocytochemical (ICC) methods have been used to detect these cells, which are present at extremely low frequencies of 10(-5) - 10(-6). The specificity and sensitivity of these techniques may vary widely. In 1996, a European ISHAGE Working Group was founded to standardize and optimize procedures used for the detection of minimal residual disease. We have attempted to develop objective criteria for the evaluation of immunocytochemically identifiable cancer cells.

METHODS

An interlaboratory ring experiment was performed, to compare the screening and detection of micrometastasis-positive events between different laboratories. The discrepant results induced us to establish a common consensus on morphological criteria applicable to the identification of immunostained micrometastatic TC.

RESULTS

Bared on this consensus evaluation, we propose a classification of stained elements into three groups: (1) 'TC's show pathognomonic signs of epithelial TC-nature, as defined by a clearly enlarged nucleus or clusters of > or = 2 immunopositive cells. (2) 'Probable TC's represent morphological overlap between hematopoietic cells (HC) and TC which lack pathognomonic signs of TC-nature, but do not exhibit clear morphological features of HC. These cells are considered as TC if control staining with an isotype-specific, unrelated Ab is negative. (3) 'TC-negative' cells are defined as 'false positive' HC, skin squamous epithelial cells and artefacts.

DISCUSSION

The proposed classification of immunostained events is a first step towards the development of standardized immunocytochemical assays for the detection of occult micrometastatic TC in BM or blood.

Interspecialty fellowships in oncoplastic surgery and breast reconstruction – the innovative training scheme in the United Kingdom

Abstract #4141

Improved survival rates for breast cancer have evolved with specialist multidisciplinary care and adjuvant treatment regimes. Surgical options for breast cancer are increasingly complex comprising adequate oncological resection with improved aesthetic outcome, quality of life and psychosexual function for cancer survivors. Such surgery requires oncoplastic skills and innovative techniques and is an integral part of delivering a modern surgical breast service.&#x2028; In 2002, an innovative interspecialty training program was established for senior trainees in breast and plastic surgery, initiated by senior breast specialist surgeons and funded by the Department of Health. Nine breast centres in the UK were selected for their high volume high quality specialist care in breast disease with dual training in breast and plastic surgery. Competitive application to the training program selected the highest quality trainees for a year of interspecialty Fellowship training. The demand for these posts has required a highly competitive curriculum vitae and a higher academic degree.&#x2028; Since 2004, detailed prospective data has been collected on the qualitative and quantitative experience of the Fellowship scheme. This has been questionnaire based using logbook data for quantitative technical experience and comparative qualitative data for Fellowship satisfaction and outcome in specialty training.&#x2028; 53 fellows have to 2008 completed interspecialty training. 43 have been in their penultimate or last year in higher surgical training, the majority (42) are breast trainees in general surgery, 11 are trainees in plastic and reconstructive surgery. The Fellowship maximises exposure to operative planning and surgical techniques. 62% of oncology surgery (including breast reconing procedures), 49% of (immediate and delayed) reconstructive procedures, and 49% of breast symmetrization and aesthetic surgery is performed by the trainee under direct supervision. Overall expectations and quality of the Fellowships scored 'high' to 'excellent' and this was reflected in the confidence of fellows to take up NHS Consultant posts and continue to use the skills acquired within a multidisciplinary specialised breast team.&#x2028; The interspecialty training program has been successful for both breast and plastics trainees. It has given senior surgical trainees the opportunity to focus and direct their own training requirements into an intense clinical year of surgical oncology and breast reconstruction. Key components to the success of this year include working in high volume, specialist breast and plastic reconstructive units with direct supervision from dedicated trainers, supernumerary training status and an elective surgical practice. It succeeds as a pioneering program designed to increase the number of trained surgeons offering seamless oncoplastic surgery for the benefit of the patients.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4141.

Subintimal angioplasty for superficial femoral artery occlusion: poor patency in critical ischaemia

INTRODUCTION

Subintimal angioplasty has been proposed for the treatment of long segment occlusive disease and for patients with critical limb ischaemia (CLI) with significant co-morbidity. There is no consensus as to short- and long-term patency. We present our experience with this technique.

METHODS

Between 1995 and 2000, 43 consecutive patients (48 limbs) underwent subintimal angioplasty for superficial femoral artery occlusions. Outcome measures were haemodynamic and/or symptomatic patency.

RESULTS

Technical success was achieved in 14/17 limbs with CLI (82%) and 30/31 (97%) with intermittent claudication (IC). There were 7 complications (15%), 6 occurring in the claudicant group. The median occlusion length was 10 cm for CLI and 6 cm for IC. Patency at 12 and 36 months, on an intention-to-treat basis, was 69% and 58% for claudicants and 25% and 25% for patients with CLI (P = 0.0005 and P = 0.0044, respectively). Following only technically successful procedures, 12-month patency was 72% (IC) and 31% (CLI) (P = 0.009). Patients with occlusions > or = 10 cm were more likely to re-occlude than those < 10 cm (12-month patency 60% versus 25%;P = 0.037).

CONCLUSIONS

In this series, short- and long-term patency in patients with CLI is poor. Subintimal angioplasty in the treatment of CLI should be reserved for those patients not fit for surgical bypass.

Interactions between selenium and sulphur nutrition in Arabidopsis thaliana

Selenium (Se) is an essential plant micronutrient, but is toxic at high tissue concentrations. It is chemically similar to sulphur (S), an essential plant macronutrient. The interactions between Se and S nutrition were investigated in the model plant Arabidopsis thaliana (L.) Heynh. Arabidopsis plants were grown on agar containing a complete mineral complement and various concentrations of selenate and sulphate. The Se/S concentration ratio in the shoot ([Se](shoot)/[S](shoot)) showed a complex dependence on the ratio of selenate to sulphate concentration in the agar ([Se](agar)/[S](agar)). Increasing [S](agar) increased shoot fresh weight (FW) and [S](shoot), but decreased [Se](shoot). Increasing [Se](agar) increased both [Se](shoot) and [S](shoot), but reduced shoot FW. The reduction in shoot FW in the presence of Se was linearly related to the shoot Se/S concentration ratio. These data suggest (i) that Se and S enter Arabidopsis through multiple transport pathways with contrasting sulphate/selenate selectivities, whose activities vary between plants of contrasting nutritional status, (ii) that rhizosphere sulphate inhibits selenate uptake, (iii) that rhizosphere selenate promotes sulphate uptake, possibly by preventing the reduction in the abundance and/or activity of sulphate transporters by sulphate and/or its metabolites, and (iv) that Se toxicity occurs because Se and S compete for a biochemical process, such as assimilation into amino acids of essential proteins.

Primary reversed gastric tube reconstruction in long gap esophageal atresia

BACKGROUND/PURPOSE

Esophageal reconstruction in long-gap esophageal atresia (EA) poses a technical challenge with several surgical options. The purpose of this study was to review the authors' experience with the reversed gastric tube (RGT) in esophageal reconstruction.

METHODS

This series describes 7 babies with pure EA treated at 2 centers between 1989 and 2001. Data, gathered by retrospective chart review, included clinical details of the esophageal and associated malformations, technique and timing of repair, early and late complications, and long-term follow-up. Institutional review board (IRB) approval of this study has been obtained.

RESULTS

Seven babies were included. Associated malformations were present in 4: trisomy 21 in 2 and imperforate anus in 2. After gastrostomy tube placement, patients were treated with gastrostomy tube feedings and continuous upper pouch suction. Median gap length was 5.5 vertebral segments (range, 3 to 9). RGT with a posterior mediastinal esophagogastric anastomosis was performed at median age of 62 days (range, 38 to 131). There were no anastomotic leaks. Three patients had strictures, one required resection. Exclusive oral nourishment was achieved in 5 patients by 6 months of age. At last follow-up (mean, 4.5 years), 6 patients were receiving oral nutrition exclusively, and all were maintaining growth curves.

CONCLUSIONS

In long gap EA, early esophageal reconstruction using an RGT can be performed with minimal morbidity and promising short-term results.

Oral folate reduces plasma homocyst(e)ine levels in hemodialysis patients with cardiovascular disease

INTRODUCTION

Hyperhomocyst(e)inemia (plasma homocyst(e)ine concentration >16.0 micromol/l) is an independent risk factor for atherosclerosis, and is ubiquitous in patients with end-stage renal disease (ESRD). Oral folate supplementation in the non-ESRD population has been demonstrated to reduce plasma homocyst(e)ine (Hcy) concentration, and may reduce atherosclerotic morbidity. This study was undertaken to evaluate the efficacy of folate supplementation in reducing Hcy in patients with ESRD and cardiovascular disease.

METHODS

Twenty-eight chronic hemodialysis patients with demonstrated hyperhomocyst(e)inemia (mean Hcy 35.2+/-13.3 micromol/l) were enrolled in the study. The presence of atherosclerosis was documented by history, physical examination, or ultrasonographic criteria. Hcy was determined initially and following six weeks' supplementation with 5.0mg folate and multvitamins.

RESULTS

Hcy fell a mean of 15.0+/-10.4 micromol/l (38.9+/-19.9%) following supplementation (p<0.0005, paired t-test). In patients whose Hcy 'normalized' (n=10) Hcy fell a mean of 51+/-14% compared to a reduction of 32+/-20% in 18 patients whose Hcy remained >16.0 micromol/l (p=0.02). A significant positive correlation was observed between initial Hcy and both absolute and percent reduction after folate supplementation (r=0.87, p<0.005 and 0.53, p<0.005, respectively). Seven patients with documented atherosclerosis were older (68+/-8 yr vs 51+/-5 yr, p=0.007) an tended to have lower initial and final Hcy than the 21 patients without atherosclerosis (26.8+/-9.9 vs. 38.0+/-13.3 micromol/l, p=0.051 and 16.5+/-5.0 vs. 21.3+/-6.7, p=0.06, respectively). The presence of atherosclerosis was not associated with significant alteration in the response to folate.

CONCLUSIONS

Supplementation with high-dose folate significantly reduces plasma Hcy in patients with and without atherosclerosis, and the presence of atherosclerosis does not impact on patients' response to folate and multivitamin supplementation. Hcy remained >16.0 micromol/l in the majority of patients, however, despite large absolute reductions in Hcy. Doses of folate greater than 5mg, or additional therapy may be required to further reduce Hcy in the majority of ESRD patients.

Salvage laparotomy for failure of peritoneal drainage in necrotizing enterocolitis in infants with extremely low birth weight

BACKGROUND/PURPOSE

Peritoneal drainage is a temporizing procedure for infants with extremely low birth weight (ELBW) who have perforated necrotizing enterocolitis (NEC). "Salvage" laparotomy is advocated when patients worsen after drainage. Some patients have survived with intact gastrointestinal functional after drainage alone. The purpose of this study is to determine if these salvage laparotomies are beneficial.

METHODS

The authors reviewed the records of ELBW infants treated at Stanford University with perforated NEC from 1993 through 1998. Data collected included demographic makeup, type of operation, survival rate, postoperative complications, length of stay (LOS), and cost.

RESULTS

The authors treated 26 patients, 9 with laparotomy and 17 with peritoneal drainage. The peritoneal drainage group had lower birth weight and more comorbid conditions. Survival rate was similar between laparotomy and drainage: 55.6% versus 41.2%. Four patients in the drainage group underwent salvage laparotomy for perceived clinical deterioration. All of these patients died. The clinical status of patients who had salvage laparotomy and died was similar to those who did not and lived. Seven of 13 patients treated with drainage followed only by supportive care and antibiotics survived. Cost and LOS for patients undergoing salvage laparotomy were much greater than for nonsurviving patients undergoing only peritoneal drainage: 84 +/- 20 days and $660,000 compared with 34 +/- 11 days and $306,000.

CONCLUSIONS

Both primary peritoneal drainage and laparotomy should be considered primary therapy for perforated NEC. Patients undergoing peritoneal drainage typically experience clinical deterioration after operation. In this limited experience, salvage laparotomy did not appear beneficial.

Response of circulating tumor cells to systemic therapy in patients with metastatic breast cancer: comparison of quantitative polymerase chain reaction and immunocytochemical techniques

PURPOSE

We previously developed a quantitative system for the detection of cytokeratin 19 (CK-19) transcripts using reverse transcriptase polymerase chain reaction (PCR) to detect breast carcinoma cells in blood and bone marrow. The aim of this study was to determine the value of this system in monitoring patients with metastatic disease and to compare it with an established immunocytochemical method.

PATIENTS AND METHODS

Patients with progressive, locally advanced, and metastatic breast cancer (all stage IV) who were due to start systemic treatment were recruited. Blood samples were analyzed for CK-19 transcripts using quantitative PCR (QPCR) and immunocytochemistry (ICC) throughout their course of treatment.

RESULTS

One hundred forty-five blood samples were obtained from 22 patients over 13 months. Seventy-two (49.6%) of these samples were positive by QPCR, and 56 (42%) of 133 were positive by ICC. Of the 133 specimens analyzed by both techniques, 95 (71.4%) had the same results for each, and of the 71 samples that were positive, 40 (56%) were positive by both methods. The relationship between the number of cells detected and the QPCR values was statistically significant (P <.0001). Of the 25 courses of assessable treatment, 17 (68%) of 25 treatment outcomes (either response or disease progression) were reflected by QPCR measurements, and 12 (57%) of 21 were reflected by ICC. During the course of the study, five patients showed a response, and of these, ICC was in agreement in four cases (80%) and QPCR in three cases (60%). Eighteen courses of treatment resulted in progression of the disease; however, only 15 of these were assessable by ICC. ICC was in agreement in eight (53%) of 15 of these cases, and QPCR in 15 (83%) of 18 cases.

CONCLUSION

Circulating carcinoma cells are frequently found in patients with metastatic breast cancer. In the majority of patients, cancer cell numbers as evaluated by QPCR or ICC reflected the outcome of systemic treatment.

Microsatellite alterations plasma DNA of primary breast cancer patients

The aim of this study was to analyze plasma DNA from primary and metastatic breast cancer cases for tumor-specific alterations and to compare these findings with immunocytochemistry and estimation of cytokeratin 19 (CK19) mRNA for detection of micrometastases. DNA was extracted from plasma, lymphocytes, and microdissected tumor tissue sections obtained from 71 patients with breast cancer and 9 controls. DNA samples were analyzed for loss of heterozygosity (LOH) and/or microsatellite instability (MI) by PCR with two polymorphic markers (DM-1 and D16S400). Reverse transcription-quantitative PCR (QPCR) and immunocytochemistry were used for detection of CK19 mRNA and protein. Breast cancer plasma DNA displayed frequent LOH (31.3%) and MI (11.6%) supported by the same alteration in microdissected tumor DNA. Most notably, 10 of the 39 patients with primary breast cancer showed LOH (n = 6) or MI (n = 4). We compared plasma tumor DNA, plasma and bone marrow QPCR, and blood and bone marrow immunocytochemistry in 32 of the patients with primary cancer. Of these, only one patient had immunocytochemically detectable carcinoma cells in the blood, and three showed abnormally high levels of plasma CK19 mRNA. All four of these patients had plasma DNA alterations. We then compared bone marrow findings: of the 10 primary breast cancers that showed LOH or MI, 6 had elevated CK19 mRNA and 5 had immunocytochemically positive cells. Tumor DNA is readily detectable in plasma of primary and metastatic breast cancer patients, and plasma DNA alterations (LOH and MI) reflect those seen in the tumor. The application of microsatellite analyses to plasma DNA may be useful in assessing tumor burden in breast cancer patients, particularly when combined with QPCR, and is preferable for patients with breast cancer, for whom sequential bone marrow aspiration is undesirable.

Cardiovascular and renal benefits of dry bean and soybean intake

Dry beans and soybeans are nutrient-dense, fiber-rich, and are high-quality sources of protein. Protective and therapeutic effects of both dry bean and soybean intake have been documented. Studies show that dry bean intake has the potential to decrease serum cholesterol concentrations, improve many aspects of the diabetic state, and provide metabolic benefits that aid in weight control. Soybeans are a unique source of the isoflavones genistein and diadzein, which have numerous biological functions. Soybeans and soyfoods potentially have multifaceted health-promoting effects, including cholesterol reduction, improved vascular health, preserved bone mineral density, and reduction of menopausal symptoms. Soy appears to have salutary effects on renal function, although these effects are not well understood. Whereas populations consuming high intakes of soy have lower prevalences of certain cancers, definitive experimental data are insufficient to clarify a protective role of soy. The availability of legume products and resources is increasing, incorporating dry beans and soyfoods into the diet can be practical and enjoyable. With the shift toward a more plant-based diet, dry beans and soy will be potent tools in the treatment and prevention of chronic disease.

Quantitative polymerase chain reaction for the detection of micrometastases in patients with breast cancer

PURPOSE

Previous reports have indicated that reverse transcriptase polymerase chain reaction (RT-PCR) for cytokeratin 19 (CK-19) may be useful in the management of patients with breast cancer. However, the specificity of this technique is low, principally because of a high rate of false-positive results. To improve the specificity of this assay, we developed a quantitative RT-PCR methodology that enables an estimate to be made of the number of CK-19 transcripts in blood and bone marrow samples.

PATIENTS AND METHODS

We examined 45 peripheral-blood samples and 30 bone marrow samples from patients with a variety of nonneoplastic conditions using nested RT-PCR for CK-19. We also examined bone marrow and peripheral-blood samples from 23 patients with primary breast cancer and peripheral-blood samples from 37 patients with metastatic breast cancer. The number of CK-19 transcripts was estimated in positive specimens by competitive PCR and normalized to the number of ABL transcripts as an internal control for the quality and quantity of cDNA. RT-PCR results were compared with the numbers of CK-19-positive cells detected by immunocytochemistry.

RESULTS

Analysis of samples from patients without cancer enabled us to define an upper limit for the background ratio of CK-19 to ABL transcripts (1:1,000 for blood samples and 1:1,600 for bone marrow samples). Using these figures as cut-off points, elevated CK-19: ABL ratios were detected in peripheral-blood samples of 20 of 37 (54%) patients with metastatic breast cancer and in bone marrow samples of 14 of 23 (61%) patients with primary breast cancer. Only three of 23 (13%) primary breast cancer peripheral-blood samples and none of the control samples were positive by these criteria. Only two of 23 patients (9%) with primary breast cancer showed immunocytochemically detectable cells in the blood; 10 of 23 (43%) showed immunocytochemically detectable cells in the bone marrow. Of 36 patients with metastatic breast cancer, eight (22%) showed positive events.

CONCLUSION

Quantitative RT-PCR for CK-19 detects a percentage of patients with breast cancer and may enable the progression or regression of the disease to be monitored.

Effects of soy protein on renal function and proteinuria in patients with type 2 diabetes

For > 150 y, clinicians and investigators have observed that high protein intakes accelerate the progression of renal disease and that low protein intakes have beneficial effects. Some studies suggest that the effects of soy-protein intake resemble those of a low-protein diet. The Brenner hypothesis suggests that high protein intakes by diabetic individuals create hyperfiltration and glomerular hypertension eventuating in renal damage. On the basis of the available evidence, we are proposing the soy-protein hypothesis, which states that substituting soy protein for animal protein in diabetes patients results in less hyperfiltration and glomerular hypertension and, therefore, resultant protection from diabetic nephropathy. Furthermore, substituting soy protein for animal protein should have therapeutic value in diabetic nephropathy with resultant slowing of deterioration of renal function and decreasing proteinuria. The preliminary results of the study of 8 type 2 diabetes patients with obesity, hypertension, and proteinuria are reported. Under the conditions of the study, providing soy protein as half of the daily protein intake had no distinct effects on renal function or proteinuria in these subjects. Soy-protein intake was associated with a significant reduction in serum cholesterol and triacylglycerol concentrations. Further studies are required to critically examine the effects of soy-protein intake on the renal function of diabetes patients.

A comparison of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in patients on hemodialysis

The hospital records of 22 patients on hemodialysis undergoing coronary artery bypass grafting, and 19 others undergoing percutaneous transluminal coronary angioplasty were reviewed to compare the outcomes of these procedures in this population. Evidence of previous myocardial infarction or triple vessel or left main coronary artery disease was more common in patients undergoing coronary artery bypass graft than those undergoing percutaneous transluminal coronary angioplasty. Perioperative mortality and complication rates following coronary artery bypass graft (4.5% and 41%, respectively) were similar to those following percutaneous transluminal coronary angioplasty (5.3% and 42%). Cardiac event-free rates at 18 months by life-table analysis following coronary artery bypass graft and percutaneous transluminal coronary angioplasty were 87 +/- 16% and 40 +/- 14%, respectively. Survival at 18 months were 67 +/- 17% following coronary artery bypass graft and 69 +/- 14% following percutaneous transluminal coronary angioplasty. Cardiac events were observed to occur in three patients undergoing coronary artery bypass graft at a median of 10 months, and in nine patients following percutaneous transluminal coronary angioplasty at a median of 6 months. One patient required percutaneous transluminal coronary angioplasty after the initial coronary artery bypass graft. Seven patients required repeat percutaneous transluminal coronary angioplasty, and two patients underwent coronary artery bypass graft after initial percutaneous transluminal coronary angioplasty. Although these conclusions are limited by the retrospective nature of the study, it is concluded that coronary artery bypass graft can be performed with morbidity and mortality equivalent to percutaneous transluminal coronary angioplasty, and provides better cardiac event-free rates than percutaneous transluminal coronary angioplasty in patients on hemodialysis. Percutaneous transluminal angioplasty does not appear to be justified in this population because of its unacceptably high restenosis and cardiac event rates.

Interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on magnetic resonance imaging and association of high-intensity zone with pain and anular disruption

STUDY DESIGN

Retrospective analysis of a spine imaging center's records of patients with chronic low back pain referred by tertiary care facilities.

OBJECTIVES

1) To assess the interobserver reliability of detecting lumbar intervertebral disc high-intensity zone on T2-weighted magnetic resonance imaging, and 2) to assess the relation between high-intensity zone and discography or post-computed tomography in symptomatic patients with low back pain.

SUMMARY OF BACKGROUND DATA

Two of the three previous studies on this subject found an association between high-intensity zone and the presence of Grade 4 anular disruption with discographic reproduction of patients' exact low back pain.

METHODS

Records of patients with low back pain who had undergone lumbar spine discography injection and post-computed tomography from June 1995 to August 1996 were reviewed. Two independent observers were asked to identify the presence of an high-intensity zone from the T12-L1 disc to L5-S1 on T2-weighted magnetic resonance images. With this data, interobserver reliability was assessed with the kappa statistic. Concordant high-intensity zone results were then compared with the Dallas Discogram rating for anular disruption and to patients' subjective pain response to discography injection. With this data, the sensitivity, specificity, and predictive values of high-intensity zone for detecting disc disruption and pain response were calculated.

RESULTS

The interobserver reliability for detecting a high-intensity zone in a given disc was fair to good (kappa = 0.57; 95% confidence interval = 0.44, 0.70). The sensitivity of high-intensity zone for detecting Grade 4 anular disruption and exact pain was poor (31%) but its specificity was relatively high (90%). The positive predictive value of a high-intensity zone was low (40%) for a severely disrupted and exactly painful disc.

CONCLUSIONS

The interobserver reliability of detecting a high-intensity zone and the positive predictive value of the presence of a high-intensity zone for detecting a severely disrupted and exactly painful disc were much lower than previous studies have shown. The relatively low positive predictive value may be attributable to differences in sample characteristics or procedural variations, or suggest that a high-intensity zone is not indicative of exactly painful internal intervertebral disc disruption.

Oral midazolam: pediatric conscious sedation

Dentists attempt to overcome patients' fears by using various oral, intramuscular, intravenous, and inhalational anxiolytic agents. This article discusses the use of oral midazolam as an alternative to oral diazepam in the management of the pediatric patient.

Congenital diaphragmatic hernia associated with aortic coarctation

Congenital diaphragmatic hernia (CDH) may be associated with other anomalies, most frequently cardiovascular in nature. Despite fetal echocardiography, diagnosis of an accompanying cardiac malformation often is not made until after birth and sometimes not until after extracorporeal membrane oxygenation (ECMO) has been instituted. Aortic coarctation associated with CDH may occur as an isolated, surgically correctable malformation or it may be a component of the usually fatal left heart "hypoplasia" or "smallness" syndrome. The authors present two cases of aortic coarctation associated with CDH requiring ECMO that illustrate the management challenges of these coincident diagnosis. In one case, the accompanying coarctation was suspected and required precannulation angiography for confirmation, whereas in the other case, the diagnosis of coarctation was not made until after ECMO cannulation. Depending on its anatomic location and severity, an aortic coarctation associated with life-threatening CDH may limit the physiological efficacy of venoarterial ECMO. Furthermore, arterial cannulation for extracorporeal support requires that flow through the remaining carotid artery be maintained during aortic reconstruction, which may prove difficult for lesions best treated by subclavian flap angioplasty. When the diagnosis of coincident aortic coarctation and CDH is suspected or proven before institution of extracorporeal support, serious consideration should be given to venovenous bypass, because this may provide better postductal oxygenation and facilitate aortic repair with the option of left carotid artery inflow occlusion.

Reconstruction of a severely atrophic maxilla using a Le Fort I downgraft and dental implants: clinical report

A 55-year-old woman developed chronic infections of the maxillary sinuses with osteomyelitis resulting in extensive bone destruction and atrophy from a failed subperiosteal implant. After surgical removal of the subperiosteal implant, extensive debridement of the maxilla, and long-term antibiotic therapy, maxillary reconstruction was initiated. A Le Fort I osteotomy and downgraft was performed, and a posterior iliac bone graft was harvested and grafted to reconstruct the severely atrophic maxilla. In a later surgical procedure, maxillary and mandibular implants were placed. Implant-retained overdentures were fabricated to restore function and esthetics.

A comparison of outcome criteria in the diagnosis of renovascular hypertension

The outcome criteria used for the diagnosis of renovascular hypertension (RVHT) following renal revascularization have not been validated. Differing criteria of indeterminate accuracy have yielded conflicting conclusions concerning the prevalence and efficacy of treatment of RVHT. We compared the accuracy of conventional outcome criteria used in the diagnosis of RVHT to that of novel, ordered outcome analysis to determine whether such an analysis might provide a more consistent means of diagnosing RVHT. Twenty-seven patients underwent intervention for treatment of presumed RVHT (group I), and 40 patients with presumed essential hypertension were treated with antihypertensive medication alone (group II). A standard dichotomized (improved or unimproved) outcome scheme and a five-level, ordered outcome scheme (ranging from definitely unimproved to definitely improved) were used to generate nominal outcomes of therapy for each patient. The resultant outcome groups were examined to determine the effect of such partitioning on blood pressure and medication requirements. To determine their diagnostic accuracy, the conventional and ordered outcome schemes were compared with a consensus outcome scheme derived from the use of numerous criteria. Significant correlations were observed between the ordered outcome score and posttreatment reductions in systolic blood pressure (r = 0.53, p = 0.007), diastolic blood pressure (r = 0.74, p = 0.0001), and medication score (r = 0.71, p = 0.0001). Overall diagnostic accuracy was estimated to be 91% for ordered criteria and 85% for dichotomized criteria. Correlation of the ordered and conventional schemes' assignments with the consensus scheme's assignments was 0.79 (p = 0.0001) and 0.63 (p = 0.0001), respectively. A simple, ordered outcome scheme compares favorably with the standard dichotomized scheme in assigning a diagnosis of RVHT to patients following renal revascularization or nephrectomy. The ordered scheme offers the advantages of simplicity and accuracy over current schemes.

Transcutaneous oxygen measurements predict healing of leg wounds with hyperbaric therapy

Twenty-six patients with chronic leg wounds had transcutaneous oxygen measurements taken from the peri-wound area and a chest reference site before undergoing hyperbaric oxygen therapy in order to evaluate the utility of transcutaneous oxygen measurements in predicting the response of wounds to hyperbaric therapy. Wound scores and wound areas were determined before treatment and after 10 hyperbaric exposures. Patients whose wounds averaged a 5% or greater reduction in wound score per treatment were designated "responders." Nine patients' wounds exhibited at least a 5% reduction in wound score per treatment. There were no differences observed between responders and the 17 nonresponders in age, duration of the wound, initial wound area, initial wound score, or in wound or reference transcutaneous oxygen measurements. Responders required significantly fewer treatments to achieve wound closure than did nonresponders. Peri-wound transcutaneous oxygen pressure when the patient was exposed to 2.4 atmospheres absolute correlated directly with the improvement in wound score per treatment (r = 0.64, p = 0.03). An inverse correlation was noted between surface peri-wound transcutaneous oxygen pressure and improvement in wound score per treatment (r = -0.74, p = 0.006). Elevated peri-wound transcutaneous oxygen measurements at 2.4 atmospheres absolute and reduced peri-wound oxygen measurements at 1 atmosphere absolute were associated with a more rapid response to hyperbaric oxygen treatments in patients with chronic leg wounds. The use of these measurements should allow this expensive and time-consuming therapy to be limited to those patients most likely to benefit.

Acute cholecystitis and cholangitis caused by Echinococcus granulosus

We report for the first time in the recent North American literature, the case of a patient with rupture of a hepatic hydatid cyst into the gallbladder, with subsequent obstruction of the cystic duct by a daughter cyst acting as a ball-valve and causing acute acalculous cholecystitis.

Sequence-selective carbohydrate-DNA interaction: dimeric and monomeric forms of the calicheamicin oligosaccharide interfere with transcription factor function

The synthetic oligosaccharide moiety of the antibiotic calicheamicin and the head-to-head dimer of this oligosaccharide are known to bind to the minor groove of DNA in a sequence-selective manner preferring distinct target sequences. We tested these carbohydrates for their ability to interfere with transcription factor function. The oligosaccharides inhibit binding of transcription factors to DNA in a sequence-selective manner, probably by inducing a conformational change in DNA structure. They also interfere with transcription by polymerase II in vitro. The effective concentrations of the oligosaccharides for inhibition of transcription factor binding and for transcriptional inhibition are in the micromolar range. The dimer is a significantly more active inhibitor than is the monomer.

Factors influencing limb salvage and survival after amputation and revascularization in patients with end-stage renal disease

BACKGROUND

Critical lower-extremity ischemia in patients with end-stage renal disease is associated with high operative mortality and low rates of limb salvage.

PATIENTS AND METHODS

The outcomes of 102 operations for lower-extremity ischemia in 77 patients with end-stage renal disease were analyzed to determine predictors of limb salvage and operative survival.

RESULTS

Patients undergoing amputation (n = 50) and revascularization (n = 52) were similar in age, cause, and duration of renal failure, and prevalence of coronary artery disease. Operative mortality was 13% in revascularized patients and 20% in amputated patients, and was caused by sepsis in 12 of the 17 deaths (71%). Limb salvage in surviving patients was 91% at 30 days and 67% at 1 year. One-year survival was 72% in both groups. Factors associated with limb loss included advanced generalized atherosclerosis, extensive tissue necrosis, failed ipsilateral bypass, and poor cardiac functional status. Overall, factors associated with mortality included failure of limb salvage procedures, hemodynamic instability, and poor cardiac functional status.

CONCLUSIONS

More liberal use of primary amputation for end-stage renal disease patients with critical leg ischemia appears to be an important factor in improving both limb salvage rates and overall operative mortality.

Lesch-Nyhan syndrome. A case report

Lesch-Nyhan syndrome is a rare anomaly consisting of a deficiency in the production of hypoxanthine phosphoribosyltransferase that leads to the overproduction of purine and the accumulation of uric acid. Major manifestations include mental retardation and self-destructive behavior resulting in self-mutilation through biting and scratching. Because no medical treatment exists to alleviate the symptoms of self-mutilation, direct dental intervention is the only way these behaviors can be affected. A unique case of this type involving two male identical twins is reported.

Laparoscopic splenectomy in childhood

The authors describe their technique for laparoscopic splenectomy in childhood. Five ports, including one 12-mm port for an endoscopic stapler, are placed. With the patient in the supine position, the short gastric vessels are divided between clips. The patient is then placed in the lateral decubitus position for mobilization of the splenic flexure of the colon, division of the posterolateral ligamentous attachments, and en masse transection of the splenic hilum using the EndoGIA stapler. The freed spleen is placed in a nylon reinforced Lap Sac, which is exteriorized at the neck. The spleen is morcellated and the sac removed. Concomitant cholecystectomy is performed in patients with hereditary spherocytosis who have cholelithiasis or sludge. The procedure has been performed without complication in six patients who had hematologic disorders. For another patient, the procedure was converted to an open splenectomy to achieve better hemostasis.

Laparoscopic Duhamel pullthrough procedure for Hirschsprung's disease in childhood

Advances in instrumentation and technique now make laparoscopic correction of some congenital anomalies possible. We report on a 2-year-old boy with biopsy-proven Hirschsprung's disease successfully treated by a laparoscopic Duhamel pullthrough procedure. The technique and its potential role in the treatment of Hirschsprung's disease are described.

Health benefits and practical aspects of high-fiber diets

Over the past 20 y dietary fiber has emerged as a leading dietary factor in the prevention and treatment of chronic diseases. High fiber intakes are associated with lower serum cholesterol concentrations, lower risk of coronary heart disease, reduced blood pressure, enhanced weight control, better glycemic control, reduced risk of certain forms of cancer, and improved gastrointestinal function. Dietary fiber can be categorized into water-soluble and water-insoluble components. Dried beans, oat products, and certain fruits and vegetables are good sources of soluble fiber. Most plant foods are good sources of insoluble fiber and wheat bran is a concentrated form of insoluble fiber. Current guidelines advise a doubling of dietary fiber intake for Americans. Inclusion of ample servings of fruits and vegetables, whole grains, and dried beans and peas will help individuals meet these guidelines.

Nonpenetrating trauma to the carotid artery: seven cases and a literature review

Nonpenetrating carotid trauma is uncommon and frequently missed on initial examination. The cases of seven patients seen over a period of 21 years are presented and 100 cases from the most recent literature are reviewed. Causes and mechanisms of injury, clinical presentation, investigations, management, and outcome are discussed. Causes of injury were three motor vehicle collisions, two falls, one sports injury, and one blow to the face. Clinical presentation was early in four and delayed in three. The earliest symptoms and signs were a change in mental status, headache, unprovoked fall, focal weakness, neglect, and dysphasia. Doppler studies may be useful in screening, but a definitive diagnosis is made with the help of angiography. Two patients were treated surgically; one died, one with delayed symptoms from a pseudoaneurysm recovered completely. Five patients were given anticoagulants; all survived with permanent deficits related to their pretreatment neurologic status. The outcome in 100 recent cases from the literature has improved compared with previous reports. The overall mortality was 12%. The outcome in our seven cases supports recent trends toward a strategy of early anticoagulation and selective surgical treatment.

Laparoscopic splenectomy

Splenectomy is easily amenable to laparoscopic technique. Compared with the open technique, its advantages include improved exposure, decreased pain, improved pulmonary function, shortened hospitalization, rapid return to unrestricted activities, and improved cosmetic appearance. These advantages are at the expense of prolonged operative time that, with experience and improved instruments, should diminish.

The lost needle: a laparoscopic dilemma

A case is presented in which a curved needle became lost during extracorporeal suturing in laparoscopic surgery. Maneuvers to find the needle were fruitless until an intraoperative x-ray showed it was stuck in the flapper mechanism of a laparoscopic cannula. Caution is given against the use of "pop-off" needles during extracorporeal suturing and an x-ray of cannulae is suggested when a lost needle cannot be found using routine maneuvers.

Use of auricular cartilage in the repair of orbital floor defects

Various materials have been used to repair orbital defects. This article advocates the use of autogenous conchal cartilage, especially in the repair of large posttraumatic defects, where contour, biocompatibility, and strength are most important. The technique for harvesting the cartilage is reviewed, and a case demonstrating its successful use is reported.

Prospective, randomized, controlled comparison of the effects of low-fat and low-fat plus high-fiber diets on serum lipid concentrations

Previous studies examining the hypocholesterolemic effects of high-soluble-fiber diets have not been designed to control for dietary fat intake. Serum cholesterol reductions may therefore be accounted for by differences in consumption of fat. Moderately hypercholesterolemic, nonobese, Caucasian men and women, 30-50 y old were randomly assigned to low-fat, low-fat plus high-fiber, or usual-diet groups and followed for 12 mo. At 12 mo the high-fiber group consumed significantly more soluble fiber than both the low-fat and usual-diet groups (P = 0.0063 and P = 0.0001); the high-fiber group did not differ from the low-fat group in quantity of dietary fat consumed. The high-fiber group experienced a greater average reduction (13%) in serum cholesterol than did the low-fat (9%) and usual-diet (7%) groups. After adjustment for relevant covariates, the reduction in the high-fiber group was significantly greater than that in the low-fat group (P = 0.0482). Supplementation with soluble fiber reduces serum cholesterol beyond the reduction observed with low-fat diet alone.

Back school programs. The ballet dancer

This article discusses factors influencing back injury in ballet dancers and describes a back rehabilitation program. This program, which applies principles of motor skill acquisition in a progressive manner, has been modified for the young ballet dancer to incorporate aspects of dance class.

Familial biliary atresia in three siblings including twins

We report a North American Indian family of five children in which dizygotic twin sisters and a third sibling had biliary atresia. This is in contrast to many reports of discordant biliary atresia in twins. Added to 29 previously documented cases of familial biliary atresia, these three cases support the theory that both genetic and acquired factors play a role in the pathogenesis of this disease.