Effect of Urate-Elevating Inosine on Early Parkinson Disease Progression: The SURE-PD3 Randomized Clinical Trial

Importance

Urate elevation, despite associations with crystallopathic, cardiovascular, and metabolic disorders, has been pursued as a potential disease-modifying strategy for Parkinson disease (PD) based on convergent biological, epidemiological, and clinical data.

Objective

To determine whether sustained urate-elevating treatment with the urate precursor inosine slows early PD progression.

Design, Participants, and Setting

Randomized, double-blind, placebo-controlled, phase 3 trial of oral inosine treatment in early PD. A total of 587 individuals consented, and 298 with PD not yet requiring dopaminergic medication, striatal dopamine transporter deficiency, and serum urate below the population median concentration (<5.8 mg/dL) were randomized between August 2016 and December 2017 at 58 US sites, and were followed up through June 2019.

Interventions

Inosine, dosed by blinded titration to increase serum urate concentrations to 7.1-8.0 mg/dL (n = 149) or matching placebo (n = 149) for up to 2 years.

Main Outcomes and Measures

The primary outcome was rate of change in the Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS; parts I-III) total score (range, 0-236; higher scores indicate greater disability; minimum clinically important difference of 6.3 points) prior to dopaminergic drug therapy initiation. Secondary outcomes included serum urate to measure target engagement, adverse events to measure safety, and 29 efficacy measures of disability, quality of life, cognition, mood, autonomic function, and striatal dopamine transporter binding as a biomarker of neuronal integrity.

Results

Based on a prespecified interim futility analysis, the study closed early, with 273 (92%) of the randomized participants (49% women; mean age, 63 years) completing the study. Clinical progression rates were not significantly different between participants randomized to inosine (MDS-UPDRS score, 11.1 [95% CI, 9.7-12.6] points per year) and placebo (MDS-UPDRS score, 9.9 [95% CI, 8.4-11.3] points per year; difference, 1.26 [95% CI, -0.59 to 3.11] points per year; P = .18). Sustained elevation of serum urate by 2.03 mg/dL (from a baseline level of 4.6 mg/dL; 44% increase) occurred in the inosine group vs a 0.01-mg/dL change in serum urate in the placebo group (difference, 2.02 mg/dL [95% CI, 1.85-2.19 mg/dL]; P<.001). There were no significant differences for secondary efficacy outcomes including dopamine transporter binding loss. Participants randomized to inosine, compared with placebo, experienced fewer serious adverse events (7.4 vs 13.1 per 100 patient-years) but more kidney stones (7.0 vs 1.4 stones per 100 patient-years).

Conclusions and Relevance

Among patients recently diagnosed as having PD, treatment with inosine, compared with placebo, did not result in a significant difference in the rate of clinical disease progression. The findings do not support the use of inosine as a treatment for early PD.

Trial Registration

ClinicalTrials.gov Identifier: NCT02642393.

Comparison of elderly and young patient populations treated with deep brain stimulation for Parkinson's disease: long-term outcomes with up to 7 years of follow-up

OBJECTIVE

Deep brain stimulation (DBS) is the procedure of choice for Parkinson's disease (PD). It has been used in PD patients younger than 70 years because of better perceived intra- and postoperative outcomes than in patients 70 years or older. However, previous studies with limited follow-up have demonstrated benefits associated with the treatment of elderly patients. This study aims to evaluate the long-term outcomes in elderly PD patients treated with DBS in comparison with a younger population.

METHODS

PD patients treated with DBS at the authors' institution from 2008 to 2014 were divided into 2 groups: 1) elderly patients, defined as having an age at surgery ≥ 70 years, and 2) young patients, defined as those < 70 years at surgery. Functional and medical treatment outcomes were evaluated using the Unified Parkinson's Disease Rating Scale part III (UPDRS III), levodopa-equivalent daily dose (LEDD), number of daily doses, and number of anti-PD medications. Study outcomes were compared using univariate analyses, 1-sample paired t-tests, and 2-sample t-tests.

RESULTS

A total of 151 patients were studied, of whom 24.5% were ≥ 70 years. The most common preoperative Hoehn and Yahr stages for both groups were 2 and 3. On average, elderly patients had more comorbidities at the time of surgery than their younger counterparts (1 vs 0, p = 0.0001) as well as a higher average LEDD (891 mg vs 665 mg, p = 0.008). Both groups experienced significant decreases in LEDD following surgery (elderly 331.38 mg, p = 0.0001; and young 108.6 mg, p = 0.0439), with a more significant decrease seen in elderly patients (young 108.6 mg vs elderly 331.38 mg, p = 0.0153). Elderly patients also experienced more significant reductions in daily doses (young 0.65 vs elderly 3.567, p = 0.0344). Both groups experienced significant improvements in motor function determined by reductions in UPDRS III scores (elderly 16.29 vs young 12.85, p < 0.0001); however, reductions in motor score between groups were not significant. Improvement in motor function was present for a mean follow-up of 3.383 years postsurgery for the young group and 3.51 years for the elderly group. The average follow-up was 40.6 months in the young group and 42.2 months in the elderly group.

CONCLUSIONS

This study found long-term improvements in motor function and medication requirements in both elderly and young PD patients treated with DBS. These outcomes suggest that DBS can be successfully used in PD patients ≥ 70 years. Further studies will expand on these findings.

Effect of creatine monohydrate on clinical progression in patients with Parkinson disease: a randomized clinical trial

IMPORTANCE

There are no treatments available to slow or prevent the progression of Parkinson disease, despite its global prevalence and significant health care burden. The National Institute of Neurological Disorders and Stroke Exploratory Trials in Parkinson Disease program was established to promote discovery of potential therapies.

OBJECTIVE

To determine whether creatine monohydrate was more effective than placebo in slowing long-term clinical decline in participants with Parkinson disease.

DESIGN, SETTING, AND PATIENTS

The Long-term Study 1, a multicenter, double-blind, parallel-group, placebo-controlled, 1:1 randomized efficacy trial. Participants were recruited from 45 investigative sites in the United States and Canada and included 1741 men and women with early (within 5 years of diagnosis) and treated (receiving dopaminergic therapy) Parkinson disease. Participants were enrolled from March 2007 to May 2010 and followed up until September 2013.

INTERVENTIONS

Participants were randomized to placebo or creatine (10 g/d) monohydrate for a minimum of 5 years (maximum follow-up, 8 years).

MAIN OUTCOMES AND MEASURES

The primary outcome measure was a difference in clinical decline from baseline to 5-year follow-up, compared between the 2 treatment groups using a global statistical test. Clinical status was defined by 5 outcome measures: Modified Rankin Scale, Symbol Digit Modalities Test, PDQ-39 Summary Index, Schwab and England Activities of Daily Living scale, and ambulatory capacity. All outcomes were coded such that higher scores indicated worse outcomes and were analyzed by a global statistical test. Higher summed ranks (range, 5-4775) indicate worse outcomes.

RESULTS

The trial was terminated early for futility based on results of a planned interim analysis of participants enrolled at least 5 years prior to the date of the analysis (n = 955). The median follow-up time was 4 years. Of the 955 participants, the mean of the summed ranks for placebo was 2360 (95% CI, 2249-2470) and for creatine was 2414 (95% CI, 2304-2524). The global statistical test yielded t1865.8 = -0.75 (2-sided P = .45). There were no detectable differences (P < .01 to partially adjust for multiple comparisons) in adverse and serious adverse events by body system.

CONCLUSIONS AND RELEVANCE

Among patients with early and treated Parkinson disease, treatment with creatine monohydrate for at least 5 years, compared with placebo did not improve clinical outcomes. These findings do not support the use of creatine monohydrate in patients with Parkinson disease.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00449865.

Brain-lung-thyroid disease: clinical features of a kindred with a novel thyroid transcription factor 1 mutation

Brain-lung-thyroid disease is a rare familial disorder caused by mutations in thyroid transcription factor 1, a gene that regulates neuronal migration. We report the clinical features of ten patients from a single family with a novel gene mutation, including observations regarding treatment. Neurologic features of the kindred included developmental delay, learning difficulties, psychosis, chorea, and dystonia. Three patients had a history of seizure, which has not been previously reported in genetically confirmed cases. Low-dose dopamine-receptor blocking drugs were poorly tolerated in 2 patients who received this therapy, levodopa improved chorea in 3 of 4 children, and diazepam was markedly effective in a single adult patient. Chorea related to brain-lung-thyroid disease appears to respond paradoxically to antidopaminergic drugs. The unusual therapeutic response seen in our patients and others may help elucidate how disease-related migratory deficits affect neural pathways associated with motor control.

Rapidly progressive atypical parkinsonism associated with frontotemporal lobar degeneration and motor neuron disease

OBJECTIVE

To report the rare but distinct clinical and neuropathological phenotype of non-familial, rapidly progressive parkinsonism and dementia associated with frontotemporal lobar degeneration with motor neuron disease (FTLD-MND).

METHODS

Subjects included two 70-year-old women presenting with rapidly progressive severe postural instability, axial-predominant parkinsonism, oculomotor dysfunction and frontal-predominant dementia with language impairment and pseudobulbar palsy. One had diffuse weakness without signs of lower motor neuron disease. Post-mortem evaluations included immunohistochemistry with antiphospho-TAR DNA-binding protein 43 (TDP-43) and genetic analysis of the TARDBP and PGRN genes.

RESULTS

Subjects died within 14 months from symptom onset. TDP-43-positive neuronal intracytoplasmic inclusions were prominent in the primary motor cortex, granule cell layer of the hippocampus, and several cranial and spinal cord nuclei. TDP-43 globular glial inclusions (GGI) were identified in one case. There were no mutations in PGRN or TARDBP genes.

CONCLUSIONS

FTLD-MND due to TDP-43-proteinopathy should be considered in patients with rapidly progressive parkinsonism and dementia phenotype, especially when aphasia and/or weakness are also present.

Cognitive and neuropsychiatric effects of subthalamotomy for Parkinson's disease

Since the advent of deep brain stimulation (DBS) for the treatment of Parkinson's disease (PD), subsequent cognitive and neuropsychiatric effects of this procedure have become well-chronicled. Yet, thermolitic lesion of the subthalamic nucleus (STN) is still a valid option when DBS cannot be applied, and little has been published regarding its impact on cognition and mood. We examined the cognitive and neuropsychiatric functions of 10 consecutive patients with advanced PD undergoing simultaneous bilateral subthalamotomies. With 24 months of follow-up, the patients, three of whom were on anticholinergics prior to surgery, showed no deterioration in cognitive assessments including verbal fluency. Hypoactive behaviors (depression and apathy) showed lasting improvement, while hyperactive behaviors (euphoria and disinhibition) transiently increased after surgery. Improvement in hypoactive behaviors correlated with improvement in hypokinetic movements, and enhanced hyperactive behaviors followed the course of post-operative hyperkinetic movements. Such correlations may support the role of the STN in modulating limbic connections between the basal ganglia and frontal cortex. The results of this proof-of-concept pilot study suggest the need for larger, long-term, randomized controlled studies to assess motor, neuropsychiatric, behavioral and radiologic correlations after subthalamotomies.

Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis

BACKGROUND

Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders.

OBJECTIVES

The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms.

DESIGN

The authors review current management and the supporting literature.

CONCLUSIONS

Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.

Treatment-responsive limbic encephalitis identified by neuropil antibodies: MRI and PET correlates

We report seven patients, six from a single institution, who developed subacute limbic encephalitis initially considered of uncertain aetiology. Four patients presented with symptoms of hippocampal dysfunction (i.e. severe short-term memory loss) and three with extensive limbic dysfunction (i.e. confusion, seizures and suspected psychosis). Brain MRI and [(18)F]fluorodeoxyglucose (FDG)-PET complemented each other but did not overlap in 50% of the patients. Combining both tests, all patients had temporal lobe abnormalities, five with additional areas involved. In one patient, FDG hyperactivity in the brainstem that was normal on MRI correlated with central hypoventilation; in another case, hyperactivity in the cerebellum anticipated ataxia. All patients had abnormal CSF: six pleocytosis, six had increased protein concentration, and three of five examined had oligoclonal bands. A tumour was identified and removed in four patients (mediastinal teratoma, thymoma, thymic carcinoma and thyroid cancer) and not treated in one (ovarian teratoma). An immunohistochemical technique that facilitates the detection of antibodies to cell surface or synaptic proteins demonstrated that six patients had antibodies to the neuropil of hippocampus or cerebellum, and one to intraneuronal antigens. Only one of the neuropil antibodies corresponded to voltage-gated potassium channel (VGKC) antibodies; the other five (two with identical specificity) reacted with antigens concentrated in areas of high dendritic density or synaptic-enriched regions of the hippocampus or cerebellum. Preliminary characterization of these antigens indicates that they are diverse and expressed on the neuronal cell membrane and dendrites; they do not co-localize with VGKCs, but partially co-localize with spinophilin. A target autoantigen in one of the patients co-localizes with a cell surface protein involved in hippocampal dendritic development. All patients except the one with antibodies to intracellular antigens had dramatic clinical and neuroimaging responses to immunotherapy or tumour resection; two patients had neurological relapse and improved with immunotherapy. Overall, the phenotype associated with the novel neuropil antibodies includes dominant behavioural and psychiatric symptoms and seizures that often interfere with the evaluation of cognition and memory, and brain MRI or FDG-PET abnormalities less frequently restricted to the medial temporal lobes than in patients with classical paraneoplastic or VGKC antibodies. When compared with patients with VGKC antibodies, patients with these novel antibodies are more likely to have CSF inflammatory abnormalities and systemic tumours (teratoma and thymoma), and they do not develop SIADH-like hyponatraemia. Although most autoantigens await characterization, all share intense expression by the neuropil of hippocampus, with patterns of immunolabelling characteristic enough to suggest the diagnosis of these disorders and predict response to treatment.

A new short practical quality of life questionnaire for use in head and neck oncology outpatient clinics

A new short questionnaire to assess the quality of life of head and neck patients has been designed at the University of Liverpool Head and Neck Oncology Department. The questionnaire is short, simple and can be easily completed by a patient whilst in the waiting room before consultation. It is filled in 6 months after completion of treatment and shows very good correlation with the standard long exhaustive questionnaires that are difficult to complete on every patient in a busy National Health Service clinic. The University of Liverpool questionnaire provides a simple score from 0%-100% which should prove valuable in the assessment of quality of care and help with decisions regarding treatment options in head and neck cancer patients.

Role of chest CT scanning in the management of patients presenting with head and neck cancer

BACKGROUND

The detection of synchronous tumors, whether they be second primaries or distant metastases, in patients with head and neck carcinoma drastically affects prognosis and may alter management. Computerized tomographic (CT) scanning of the chest is an effective screening investigation in this group of patients, both in the detection of synchronous second primary tumors, the incidence of which in this study is 15%, and for accurate staging of metastatic pulmonary disease. The incidence of synchronous tumors in patients who are initially seen with head and neck squamous cell carcinoma (HNSCC) has been reported in large retrospective studies as being between 1% and 3%. These may be either second primary tumors or metastases, and the lung is the commonest site for both.

METHODS

Eighty-one head and neck cancer patients (67 primary and 14 secondary referrals) treated at the Royal Liverpool University Hospital between 1994 and 1996 underwent CT scanning of the chest with ultrasound of the liver as part of their routine staging. The results were compared with standard chest x-rays also performed in each patient.

RESULTS

Fourteen patients had pulmonary tumors detected on the chest CT scan. In 67 patients, the scan was negative. Patients with negative scans tended not to have neck node metastases (64%), whereas patients with positive scans were much more likely to have neck node metastases with negative necks present in only 36% of patients. Where multivariate analysis was carried out, there was a correlation between neck node metastases and positive CT scans of the chest (estimate = 0.5755, standard error = 0.3066, chi2(1) = 6.73, p .047). The sensitivity of chest x-ray compared with CT scan was only 21 % and the specificity 99%. The positive predictive value of a chest x-ray was 75% and the negative predictive value 86%. Intra-abdominal lesions were detected in two patients, one in the liver and one in the adrenal gland. In the latter patient, this was an isolated lesion, but in the former, the chest scan was also positive. In the 67 patients, who were initially seen at the Royal Liverpool Hospital (primary referrals), the incidence of synchronous tumors was 15%.

CONCLUSIONS

Synchronous tumors, whether they be second primary tumors or distant metastases, are more common in patients initially seen with head and neck cancer than is realized, their incidence being significantly higher in those patients with cervical metastases. Computerized tomographic scanning of the chest is a more effective screening investigation than chest x-ray in this group of patients and is now used routinely in our department prior to undertaking major head and neck surgery.

Chest computerized tomography scanning in patients presenting with head and neck cancer

Between 1 to 16% of patients with head and neck squamous cell carcinoma (HNSCC) have synchronous tumours; the majority (> 50%) occurring within the lung. Previous studies have relied upon endoscopy and chest radiographs. The aim of this study was to determine the incidence of synchronous intrapulmonary tumours in this group of patients using computerized tomography (CT) scanning. Over 36 months, 111 consecutive patients were assessed at presentation by contrast enhanced CT scanning from the skull base to the diaphragm. Chest scans showed intrapulmonary lesions in 17 patients and 10 have, with time, been confirmed as neoplastic. These allowed treatment of three primary bronchial carcinomas following radical treatment of the index tumour and cancellation of radical treatment in five patients with metastases. Two patients with possible metastases at presentation underwent radical treatment to the index tumour with subsequent follow-up confirming metastatic chest disease. All 10 patients eventually died of either locoregional or metastatic disease. This is one of the first prospective reports of chest scanning in patients with head and neck cancer. An additional chest scan in this group, many of whom undergo a staging scan of the neck, requires an extra 10 min with no further contrast and in this study yielded a synchronous tumour rate of 9%.

Improved survival in patients with head and neck cancer in the 1990s

It is generally felt amongst the medical profession and the lay public that cancer is being treated more successfully than in the past. This is certainly true for childhood malignancies and leukaemia but evidence that significantly improved survival is occurring in the common solid tumours is lacking. Since 1963 the University of Liverpool Department of Otolaryngology/Head and Neck Surgery has collected data on all patients with head and neck tumours presenting to the department. The present study investigates patients with histologically proven squamous cell carcinoma of the four main sites: larynx, hypopharynx, oral cavity and oropharynx. From 1963 until the end of 1989, 2738 patients were seen by the department and from 1990 a further 717 patients have been seen. Since 1990 patients have tended to be in better general physical condition but, on the other hand, have tended to have more advanced disease at the primary site. The department has latterly tended to see fewer laryngeal cancers and more cancers of the oropharynx. Significantly fewer patients have presented with neck node metastases. Multiple logistic regression suggests that the most significant difference between the two groups is the great reduction in neck node recurrence rates in the group of patients seen since 1990 (P = 0.0001). The recurrence of tumours at the primary site since 1990 has been 35% compared with 41% before 1990, and recurrence in the neck nodes since 1990 has been 12%, compared with 15% before 1990. These differences are significant (P = 0.0141 and P = 0.0494, respectively). When studying survival in the 1960s, 1970s and 1980s, the 5-year cure rate was 50%, whereas since 1990 the figure has risen to 60% tumour-specific 5-year survival--a significant difference. A similar effect was noted in observed survival. This improvement in cure rate occurred for all four main sites. The results were confirmed by Cox's proportional hazards model where year of treatment was highly significantly associated with improved survival (P = 0.0001). It has been demonstrated that locoregional recurrence has improved since 1990 and this is reflected in improved survival figures. Although there are differences in the parameters of tumours referred before 1990 and since 1990, multivariate analysis suggests that the improvement in neck node recurrence rates may be responsible for this improved survival rate. Multivariate analysis for survival also suggests that the improvement in cure rates is independent of compounding variables and dependent on the year of presentation of the tumour. This improved survival may be related to factors, such as the administration of radical postoperative radiotherapy.

The tender neck: thyroiditis or thyroid abscess?

Following apparent subacute thyroiditis, a 16-year-old girl developed a left thyroid abscess thought to be secondary to steroids and haematogenous spread from a pilonidal abscess. The thyroid suppuration became recurrent and required partial thyroidectomy. Further left-sided abscess formation in the neck prompted a barium swallow which revealed the source of infection to be a sinus tract arising from the left piriform fossa. The patent fourth branchial sinus tract was later excised. All patients with a tender thyroid should have ultrasound-guided fine needle aspiration to establish the diagnosis. If suppuration is confirmed, a barium swallow is advised to exclude a sinus tract from the piriform fossa.

Efficacy of external fixation following nasal manipulation under local anaesthesia

Nasal fractures are one of the commonest reasons for patients being referred to ENT departments, but few studies have been published about the management of this condition. In particular, the efficacy of external splintage following manipulation has not been assessed. This was a prospective randomized study, which examined the results of manipulation under local anaesthetic and the benefit to be gained from external fixation with Plaster of Paris (POP) following this procedure. Accurate measurements of the degree of deviation of the nose pre- and post-manipulation were obtained using a camera mounted on a specially designed frame. Thirty-three out of 241 consecutive patients seen at a research clinic over the course of 12 months were included in the study. The mean deviation of the nasal bridge at presentation was 4.12 mm. Manipulation under local anaesthetic significantly improved the degree of deviation (mean 2.47 mm, P = 0.0011, 90% CI, 1-2 mm). Randomization of the patients, following manipulation, into POP/none-POP groups showed that external splintage of the nose appeared to be of little practical benefit.

Treatment of oropharyngeal carcinoma by irradiation or by surgery

Of previously untreated patients with squamous cell carcinoma of the oropharynx, 145 are reviewed in this study. All were treated in the Department of Head and Neck Surgery at the University of Liverpool from 1990 to 1997. Seventy-seven patients were treated with irradiation, 28 patients by surgery and 40 patients were deemed not suitable for any curative treatment. Univariate analysis showed no difference in the two groups treated by curative modalities but multivariate analysis did suggest that the surgical group tended to have larger neck node metastases. The 5-year tumour specific actuarial survival for all patients was 53%, 65% for the radiotherapy group and 51% for the surgery group. The difference was not statistically significant (chi (1)2 = 1.5070). The modality of treatment had no affect on either the development of a primary or neck node recurrence or the survival after such a recurrence. Where neck node disease was present it was treated as appropriate. As is generally standard practice, lymph nodes over 2 cm were treated with radical neck dissection whether the patient was having irradiation therapy or surgery. If the patient was having irradiation therapy, the neck dissection was carried out before and irradiation after operation, both on the primary and on the neck, if appropriate. It is concluded that irradiation therapy in properly selected cases in combined head and neck clinics is a safe and effective treatment for squamous cell carcinoma of the oropharynx. Neck node disease should be treated appropriately, but there is no support for the old adage that whatever form of treatment is being used for the neck node should also be used for the primary site.

Tumours of the minor salivary glands

One hundred and forty-five patients were identified with minor salivary gland tumours. General information and tumour-specific information on stage, grade of tumour, resection margins, recurrence and survival were collected. Data was analysed by both univariate and multivariate methods. Indices predicting tumour recurrence and survival were analysed. Forty-two benign lesions, mostly pleomorphic adenomas were identified, one recurred, all survived. One hundred and three malignant lesions were identified, mostly adenoid cystic carcinomas (70%) or mucoepidermoid carcinomas (19%). Late stage disease and the presence of neck node metastases predicted both early recurrence and high eventual mortality. Survival was favoured by the histological type (mucoepidermoid > adenoid cystic), site of primary (oral cavity and oropharynx > nose, sinuses and larynx) and good general condition. Many tumours recurred after 5 years of disease-free survival and late mortality was a feature (80% survival at 5 years, 20% at 20 years). Many patients survive some time with either local recurrence or distant metastases. Long-term follow-up is advocated as local or distant recurrence may be treatable. The value of super radical treatment of the primary is questionable given the likelihood of recurrence at distant sites.

Predictors of outcome in children with otitis media with effusion

Otitis media with effusion (OME) is the commonest cause of hearing impairment in young children. The fluctuating nature of the condition makes identification of those with persistent disease difficult without subjecting each child to a period of 'watchful waiting'. The aim of this study was to determine if the outcome of this observation period could in any way be predicted. The study involved the retrospective analysis of 517 children, aged 3-15 years (mean 5 years and 4 months) in whom the diagnosis of OME had been established. All children had been subjected to an observation period before a decision on surgery was taken. There was a significant correlation between the degree of hearing loss at presentation and after the period of observation. Sex was not a reliable predictor of outcome, but age less than 4 years and presentation in autumn or winter were associated with a poor audiometric outcome. This study identifies a predictive influence on the resolution of OME for these three factors and points the way for future research aimed at identifying the subgroup of children with OME who would benefit from early surgical intervention.

Informed consent: patients' and junior doctors' perceptions of the consent procedure

The important task of obtaining informed consent is often left to the most junior member of the surgical team, whose understanding of the surgical procedures involved may be limited. Little is known about patients' and junior doctors' satisfaction with the consent procedure, which was studied with the use of questionnaires. The vast majority of patients (95%) were satisfied with the explanation given to them prior to obtaining consent although 45% thought that the doctor who signed the consent form would be performing the surgery. Thirty-seven per cent of the junior doctors questioned admitted to obtaining consent for procedures of which they had little understanding. The majority of both junior doctors and patients felt that the surgeon performing surgery should sign the consent form. Junior doctors cannot be expected to obtain informed consent for procedures they do not fully understand and patients's; expectations must be taken into consideration if the seemingly inexorable rise in medico-legal litigation is to be halted.

Adult obstructive sleep apnoea syndrome and tonsillectomy

A surgical cure for adult obstructive sleep apnoea syndrome (OSAS) is an attractive alternative to nasal continuous positive airway pressure, but current research suggests that uvulopalatopharyngoplasty is not effective in all patients. No subgroup of these patients, who might benefit from surgery to the oropharynx, has as yet been identified. In this study we examined the results of tonsillectomy either as an isolated procedure or as part of uvulopalatopharyngoplasty in seven patients, who had tonsillomegaly. In all seven there was a short-term improvement between the pre-operative and post-operative apnoea/hypoapnoea (A/H) index (100-65 per cent), which could not be accounted for by change in the body mass index (BMI). In one patient a diagnosis of Non-Hodgkin's lymphoma was made from histological examination of the tonsils. The results suggest that adult patients with tonsillomegaly may represent a subgroup of patients with OSAS, who would benefit from surgery aimed at the oropharynx.

Laryngeal tuberculosis: an unsuspected danger

It is always important to treat conditions which may be cancerous with respect and, where there is suspicion, to take biopsies for histological examination. A hoarse voice may, in addition, be a sign of tuberculosis of the larynx, and the clinical appearance can be similar to a carcinoma. Preoperative chest x-ray (not always performed) and an awareness by the histologist of such a possibility are important now that this condition is increasing in frequency in parallel with conditions where immunological status is compromised.

Dysphagia caused by a hard cervical collar

It is important to consider unusual neck anatomy when fitting hard cervical collars after neurosurgical procedures. A collar which fits too tightly may restrict laryngeal movement during swallowing causing dysphagia, which could be mistaken for damage to neuromuscular function in this group of patients.

The value of skin testing in patients with chronic rhinitis

The value of skin prick testing in the management of patients with chronic rhinitis has still to be established. The aim of the study was to determine how accurately atopic status could be predicted from the clinical history of allergy. We carried out a prospective audit of 103 patients undergoing skin tests in three ORL departments over a three-month period. Of 73 patients with a history of allergy or an atopic family history, 44 (60%) had a positive skin test. Twenty-one out of 30 (70%) with no history had a negative skin test. In subjects where a negative atopic history to inhaled allergens is combined with a negative family history, the incidence of negative skin test results was 79%. Skin prick testing is of questionable clinical value in the absence of positive atopic feature in the personal or family history of the patient.

The carcinogenic risk of exposure to sulphuric acid fumes from lead acid batteries

Prolonged exposure to sulphuric acid fumes is associated with an increased risk of developing laryngeal carcinoma. Lead acid batteries are a potential source of these fumes. We present a case of an electric fork lift truck driver who developed laryngeal carcinoma as a result of such exposure.

Relationship of maternal and fetal levels of human placental lactogen to the weight and sex of the fetus

In a study of 101 patients at term, the maternal and umbilical cord artery and vein levels of human placental lactogen (hPL) were correlated against the sex and birthweight of the fetus. No difference in hPL levels was found between cord artery and vein. The maternal hPL level correlated well with the delivered weight of the child, but no relationship could be demonstrated in the case of umbilical cord blood. Pregnancies with a female child had a higher level of hPL, which was significant only in cord samples.

Use of lorazepam as a premedicant for caesarean section. An evaluation of its effects on the mother and the neonate

The effects of lorazepam premedication on the mother and baby were compared with those of a placebo in a double-blind study of 10 patients undergoing elective Caesarean section. There was little anxiolytic effect on the mothers, and no harmful effects to the babies occurred in respect of blood-gas tensions, heart rate, temperature or feeding patterns. Lorazepam did produce a transient effect on the neonatal respiratory rate and initially the babies had a reduced score on the Brazelton Assessment System.

Short-term variation in the level of alpha-fetoprotein in maternal serum

Serial serum levels of alpha-fetoprotein (AFP) were examined over a 24-h period in six subjects. A short-term variation was demonstrated which was significantly greater than that due to the assay alone, but which showed no particular pattern. These findings may explain why an 'abnormal' AFP level frequently reverts to a 'normal' level on second sampling.

An evaluation of the Bishop scoring system in relation to a method of induction of labour by intra-vaginal prostaglandin

This paper is a prospective study of the outcome of labour in 109 patients with favourable and unfavourable cervices in whom labour was induced by intravaginal prostaglandin, with supplementary syntocinon infusion where necessary. There were 61 primigravidae and 48 multigravidae. The rate of operative intervention was virtually no higher than in those labours of spontaneous onset. The length of labour varied inversely with the Bishop score of the cervix before induction, with a coefficient of correlation of -0·995 for primigravidae and of -0·929 for multigravidae. Bishop score was shown to be a poor indicator of the number of doses of prostaglandin needed for successful induction.