Nasal Cavity Squamous Cell Carcinoma: Factors Associated With Treatment Outcomes and Potential Organ Preservation

Background

Squamous cell carcinoma of the nasal cavity (NCSCC) is a rare, challenging malignancy. Surgical resection of this tumor can cause significant facial deformity, and indications for adjuvant or organ preservation therapies are not well-described.

Objective

To examine the impact of treatment regimen on survival outcomes in NCSCC and to compare surgical to non-surgical based therapies.

Methods

The National Cancer Database was queried for NCSCC from 2004 to 2014. Patient demographics, tumor characteristics, and treatment regimen were compared for the entire cohort. Multivariable Cox proportional hazards regression was performed for statistical analysis of treatment regimen and surgical margins on overall survival (OS) for early and late-stage disease.

Results

A total of 1883 NCSCC patients were identified. The OS for the cohort was 83 months, and median age at diagnosis was 65 years. NCSCC patients who underwent surgery followed by adjuvant radiation therapy (RT) had a better OS compared to definitive RT (HR: 0.58, P < .001). In early stage NCSCC (T1/T2, N0), there was no significant difference in OS between patients treated with surgery only or surgery with adjuvant RT compared to definitive RT. In advanced stage NCSCC, surgery with adjuvant RT had a better OS compared to definitive chemoradiation. Having positive margins was shown to predict a worse OS when compared to negative margins in surgical patients despite adjuvant RT or chemoradiation.

Conclusions

NCSCC appears to be best treated with surgery followed by adjuvant RT in advanced-stage disease whereas in early-stage disease, surgery does not improve OS compared to definitive RT.

Survival Outcomes in Sinonasal Poorly Differentiated Squamous Cell Carcinoma

OBJECTIVE

Sinonasal squamous cell carcinoma (SCC) is rare with no consensus on treatment regimen. Our goal is to analyze treatment outcomes in poorly differentiated SCC (PDSCC) using a large national database.

STUDY DESIGN

Retrospective database study.

METHODS

The National Cancer Database was queried for sinonasal invasive SCC, grade 3 (poorly differentiated) from 2004 to 2014. Patient demographics and tumor and treatment characteristics were tabulated. Kaplan-Meier (KM) analysis was performed to compare overall survival (OS) between histology subtype and primary site. Multivariable Cox proportional hazards regression was performed for statistical analysis of treatment regimen on OS.

RESULTS

A total of 1,074 patients were identified. The maxillary sinus was the most common site (45%). T4 tumors were observed in 50% of patients, with most patients treated at high-volume facilities (77%). In KM analysis, spindle cell SCC histological subtype, primary tumors of the maxillary sinus, and poorly differentiated grade had worse OS. In our Cox-PH model, higher T stage and age were associated with worse OS. Those treated at a high-volume facility and those who underwent surgical resection followed by adjuvant radiation had improved OS. Chemotherapy within the treatment regimen did not confer survival benefit except in surgical patients when positive margins were present, and surgery with adjuvant chemoradiation trended toward improved survival.

CONCLUSIONS

Sinonasal PDSCC appears to be best treated at high-volume centers with surgical resection followed by adjuvant radiation. Poorly differentiated grade has worse OS compared to more differentiated tumors. Chemotherapy along with adjuvant radiation may have a role in patients with positive surgical margins.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1040-E1048, 2021.

Predicting Outcome in Subarachnoid Hemorrhage (SAH) Utilizing the Full Outline of UnResponsiveness (FOUR) Score

BACKGROUND

Existing scoring systems for aneurysmal subarachnoid hemorrhage (SAH) patients fail to accurately predict patient outcome. Our goal was to prospectively study the Full Outline of UnResponsiveness (FOUR) score as applied to newly admitted aneurysmal SAH patients.

METHODS

All adult patients presenting to Health Sciences Center in Winnipeg from January 2013 to July 2015 (2.5 year period) with aneurysmal SAH were prospectively enrolled in this study. All patients were followed up to 6 months. FOUR score was calculated upon admission, with repeat calculation at 7 and 14 days. The primary outcomes were: mortality, as well as dichotomized 1- and 6-month Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) values.

RESULTS

Sixty-four patients were included, with a mean age of 54.2 years (range 26-85 years). The mean FOUR score upon admission pre- and post-external ventricular drain (EVD) was 10.3 (range 0-16) and 11.1 (range 3-16), respectively. There was a statistically significant association between pre-EVD FOUR score (total, eye, respiratory and motor sub-scores) with mortality, 1-month GOS, and 6-month GOS/mRS (p < 0.05 in all). The day 7 total, eye, respiratory, and motor FOUR scores were associated with mortality, 1-month GOS/mRS, and 6-month GOS/mRS (p < 0.05 in all). The day 14 total, eye, respiratory, and motor FOUR scores were associated with 6-month GOS (p < 0.05 in all). The day 7 cumulative FOUR score was associated with the development of clinical vasospasm (p < 0.05).

CONCLUSIONS

The FOUR score at admission and day 7 post-SAH is associated with mortality, 1-month GOS/mRS, and 6-month GOS/mRS. The FOUR score at day 14 post-SAH is associated with 6-month GOS. The brainstem sub-score was not associated with 1- or 6-month primary outcomes.

Intravenous Immunoglobulins for Refractory Status Epilepticus: A Scoping Systematic Review of the Pediatric Literature

Our goal was to perform a scoping systematic review of the literature on the use of intravenous immunoglobulins (IVIGs) for refractory status epilepticus (RSE) in pediatric patients. Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, ClinicalTrials.gov (inception to June 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendation Assessment Development and Education (GRADE) methodology by two independent reviewers. We identified 21 original articles. Eighty-seven pediatric patients were described as having received IVIG therapy for RSE. The mean age was 7.8 years (range: 2–17.5 years). Seizure response occurred in 14 of the 87 patients (16.1%), with 3 (3.4%) and 11 (12.6%) displaying partial and complete responses, respectively. Seventy-three of the 87 patients (83.9%) failed to display any seizure response to IVIG therapy. No complications related to IVIG therapy were recorded. The majority of patients had moderate to severe neurological deficits upon follow-up. Oxford level 4, GRADE D evidence exists to suggest little to no impact on seizure control in pediatric autoimmune RSE. Routine use of IVIG for pediatric RSE cannot be recommended at this time and should be considered experimental.

Time for a Time Window Extension: Insights from Late Presenters in the ESCAPE Trial

BACKGROUND AND PURPOSE

The safety and efficacy of endovascular therapy for large-artery stroke in the extended time window is not yet well-established. We performed a subgroup analysis on subjects enrolled within an extended time window in the Endovascular Treatment for Small Core and Proximal Occlusion Ischemic Stroke (ESCAPE) trial.

MATERIALS AND METHODS

Fifty-nine of 315 subjects (33 in the intervention group and 26 in the control group) were randomized in the ESCAPE trial between 5.5 and 12 hours after last seen healthy (likely to have groin puncture administered 6 hours after that). Treatment effect sizes for all relevant outcomes (90-day mRS shift, mRS 0-2, mRS 0-1, and 24-hour NIHSS scores and intracerebral hemorrhage) were reported using unadjusted and adjusted analyses.

RESULTS

There was no evidence of treatment heterogeneity between subjects in the early and late windows. Treatment effect favoring intervention was seen across all clinical outcomes in the extended time window (absolute risk difference of 19.3% for mRS 0-2 at 90 days). There were more asymptomatic intracerebral hemorrhage events within the intervention arm (48.5% versus 11.5%, P = .004) but no difference in symptomatic intracerebral hemorrhage.

CONCLUSIONS

Patients with an extended time window could potentially benefit from endovascular treatment. Ongoing randomized controlled trials using imaging to identify late presenters with favorable brain physiology will help cement the paradigm of using time windows to select the population for acute imaging and imaging to select individual patients for therapy.

Intravenous immunoglobulins for refractory status epilepticus, part I: A scoping systematic review of the adult literature

PURPOSE

Our goal was to perform a scoping systematic review of the literature on the use of intravenous immunoglobulins (IVIG) for refractory status epilepticus (RSE) in adults.

METHOD

Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers.

RESULTS

Twenty-four original articles were identified. A total of 33 adult patients were described as receiving IVIG for RSE. Seizure reduction/control with IVIG occurred in 15 of the 33 patients (45.4%), with 1 (3.0%) and 14 (42.4%) displaying partial and complete responses respectively. No adverse events were recorded.

CONCLUSION

Oxford level 4, GRADE D evidence exists to suggest an unclear impact of IVIG therapy in adult RSE. Routine use of IVIG in adult RSE cannot be recommended at this time.

Mechanism of death after early decompressive craniectomy in traumatic brain injury

Background

Decompressive craniectomy in devastating traumatic brain injury is controversial. The impact of decompressive craniectomy on mechanism of death is unclear in the literature to date. Our goal was to determine the mechanism of death between those receiving early decompressive craniectomy and those managed medically.

Methods

We performed an institutional retrospective review, from June 2003 to June 2013, of adult patients with devastating blunt traumatic brain injury undergoing early decompressive craniectomy who subsequently died. We compared this group to a retrospectively matched group based on: age, pre-hospital KPS, Marshall diffuse computed tomography grades, Injury Severity Scores, and admission laboratory values.

Results

Forty patients were analyzed; 20 with decompressive craniectomy and 20 without. The two groups were similar based on admission demographics, with the only statistically significant difference being platelet levels. Upon analysis, through both univariate and multivariate regression analysis, the mechanism of death was significantly different (p = 0.003; OR: 0.07 (0.01–0.41) and p = 0.04; OR: 0.08 (0.01–0.87)) with the decompressive craniectomy and non-decompressive craniectomy groups displaying neurological death rates of 10.0% versus 60.0%, respectively, with all other patients in both groups dying secondary to circulatory arrest after withdrawal of life-sustaining therapy. Time to death was significantly longer in the decompressive craniectomy group (2.83 vs. 9.21 days, respectively) (p = 0.01; OR: 0.65 (0.46–0.91).

Conclusions

Progression to neurological death appears to be more common in those devastating blunt traumatic brain injury patients treated medically compared to those undergoing early decompressive craniectomy. Given the implications of end-of-life care and societal implications, the mechanism of death determination and organ donation should be reported as relevant outcomes in devastating traumatic brain injury studies.

Plasmapheresis for refractory status epilepticus Part II: A scoping systematic review of the pediatric literature

BACKGROUND

Our goal was to perform a scoping systematic review of the literature on the use of plasmapheresis or plasma exchange (PE) for refractory status epilepticus (RSE) in children.

METHODS

Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers.

RESULTS

Twenty-two original articles were identified, with 37 pediatric patients. The mean age of the patients was 8.3 years (age median: 8.5, range: 0.6 years-17 years). Seizure response to PE therapy occurred in 9 of the 37 patients (24.3%) included in the review, with 7 patients (18.9%) displaying resolution of seizures and 2 patients (5.4%) displaying a partial reduction in seizure volume. Twenty-eight of the 37 patients (75.7%) had no response to PE therapy. No adverse events were recorded.

CONCLUSIONS

Oxford level 4, GRADE D evidence exists to suggest little to no benefit of PE in pediatric RSE. Routine application of PE for pediatric RSE cannot be recommended at this time.

Time to loss of brain function and activity during circulatory arrest

PURPOSE

Brain function during the dying process and around the time of cardiac arrest is poorly understood. To better inform the clinical physiology of the dying process and organ donation practices, we performed a scoping review of the literature to assess time to loss of brain function and activity after circulatory arrest.

MATERIALS AND METHODS

Medline and Embase databases were searched from inception to June 2014 for articles reporting the time interval to loss of brain function or activity after loss of systemic circulation.

RESULTS

Thirty-nine studies met selection criteria. Seven human studies and 10 animal studies reported that electroencephalography (EEG) activity is lost less than 30seconds after abrupt circulatory arrest. In the setting of existing brain injury, with progressive loss of oxygenated circulation, loss of EEG may occur before circulatory arrest. Cortical evoked potentials may persist for several minutes after loss of circulation.

CONCLUSION

The time required to lose brain function varied according to clinical context and method by which this function is measured. Most studies show that clinical loss of consciousness and loss of EEG activity occur within 30seconds after abrupt circulatory arrest and may occur before circulatory arrest after progressive hypoxia-ischemia. Prospective clinical studies are required to confirm these observations.

Magnesium sulfate for non-eclamptic status epilepticus

BACKGROUND

Our goal was to perform a systematic review of the literature on the use of intravenous magnesium sulfate (MgSO4) for non-eclamptic status epilepticus (SE) and refractory status epilepticus (RSE).

METHODS

Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to June 2015), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers.

RESULTS

We identified 19 original articles. A total of 28 patients were described in these articles with 11 being adult, 9 being pediatric, and 8 of unknown age. Seizure reduction/control with IV MgSO4 occurred in 14 of the 28 patients (50.0%), with 2 (7.1%) and 12 (42.9%) displaying partial and complete responses respectively. Seizures recurred upon withdrawal of MgSO4 therapy in 50% of the patients whom had reduction/control of their SE/RSE. Three patients had recorded adverse events related to MgSO4 therapy.

CONCLUSIONS

Oxford level 4, GRADE D evidence exists to suggest a trend towards improved seizure control with the use of intravenous MgSO4 for non-eclamptic RSE. Routine use of IV MgSO4 in non-eclamptic SE/RSE cannot be recommended at this time. Further prospective study of this drug is required in order to determine its efficacy as an anti-epileptic in this setting.

Lidocaine for status epilepticus in adults

INTRODUCTION

Our goal was to perform a systematic review of the literature on the use of intravenous lidocaine in adults for status epilepticus (SE) and refractory status epilepticus (RSE) to determine its impact on seizure control.

METHODS

All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2014), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers.

RESULTS

Overall, 13 studies were identified, with 11 manuscripts and 2 meeting abstracts. Seventy-six adult patients were treated for 82 episodes of SE/RSE. Patients had varying numbers of anti-epileptic drugs (AEDs), 1-12, on board prior to lidocaine therapy. During 69 of the 82 (84.1%) episodes of SE/RSE, phenytoin was on board. The dose regimen of lidocaine varied, with some utilizing bolus dosing alone; others utilizing a combination of bolus and infusion therapy. Overall, 70.7% of seizures responded to lidocaine, with complete cessation and greater than 50% reduction seen in 64.1% and 6.1% respectively. Patient outcomes were sparingly reported.

CONCLUSIONS

There currently exists level 4, GRADE C evidence to support the consideration of lidocaine for SE and RSE in the adult population. Thus there is currently weak evidence to support the use of lidocaine in this context. Further prospective studies of lidocaine administration in this setting are warranted.

An Improved Forensic Science Information Search

Although thousands of search engines and databases are available online, finding answers to specific forensic science questions can be a challenge even to experienced Internet users. Because there is no central repository for forensic science information, and because of the sheer number of disciplines under the forensic science umbrella, forensic scientists are often unable to locate material that is relevant to their needs. The author contends that using six publicly accessible search engines and databases can produce high-quality search results. The six resources are Google, PubMed, Google Scholar, Google Books, WorldCat, and the National Criminal Justice Reference Service. Carefully selected keywords and keyword combinations, designating a keyword phrase so that the search engine will search on the phrase and not individual keywords, and prompting search engines to retrieve PDF files are among the techniques discussed.

Mood instability and functional recovery in bipolar disorders

OBJECTIVE

The aim of this study was to identify psychopathological factors associated with long-term functional outcome in euthymic bipolar disorder patients and to test new measures of mood instability and symptoms intensity.

METHOD

Fifty-five patients with more than 12 months of follow-up were included. In addition to traditional clinical variables, the time spent ill was documented using a modified life-charting technique based on NIHM life-charting method. New measures, Mood Instability Factor, and Mood Intensity Factor were defined and assessed. Functioning Assessment Short Test (FAST) was used to assess disability.

RESULTS

The follow-up period was 3.00 ± 1.51 years. Weeks with subsyndromal depressive symptoms (β = 0.133, t = 2.556, P = 0.014), weeks with mild manic symptoms (β = 1.441, t = 3.10, P = 0.003), and the Mood Instability Factor (β = 0.105, t = 3.593, P = 0.001) contributed to approximately 46% of the FAST total score variance.

CONCLUSION

New methodologies including subsyndromal symptoms and mood instability parameters might contribute to understand the worse long-term functional outcome that affects a considerable percentage of BD patients even after episode remission. Concerns about therapeutic approaches are discussed.

Dopamine sudden depletion as a model for mixed depression

Up to date research on Bipolar Disorders' phenomenology is in keeping with early descriptions made by E. Kraëpelin regarding the overlap in clinical presentation of both manic and depressive symptoms, namely, mixed states. The latter constitute a highly prevalent and characteristic clinical presentation of Bipolar Disorders' and entail therapeutic difficulties, prognostic implications and increased suicidal risk. Notwithstanding, mixed states', more specifically mixed depression, have been underestimated and bypassed to the point where currently neither diagnostic criteria nor specific therapeutic recommendations are provided. In addition to the lack of agreement on nosography and diagnostic criteria, mixed depression is usually excluded from Bipolar Disorders' neurobiological models. Furthermore, renewed interest in the role of dopamine in Bipolar Disorders' physiopathology has left aside hypothesis that may account for the aforementioned clinical presentation. Interestingly enough, other syndromes arising from sudden dopamine depletion such as neuroleptic dysphoria or withdrawal syndromes from dopaminergic drugs, bear remarkable clinical similarities with mixed depression. These syndromes have been subject of further research and may thus provide a model for mixed states' physiopathology. Indeed, this article accounts for clinical similarities between mixed depression, neuroleptic induced dysphoria, and other behavioural syndromes arising from sudden dopamine depletion. After reviewing neurochemical basis of such syndromes we present, to the best of our knowledge, the first neurobiological hypothesis for mixed depression. Specifically, such hypothesis regards over activation symptoms as auto regulatory attempts to compensate for sudden dopaminergic depletion. This hypothesis provides with a beginning step for the neglected problem of mixed depression, a non-antithetic link between the dopaminergic hypothesis for both manic and depressive symptoms, a plausible explanation regarding inter individual variability to mixed depression susceptibility, and suggests new approaches for the development of novel treatments in which dopamine dysregulation should be targeted.

[Is condylar resorption a contra-indication for surgery?]

INTRODUCTION

Idiopathic condylar resorption, often fortuitously discovered when performing orthodontic-surgical assessment, is a clinical entity in itself. There is a significant risk of postoperative degenerating and worsening. Is this sufficient to contra-indicate orthognathic surgery? The authors suggest an answer after studying a series of patients.

MATERIAL AND METHOD

A retrospective study of 10 consecutive patients was made from July 1999 to October 2004. The preoperative assessment was triple: clinical, radiological and photographic. At least 6 months of occlusal, radiological and morphological stability was observed before any therapy was initiated. A fixed orthodontic set-up was placed and patients were regularly followed by a speech therapist for parafunctions. Stability of the occlusal correction, acquisition of a more harmonious aesthetic profile, and resolution of joint symptomatology were used to define therapeutic success at one year.

RESULTS

All patients were female. Resorption affected the mandibular side of the joint in all cases and the temporal side in 7 cases. Three types of osteotomies were performed: maxillary (N=1), mandibular (N=5), and bibasilar (N=4). Genioplasty was not systematic. Joint symptoms were resolved in all cases. Postoperative occlusion corresponded to the therapeutic project in 9 cases. All patients were aesthetically improved.

DISCUSSION

Idiopathic condylar resorption is not a contra-indication for orthognathic surgery. However, this treatment requires meeting and respecting four principles: a minimal delay of 6 months of occlusal, radiological, and morphological stability, an adapted and meticulous surgical technique, early and prolonged parafunction therapy, and a close follow-up of the patients.

L'exploration téléradiographique desvoiesaériennes supérieures dans l'évaluation du traitement chirurgical des syndromes d'apnées obstructives du sommeil

INTRODUCTION

A lateral cephalometric radiograph is frequently performed for diagnostic and pretherapeutic purposes in patients with obstructive sleep apnea syndrome (OSAS). We studied the prognostic value of this exploration in terms of therapeutic outcome in surgically treated patients.

MATERIAL AND METHOD

Fifty-five patients underwent surgery from May 1994 through December 1998. Forty-seven had phase I surgery (UPPP, hyothyrohyoidopexy and genioglossal advancement), 18 phase II surgery (bimaxillar advancement) after failure of a phase I procedure and 8 primary phase II surgery. For the "phase I" group: mean body mass index (BMI) was 26.3+/-2.9 kg/m2 and mean age was 47+/-11 years. For the "phase II" group: mean BMI was 25.9+/-3 kg/m2 and mean age was 48+/-9 years. Polysomnography was performed in all patients preoperatively and six months after each surgical procedure. The preoperative apnea-hypopnea index (AHI) was 45.2+/-26.8/h of sleep for the phase I group and 53.8+/-26.9/h for the phase II group. All the patients had a lateral cephalometric radiograph, preoperatively, postoperatively, and at 6 months. The following parameters were measured on each radiograph: posterior airway space (PAS), mandibular plane-hyoid bone distance (MPH), minimal retrolingual space, minimal retrovelar space, surfaces of the rhinopharynx, the oropharynx, the hypopharynx and total upper airway surface. Therapeutic success was defined as a AHI<15/h and 50% decrease compared with the preoperative AHI, associated with normal sleep structure, respiratory microarousal score less than 15/h, normal oxymetry and absence of symptoms.

RESULTS

After phase I surgery: the success rate was 21.2%. For the whole group, the total upper airway surface has significatively increased between preoperative and immediate postoperative time, as well the MPH, the PAS and the minimal retrolingual space. But at the late postoperative control, no significative difference compared with the preoperative data has been observed. The comparison between failures and successes has demonstrated that there was no difference in surface or distance benefit between the two groups. But it existed a preoperative difference as the failures have a greater rhinopharynx and a shorter retro velar oropharynx compared with the successes. This difference has been noticed in the immediate postoperative time but not in the late postoperative time. In the "failure" group, the immediate postoperative increase in the upper airway surface, the PAS and the minimal retrolingual space was totally lost in the late postoperative control. In the opposite, in the "success" group, the minimal retro velar space was the only parameter significatively increased at the postoperative time. After phase II surgery: the success rate was 76.9%. All measured parameters except rhinopharynx surface and MPH were increased at last follow-up; part of the increase in the hypopharynx and the minimal retrolingual space observed postoperatively was lost during later follow-up. Nevertheless, in the "failure" group patients, no significant increase could be demonstrated at the last postoperative control. Linear parameters (PAS, minimal retro lingual and retro velar spaces) were smaller in the "successful" group than in the "failure" group.

DISCUSSION

It is difficult to ascertain the exact contribution of the lateral cephalometric radiograph to the assessment of surgical outcome. Apparently, and independently of the technique used, part of the gain in the upper airway surface observed immediately after surgery is progressively lost. We were unable to define any parameter on the lateral cephalometric radiograph predictive of success after phase I surgery. Discrimination between success and failure after phase I surgery might be related to the stability of the increase in the minimal retro velar space and the MPH. For phase II surgery, the initial shortness of the upper airway surface is a good prognostic factor for therapeutic success, defined as a stable increase in the oropharynx.

An evaluation of agreements between managed care organizations and community-based mental illness and addiction disorder treatment and prevention providers

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA), examines contracts between managed care organizations (MCOs) and community-based providers of mental illness and addiction disorder treatment and prevention services (MI/AD providers). Building upon initial research published in 1997, this brief explores in depth one of the most hidden aspects of managed care: the relationship between the managed care organizations and health care providers.

Improving accuracy in the grading of renal cell carcinoma by combining the quantitative description of chromatin pattern with the quantitative determination of cell kinetic parameters

The determination of grade and stage in renal cell carcinomas (RCCs) often fails to predict the actual clinical outcome for individual patients. The aim of the present work was to investigate whether it is possible to significantly improve the prognostic accuracy of the grading system by using the combination of two independent computer-assisted microscopy techniques. The first technique relates to the quantitative description of morphonuclear and nuclear DNA content features by means of the image analysis of Feulgen-stained cell nuclei, and the second quantitatively characterizes tumor growth by means of different cell kinetic parameters. These parameters consist of a duplication of a time-related parameter determined by means of the technique of using silver-stained proteins in interphase nucleolar organizer regions (AgNOR), a proliferation index determined by means of MIB-1 immunohistochemistry, and an apoptotic index determined by means of the terminal dUTP nick end labeling technique. The prognostic value of these quantitative features was investigated in a series of 60 RCCs. The quantitative analysis of Feulgen-stained nuclei made it possible to identify subgroups of patients with significantly different prognoses in both grade II and grade III RCCs. We labeled the RCCs associated with the most favorable prognoses as grade II- and III- and those with the least favorable ones as grade II+ and III+. The two most important kinetic variables to identify patients with different clinical outcomes were the MIB-1 index and the mean AgNOR area in the MIB-1-positive cells. Three significantly different survival curves were obtained for the 53 grade II and III RCC patients. Our results show that conventional RCC grading can be significantly improved by the quantitative analysis of Feulgen-stained nuclei, by cell kinetic parameter determination, and, more importantly, by combining the proliferation index with the mean AgNOR area parameter.

Results in 95 hemorrhagic stroke patients included in CLASS, a controlled trial of clomethiazole versus placebo in acute stroke patients

BACKGROUND AND PURPOSE

Clomethiazole is a neuroprotective drug that enhances gamma-aminobutyrate type A (GABA(A)) receptor activity. Its efficacy and safety were tested in the CLomethiazole Acute Stroke Study (CLASS). The protocol allowed a CT scan to be done after randomization but within 7 days of stroke onset to minimize delays before start of treatment. Ninety-five of the 1360 patients randomized were diagnosed as having intracranial hemorrhage rather than ischemic stroke. Safety results for clomethiazole compared with placebo in this group are reported.

METHODS

The study included patients with a clinical diagnosis of acute hemispheric cerebral infarction. Treatment was a 24-hour intravenous infusion of 75 mg/kg clomethiazole or placebo. Patients with intracranial hemorrhage discovered on a postrandomization CT were withdrawn from study treatment if treatment was ongoing, and all patients were followed up to 90 days.

RESULTS

Ninety-four patients received treatment, 47 in each group. The hemorrhage was classified as intracerebral in 89 patients (94%). Mortality at 90 days was 19.1% in the clomethiazole group and 23.4% in the placebo group. Sedation was the most common adverse event, occurring at a higher incidence in clomethiazole-treated patients (clomethiazole 53%, placebo 17%), followed by rhinitis and coughing. The incidence and pattern of serious adverse events was similar between the treatment groups. The percentage of patients reaching relative functional independence on the Barthel Index (score >/=60) at 90 days was 59.6% in the clomethiazole group and 53.2% in the placebo group.

CONCLUSIONS

Clomethiazole appears safe to administer to hemorrhagic stroke patients compared with placebo. These results would obviate the need for a CT scan before therapy is initiated in acute stroke. The safety of clomethiazole in hemorrhagic stroke patients will be further evaluated in a prospective study that is under way in North America.

The Americans with Disabilities Act: implications for managed care for persons with mental illness and addiction disorders

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration, examines the Americans with Disabilities Act ("the ADA") and its application to managed care. The ADA provides important protections for persons with disabilities who are members of managed care arrangements, regardless of whether their membership is sponsored by an employer, Medicare, or Medicaid or is purchased privately. The interaction between the ADA and managed care is complex, and different issues can arise under publicly and privately sponsored plans.

Selected key issues in the development and drafting of public managed behavioral health care carve-out contracts

The development of managed behavioral health care carve-out contracts covering a discrete subset of benefits available for use by persons with mental health and/or substance abuse disorders poses major challenges for public purchasers. This Issue Brief explores several key issues that arise when drafting such agreements. Many of the issues that arise in the drafting of carve-out agreements will require the public purchaser to resolve basic policy questions well before the drafting of requests for proposals or contracts can proceed. Analyses of public sector managed behavioral health care contracts by attorneys at the Center for Health Policy Research suggest that there are four essential areas that must be addressed if mental health and substance abuse services are carved-out (either by the purchaser or by a comprehensive managed health care entity): (1) what population is eligible for enrollment; (2) what services is the contractor expected to furnish; (3) what triggers a duty on the part of the mental health or substance abuse carve-out contractor to provide services; and (4) how are services furnished by the managed behavioral health care contractor integrated with or coordinated with services furnished by a beneficiary's primary health care provider, with pharmaceutical benefits, and with other services that may be available to a beneficiary through a fee-for-service or other mechanism. However a purchaser chooses to resolve these four issues, it is essential that parallel clarifying clauses are also built into the contracts of primary health care providers and other entities providing needed services for persons whose mental health and substance abuse service needs are covered by the carve-out. Underlying all of these issues is the fact that ambiguity, vagueness, or failure to define terms and responsibilities can create unexpected and unwelcome clinical and financial liabilities to purchasers.

An overview of Medicaid managed care litigation

Since the enactment of Medicaid in 1965, states have had the option of offering beneficiaries enrollment in managed care arrangements. With the advent of mandatory managed care reaching millions of beneficiaries (including a growing proportion of disabled recipients), the amount and scope of litigation involving Medicaid managed care plans can be expected to grow. A review of the current litigation regarding Medicaid managed care reveals two basic types of lawsuits: (1) those that challenge the practices of managed care companies under various federal and state laws that safeguard consumer rights, protect health care quality, and prohibit discrimination; and (2) suits that assert claims arising directly under the Medicaid statute and implementing regulations, as well as claims related to Constitutional safeguards that undergird the program. Lawsuits asserting claims arising under Medicaid tend to raise two basic questions: (1) the extent to which enrollment in a Medicaid managed care plan alters existing Medicaid beneficiary rights and state agency duties under federal or state Medicaid law; and (2) the extent to which managed care companies, as agents of the state, act under "color of law" (i.e., undertaking to perform official duties or acting with the imprimatur of state authority). Additionally, states might see an increase in litigation brought by prospective and current contractors who assert that they have been wrongfully denied contracts or improperly penalized for poor performance. These assertions may involve claims that are grounded in federal and state law, the Medicaid statute, and the Constitution. Moreover, in light of the consumer protection elements of the managed care reforms contained in the Balanced Budget Act, future managed care litigation may focus on the manner in which companies carry out states' obligations toward managed care enrollees. Resolution of Medicaid managed care cases involves the application of general principles of administrative and regulatory law. Thus, Medicaid managed care cases have implications for other public purchasers of managed care arrangements, including state mental health and alcohol and substance abuse agencies.

Effect of selective diaphragmatic paralysis on the inspiratory motor drive

Using alpha-chloralose-anesthetized mechanically ventilated vagotomized dogs, we assessed the effects of selective diaphragmatic paralysis on the inspiratory motor drive. Diaphragmatic paralysis was accomplished by a bolus injection of vecuronium, a neuromuscular junction blocker, into the left phrenic artery of an in situ vascularly isolated and innervated left diaphragm. The inspiratory motor drive during spontaneous breathing attempts was assessed by measuring peak integrated electromyographic (EMG) activities of the left and right diaphragms and parasternal and alae nasi muscles. Respiratory timing parameters were measured from the integrated EMG signals of the diaphragm. Three groups of dogs were studied. In group 1 (n = 9), vecuronium was injected into the phrenic artery with the left diaphragmatic length adjusted at the functional residual capacity. Vecuronium injection (0.2 mg) resulted in a significant decline in left diaphragmatic tension and integrated EMG. Breathing frequency increased by 24% of the baseline value, whereas right diaphragm, parasternal, and alae nasi EMG activities rose to 136, 227, and 165% of their respective baseline values a few seconds after the vecuronium injection. In group 2 (n = 6), vecuronium injection in left phrenectomized animals did not alter the EMG activities of the inspiratory muscles (left EMG signal was abolished) nor did it alter respiratory timing. In group 3 (n = 4), the left diaphragm was placed in a flaccid position. Vecuronium injection in this group did not produce any changes in the EMG activities or respiratory timing. We conclude that selective diaphragmatic paralysis elicits a significant rise in the inspiratory motor drive. This effect is likely to be mediated through the inhibition of diaphragmatic Golgi tendon organ activity.

Thin-fiber phrenic afferents mediate the ventilatory response to diaphragmatic ischemia

We assessed the role of groups III and IV phrenic afferents in the ventilatory response to diaphragmatic ischemia in mechanically ventilated, chloralose-anaesthetized dogs using the in-situ isolated and innervated left hemidiaphragm preparation. The inspiratory motor drive to the right (Rt Edi) and left (Lt Edi) diaphragms, parasternal (Eps), and alae nasi (Ean) muscles was measured from the peak integrated EMG activities. When left diaphragmatic ischemia was produced in the control group (n = 6) by occluding the left phrenic artery for 20 min, LtEdi increased to 158%, RtEdi to 160%, Eps to 150% and Ean to 135% of baseline values. Left diaphragmatic tension, however, remained unchanged during the ischemia period. In the capsaicin-treated group (n = 6), we injected repeated doses of capsaicin, a selective stimulant of groups III and IV afferents, into the left phrenic artery to eliminate inputs from these afferents. Repeated injections of capsaicin are known to induce prolonged periods of afferent dysfunction. The first two injections of capsaicin (1 mg each) produced transient activation of the inspiratory muscles and higher breathing frequencies. Subsequent injections, however, failed to elicit any ventilatory changes. When diaphragmatic ischemia was induced after the last injection of capsaicin, no changes in the Right Edi, Eps and Ean were observed, whereas Left Edi and left diaphragmatic tension declined significantly. We conclude that increased inspiratory motor drive during selective diaphragmatic ischemia is mediated through the activation of groups III and IV phrenic afferents.

Epileptic Munchausen's syndrome: a form of pseudoseizures distinct from hysteria and malingering

A young woman with seizures and status epilepticus sought and obtained hospitalization in at least 25 hospitals in the province of Quebec between 1980 and 1987. She was thought to have uncontrolled epilepsy; her treatment led to intoxication with anticonvulsants and once to anesthesia for three consecutive periods of 7 days each. The nonepileptic nature of her attacks was proven and a diagnosis of Munchausen's syndrome made. She was transferred to a psychiatric center where she committed suicide. We found no documented cases of epileptic chronic factitious disorder in the literature.

Control of disaccharidase activities in brush-border membranes of guinea pig fetuses: a role of pancreatic proteases?

The intestinal brush-border disaccharidases most resistant to pancreatic protease digestion in vitro are lactase and trehalase. When compared to maltase and sucrase, they are also those which showed the largest increase during development of guinea pig fetuses. These results suggest that pancreatic proteases may play a role in the control of brush-border disaccharidase activities during fetal development.

Purification and some properties of liver and brain beta-N-acetyl-hexosaminidase S

beta-N-Acetyl-hexosaminidase S (2-acetamido-2-deoxy-beta-hexoside acetamido-deoxyhexohydrolase, EC 3.2.1.52) was purified from liver and brain of a patient deceased of type O GM2 gangliosidosis (Sandhoff's disease). Brain beta-N-acetyl-hexosaminidase S was further purified by preparative polyacrylamide gel electrophoresis. The pH optimum of the purified liver and brain enzyme was 5.0 and Km values were 0.8--0.9 mM and 0.3--0.4 mM with 4-methylumbelliferyl-beta-D-N-acetylglucosamine and beta-D-N-acetylgalactosaminide derivatives, respectively. beta-N-Acetyl-hexosaminidase S was thermolabile losing most of its activity after 50 min at 50 degrees C. The apparent molecular weights of the purified liver and brain enzymes were 154 000 and 152 000, respectively. Hexosamines activated beta-N-acetyl-hexosaminidase S whereas the isoenzyme A and B were inhibited. The glycoprotein nature of beta-N-acetyl-hexosaminidase S was suggested by its affinity towards Concanavalin A-Sepharose.