Submandibular gland transfer: a new method of preventing radiation-induced xerostomia

OBJECTIVE

Radiation-induced xerostomia is a significant morbidity of radiation therapy in the management of patients with head and neck cancers. We have recently reported a method of transfer of one submandibular gland to the submental space in a small pilot series of eligible surgical patients. The submental space was shielded during postoperative radiation therapy. The transferred gland continued to function after the completion of radiation therapy and none of the patients developed xerostomia. The purpose of this article is to present the technique of submandibular gland transfer in detail and to evaluate the postoperative survival and function of the transferred submandibular glands.

DESIGN

Prospective clinical trial.

METHODS

The submandibular gland was transferred on eligible patients as part of their surgical intervention. The patients were followed clinically, with salivary flow and radioisotope studies.

RESULTS

We performed the surgical transfer of the submandibular salivary gland in 24 of 25 patients placed on the protocol. All the glands survived transfer and functioned well postoperatively as demonstrated on the salivary flow and the radioisotope studies. The surgical transfer was relatively simple and added 45 minutes to the surgical procedure. There were no complications attributed to the submandibular gland transfer.

CONCLUSIONS

We have successfully demonstrated that the submandibular gland can be surgically transferred to the submental space with its function preserved. The gland seems to continue functioning even after radiation therapy with the appropriate shielding. This surgical transfer procedure has the potential to change the way we currently manage patients with head and neck cancer.

Piloting new ways of working: evaluation of the WILSTAAR Programme

The current study aims to investigate the reliability and effectiveness of the WILSTAAR screening assessment and intervention programme. It also explores parental perceptions and evaluations of their involvement in the intervention programme. At this stage data collection is incomplete however interim results are presented. False positive rates are slightly higher than expected raising questions regarding the screen's reliability. Numbers are too small at present to report with confidence on the effectiveness of the intervention programme. Results indicate that parents rate their involvement in the WILSTAAR programme in a highly positive manner. The need for further research in this area is highlighted to ensure that early identification and intervention programmes meet the needs of parents and their children.

Evaluation of the Hanen Early Childhood Educators Programme

The current study is an evaluation of the Hanen Early Childhood Educators Programme (Weitzman 1992). It explores outcomes for both staff and children following staff participation in the training programme. Using a comparative study design and pre- and post-training measures the changes in staff and children were investigated. Results revealed that the training programme did not bring about change in children's receptive and expressive language skills. Changes were observed in children's social interaction skills. This was reinforced by staff reports of changes in children's interaction. Staff changes included increased skills and confidence in identifying and supporting children with speech and language difficulties alongside positive changes in their interaction styles. The methodological difficulties inherent in evaluating training effects and the need for further research are highlighted.

Submandibular salivary gland transfer prevents radiation-induced xerostomia

BACKGROUND

Xerostomia is a significant morbidity of radiation therapy in the management of head and neck cancers. We hypothesized that the surgical transfer of one submandibular salivary gland to submental space, outside the proposed radiation field, prior to starting radiation treatment, would prevent xerostomia.

METHODS

We are conducting a prospective clinical trial where the submandibular gland is transferred as part of the surgical intervention. The patients are followed clinically, with salivary flow studies and University of Washington quality of life questionnaire.

RESULTS

We report early results of 16 patients who have undergone this procedure. Seven patients have finished and 2 patients are currently undergoing radiation treatment. In 2 patients, no postoperative radiation treatment was indicated. Two patients are waiting to start radiation treatment and 2 patients refused treatment after surgery. The surgical transfer was abandoned in 1 patient. All of the transferred salivary glands were positioned outside the proposed radiation fields and were functional. The patients did not complain of any xerostomia and developed only minimal oral mucositis. There were no surgical complications.

CONCLUSIONS

Surgical transfer of a submandibular salivary gland to the submental space (outside the radiation field) preserves its function and prevents the development of radiation-induced xerostomia.

Encouraging speech and language development in exceptional circumstances

An evaluation of the accessibility of the speech and language therapy service within Down Lisburn Trust and a needs assessment of the levels of speech and language difficulties in preschool children was conducted between October 1996 and March 1997. Results highlighted that 42% of preschool children had speech and language difficulties, however only 17.8% were able to access the speech and language therapy service for remediation of their difficulties. A further 2-3 year project is now planned. This aims to tackle the high levels of speech and language difficulties in children through prevention, early identification and remediation programmes. It also aims to ensure equitable access to the speech and language therapy service for all children.

Semantic pragmatic disorder with application of selected pragmatic concepts

Children with semantic pragmatic disorder have been described as having difficulties in conversational interaction. The content of their conversations has been described as 'odd', 'loose', tangential', 'irrelevant' and 'inappropriate' (Stubbs 1986). A diagnosis of semantic pragmatic disorder is currently made based on whether or not a child displays certain surface characteristics. The present study attempts to apply precision to the intuitive terms which have been used to describe these children's conversations. To this end conversation samples from three children identified by speech and language therapists as fitting the clinical diagnosis of semantic pragmatic disorder were analysed. Aspects of pragmatic theory which best explained the strengths and weaknesses which emerged in the conversations are discussed. Therefore this represents an essentially data driven study.

A randomized comparison of intravenous amrinone versus dobutamine in older patients with decompensated congestive heart failure

OBJECTIVE

To compare the hemodynamic effects of amrinone and dobutamine in patients 75 years of age or older who have severe congestive heart failure requiring invasive hemodynamic monitoring and inotropic support.

DESIGN

Prospective, randomized, double-blind clinical trial.

SETTING

Coronary care unit of a university teaching hospital.

PARTICIPANTS

Fourteen patients > or = 75 years of age (mean 80.3 +/- 5.7 years) with refractory New York Heart Association class IV congestive heart failure. All patients had a cardiac index < 2.5 L/min/M2 (mean 1.8 +/- 0.3 L/min/M2), pulmonary capillary wedge pressure > or = 18 mm Hg (mean 26 +/- 10 mm Hg), and left ventricular ejection fraction < 40% (mean 26 +/- 10%).

INTERVENTION

Patients were randomly assigned to treatment with 2-hour infusions of amrinone (n = 7) or dobutamine (n = 7) at fixed dosages of 5 and 10 micrograms/kg/min.

MEASUREMENTS

Complete hemodynamic data were obtained at baseline and after each 2-hour medication infusion. Transthoracic two-dimensional echocardiography was performed at baseline and after the 10 micrograms/kg/min medication dose. The primary analysis compared the effects of the two drugs on cardiac index and stroke volume index at each of the two dosages.

RESULTS

Both amrinone and dobutamine had salutary hemodynamic effects, as indicated by improvements in cardiac index, stroke volume index, pulmonary capillary wedge pressure, and systemic vascular resistance (all P < .05 except effect of amrinone on stroke index and wedge pressure). Although the overall hemodynamic effects of amrinone and dobutamine were similar, stroke volume index was higher with dobutamine at the 10 micrograms/kg/min dose (35 +/- 7 ml/M2 vs 26 +/- 6 mL/M2; P = .045). Two dobutamine patients were withdrawn from the study after the 5 micrograms/kg/min dose due to adverse effects (tachycardia, increased ventricular ectopy). One additional patient in each group was noted to have ventricular arrhythmias not requiring termination of the protocol.

CONCLUSIONS

Both amrinone and dobutamine are efficacious in improving hemodynamics in older patients with severe congestive heart failure caused by left ventricular contractile dysfunction. Despite the effect of aging on beta-adrenergic responsiveness, dobutamine is at least as effective as amrinone but may be associated with a higher incidence of arrhythmic side effects.

Anosognosia in Alzheimer's disease: relationships to depression, cognitive function, and cerebral perfusion

Awareness of memory loss was rated in 57 patients with clinically diagnosed Alzheimer's disease, and analyzed in relation to neuropsychological tests and presence of depression. Single photon emission computed tomography measures of regional cerebral blood flow were obtained on an unselected subsample of 20. Anosognosia was associated with diminished relative right dorsolateral frontal lobe perfusion and with high rates of false positive errors on recognition memory testing. Less aware patients did not differ from others on learning or recall scores, or on dementia severity as measured by mental status scores. Neither anosognosia nor depression was associated with disease duration or dementia severity and patients who were aware of their memory loss were no more likely than others to be depressed. This is further evidence that dementia severity alone does not account for anosognosia in Alzheimer's disease; frontal lobe involvement and the presence of specific memory impairments may be important determining factors.

Distribution and projection pattern of motoneurons that innervate hindlimb muscles in the quail

We characterized the motoneuron pool positions and projection patterns in the embryonic quail hindlimb and compared them to those in the chick to determine the degree of similarity and to form a baseline for future chimeric experiments. We find that the most similar parameters of pool position correlate with the major axonal pathway choices. First, the medial-lateral pool position, which is highly conserved among birds and mammals, is identical in the quail and chick and correlates with the dorsal-ventral pathway choice, the first and least plastic of the choices within the limb. Second, although quail pools were known to be compressed into seven rather than eight segments, we show that the map of pools is compressed about a central point (segment three) that preserves the spatial relationships between anterior pools and the crural plexus, and between posterior pools and the sciatic plexus. Access to guidance cues that are restricted to each plexus region is thus maintained between species. Third, pool position along the anterior-posterior axis is the least similar parameter between species. In fact, the entire lumbosacral motor complex may shift by +/- half a segment in individual quail. Despite the consequent differences in segmental projections, the specific projection pattern within each quail hindlimb is identical to that in the chick. There is no need to preserve the exact segmental pattern either phylogenetically or during development, because motoneurons accommodate to modest variations in their position along the anterior-posterior axis by sorting out at the limb base. The contrast between variable segmental and constant limb projections also demonstrates that neither the specification nor the precise projection of motoneurons is dependent upon the specification or development of somites.