The cartilaginous Eustachian tube: Reliable CT measurement and impact of the length

Purpose

Balloon dilation of the Eustachian tube is a treatment option for obstructive Eustachian tube dysfunction. The desired balloon position is in the cartilaginous portion. However, the balloon catheter may slide into the bony portion without the surgeon's knowledge. Knowing the length of the cartilaginous portion may improve catheter positioning, but there is no published research on measuring this portion selectively or on whether the length has an impact on development of disease or treatment outcome.To evaluate whether a measurement obtained from CT images is valuable and accurate, to standardize the manner of which the length is measured, and to compare our radiologic measurements to procedural findings, we designed a combined study. Further, we tested the length's influence on development of disease and treatment outcome.

Evaluation of HPV type‐replacement in unvaccinated and vaccinated adolescent females—Post‐hoc analysis of a community‐randomized clinical trial (II)

Efficacy of human papillomavirus (HPV) vaccines promises to control HPV infections. However, HPV vaccination programs may lay bare an ecological niche for non‐vaccine HPV types. We evaluated type‐replacement by HPV type and vaccination strategy in a community‐randomized trial executed in HPV vaccination naïve population. Thirty‐three communities were randomized to gender‐neutral vaccination with AS04‐adjuvanted HPV16/18 vaccine (Arm A), HPV vaccination of girls and hepatitis B‐virus (HBV) vaccination of boys (Arm B) and gender‐neutral HBV vaccination (Arm C). Resident 1992‐95 born boys (40,852) and girls (39,420) were invited. 11,662 boys and 20,513 girls were vaccinated with 20–30% and 45–48% coverage, respectively. HPV typing of 11,396 cervicovaginal samples was performed by high throughput PCR. Prevalence ratios (PR) between arms and ranked order of HPV types and odds ratio (OR) for having multiple HPV types in HPV16 or 18/45 positive individuals were calculated. The ranked order of HPV types did not significantly differ between arms or birth cohorts. For the non‐HPV vaccinated 1992–1993 birth cohorts increased PR, between the gender‐neutral intervention versus control arms for HPV39 (PR_A 1.84, 95% CI 1.12–3.02) and HPV51 (PR_A 1.56, 95% CI 1.11–2.19) were observed. In the gender‐neutral arm, increased clustering between HPV39 and the vaccine‐covered HPV types 16 or 18/45 (OR_A16 = 5.1, OR_A18/45 = 11.4) was observed in the non‐HPV vaccinated 1994–1995 birth cohorts. Comparable clustering was seen between HPV51 and HPV16 or HPV18/45 (OR_B16 = 4.7, OR_B18/45 = 4.3), in the girls‐only arm. In conclusion, definitively consistent postvaccination patterns of HPV type‐replacement were not observed. Future occurrence of HPV39 and HPV51 warrant investigation.     

Hormone-resistant prostate cancer with symptomatic pelvic tumours: patient survival and prognostic factors

OBJECTIVES: To determine the survival and investigate the prognostic significance of immunohistochemical variables and clinical factors in patients with hormone-resistant prostate cancer (HRPC) and symptomatic pelvic tumours, in whom preliminary observations indicated that survival exceeded the median 8-10 months of patients with HRPC and painful bone metastases. PATIENTS AND METHODS: Seventy-five patients with HRPC referred for palliative pelvic radiotherapy between 1980 and 1996 were identified. For all patients at least two prostate biopsies had been obtained, one before primary hormone treatment and at least one after clinical progression despite androgen deprivation (HRPC biopsy). Bone scans at the time of referral were assessed. The medical records were reviewed for clinical variables of possible prognostic significance. Histological grade was recorded, and prostate-specific antigen (PSA), androgen receptors (ARs), Ki-67 and p53 determined immunohistochemically. In 18 HRPC specimens the degree of AR amplification was analysed. RESULTS: Positive staining for ARs was high in the HRPC biopsies, although there was no association with AR amplification. Ki-67 positivity increased after the development of HRPC. The median (range) survival was 14 (1-141) months; age < 65 years was associated with increased survival. In a multivariate analysis the following variables remained independent prognostic factors for survival from the time of the HRPC biopsy: bone metastases (0-10 vs > 10 lesions, P < 0.001), low Ki-67 score (0 vs 1-3, P = 0.006) and low p53 positivity score (0 vs 1-3, P = 0.014) in the HRPC biopsy. CONCLUSIONS: The median survival of patients with HRPC and pelvic tumours requiring palliation seems to exceed that of patients with HRPC and dominating painful bone metastases by at least 4-6 months. Simple clinical (bone metastases) and immunohistochemical variables (Ki-67, p53) enable patients with particularly long survival times to be identified, and in whom palliative treatment needs to be improved.     

Discovery Elbow System: clinical and radiological results after 2- to 10-year follow-up

Background

Discovery Elbow System (DES) is a semi-constrained prosthesis, mainly used for patients with rheumatoid arthritis (RA).

Methods

Records from 79 patients with RA (90 DES arthroplasties) were reviewed; 47 patients with 55 DES elbows were re-examined. Range of motion (ROM) of both elbows, upper limb function, and quality of life (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Elbow Performance Score [MEPS], and the RAND 36-Item Health Survey [RAND-36]) were assessed. Cementing quality was assessed, and radiolucent lines measured from plain radiographs. Mean follow-up was 64 (range 24–123) months.

Results

Pre-operatively to post-operatively, mean elbow flexion improved from 120° to 146° (p < 0.001) and mean extension lag improved from 29° to 24° (p = 0.02), respectively. At follow-up, mean supination was 66°, mean pronation was 69°, and mean grip strength was 14 kg. Grip strength and ROM (except supination) were similar between the DES elbow and contralateral un-operated elbow. Mean post-operative MEPS was 93 points (excellent, n = 38; good, n = 14; fair, n = 2; and poor, n = 1). Mean DASH score was 43 points. The RAND-36 showed that physical functioning, physical role functioning, bodily pain, and general health were lower than the Finnish reference values. Primary cementing was challenging, and radiolucent lines appeared during follow-up. Four prostheses were revised because of aseptic loosening (n = 3) and periprosthetic fracture (n = 1).

Conclusion

DES provides significant improvement in patient’s flexion–extension arc. Cementing of the elbow prosthesis was challenging; radiolucent lines appeared during the 5-year follow-up, but their clinical relevance remains unclear. First-generation locking screws may loosen over time.

Level of evidence

Level IV.

     

Early working alliance in outpatient substance abuse treatment: Predicting substance use frequency and client satisfaction

Background: The study examined the effect of the early working alliance on outcome in outpatient substance abuse treatment. Methods: A total of 327 clients and 33 therapists participated in the study. Data were collected in southern and western Finland in outpatient treatment units (N = 7). The dependent variables were percentage of days abstinent and client satisfaction at six‐month follow‐up. The independent variables were both client and therapist alliance ratings of the first and third sessions. The client's percentage of days abstinent for the month preceding treatment was used as a covariate. Intra‐class correlation was used to measure between‐therapist variation. Results: The main finding was that there was considerable between‐therapist variation in both the frequency of clients’ substance use and client satisfaction at follow‐up. The client's earlier substance use frequency was a significant predictor of the substance use frequency at follow‐up. Client satisfaction was significantly predicted by the client's rating of the early alliance. Conclusions: More research on therapists is needed because between‐therapist differences seem to be associated with patient outcomes over differences within therapists. While the study confirmed that good early working alliance improves outcome during treatment without being linked to post‐treatment recovery, more research is needed also in that area.     

Determinants of Changes in Bone Density: A 5-Year Follow-Up Study of Adult Male Monozygotic Twins

The relative importance of determinants in bone mineral density (BMD) in adult men is partly unclear. Our goals were to investigate the effects of familial aggregation and behavioral factors on the change in BMD during a 5-yr follow-up. Subjects (n = 140) were 70 exposure-discordant monozygotic twin pairs (age 35–69 yr). BMD was measured with the same dual-energy X-ray absorptiometry scanner at baseline and at the 5-yr follow-up. A variety of covariates were used including physical examination and interview data. Multivariate linear regression was used. The mean annual decrease in femoral BMD was 0.2%. The mean lumbar BMD was unchanged, although 8–17% of subjects had a decrease of more than 5%. Familial aggregation explained 14% of the changes in femoral BMD and 19% in lumbar BMD. The stability of BMD in the follow-up was high, both for individuals (intraclass correlation coefficient [ICC] = 0.90–0.94) and for co-twins in a pair (ICC = 0.77–0.84). In femoral BMD, use of alcohol (p = 0.006), coffee (p = 0.046), and beta-blockers (p = 0.043) led to increases, whereas smoking led to a decrease (p < 0.01). We concluded that frequent increases in BMD, influenced by beta-blockers, partly explain the minor mean changes during follow-up; however, about every 10th subject had a significant decrease. Overall, familial effects played a dominant role in BMD changes in adult men.     

Major histopathological patterns of lung cancer related to arsenic exposure in German uranium miners

Objective  The mechanisms of action of arsenic in the development of lung cancer are still not yet elucidated. Considering the relationship between arsenic and squamous cell carcinomas of the skin, we hypothesized that arsenic exposure may be more closely associated with squamous cell carcinoma of the lung. Methods  A comprehensive histopathological database and a detailed job-exposure matrix developed for former German uranium miners with exposure to arsenic, radon, and quartz were analyzed to quantitatively assess the effect of arsenic regarding cell type of lung cancer. The distributions of major lung cancer cell types in 1,786 German uranium miners were associated with levels of arsenic exposure under control for the other lung carcinogens. To evaluate the arsenic effects in association with a frequent occupational lung disease in miners stratification by silicosis was performed. Results  There was an arsenic-related increase of the proportion of squamous cell carcinoma of the lung but restricted to miners without silicosis. The increase was found at all levels of co-exposure to radon and quartz dust. In miners with silicosis, the proportion of adenocarcinoma increased with rising arsenic exposure. Arsenic exposure was associated with non-small cell lung cancer. Silicosis turned out as major determinant of the cell type related with arsenic. Conclusion  These results indicate a cell type characteristic effect of arsenic in the development of lung cancer.     

Length of paternal lifespan is manifested in the DNA methylome of their nonagenarian progeny

The heritability of lifespan is 20-30%, but only a few genes associated with longevity have been identified. To explain this discrepancy, the inheritance of epigenetic features, such as DNA methylation, have been proposed to contribute to the heritability of lifespan.We investigated whether parental lifespan is associated with DNA methylation profile in nonagenarians. A regression model, adjusted for differences in blood cell proportions, identified 659 CpG sites where the level of methylation was associated with paternal lifespan. However, no association was observed between maternal lifespan and DNA methylation. The 659 CpG sites associated with paternal lifespan were enriched outside of CpG islands and were located in genes associated with development and morphogenesis, as well as cell signaling. The largest difference in the level of methylation between the progeny of the shortest-lived and longest-lived fathers was identified for CpG sites mapping to CXXC5. In addition, the level of methylation in three Notch-genes (NOTCH1, NOTCH3 and NOTCH4) was also associated with paternal lifespan.There are implications for the inheritance of acquired traits via epigenetic mechanisms in mammals. Here we describe DNA methylation features that are associated with paternal lifespan, and we speculate that the identified CpG sites may represent intergenerational epigenetic inheritance.