Reduction of occult metastatic disease by extension of the supraomohyoid neck dissection to include level IV

BACKGROUND: Patients with clinically N0 necks will undergo elective removal of lymphatic tissue from levels I, II, and III as part of their routine surgical management. Level IV is omitted on the basis that there is negligible chance of containing significant occult disease. Evidence to support this approach is minimal, and the aim of this study was to increase the yield of metastatically involved lymph nodes by simply extending the supraomohyoid neck dissection (SOHND) to include level IV. METHODS: The records of 49 patients with cancer of the oral cavity undergoing extended supraomohyoid neck dissection (ESOHND) during the period January 1996-March 1999 were reviewed. All patients were staged as having N0 disease. The follow-up period ranged from 12 to 36 months. RESULTS: Thirteen of 55 N0 stage necks showed occult metastasis (26.5%). Neck failure rate occurred in 4 of 49 patients (8.2%). Neck failure rate in the pN0 group was 5.4% and in the pN+ group was 16.6%. Complication rates of ESOHND were noted as 3.6%. No long-term morbidity arose. Occult metastasis in level IV occurred in 5 of 49 cases (10%). Two cases involved other surgical levels. CONCLUSIONS: ESOHND as performed in this study removed occult level IV metastatic regional disease from an extra 10% of patients that, if the patients had undergone SOHND, would have remained undiscovered. No long-term morbidity is associated with this procedure that the authors now recommend as a first-line treatment in all patients with N0 necks.     

Topical ciprofloxacin/dexamethasone is superior to ciprofloxacin alone in pediatric patients with acute otitis media and otorrhea through tympanostomy tubes

OBJECTIVE: To determine whether topical administration of a corticosteroid improves resolution of acute tympanostomy tube otorrhea when combined with topical antibiotic drops. STUDY DESIGN: Randomized, patient-masked, parallel-group, multicenter trial of topical otic ciprofloxacin/dexamethasone versus topical ciprofloxacin alone in 201 children aged 6 months to 12 years with acute otitis media with tympanostomy tubes (AOMT) of less than or equal to 3 weeks' duration and visible otorrhea. METHODS: Eligible patients were randomized to receive three drops of either ciprofloxacin 0.3%/dexamethasone 0.1% or ciprofloxacin 0.3% into the affected ear or ears twice daily for 7 days. Clinical signs and symptoms of AOMT were evaluated on days 1 (baseline), 3, 8 (end-of-therapy), and 14 (test-of-cure), and twice-daily assessments of otorrhea were recorded in patient diaries. RESULTS: The mean time to cessation of otorrhea in the microbiologically culture-positive patient population (n = 167) was significantly shorter with topical ciprofloxacin/dexamethasone than with ciprofloxacin alone (4.22 vs. 5.31 days; P =.004). This resulted in significantly better clinical responses on days 3 and 8 (P <.0001 and P =.0499, respectively). However, there were no significant differences between the two treatment groups in either the clinical response or the microbial eradication rate by day 14. CONCLUSIONS: Topical otic treatment with ciprofloxacin/dexamethasone is superior to treatment with ciprofloxacin alone and results in a faster clinical resolution in children with AOMT. The contribution of the corticosteroid in achieving a 20% reduction (1.1 day) in time to cessation of otorrhea is clinically meaningful and represents an important advance over single-agent antibiotic therapy.     

A requiem for whole brain death: a response to D. Alan Shewmon's 'the brain and somatic integration'

Alan Shewmon's article, 'The brain and somatic integration: Insights into the standard biological rationale for equating "brain death" with death' (2001), strikes at the heart of the standard justification for whole brain death criteria. The standard justification, which I call the 'standard paradigm', holds that the permanent loss of the functions of the entire brain marks the end of the integrative unity of the body. In my response to Shewmon's article, I first offer a brief summary of the standard paradigm and cite recent work by advocates of whole brain criteria who tenaciously cling to the standard paradigm despite increasing evidence showing that it has significant weaknesses. Second, I address Shewmon's case against the standard paradigm, arguing that he is successful in showing that whole brain dead patients have integrated organic unity. Finally, I discuss some minor problems with Shewmon's article, along with suggestions for further elaboration.     

Effect of combination therapy on immunologic progression of human immunodeficiency virus at a population level

There is accumulating evidence from clinical trials and cohort studies that highly active antiretroviral combination therapy is effective at halting immunologic and clinical progression of human immunodeficiency virus (HIV). Its impact at a population level is less well known because the regimes may be difficult to tolerate and compliance poorer. The authors make use of population data for almost all of the HIV-infected people in Scotland in 1997 who were under clinical care and monitor their response to therapy during the first year when these effective treatments became widely available. More than two thirds of the HIV-positive patients were on some form of antiretroviral therapy during the year. The authors show that all treated groups, even those who were on changing regimes, showed net improvement in immunologic status during the year. For the group of patients on triple or quadruple therapy, there was an average increase of more than 100 CD4 cells/mm(3) over the year, with other treatment groups showing more modest, but significant, increases.     

Lack of mental well-being in 15-year-olds: an undisclosed iceberg?

BACKGROUND: Young people suffer from psychiatric symptoms and illness, and the frequency of both may be higher than currently is recognized. The frequency with which young people consult GPs with emotional problems is not established. OBJECTIVE: The purpose of this study was to identify the number of 15-year-olds who consult their GP directly or indirectly with psychiatric symptoms or illness. METHODS: A two part survey was carried out involving (i) general practice casenote review; and (ii) questionnaires self-report. The subjects comprised all adolescents aged 15 years from 34 randomly selected general practices and a randomly selected subsample of these adolescents. The main outcome measures were a purpose-designed data collection sheet, General Health Questionnaire (GHQ-12) and a purpose-designed self-report questionnaire. RESULTS: In phase 1, the general practice casenotes of 2359 adolescents were examined. Five per cent of subjects were identified as attending the GP with mental health problems; 1% had attempted suicide during the year. In phase 2, 99 subjects returned completed self-report questionnaires. Although over a quarter (26%) were rated as GHQ-12 'cases' and approximately half reported having felt 'sad, unhappy or low' or 'anxious or worried' in the previous year, only one subject reported attending his/her GP with any of these concerns. CONCLUSIONS: Fifteen-year-olds rarely consult their GP about their emotional well-being, yet, with the GHQ-12, the self-reported rate of psychiatric morbidity was nearly seven times greater than that suggested by these same subjects' medical records. Although the majority of adolescents consult their GP throughout the course of a year, those with mental health problems, including those who attempt suicide, are indistinguishable in the frequency of their GP consultations from adolescents without mental health problems.     

Performance of dual-microphone in-the-ear hearing aids

Fifty subjects with mild to moderate-severe sensorineural hearing loss and prior experience with binaural amplification were evaluated at two sites (25 subjects at each site). Signal-to-noise ratios (SNRs) were measured using the Hearing in Noise Test (HINT) after each subject wore binaural in-the-ear hearing aids programmed for omnidirectional and dual-microphone performance, for 4 weeks. Both microphone conditions were evaluated under "ideal" (signal at 0 degrees; noise at 180 degrees) and "diffuse" (signal at 0 degrees; correlated noise at 45 , 135 degrees, 225 degrees, and 315 degrees) listening conditions. Results revealed statistically significant mean improvements in SNRs between 3.7 and 3.5 dB at Site I and 3.2 and 2.7 dB at Site II for the ideal and diffuse listening conditions, respectively, for the dual-microphones in comparison to the performance provided by the omnidirectional microphone.     

The GlucoWatch biographer: a frequent automatic and noninvasive glucose monitor

The GlucoWatch (Cygnus, Inc, Redwood City, CA, USA) biographer provides automatic, frequent and noninvasive blood glucose measurements for up to 12 h. The device extracts glucose through intact skin where it is measured by an amperometric biosensor. Clinical trials in a variety of environments have shown that the biographer provides accurate and precise glucose measurements when compared with serial fingerstick blood glucose measurements. Mean difference between these measurements was 0.26 mmol/L in the home environment (r = 0.80). Over 94% of biographer readings were in the clinically acceptable A+B region of the Clarke Error Grid. A slight positive bias is observed for the biographer readings at low glucose levels. Biographer precision, as measured by coefficient of variation (CV)%, is approximately 10%. The low glucose alert function of the biographer was able to detect up to 75% of hypoglycaemic episodes with a low false alert level. Skin irritation, characterized by erythema and oedema was either nonexistent or mild in over 87% of subjects and resolved in virtually all subjects without treatment in several days. The GlucoWatch biographer has been shown to be a safe and effective method to track glucose level trends and patterns, which should enable improved glycaemic control for many patients.     

Ceiling fan injuries: the Townsville experience

From 1 April 1995 to 31 March 1997, 50 people presented to Townsville General Hospital with injuries caused by ceiling fans. Injuries ranged from grazes to compound skull fractures, and seven patients required admission to hospital for ongoing treatment. Most of these injuries could have been avoided. Current safety guidelines for the use of ceiling fans are inadequate.     

Reproducibility and Sources of Variability in Radiographic Texture Analysis of Densitometric Calcaneal Images

Radiographic texture analysis (RTA) is a computerized analysis of the spatial pattern of radiographic images used as a way of evaluating bone structure. We have shown that RTA performed on high-resolution heel images obtained using a portable densitometer differentiates subjects with and without osteoporotic fractures. In the present study, short-term precision of RTA was examined on densitometric heel images obtained from 33 subjects scanned 8 times each, with 3 observers placing a region of interest (ROI) 3 times on each image. The long-term precision was examined on images obtained from 10 subjects 3 times on each of 3 days separated by 1 week, with 2 observers placing an ROI on each image. The RTA features examined included the root mean square (RMS) variation, a measure of the contrast between the light and dark areas of the image, the first moment of the power spectrum, a measure of the spatial frequency of the trabecular pattern, and Minkowski fractal (MINK), a measure of roughness/smoothness of the trabecular pattern. The precision of the RTA features expressed as coefficient of variation ranged between the lowest of 0.5–0.7% for MINK and the highest of 14–16% for RMS. The short- and long-term precision was similar, and was not significantly influenced by repositioning and rescanning, or by ROI placement by the same or different observers. Significant sources of variability of RTA were the between-subject differences and differences between regions of the heel, but not differences due to repositioning, rescanning in the same position, or ROI placement by the same or different observers. We conclude that technical aspects of image acquisition and processing are adequate to allow further development of RTA of the densitometric images for clinical application as a method for noninvasive assessment of bone structure.     

Guidelines for Evaluating the Educational Performance of Medical School Faculty: Priming a National Conversation

Background: The academic community needs a sound framework for the promotion and advancement of educators. The Group on Educational Affairs of the Association of American Medical Colleges organized a consensus conference that affirmed the use of five domains for documenting the quantity and quality of scholarly engagement in educational activities: teaching, curriculum, advising/mentoring, educational leadership/administration, and learner assessment. Summary: In this article, we offer detailed guidelines to evaluate these five domains of educator performance and the essential elements of scholarly activity. The guidelines are adapted from our developmental educator portfolio template and educator portfolio analysis tool, previously published in MedEdPORTAL. A short tool for educator performance evaluation that summarizes items in the guidelines is proposed for discussion. Conclusions: Our goal in this article is to itemize criteria for systematic faculty evaluation that can be applied in any institutional setting to assist promotion decision makers in their task of evaluating medical school faculty.