Olfactory Neuroblastoma and Neuroendocrine Carcinoma of the Anterior Skull Base: Treatment Results at the M.D. Anderson Cancer Center

Updated information on the pathologic characterization and treatment of olfactory neurobiastoma (ON) and neuroendocrine carcinoma (NEC) diseases is presented. A series of patients with ON or NEC was evaluated and retrospectively staged using the UCLA system. The parameters evaluated were symptoms, age, sex, risk factor assessment, stage of disease, treatment, and clinical outcome. The median follow-up was 3 years (range, 18 months to 23 years). The predominant therapy (63%) for ON was combined surgery and radiotherapy. Surgery alone or in combination with ancillary treatment was used in 58% of patients with NEC. For the most receat years of the study, patients with NEC have been treated successfully with combined chemotherapy and radiotherapy. Seventy percent of the patients with ON and 75% of the patients with NEC were clinically free of disease during the defined follow-up period. Surgical therapy consisting of a craniofacial resection combined with postoperative radiotherapy has resulted in good local and long-term control of ON. Our experience indicates that combined chemoradiation is an appropriate therapeutic approach for NEC.     

Intrauterine growth restriction (IUGR) is associated with increased leptin synthesis and binding capability in neonates

Objective Animal studies suggest pathological foetal programming of hypothalamic circuits regulating food intake in the setting of leptin deficiency and intrauterine growth restriction (IUGR). We aimed to compare placental leptin synthesis and leptin‐binding capability in venous cord blood between IUGR newborns and neonates born appropriate for gestational age (AGA). Design Prospective controlled multicentre study. Patients Twenty‐one ultrasound‐proven IUGR and 33 AGA neonates. Measurements The concentration of leptin and soluble leptin receptor (sOB‐R) in venous cord blood at birth was determined. Moreover, placental gene and protein expression of leptin and placental mRNA expression of functional and total leptin receptor isoforms were measured. Results Whereas log‐leptin concentration in venous cord blood did not differ between IUGR and AGA newborns, the concentration of log‐sOB‐R was elevated in IUGR neonates (p^{confounder adjusted} = 0·009). Placental leptin protein synthesis as well as leptin mRNA was significantly higher in IUGR than in AGA infants (log‐transformed, relative gene expression, p^{confounder adjusted} = 0·004). Analysis of gene expression of functional and total leptin receptor isoforms did not show any difference between both groups. Conclusions Leptin‐binding capability in venous cord blood is increased in IUGR newborns. Thus, via foetal programming, reduced biologically active leptin levels might contribute to a perturbed regulation of appetite.     

Psychische Veränderungen bei Patienten mit komplexem regionalem Schmerzsyndrom (CRPS)

Question

Do comorbid psychological disorders, dysfunctional pain processing, and psychosocial pain coping occur with complex regional pain syndrome (CRPS) and is a connection between clinical and psychological manifestations apparent?

Methods

In addition to securing information on case histories and performing clinical neurological examinations of chronic CRPS patients, the structured clinical interview (SCID), pain perception scale, and the Kiel Pain Inventory were employed.

Results

The structured clinical interview revealed evidence of a depressive episode in 65% of CRPS patients. Pain perception is similar to neuropathic pain syndromes and patient history revealed a slightly increased frequency of anxiety and affective disorders. Depressive syndrome occurred significantly more often in right-sided CRPS; otherwise, there were no significant correlations between medical history, clinical examination, and frequency of psychological disorders. However, CRPS patients with allodynia manifest clinical signs of special psychological distress.

Conclusion

In chronic CRPS depressive syndrome frequently develops and psychological treatment can be recommended.     

WHO stufe II—Klinische Realität oder didaktisches Instrument?

INTRODUCTION: In 1986 the World Health Organisation (WHO) proposed an analgesic ladder for the effective therapy of cancer pain. The three standard analgesics making up this ladder are aspirin (non-opioid), codeine (weak opioid) and morphine (strong opioid). Adjuvant drugs may be added at any level. However, before 1986 step II analgesics (weak opioids) had never been tested in cancer pain relief. METHODS: This report presents a computer-assisted Medline (US National Library of Medicine) literature search restricted to the years 1986-1994, which was conducted to test the validity of the WHO guidelines, and in particular that of step II. RESULTS: We found seven retrospective studies and one prospective study on cancer pain treatment according to the proposed WHO guidelines that had been published since 1986. Every publication decribed the use of all three steps of the analgesic ladder. We found no prospective controlled trials demonstrating the efficacy and safety of WHO step II in particular. DISCUSSION: The use of the WHO guidelines "by mouth, by the clock and by the ladder" is now the mainstay of cancer pain management. Because of the guidelines' simplicity they found general acceptance and helped to establish an international pain therapy standard for worldwide use. Nevertheless, there is no scientific validation of WHO step II. In the absence of prospective controlled randomized trials additional longterm results are necessary. We need more data on the use of WHO step II and an update of the published guidelines taking account of modern sustained-release drugs. Up to now, step II of the WHO guidelines for cancer pain is not a clinical reality but at best a didactic instrument.     

Chronischer Schmerz im ärztlichen Alltag

Acute or chronic pain are the most frequent reasons to seek medical help. Primarily acute pain is a symptom and warning sign. However, insufficient treatment of acute pain may induce a change to a chronic long lasting pain illness. Therefore a consequent immediate treatment is essential. Chronic pain is a bio-psycho-social illness. In this situation pharmacotherapy or any other monotherapy alone is no longer effective. Interdisciplinary treatment is needed. Effective treatment of acute pain to prevent from long lasting pain episodes is an essential and the only way to prevent from enormous financial consequences of chronic pain.     

Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial

The objective of the study was to evaluate the effectiveness of chlorhexidine-impregnated sponges for reducing catheter-related infections of central venous catheters inserted for cancer chemotherapy. The method used was a randomized, prospective, open, controlled clinical study (three-step group sequential analysis protocol). The patients were from two high dependency units at a university hospital undergoing chemotherapy for haematological or oncological malignancies requiring central venous catheters (CVCs) expected to remain in place for at least 5 days. Six hundred and one patients with 9,731 catheterization days were studied between January 2004 and January 2006. Patients admitted for chemotherapy received chlorhexidine and silver sulfadiazine-impregnated triple-lumen CVCs under standardized conditions and were randomized to the groups receiving a chlorhexidine gluconate-impregnated wound dressing or a standard sterile dressing. Daily routine included clinical assessment of the insertion site (swelling, pain, redness), temperature, white blood count and C-reactive protein. Catheters remained in place until they were no longer needed or when a CVC-related infection was suspected. Infection was confirmed with blood cultures via the catheter lumina and peripheral blood cultures according to the time-to-positivity method. Six hundred and one patients were included. The groups were comparable with respect to demographic and clinical data. The incidence of CVC-related infections were 11.3% (34 of 301) and 6.3% (19 of 300) in the control and chlorhexidine-impregnated wound dressing groups, respectively (p = 0.016, relative risk 0.54; confidence interval 0.31–0.94). Especially, catheter-related infections at internal jugular vein insertions could be reduced (p = 0.018). No adverse effects related to the intervention were observed. The use of chlorhexidine-impregnated wound dressings significantly reduced the incidence of CVC-related infections in patients receiving chemotherapy.     

Tick-borne encephalitis in a 3-month-old child

Tick-borne encephalitis has not been reported in infants younger than 12 months of age. We report a 3.5-month-old child with a serologically proven tick-borne encephalitis. The infant had a history of a tick bite 3.5 weeks before the first symptoms of encephalitis appeared. The family lives in an endemic area of the disease. There were no prodromal signs and the course of the disease was monophasic. In an endemic area, prophylactic treatment with hyperimmunoglobulin after a tick bite should be considered even in very young infants, but in most children active immunization is probably not necessary because of infrequent exposure. Acitve immunization is still recommended after the 1st year of life.