FDG-PET prediction of head and neck squamous cell cancer outcomes

OBJECTIVE: To confirm that high pretreatment uptake of 2-deoxy-2[(18)F]fluoro-d-glucose (FDG) detected by positron emission tomography (PET) measured at the primary head and neck squamous cell carcinoma (HNSCC) and at metastatic nodal disease predicts poor outcomes for HNSCC. DESIGN AND PATIENTS: We enrolled 63 consecutive patients with a histological diagnosis of HNSCC (including tumors of the oral cavity, oropharynx, larynx, and hypopharynx) from September 2000 through June 2003, into a prospective institutional imaging trial. Fifty-four patients (86%) underwent a baseline FDG-PET scan before curative treatment and were eligible for analysis. RESULTS: A primary tumor standardized uptake value (SUV) of greater than 9.0 predicted inferior local recurrence-free survival (P = .02) and disease-free survival (P = .03). Nodal SUV dichotomized according to the cohort median of 6.1 did not predict for either disease outcome (P = .71 and P = .98, respectively). On proportional hazards analysis, local recurrence and disease event hazard ratios for a primary tumor SUV of 9.0 or greater remained significant or at borderline significance when adjusted for nodal SUV or other clinical covariates. CONCLUSIONS: Our findings support an association between baseline primary tumor FDG SUV and HNSCC outcomes. In contrast, nodal FDG SUV was not predictive. Primary tumor FDG SUV is a promising prognostic factor and may establish the need for intensified locoregional therapy in individual patients. Multi-institutional imaging trials and further characterization of the biology responsible for elevated FDG uptake in HNSCC will be necessary to confirm the prognostic utility of FDG-labeled PET.     

Development and validation of the effectiveness of [corrected] auditory rehabilitation scale

OBJECTIVE: To develop a new scale of hearing-related function and quality of life in patients with hearing aids that addresses overlooked concerns, such as hearing-aid comfort, convenience, and cosmetic appearance, that may influence hearing-aid adherence while maintaining brevity and sensitivity to clinical change. DESIGN: Prospective, multicenter instrument validation. SETTING: Four diverse sites in Washington State, including 2 private practices, 1 university setting, and 1 Veterans Affairs hospital. PATIENTS: Seventy-eight patients with hearing aids. INTERVENTIONS: We created 2 modules in the Effectiveness of Auditory Rehabilitation (EAR) scale. The first module (Inner EAR) covers intrinsic hearing issues such as hearing in quiet and hearing in noise and is administered both before and after treatment. The second module (Outer EAR) covers extrinsic (hearing-aid related) issues such as comfort, appearance, and convenience and is administered after hearing-aid fitting. MAIN OUTCOME MEASURES: Both scales were developed and validated in 3 stages. Stage 1 used a qualitative approach from multiple data sources to develop preliminary instruments. Stage 2 used approaches from classic test theory to reduce the number of items and psychometrically validate the instruments. Stage 3 examined the responsiveness or sensitivity to clinical change. RESULTS: A 10-item Inner EAR module and a 10-item Outer EAR module were created and validated. Internal consistency of individual domains (Cronbach alpha = 0.85 and 0.72, respectively) and test-retest reliability (intraclass correlation coefficients = 0.76 and 0.81, respectively) were excellent. Evidence of construct validity included concurrent validity with other hearing scales and global visual analog scales, discriminant validity with dizziness handicap, correlation with hearing-aid adherence, and confirmatory factor analyses. Both scales had strong evidence of responsiveness (sensitivity to change), with higher effect sizes and Guyatt responsiveness statistics than the 2 widely used hearing scales in this study. The scales took an average of 5 minutes to complete. CONCLUSIONS: The EAR scale is a valid and reliable measure of the effectiveness of amplification in the treatment of sensorineural hearing loss. It addresses the range of issues that are of importance to hearing-aid patients. The scales have excellent psychometric properties, are more responsive than several widely used hearing scales, and are minimally burdensome for patients to complete. The EAR may be a valuable outcome measure in future studies of both existing hearing aids and newer hearing-aid technologies, such as bone-anchored aids or middle ear implants.     

Styrene respiratory tract toxicity and mouse lung tumors are mediated by CYP2F-generated metabolites

Mice are particularly sensitive to respiratory tract toxicity following styrene exposure. Inhalation of styrene by mice results in cytotoxicity in terminal bronchioles, followed by increased incidence of bronchioloalveolar tumors, as well as degeneration and atrophy of nasal olfactory epithelium. In rats, no effects on terminal bronchioles are seen, but effects in the nasal olfactory epithelium do occur, although to a lesser degree and from higher exposure concentrations. In addition, cytotoxicity and tumor formation are not related to blood levels of styrene or styrene oxide (SO) as measured in chronic studies. Whole-body metabolism studies have indicated major differences in styrene metabolism between rats and mice. The major differences are 4- to 10-fold more ring-oxidation and phenylacetaldehyde pathways in mice compared to rats. The data indicate that local metabolism of styrene is responsible for cytotoxicity in the respiratory tract. Cytotoxicity is seen in tissues that are high in CYP2F P450 isoforms. These tissues have been demonstrated to produce a high ratio of R-SO compared to S-SO (at least 2.4 : 1). In other rat tissues the ratio is less than 1, while in mouse liver the ratio is about 1.1. Inhibition of CYP2F with 5-phenyl-1-pentyne prevents the styrene-induced cytotoxicity in mouse terminal bronchioles and nasal olfactory epithelium. R-SO has been shown to be more toxic to mouse terminal bronchioles than S-SO. In addition, 4-vinylphenol (ring oxidation of styrene) has been shown to be highly toxic to mouse terminal bronchioles and is also metabolized by CYP2F. In human nasal and lung tissues, styrene metabolism to SO is below the limit of detection in nearly all samples, and the most active sample of lung was approximately 100-fold less active than mouse lung tissue. We conclude that styrene respiratory tract toxicity in mice and rats, including mouse lung tumors, are mediated by CYP2F-generated metabolites. The PBPK model predicts that humans do not generate sufficient levels of these metabolites in the terminal bronchioles to reach a toxic level. Therefore, the postulated mode of action for these effects indicates that respiratory tract effects in rodents are not relevant for human risk assessment.     

Bleeding disorders: A common cause of menorrhagia in adolescents

OBJECTIVE: To determine the frequency of underlying bleeding disorders in adolescents with menorrhagia. STUDY DESIGN: We retrospectively reviewed the charts of all girls, aged 10 to 19 years, who presented to our children's hospital for inpatient or outpatient evaluation of menorrhagia between January 1990 and November 1998. RESULTS: At presentation, 9 of the 71 girls (13%) had thrombocytopenia (platelet count <150,000/microL; range, 5000-106,000/microL). The most common causes for thrombocytopenia were immune thrombocytopenic purpura (n = 5) and myelosuppression caused by chemotherapy (n = 2). Of 14 girls who underwent a more detailed hemostatic evaluation, 8 were given a diagnosis of a hereditary coagulation disorder: 6 had platelet function defects and 2 had type 1 von Willebrand disease. Excessive menstrual bleeding commonly results in anemia. One half of the total group had anemia (hemoglobin <12.0 g/dL). Seven girls (10%) had potentially life-threatening anemia (hemoglobin <5.0 g/dL). CONCLUSIONS: Acquired and congenital bleeding disorders are common causes of menorrhagia in adolescent girls. Severe anemia is a frequent complication of menorrhagia. We recommend that adolescents without thrombocytopenia who present with menorrhagia receive a comprehensive hemostatic evaluation, including testing for von Willebrand disease and platelet function defects.     

Rapid method for the estimation of octanol/water partition coefficient (log P(oct)) from gradient RP-HPLC retention and a hydrogen bond acidity term (zetaalpha(2)(H))

We propose a rapid method for the measurement of octanol/water partition coefficients (log P(oct)) via fast gradient reversed phase retention and the calculation of the hydrogen bond acidity of the compounds. The cycle time of the generic gradient HPLC method is 5 minutes. The general solvation equation obtained for the log Poct values and the fast gradient Chromatographic Hydrophobicity Indices with acetonitrile (CHI(ACN)) and methanol     

Automatic detection of distorted plethysmogram pulses in neonates and paediatric patients using an adaptive-network-based fuzzy inference system

Despite the fact that pulse oximetry has become an essential technology in respiratory monitoring of neonates and paediatric patients, it is still fraught with artefacts causing false alarms resulting from patient or probe movement. As the shape of the plethysmogram has always been considered as a useful visual indicator for determining the reliability of SaO(2) numerical readings, automation of this observation might benefit health care providers at the bedside. We observed that the systolic upstroke time (t(1)), the diastolic time (t(2)) and heart rate (HR) extracted from the plethysmogram pulse constitute features, which can be used for detecting normal and distorted plethysmogram pulses. We developed a technique for classifying plethysmogram pulses into two categories: valid and artefact via implementations of fuzzy inference systems (FIS), which were tuned using an adaptive-network-based fuzzy inference system (ANFIS) and receiver operating characteristics (ROC) curves analysis. Features extracted from a total of 22,497 pulse waveforms obtained from 13 patients were used to systematically optimise the FIS. A further 2843 waveforms obtained from another eight patients were used for testing the system, and visually classified into 1635 (58%) valid and 1208 (42%) distorted segments. For the optimum system, the area under the ROC curve was 0.92. The system was able to classify 1418 (87%) valid segments and 897 (74%) distorted segments correctly. The calculations of the system's performance showed 87% sensitivity, 81% accuracy and 74% specificity. In comparison with the 95% confidence interval (CI) thresholding method, the fuzzy system showed higher specificity (P=0.008,P<0.01), and no significant difference was found between the two methods in terms of sensitivity (P=0.720,P>0.05) and accuracy (P=0.053,P>0.05). We therefore conclude that the algorithm used in this system has some potential in detecting valid and distorted plethysmogram pulse. However, further evaluation is needed using larger patient groups.     

Platelet pheresis is not a useful adjunct to blood-sparing strategies in cardiac surgery

OBJECTIVE: To examine whether specific platelet pheresis (minimal plasma harvested) would contribute toward reduced blood loss and allogenic blood requirements after cardiac surgery. DESIGN: A prospective randomized trial. SETTING: A large cardiothoracic surgical center. PARTICIPANTS: Consenting patients undergoing routine coronary artery or valve surgery (n = 54). INTERVENTIONS: Patients in the pheresis group underwent platelet pheresis in the anesthetic preparation room before general anesthesia. Pheresed platelets were stored during cardiopulmonary bypass and were returned to the patients after reversal of heparin with protamine toward the end of surgery. Control patients underwent their operations without this intervention. MEASUREMENTS AND MAIN RESULTS: Primary endpoints were blood loss and transfusion requirements. There were no differences between the 2 groups (pheresis v control: median loss, 960 mL v 1100 mL, p = 0.15; median blood transfused, 896 mL v 635 mL, p = 0.71). Secondary endpoints included analysis of platelet counts, platelet function, and surface markers. Counts remained the same after retransfusion of platelets up to 2 hours after surgery. Platelet aggregation to ristocetin was well preserved, but adenosine diphosphate caused almost no aggregation of the harvested platelets. Flow cytometry revealed the platelets to have a reduced surface density of the glycoprotein 1b receptor, and 13% of them were irreversibly activated. CONCLUSION: Platelet pheresis activates a proportion of the harvested platelets and impairs the function of the remainder; this may explain its failure to reduce postoperative blood loss and transfusion requirements.