Five-year outcomes of sparing level IB in node-positive, human papillomavirus-associated oropharyngeal carcinoma: A safety and efficacy analysis.

INTRODUCTION: The conformality of modern intensity modulated radiation therapy (IMRT) allows avoidance of the submandibular glands (SMG) in select patients, potentially improving late xerostomia. This study explores the safety and efficacy of this approach in select oropharyngeal carcinoma (OPC) patients. METHODS: Patients with T1-2N+ human papillomavirus (HPV)-associated OPC treated with definitive IMRT at one institution from 2009 to 2014 were identified. Patients were divided into 3 groups: bilateral level IB targeted (A, n = 16), a single level IB targeted (B, n = 61), and bilateral IB spared (C, n = 9). Outcomes were reviewed to identify the rate of level IB regional recurrence. Odds ratios were calculated for xerostomia between groups. RESULTS: Level Ib was targeted in 93 instances (54.1%) and avoided in 79 instances (45.9%). Mean SMG doses were significantly lower when level IB was spared compared to when targeted (37.5 Gy vs 67.5 Gy; P < 0.0001). Median doses to oral cavity decreased with increasing level Ib sparing (40.7 Gy [A] vs 35.4 Gy [B] vs 30.7 [C]; P = 0.002). The rate of late grade ≥2 xerostomia was significantly lower in patients with bilateral 1b sparing (53% in A vs 0% in C; P = 0.007). Sparing 1b unilaterally resulted in a non-significant decrease in late grade ≥2 xerostomia (P = 0.181). No regional failures were identified in levels IB (median follow up = 59.3 months). CONCLUSION: Sparing level IB is safe in T1-2N+ HPV+ OPC. Avoiding level Ib translates into significantly lower SMG and oral cavity doses. Larger studies are needed to validate these findings and the impact of this technique.

Role of adjuvant radiation in the management of central neurocytoma: Experience from a tertiary cancer care center of India.

BACKGROUND AND OBJECTIVE: Neurocytoma (NC) is a rare benign neuronal tumor. A complete excision remains curative for most of these tumors, but atypical histology and extra-ventricular location often necessitates adjuvant therapy. We intended to explore the clinico-pathological features and treatment outcome in patients of NC in our institute. MATERIALS AND METHODS: Medical records were reviewed and data collected on NC over a 6-year period (2006-2012) from the departmental archives. Disease free survival (DFS) was analyzed by Kaplan-Meier method. RESULTS: A total of 18 patients met the study criteria. Fourteen patients had intra-ventricular neurocytoma (IVNC), right lateral ventricle being the most common site of origin. Gross total resection and near total resection were achieved in eight cases each whereas tumor decompression and biopsy could be done in two cases. On post-operative histopathological examination, eight patients were found to have atypical NC while 10 patients had typical NC. All patients underwent adjuvant radiation. The median dose of post-operative radiation was 56 Gy. All patients were alive at their final follow-up. One patient had both clinical and radiological evidence of local relapse. In the evaluable patients (n = 18), after a median follow-up of 35 months the DFS rate at 2 years and 3 years are 100% and 83% respectively. CONCLUSION: Use of adjuvant radiation to a total dose of 56 Gy enhances the local control and achieves superior survival in patients of NC. Use of 3D conformal planning techniques may help us to achieve better therapeutic ratio in patients with NC.

Clinical outcome of patients with primary gliosarcoma treated with concomitant and adjuvant temozolomide: A single institutional analysis of 27 cases.

CONTEXT AND AIM: The prognosis of primary gliosarcoma (PGS) remains dismal with current treatment modalities. We analyzed the outcome of PGS patients treated with concurrent and adjuvant temozolomide (TMZ). SETTINGS AND DESIGN: Retrospective single institutional analysis. MATERIALS AND METHODS: We retrospectively evaluated 27 patients of PGS treated with radiotherapy (RT) and TMZ during 2007-2012. STATISTICAL ANALYSIS USED: Overall survival (OS) was estimated by the use of Kaplan Meier method and toxicities were evaluate using common terminology criteria for adverse events version 2.0 (National Cancer Institute, USA). RESULTS: Median age at presentation and Karnofsky performance status was 45 years and 90 respectively and male: female ratio was 20:7. Patients received adjuvant RT to a total dose of 60 Gy at 2 Gy/fraction. All patients except 5 received adjuvant TMZ to a median number of 6 cycles. Grade 2 and 3 hematological toxicity was seen in 8% and 4% of patients respectively during concurrent RT. During adjuvant chemotherapy, 13.6% had Grade 3 thrombocytopenia and 9.5% had Grade 3 neutropenia. Median OS was 16.7 months (1 year and 2 year actuarial OS was 70.8% and 32.6% respectively). Adjuvant TMZ was associated with a better survival (median survival 21.21 vs. 11.93 months; P = 0.0046) on univariate analysis and also on multivariate analysis (hazard ratio 1.82, 95% confidence interval: 1.503-25.58; P = 0.012). CONCLUSIONS: The results of our study, largest series of patients with PGS treated with concurrent and adjuvant TMZ shows an impressive survival with acceptable toxicity. We suggest TMZ be included in the "standard of care" for this tumor.

Re-irradiation in head and neck cancers: an Indian tertiary cancer centre experience.

OBJECTIVE: To explore the treatment outcomes of patients treated with re-irradiation for recurrent or second primary head and neck cancer. METHOD: An analysis was performed of 79 head and neck cancer patients who underwent re-irradiation for second primaries or recurrent disease from January 1999 to December 2011. RESULTS: Median time from previous radiation to re-irradiation for second primary or recurrence was 53.6 months (range, 2.7-454.7 months). Median age at diagnosis of first primary was 54 years. Median re-irradiation dose was 45 Gy (range, 45-60 Gy). Acute grade 3 or worse toxicity was seen in 30 per cent of patients. Median progression-free survival for recurrent disease was 15.0 months (95 per cent confidence interval, 8.33-21.66). The following factors had a statistically significant, positive impact on progression-free survival: patient age of less than 50 years (median progression-free survival was 29.43, vs 13.9 months for those aged 50 years or older; p = 0.004) and disease-free interval of 2 years or more (median progression-free survival was 51.66, vs 13.9 months for those with less than 2 years disease-free interval). CONCLUSION: Re-irradiation of second primaries or recurrences of head and neck cancers with moderate radiation doses yields acceptable progression-free survival and morbidity rates.

Waiting time care guarantees: necessity or nemesis?

One of the priorities of governments in Canada is to reduce long waiting times for health services. This has raised the prospect of introducing waiting time care guarantees. Such guarantees affirm the healthcare system's social contract with the public and provide an entitlement to Canadians to receive timely care. There are clinical, legal and political implications, which must be considered and well managed before introduction. Other countries have ventured down this path. They teach us that waiting time care guarantees are good policy and make good sense. Correspondingly, they remind us not to make a promise we are not ready to keep.

Water sorption by maxillary acrylic resin denture base and consequent changes in vertical dimension.

Many kinds of materials have been tried in the Laboratory and to some extent clinically prior to introduction of acrylic resin. With the introduction of acrylic resin as denture base material, continuous attempts have been made to evaluate its physical properties. To observe the changes in vertical measurements of acrylic resin dentures due to water sorption and to assess variations of vertical movements of individual teeth within dentures due to water sorption; present study was carried out on 25 maxillary acrylic dentures. From results, the maximum water sorption appears to take place within 24 hours and after 28 day of water sorption; there is no change in vertical dimension if the denture is placed for further more time. With the introduction of acrylic resin as denture base material continued attempts have been made to evaluate physical properties so as to determine its suitability as an ideal nonmetalic denture base materials. Several investigations have been carried out on physical properties of this material such as compressive strength, tensile strength, solubility and colour stability. These have proved their superiority over other nonmetalic denture base materials used so far. Also several studies have been carried out to assess dimensional changes that occur in acrylic resin during processing, but very few studies have been carried out about the water sorption changes in the acrylic resin and still few about the vertical dimensional changes in acrylic resin due to water sorption. While fabricating the denture base from the acrylic resin, it comes in contact with water during polishing as well as cleaning, consequently during the use of denture it is constantly wetted by oral fluids. It is the hypothesis that water sorption by denture base acrylic may effect the retention and stability of the denture. It has been shown that water molecules act according to the laws of diffusion. The diffusion presumably occurs between the macromolecules which are forced slightly apart. This separation renders the molecules mobile and the inherent stresses created during heat curing of the acrylic resin can be relieved with consequent intermolecular relaxation and possible changes in the shape of the denture. Exposure time also plays a significant role in water sorption. The present investigation was therefore, carried out by keeping the following objectives: (1) The primary objective was to observe the changes in vertical measurements of acrylic resin dentures due to water sorption. (2) To assess the variations of vertical movement of individual teeth within the dentures due to water sorption.

Hospitalized teens. Ambulatory care utilization patterns.

Twelve- to eighteen-year-olds enrolled in a federally qualified HMO in Central Massachusetts who had an admission to a hospital with a diagnosis of trauma or mental health problems were identified. Routine and episodic health care utilization for a 24-month period of each study case was determined and compared with the same for a comparison group matched for age, sex and length of enrollment. Although information on health habits and lifestyle was often missing from the charts, it was determined that the study cases were less likely to be in school and living with their parents and used episodic care more frequently, especially in the 6 months prior to admission. Both hospitalized and non-hospitalized youth had a higher average number of visits to office-based providers than their national counterparts. The study suggests that (1) greater awareness of morbidity and health care utilization patterns and risk behaviors may enhance prevention efforts; (2) use of instruments to capture more information on health habits and lifestyle may facilitate preventive interventions; (3) collaborations among pediatric primary care providers, the Information Services (IS) and Quality Management (QM) departments may facilitate this type of research in a managed care setting.

Adolescent fathers: an approach for intervention.

Many myths exist concerning the needs and problems confronting adolescent fathers. Research on adolescent pregnancy has proliferated in the last decade. We now have a substantial body of empirically-based findings in this area. Unfortunately, few substantive findings are available on adolescent fathers, yet the magnitude of this problem has reached epidemic proportion. This article will provide an overview of current research on adolescent fathers and their needs and offer suggestions for appropriate intervention.

PIP: An overview of current findings on and suggestions for appropriate intervention for adolescent fathers are discussed. Topics are identified as follows: adolescent pregnancy and demographic factors; adolescent fathers and sexuality ad contraception, attitudes toward abortion, psychological correlates, the role of and commitments and concerns, competency in parenting, infant development, problems, and needs; and needs for research and services. Adolescent fathers are trapped by low levels of educational attainment and family instability. Judgmental behavior of families, schools, and providers is a further hindrance. Minorities are prominently involved and their futures are not promising. In order to strengthen the role and position of minority men within the family, the community, and society, strategies need to be developed that must involve family members, peers, health care services, schools, and organizations such as the Urban League, Planned Parenthood, and churches. Important components of programs are the teaching and modeling of responsibility along with sustaining group identity. Research needs to be conducted to go beyond the limitations of prior studies which 1) are based on small, biased samples recruited through pregnant or parenting females, 2) are cross-sectional observations of social and psychological factors of only teen fathers in a crisis situation, and 3) lack standardized measurement of the social and behavioral characteristics. Suggested future research should emphasize studies 1) with a longitudinal format and adequate samples that have predictive value; 2) of sexual attitudes, contraceptive knowledge, and behavior; 3) of adolescent couples and contraceptive intentions; 4) of gender differences in parenting and responsibility; 5) of what constitutes competent functioning for the teenage male; 6) of the role and influence of parents in the adolescent decision to continue or not to continue the pregnancy; and 7) of the nature and extent of father and infant play which facilitates infant development. Since males receive most of their sexual and contraceptive information from schools and the media, schools adopt curricula on family planning and sexuality. comprehensive health care services and evaluation should be provided by schools in a manner that supports abstention and contraception. Service programs need to involve males in prenatal and parenting classes, and maternity wards must meet adolescent fathers' needs in basic caretaking. Infant development and caretaking training classes in some school or other location need to involve adolescent males. Paternity leave is a must.

Drug use, depression, and adolescents.

This article reviews use and depression in adolescents and explores the thesis that depressed mood and deviant actions represent deviant modes of coping and are the result of failed efforts to handle different and sometimes overlapping constitutional and social risk factors. Theories of drug use and depression and various studies in support of the theoretical framework are examined. Implications are suggested for public health interventions and clinical management as derived from the theoretic background and empiric evidence. Also provided are guidelines for assessment and intervention that can be useful for primary care physicians and other professionals working with troubled teenagers.

Diagnostic laparoscopy in apparent uterine agenesis.

We report a case of an adolescent female with apparent agenesis of the uterus with chromosomally competent ovarian dysgenesis. In our case, the apparent absence of the uterus on the laparoscopy constituted a severe hypoplasia of the organ prior to estrogen stimulation, rather than aplasia. Following a year of estrogen/progesterone replacement, an infantile but otherwise normal uterus could be demonstrated by hysterosalpinogogram. In gonadal dysgenesis, therefore, it is not possible to differentiate the absence of the uterus from severe hypoplasia using laparoscopy.

Delayed cold-induced urticaria: a dominantly inherited disorder.

A delayed cutaneous response to cold, characterized by areas of erythematous, edematous deep swelling at 9 to 18 hr after experimental ice challenge, was recognized in a 10-yr-old boy and several members of his family. Biopsy of the cold-induced lesion showed edema and an infiltrate of mononuclear cells; mast cells were normal, and immunoglobulins, complement factors, and fibrin were not detected by immunofluorescence techniques. Local cold challenge did not release histamine or induce alterations in the complement system or the enzymes, histaminase, and histamine methyl transferase. The delayed cutaneous response to cold could not be passively transferred with serum or tissue extracts to monkey skin. Family studies suggested an autosomal-dominant mode of inheritance.