Cognitive problems following hematopoietic stem cell transplant: relationships with sleep, depression and fatigue.

Cognitive problems are a significant, persistent concern for patients undergoing hematopoietic stem cell transplant (HSCT). Sleep is important for many cognitive tasks; however, the relationship between sleep and cognitive problems for HSCT patients is unknown. This study examined the relationship between sleep and cognitive problems for HSCT patients from pre to post transplant. Patients undergoing HSCT (N=138) completed questionnaires at pre-transplant and during the 12 months following transplant. Questionnaires assessed sleep and cognitive problems as well as commonly co-occurring symptoms: depressive symptoms, fatigue and pain. Post hoc analyses examined the relationship of specific sleep problems with cognitive problems. Sleep problems covaried with cognitive problems even after controlling for depressive symptoms, fatigue and pain. Depressive symptoms and fatigue were also uniquely related to cognitive problems. Post hoc analyses suggest that sleep somnolence, shortness of breath, snoring and perceptions of inadequate sleep may contribute to the association found between sleep and cognitive problems. Findings suggest that sleep problems are associated with and may contribute to cognitive problems for HSCT patients. However, sleep problems are rarely screened for or discussed during clinic visits. Assessing and treating specific sleep problems in addition to depressive symptoms and fatigue may have implications for improving cognitive problems for HSCT patients.

Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study.

OBJECTIVES: To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting. DESIGN AND SETTING: Multicentre retrospective study in eight tertiary referral hospitals over 17 years. PARTICIPANTS: Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised. MAIN OUTCOME MEASURES: Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded. RESULTS: In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves. CONCLUSIONS: We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery.

Exploratory secondary analyses of a cognitive-behavioral intervention for knee osteoarthritis demonstrate reduction in biomarkers of adipocyte inflammation.

OBJECTIVE: To investigate the effects of pain coping skills training (PCST) and a lifestyle behavioral weight management (BWM) program on inflammatory markers and biomarker associations with pain and function in the OA LIFE study. METHOD: Serum samples were available from a subset (N = 169) of the overweight or obese knee OA participants in the OA LIFE study that evaluated: PCST, BWM, combined PCST + BWM, or standard care (SC). Inflammatory markers (hsCRP, IL-1ra, IL-1ß, IL-6, IL-8, TNF-α, TNFRI, TNFRII, and hyaluronic acid (HA)), and adipokines (leptin and adiponectin) were measured before and after the 24-week treatment period. Biomarkers were assessed for effects of treatment and for associations with change in weight, pain and disability (unadjusted and adjusted for age, race, sex, baseline body mass index (BMI), and baseline biomarker concentration). RESULTS: PCST + BWM was associated with significant reductions in hsCRP (P = 0.0014), IL-6 (P = 0.0075), and leptin (P = 0.0001). After adjustment, there was a significant effect of PCST + BWM on changes in leptin (b = -0.19, P = 0.01) and IL-6 (b = -0.25, P = 0.02) relative to SC. Reductions in leptin and IL-6 were significantly correlated with reductions in weight, BMI and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain; reductions in IL-6 were correlated with improvements in WOMAC and Arthritis Impact Measurement Scales (AIMS) physical function. By mediation analyses, weight loss was responsible for 54% of the change in IL-6 and all of the change in leptin. CONCLUSIONS: OA-related inflammatory markers were reduced by a 24-week combined PCST + BWM intervention. This suggests that the inflammatory state can be successfully modified in the context of a readily instituted clinical intervention with a positive clinical outcome.

Energy recovery in individuals with knee osteoarthritis.

OBJECTIVE: Pathological gaits have been shown to limit transfer between potential (PE) and kinetic (KE) energy during walking, which can increase locomotor costs. The purpose of this study was to examine whether energy exchange would be limited in people with knee osteoarthritis (OA). METHODS: Ground reaction forces during walking were collected from 93 subjects with symptomatic knee OA (self-selected and fast speeds) and 13 healthy controls (self-selected speed) and used to calculate their center of mass (COM) movements, PE and KE relationships, and energy recovery during a stride. Correlations and linear regressions examined the impact of energy fluctuation phase and amplitude, walking velocity, body mass, self-reported pain, and radiographic severity on recovery. Paired t-tests were run to compare energy recovery between cohorts. RESULTS: Symptomatic knee OA subjects displayed lower energetic recovery during self-selected walking speeds than healthy controls (P = 0.0018). PE and KE phase relationships explained the majority (66%) of variance in recovery. Recovery had a complex relationship with velocity and its change across speeds was significantly influenced by the self-selected walking speed of each subject. Neither radiographic OA scores nor subject self-reported measures demonstrated any relationship with energy recovery. CONCLUSIONS: Knee OA reduces effective exchange of PE and KE, potentially increasing the muscular work required to control movements of the COM. Gait retraining may return subjects to more normal patterns of energy exchange and allow them to reduce fatigue.

Psychosocial interventions for managing pain in older adults: outcomes and clinical implications.

Interest in the use of psychosocial interventions to help older adults manage pain is growing. In this article, we review this approach. The first section reviews the conceptual background for psychosocial interventions with a special emphasis on the biopsychosocial model of pain. The second section highlights three psychosocial interventions used with older adults: cognitive behavioural therapy, emotional disclosure, and mind-body interventions (specifically mindfulness-based stress reduction and yoga). The final section of the paper highlights important future directions for work in this area.

Jugular bulb diverticulum dehiscence towards the vestibular aqueduct in a patient with otosclerosis.

OBJECTIVES: To demonstrate the need for computed tomography imaging of the temporal bone before considering revision stapes surgery in patients with recurrent or residual conductive hearing loss. CASE REPORT: We report the case of a high-riding jugular bulb with an associated jugular bulb diverticulum, which was dehiscent towards the vestibular aqueduct, in a patient with confirmed otosclerosis who did not experience hearing improvement after stapedotomy. CONCLUSION: This case demonstrates the usefulness of temporal bone computed tomography in the evaluation of patients with otosclerosis in whom stapedotomy has not improved hearing. In such patients, revision surgery to address residual hearing loss would eventually prove unnecessary and avoidable.

Multidisciplinary management of vestibular schwannomas: state of the art.

The preferred setting for the treatment for vestibular schwannoma these days is multidisciplinary and multimodal. A balance has to be struck between a wait-and-scan attitude and a more active approach (surgery or radiotherapy). An initial wait-and-scan attitude is a reasonable management option because many tumours do not grow during a prolonged period of observation. The different surgical approaches may or may not involve attempts to preserve hearing. Stereotactic radiotherapy as treatment of choice is often considered in the elderly patient presenting with a vestibular schwannoma smaller than 2.5 cm with documented growth. This paper will review current treatment modalities and the respective pros and cons. A decisional algorithm as currently adopted by our skull base team is presented at the end of the paper.

Prognostic significance of electrophysiological tests for facial nerve outcome in vestibular schwannoma surgery.

OBJECTIVE: To assess the prognostic significance of pre-operative electrophysiological tests for facial nerve outcome in vestibular schwannoma surgery. METHODOLOGY: Retrospective study design in a tertiary referral neurology unit. We studied a total of 123 patients with unilateral vestibular schwannoma who underwent microsurgical removal of the lesion. Nine patients were excluded because they had clinically abnormal pre-operative facial function. Pre-operative electrophysiological facial nerve function testing (EPhT) was performed. Short-term (1 month) and long-term (1 year) post-operative clinical facial nerve function were assessed. RESULTS: When pre-operative facial nerve function, evaluated by EPhT, was normal, the outcome from clinical follow-up at 1-month post-operatively was excellent in 78% (i.e. HB I-II) of patients, moderate in 11% (i.e. HB III-IV), and bad in 11% (i.e. HB V-VI). After 1 year, 86% had excellent outcomes, 13% had moderate outcomes, and 1% had bad outcomes. Of all patients with normal clinical facial nerve function, 22% had an abnormal EPhT result and 78% had a normal result. No statistically significant differences could be observed in short-term and long-term post-operative facial function between the groups. CONCLUSION: In this study, electrophysiological tests were not able to predict facial nerve outcome after vestibular schwannoma surgery. Tumour size remains the best pre-operative prognostic indicator of facial nerve function outcome, i.e. a better outcome in smaller lesions.

Diffusion-weighted magnetic resonance imaging of the temporal bone.

This paper summarizes the value of diffusion-weighted magnetic resonance imaging in the evaluation of temporal bone pathology. It highlights the use of different types of diffusion-weighted magnetic resonance imaging in the different types of cholesteatoma, prior to first stage surgery and prior to second look surgery. The value of diffusion-weighted magnetic resonance imaging in the evaluation of pathology of the apex of the petrous bone and the cerebellopontine angle is also discussed.

Long-term follow up after bony mastoid and epitympanic obliteration: radiological findings.

OBJECTIVE: The canal wall up bony obliteration technique lowers the incidence of recurrent cholesteatoma, but carries the potential risk of obliterating residual cholesteatoma. The objective of this study was to report long-term follow-up radiological findings after performing a canal wall up bony obliteration technique procedure, in order to detect residual and/or recurrent cholesteatoma. PATIENTS: Fifty-one patients presenting with a cholesteatoma or a troublesome cavity were operated upon using the canal wall up bony obliteration technique, and were evaluated by follow-up imaging a mean of 76.4 months post-operatively (range, 53.8-113.6 months). INTERVENTION: All patients were evaluated with high resolution computed tomography and magnetic resonance imaging (including delayed contrast, T1-weighted imaging and non-echo-planar, diffusion-weighted imaging). RESULTS: Imaging revealed the presence of one residual, one recurrent and one congenital petrosal apex cholesteatoma. On high resolution computed tomography, completely obliterated mastoid filled with bone was observed in 74.5 per cent (38/51) of patients, and an aerated middle-ear cavity in 64.7 per cent (33/51). High resolution computed tomography clearly detected any associated soft tissue present in the middle-ear cavity (18/51) and in the obliterated mastoids (13/51), but could not characterise this tissue. Non-echo-planar, diffusion-weighted magnetic resonance imaging clearly identified all three cholesteatomas, and differentiated them from other associated soft tissues. No cholesteatoma was found within the obliterated mastoids. CONCLUSION: Long-term follow up indicated that the canal wall up bony obliteration technique is a safe method with which to treat primary and recurrent cholesteatoma and to reconstruct unstable cavities. Soft tissue was found quite often in the middle ear and obliterated mastoids. High resolution computed tomography identified its presence but could not further characterise it. However, non-echo-planar, diffusion-weighted magnetic resonance imaging succeeded in differentiating soft tissues, enabling detection of residual or recurrent cholesteatoma after a canal wall up bony obliteration technique procedure.

Magnetic resonance imaging of cholesteatoma: an update.

OBJECTIVE: To report on the value and limitations of new MRI techniques in pre- and post-operative MRI of cholesteatoma. The current value of magnetic resonance imaging (MRI) in diagnosing congenital, acquired, and post-operative recurrent or residual cholesteatoma is described. METHODOLOGY AND RESULTS: High resolution computed tomography (HRCT) is still considered the imaging modality of choice for detecting acquired or congenital middle ear cholesteatoma. However, MRI may provide additional information on the delineation and extension of cholesteatoma and on potential complications. Detecting post-operative residual or recurrent cholesteatoma with HRCT was shown to be inaccurate due to the technique's low sensitivity and specificity. CONCLUSIONS: Recently, improvements in MRI techniques have led to a more accurate diagnoses of cholesteatoma using delayed contrast enhanced T1-weighted imaging and diffusion-weighted imaging.

Pain catastrophizing in borderline morbidly obese and morbidly obese individuals with osteoarthritic knee pain.

OBJECTIVE: There is limited information about how morbidly obese osteoarthritis (OA) patients cope with the pain they experience. Pain catastrophizing is an important predictor of pain and adjustment in persons with persistent pain. This may be particularly relevant in the morbidly obese (body mass index [BMI] of 40 kg/m(2) or greater) OA population at risk for increased pain. The present study first examined whether borderline morbidly obese and morbidly obese OA patients report higher levels of pain catastrophizing than a sample of OA patients in the overweight and obese category (BMI between 25 kg/m(2) and 34 kg/m(2)). Next, it examined how pain catastrophizing is related to important indexes of pain and adjustment in borderline morbidly obese and morbidly obese OA patients. METHODS: Participants included 43 individuals with knee OA who were borderline morbidly obese or morbidly obese (BMI of 38 kg/m(2) or greater). Participants completed self-report measures of pain catastrophizing, pain, psychological distress, quality of life, binge eating and eating self-efficacy. RESULTS: The sample of borderline morbidly obese and morbidly obese OA patients reported significantly higher levels of pain catastrophizing (P=0.007) than a comparison sample of overweight and obese OA patients. Results suggested that patients who engaged in a high level of pain catastrophizing reported having much more intense and unpleasant pain, higher levels of binge eating, lower self-efficacy for controlling their eating and lower weight-related quality of life (P<0.05 for all). CONCLUSIONS: Pain catastrophizing is related to pain and adjustment in borderline morbidly obese and morbidly obese OA patients. Clinicians working with this population should consider assessing pain catastrophizing in the patients they treat.

Imaging of intralabyrinthine schwannomas: a retrospective study of 52 cases with emphasis on lesion growth.

BACKGROUND AND PURPOSE: Only a few case reports and small series of intralabyrinthine schwannomas (ILSs) have been reported. The purpose of this study was to assess prevalence, MR characteristics, location, clinical management, and growth potential/patterns of ILSs in the largest series reported. MATERIALS AND METHODS: Lesion localization, MR characteristics, lesion growth, and clinical management were reviewed in 52 patients diagnosed with an ILS between February 1991 and August 2007 in 2 referral centers. The number of ILSs and vestibulocochlear schwannomas in the cerebellopontine angle/internal auditory canal was compared to assess the prevalence. RESULTS: ILSs most frequently originate intracochlearly, are hyperintense on unenhanced T1-weighted images, enhance strongly after gadolinium administration, and are sharply circumscribed and hypointense on thin heavily T2-weighted 3D images. The scala tympani is more frequently or more extensively involved than the scala vestibuli. Follow-up MR imaging, available in 27 patients, showed growth in 59% of subjects. Growth was seen from the scala tympani into the scala vestibuli and from the scala vestibuli to the saccule and vice versa. Twelve lesions were resected, and the diagnosis of ILS histopathologically confirmed. CONCLUSION: ILSs can account for up to 10% of all vestibulocochlear schwannomas in centers specializing in temporal bone imaging, grow in more than 50%, and are most frequently found intracochlearly, often anteriorly between the basal and second turn. Cochlear ILSs most often originate in the scala tympani and only later grow into the scala vestibuli. Growth can occur from the cochlea into the vestibule or vice versa through the anatomic open connection between the perilymphatic spaces in the scala vestibuli and around the saccule.

Transient depression of inner ear function after stapedotomy: skeeter versus CO(2) laser technique.

Performing stapes surgery for otosclerosis is known to be potentially irreversibly harmful to the inner ear function in about 1% of the cases. An early postoperative transient depression of the bone conduction thresholds is frequently detected after stapes surgery. The purpose of this study was to compare the evolution of bone conduction thresholds after primary stapedotomy with two different techniques: skeeter versus CO(2) laser stapedotomy. Audiological data of 336 otosclerosis operations performed by 2 surgeons between 1997 and 2003 were subjected to analysis. The calibrated hole in the footplate was performed randomly either with the skeeter drill or with the CO(2) laser. Preoperative bone conduction thresholds were compared with the postoperative levels (day 2-3, week 2, week 6 and month 6) in all patients. Evolution of the bone conduction was compared for the two studied subgroups (laser versus skeeter).

Single-shot, turbo spin-echo, diffusion-weighted imaging versus spin-echo-planar, diffusion-weighted imaging in the detection of acquired middle ear cholesteatoma.

Diagnosis of acquired middle ear cholesteatoma on MR imaging is mostly done on late postgadolinium T1-weighted MR images and/or echo-planar (EPI) diffusion-weighted (DWI) MR images. We describe the appearance of a case of a complicated attical middle ear cholesteatoma on single-shot (SS) turbo spin-echo (TSE) DWI compared with EPI-DWI. This case suggests a higher reliability of SS TSE-DWI in the diagnosis of acquired middle ear cholesteatoma.

Allograft tympanoplasty.

Tympano-ossicular allografts are human transplants of the tympanic membrane alone or with the ossicles included. The authors review its use in their department since the introduction of the technique 40 years ago by J. Marquet. The advantages of the technique (near normal anatomical and physiological reconstruction) are discussed, as well as its disadvantages (time consuming harvesting, risk of disease transmission). Some technical modifications for specific indications have been adapted in our department and are described in detail. The authors believe that the tympano-ossicular allograft is the material of choice in extensively diseased middle ears destroyed by chronic otitis media with or without cholesteatoma.

Otosclerosis: a genetically heterogeneous disease involving at least three different genes.

Otosclerosis is caused by abnormal bone homeostasis of the otic capsule, resulting in hearing impairment in 0.3%-0.4% of the white population. The etiology of the disease remains unclear and environmental as well as genetic factors have been implicated. We localized the first autosomal-dominant locus to chromosome 15 in 1998 (OTSC1) in an Indian family and, recently, we reported the localization of a second gene for otosclerosis to a 16 cM interval on chromosome 7q (OTSC2). In this study, we recruited and analyzed nine additional families (seven Belgian and two Dutch families with 53 affected and 20 unaffected subjects) to investigate the importance of these loci in autosomal-dominant otosclerosis. We completed linkage analysis with three microsatellite markers of chromosome 15 (D15S652, D15S1004, D15S657) and five microsatellite markers of chromosome 7 (D7S495, D7S2560, D7S684, D7S2513, D7S2426). In two families, results compatible with linkage to OTSC2 were found, but in the seven remaining families OTSC1 and OTSC2 were excluded. Heterogeneity testing provided significant evidence for genetic heterogeneity, with an estimated 25% of families linked to OTSC2. These results indicate that, besides OTSC1 and OTSC2, there must be at least one additional otosclerosis locus.