A Randomised Clinical Feasibility Trial of a Breast Immobilisation Device: The SuPPORT 4 All Bra.

AIMS: Despite the breast being a mobile organ, there is currently no standard suitable immobilisation device to optimise radiotherapy for women with larger breasts treated after a wide local excision. The SuPPORT 4 All (S4A) bra was co-designed with patients and radiotherapy professionals. The purpose of this study was to test the feasibility of using the S4A bra in the existing breast cancer radiotherapy pathway. MATERIALS AND METHODS: A randomised feasibility trial was conducted in a single institution; the primary feasibility endpoint was the recruitment of 50 participants. Efficacy endpoints were also tested, including assessment of skin reactions, dose to organs at risk and patient comfort. Fifty women were randomised to receive either standard radiotherapy with no immobilisation (control) or radiotherapy with the S4A bra (intervention). A separate planning study was undertaken on the cases randomised to receive the S4A bra. Participants in the intervention arm (S4A bra) underwent two planning computed tomography scans, one with the bra on and one without the bra; allowing direct comparison of organs at risk data for S4A bra versus no bra. RESULTS: All women who started radiotherapy wearing the S4A bra completed treatment with the bra; patient comfort did not change across the 3 weeks of treatment. Positional accuracy using the bra was comparable with existing published accuracy for methods without immobilisation. The mean ipsilateral lung doses showed some improvement when positioning with the S4A bra was compared with the no bra set-up (3.72 Gy versus 4.85 Gy for right-sided cases, 3.23 Gy versus 3.62 Gy for left-sided cases). CONCLUSIONS: The S4A bra is feasible to use in the radiotherapy pathway with good patient adherence. The S4A bra has potential to reduce dose to organs at risk (specifically ipsilateral lung dose) while maintaining good breast tissue coverage, and improved patient dignity, warranting further investigation on a larger scale.

Perceptions of friendship, peers and influence on adolescent smoking according to tobacco control context: a systematic review and meta-ethnography of qualitative research.

BACKGROUND: A relationship between smoking and interpersonal influences has been well established within the literature. There have been cultural shifts in denormalisation and a reduction in tobacco smoking in many countries. Hence there is a need to understand social influences on adolescents' smoking across smoking normalisation contexts. METHODS: The search was conducted in July 2019 and updated in March 2022 within 11 databases and secondary sources. Search terms included schools, adolescents, smoking, peers, social norms and qualitative research. Screening was conducted by two researchers independently and in duplicate. Study quality was assessed using the eight-item Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-centre) tool for the appraisal of qualitative studies. Results were synthesised using a meta-narrative lens for meta-ethnography and compared across smoking normalisation contexts. RESULTS: Forty one studies were included and five themes were developed, mapping onto the socio ecological model. The social processes by which adolescents take up smoking differed according to a mixture of school type, peer group structure and the smoking culture within the school, as well as the wider cultural context. Data available from smoking denormalised contexts, described changes in social interactions around smoking to cope with its stigmatisation. This was manifested through i) direct peer influence, whereby subtle techniques were employed, ii) group belonging whereby smoking was less likely to be seen as a key determinant of group membership and smoking was less commonly reported to be used as a social tool, and iii) popularity and identity construction, whereby smoking was perceived more negatively in a denormalised context, compared with a normalised context. CONCLUSIONS: This meta-ethnography is the first study to demonstrate, drawing on international data, that peer processes in adolescent smoking may undergo changes as smoking norms within society change. Future research should focus on understanding differences across socioeconomic contexts, to inform the adaptation of interventions.

Exploring the association between school-based peer networks and smoking according to socioeconomic status and tobacco control context: a systematic review.

BACKGROUND: Whilst prevalence of youth smoking in middle and high income countries has decreased, inequality has prevailed. The introduction of legislation regulating tobacco use in public spaces varies across countries, impacting the tobacco control context. Thus reviewing our knowledge of how social networks may influence smoking differently within different contexts is required to facilitate the development of context-specific interventions. METHODS: The search, conducted on 31st May 2019, included the following smoking-related terms; schools, adolescents, peers and social networks. Inclusion and exclusion criteria were applied throughout the title and abstract screening and full text screening. Quality assessment and synthesis followed. Studies were narratively synthesised to identify changes according to legislative context. This synthesis was conducted separately for findings relating to three categories: socioeconomic status; social selection and influence; and network position. RESULTS: Thirty studies were included. Differences in the relationship between network characteristics and smoking according to socioeconomic status were measured in five out of fifteen studies in Europe. Results varied across studies, with differences in network characteristics and their association with smoking varying both between schools of a differing and those of a similar socioeconomic composition. For studies conducted both before and after the introduction of comprehensive smoking legislation, the evidence for selection processes was more consistent than influence, which varied according to reciprocity. Findings showed that isolates were more likely to smoke and in-degree and out-degree centrality were related to smoking both before and after the introduction of legislation. The relationship between popularity and smoking was contingent on school level smoking prevalence in studies conducted before the introduction of legislation, but not after. CONCLUSIONS: Overall, effects according to socioeconomic status were underreported in the included studies and no consistent evidence of change after the introduction of a comprehensive smoking ban was observed. Further network analyses are required using more recent data to obtain a comprehensive understanding of how network processes may influence smoking differently according to socioeconomic status, and how adaptation could be used to enhance intervention effectiveness. SYSTEMATIC REVIEW REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42019137358 .

Emergency Laparotomy Follow-Up Study (ELFUS): prospective feasibility investigation into postoperative complications and quality of life using patient-reported outcome measures up to a year after emergency laparotomy.

BACKGROUND: Emergency laparotomy carries a significant risk profile around the time of surgery. This research aimed to establish the feasibility of recruitment to a study using validated scoring tools to assess complications after surgery; and patient-reported outcome measures (PROMs) to assess quality of life and quality of recovery up to a year following emergency laparotomy (EL). METHODS: We used our local National Emergency Laparotomy Audit (NELA) register to identify potential participants at a single NHS centre in England. Complications were assessed at 5, 10 and 30 days after EL. Patient-reported outcome measures were collected at 1, 3, 6 and 12 months after surgery using EQ5D and WHODAS 2.0 questionnaires. RESULTS: Seventy of 129 consecutive patients (54%) agreed to take part in the study. Post-operative morbidity survey data was recorded from 63 and 37 patients at postoperative day 5 and day 10. Accordion Complication Severity Grading data was obtained from 70 patients. Patient-reported outcome measures were obtained from patients at baseline and 1, 3, 6 and 12 months after surgery from 70, 59, 51, 48, to 42 patients (100%, 87%, 77%, 75% and 69% of survivors), respectively. CONCLUSIONS: This study affirms the feasibility of collecting PROMs and morbidity data successfully at various time points following emergency laparotomy, and is the first longitudinal study to describe quality of life up to a year after surgery. This finding is important in the design of a larger observational study into quality of life and recovery after EL.

The patient experience of radiotherapy for breast cancer: A qualitative investigation as part of the SuPPORT 4 All study.

INTRODUCTION: Breast cancer is a global health problem with 2.09 million cases of breast cancer diagnosed worldwide in 2018. With an increase in breast cancer survival attention has now focussed on the impact treatment side effects can have on the quality of life for women during survivorship. The aim of the SuPPORT 4 All project is to develop a support bra for use during radiotherapy, that can reduce normal tissue toxicity (for women with larger breasts) and provide accuracy, dignity and modesty for all women. The first stage of the project involved a co-design process to understand the current patient experience where no support bra or modesty device is used. METHOD: A participatory co-design methodology was adopted. Workshops were held with patient representatives (n = 9) to seek understanding of experience during radiotherapy; a total of three workshops over 4 h. The workshops were audio recorded and framework analysis was adopted to identify key patient experiences. RESULTS: Twelve categories and twenty-six sub categories were identified specific to patient experience. Patient concerns focussed on information provision, Healthcare Practitioner (HCP) knowledge of breast lymphoedema, lack of choice, experiences of being naked, and feelings of disempowerment. CONCLUSIONS: A number of areas were identified that had negative effects on overall patient experience. IMPLICATIONS FOR PRACTICE: Practitioners should consider patient dignity when configuring services to support patient needs regarding undressing, outside or inside the linear accelerator room. Additionally, practitioners should have an understanding of the impact permanent tattoos may have on some patients' wellbeing and the impact that breast lymphoedema has on patient quality of life. Practitioners should also consider methods to encourage patient empowerment during radiotherapy; supporting patient self-monitoring of side-effects may be one way to facilitate this.

Population genetic screening efficiently identifies carriers of autosomal dominant diseases.

Three inherited autosomal dominant conditions-BRCA-related hereditary breast and ovarian cancer (HBOC), Lynch syndrome (LS) and familial hypercholesterolemia (FH)-have been termed the Centers for Disease Control and Prevention Tier 1 (CDCT1) genetic conditions, for which early identification and intervention have a meaningful potential for clinical actionability and a positive impact on public health1. In typical medical practice, genetic testing for these conditions is based on personal or family history, ethnic background or other demographic characteristics2. In this study of a cohort of 26,906 participants in the Healthy Nevada Project (HNP), we first evaluated whether population screening could efficiently identify carriers of these genetic conditions and, second, we evaluated the impact of genetic risk on health outcomes for these participants. We found a 1.33% combined carrier rate for pathogenic and likely pathogenic (P/LP) genetic variants for HBOC, LS and FH. Of these carriers, 21.9% of participants had clinically relevant disease, among whom 70% had been diagnosed with relevant disease before age 65. Moreover, 90% of the risk carriers had not been previously identified, and less than 19.8% of these had documentation in their medical records of inherited genetic disease risk, including family history. In a direct follow-up survey with all carriers, only 25.2% of individuals reported a family history of relevant disease. Our experience with the HNP suggests that genetic screening in patients could identify at-risk carriers, who would not be otherwise identified in routine care.

Treating Brain Metastases from Breast Cancer: Outcomes after Stereotactic Radiosurgery.

AIMS: Stereotactic radiosurgery (SRS) is an alternative to surgery or whole brain radiotherapy for the control of single or multiple brain metastases in patients with breast cancer. To date, there is no clear consensus on factors that might predict overall survival following SRS. The aim of this study was to assess the overall survival of breast cancer patients with brain metastases treated with SRS at a single centre and to examine the factors that might influence survival. MATERIALS AND METHODS: A retrospective analysis of consecutive patients with breast cancer and brain metastases, considered suitable for SRS by the regional neuro-oncology multidisciplinary team. All patients were treated at a single National Health Service centre. RESULTS: In total, 91 patients received SRS between 2013 and 2017, of whom 15 (16.5%) were alive at the time of analysis. The median overall survival post-SRS was 15.7 months (interquartile range 7.7-23.8 months) with no significant effect of age on survival (67 patients ≤ 65 years, 16.3 months; 26 patients > 65 years, 11.4 months, P = 0.129). The primary tumour receptor status was an important determinant of outcome: 31 oestrogen receptor positive (ER+)/human epidermal growth factor receptor 2 negative (HER2-) patients had a median overall survival of 13.8 months, 14 ER+/HER2+ patients had a median overall survival of 21.4 months, 30 ER-/HER2+ patients had a median overall survival of 20.4 months and 16 patients with triple negative breast cancer (TNBC) had a median overall survival of 8.5 months. A larger total volume of tumour treated (>10 cm3), but not the number of individual metastases treated, was associated with worse survival (P = 0.0002) in this series. Patients with stable extracranial disease at the time of SRS had improved overall survival compared with those with progressive extracranial disease (30 patients stable extracranial disease overall survival = 20.1 months versus 33 patients progressive extracranial disease overall survival = 11.4 months; P = 0.0011). Seventeen patients had no extracranial disease at the time of SRS, with a median overall survival of 13.1 months. CONCLUSIONS: This single-centre series of consecutive patients with brain metastases from breast cancer, treated with SRS, had a similar overall survival compared with previous studies of SRS. TNBC and ER+/HER2- histology, metastatic volumes >10 cm3 and progressive extracranial disease at the time of SRS were associated with worse survival.

El registro y la medición de la criminalidad. El problema de los datos faltantes y el uso de la ciencia para producir estimaciones en relación con el homicidio en Colombia, demostrado a partir de un ejemplo: el departamento de Antioquia (2003-2011) / Criminality registration and measurement. The problem of missing data, and the use of science to produce estimations relating to homicide in Colombia, as demonstrated with an example from one of its administrative and political divisions: the Department of Antioquia (2003-2011) / O registro e a medição da criminalidade. O problema dos dado faltantes e o uso da ciência para produzir estimativas com relação ao homicídio na Colômbia, demonstrado a partir de um exemplo: o departamento de Antioquia (2003-2011)

La integridad del ciclo de políticas públicas depende de la calidad de la información disponible para tomar decisiones en cualquiera de las fases. De manera preocupante, este ciclo -especialmente en el campo de la política criminal- se aparta del análisis técnico, que debería basarse en prueba empírica y sustento teórico. Este artículo retoma ejes clásicos (pero olvidados) de la medición de la criminalidad, con el propósito de resaltar la función esencial de datos confiables en el ciclo de políticas públicas. Brinda un análisis del proceso de registro y medición del crimen, y destaca los problemas y límites de cualquier ejercicio de registro delictivo. Resalta la necesidad de examinar el universo de lo desconocido por los diversos proyectos de registro, y explica las herramientas que se utilizan para dar cuenta de datos faltantes. Con el fin de ilustrar el potencial de la aplicación de estas herramientas en Colombia, ilustra los resultados del registro integrado de homicidios en el departamento de Antioquia, en el período 2003-2011, según cinco proyectos de registro (incluyendo el de la Policía Nacional), y presenta una estimación probabilística de los homicidios, que incorpora el cálculo de los datos faltantes según un técnica que se denomina Estimación por Sistemas Múltiples (ESM).

The integrity of the public policy cycle depends upon the quality of information available to make decisions in any of the relevant phases. In a disturbing manner, this cycle -and particularly in the field of criminal policy- diverges from the technical analysis that should be based on empiric proof and theoretical justification and support. This article retakes classical -though forgotten- axes of criminality measurement, for the purpose of stressing the essential function of reliable data in the public policy cycle. It offers an analysis of the registration and measurement process, and highlights both problems and limits involved in any crime registration exercise. It points out the need to examine the universe of what has been ignored in the diverse registration projects, and explains the tools used to account for the missing data. In order to illustrate the potential involved in the application of these tools in Colombia, it exemplifies the results found in the integrated homicide record keeper in one of the Colombian 32 administrative and political divisions: the Department of Antioquia, in the 2003-2011 period, pursuant to five registration projects (including that of the National Police); and it offers a probabilistic estimation of homicides incorporating the calculation of missing data, according to a technique known as the Multiple Systems Estimation (MSE).

A integridade do ciclo de políticas públicas depende da qualidade da informação disponível para fazer decisões em qualquer uma das fases. De maneira preocupante, este ciclo - especialmente no campo da política criminal - afasta-se da análise técnica, que teria que ser baseada no teste empírico e no apoio teórico. Este artigo retoma eixos clássico (mas esquecidos) da medição da criminalidade, a fim de enfatizar a função essencial de dados fiáveis no ciclo de políticas públicas. Oferece uma análise do processo do registo e medição do crime, e destaca os problemas e os limites de todo o exercício do registo criminal. Resalta a necessidade para examinar o universo do desconhecido pelos diversos projetos de registo, e explica as ferramentas que são usadas para apresentar os dados faltantes. A fim de ilustrar o potencial da aplicação destas ferramentas na Colômbia, ilustra os resultados do registro integrado dos homicídios no departamento de Antioquia, no período 2003-2011, de acordo com cinco projetos de registro (incluindo aquele da Polícias Nacional), e apresenta uma estimativa probabilística dos homicídios, que incorpora o cálculo dos dados faltantes de acordo com uma técnica chamada estimativa por múltiplos sistemas.

Human and Helicobacter pylori coevolution shapes the risk of gastric disease.

Helicobacter pylori is the principal cause of gastric cancer, the second leading cause of cancer mortality worldwide. However, H. pylori prevalence generally does not predict cancer incidence. To determine whether coevolution between host and pathogen influences disease risk, we examined the association between the severity of gastric lesions and patterns of genomic variation in matched human and H. pylori samples. Patients were recruited from two geographically distinct Colombian populations with significantly different incidences of gastric cancer, but virtually identical prevalence of H. pylori infection. All H. pylori isolates contained the genetic signatures of multiple ancestries, with an ancestral African cluster predominating in a low-risk, coastal population and a European cluster in a high-risk, mountain population. The human ancestry of the biopsied individuals also varied with geography, with mostly African ancestry in the coastal region (58%), and mostly Amerindian ancestry in the mountain region (67%). The interaction between the host and pathogen ancestries completely accounted for the difference in the severity of gastric lesions in the two regions of Colombia. In particular, African H. pylori ancestry was relatively benign in humans of African ancestry but was deleterious in individuals with substantial Amerindian ancestry. Thus, coevolution likely modulated disease risk, and the disruption of coevolved human and H. pylori genomes can explain the high incidence of gastric disease in the mountain population.

Improving the diagnosis of genuine stress incontinence in symptomatic women with negative cough stress test: the Distal Urethral Electrical Conductance test (DUEC) revisited.

This retrospective descriptive study was performed to assess the practice of using the distal urethral electrical conductance (DUEC) test to objectively demonstrate urinary incontinence in symptomatic women with a negative cough stress test on examination. One hundred women had stable bladders on cystometry (CMG). Genuine stress incontinence (GSI) was diagnosed during CMG in 45 (45%). DUEC performed prior to cystometry had revealed stress incontinence in an additional 13 with negative CMG, thereby improving the diagnosis of GSI by 13%. The test detected urge incontinence in one (1%). The DUEC test improves the detection of stress incontinence. However, it should not be considered as an alternative to cystometry, but as an additional test when stress incontinence cannot be demonstrated clinically.

Effects of vasoactive intestinal polypeptide on neurones of the rat suprachiasmatic nuclei in vitro.

The suprachiasmatic nuclei (SCN) of the hypothalamus house the main circadian pacemaker in mammals. Vasoactive intestinal polypeptide (VIP) is the most abundant neuropeptide in the SCN and has been shown to phase-shift the electrical activity rhythm of SCN cells in vitro. However, the effects of VIP on the cellular activity of rat SCN neurones are unknown. In this study, we examined the acute effects of VIP on the extracellularly recorded spontaneous firing rate of SCN neurones in an in-vitro hypothalamic slice preparation. Furthermore, with the use of receptor-selective agonists and antagonists, we determined which receptors might mediate the effects of VIP in the SCN. Approximately 50% of cells responded to VIP; the main type of response was suppression in firing rate, although a few cells were activated. Suppression responses to VIP were mimicked by the VPAC(2) receptor agonist Ro 25-1553 and blocked by the selective VPAC(2) receptor antagonist PG 99-465. The PAC(1) receptor agonist maxadilan evoked responses from 40% of SCN cells, and activations to this agonist were not altered by PG 99-465. Responses to VIP were not blocked by antagonists to ionotropic glutamate receptors, but the duration of suppression was modulated by the GABA(A) receptor antagonist bicuculline. Our data indicate that VIP alters the electrical activity of rat SCN neurones in vitro, via both VPAC(2) and PAC(1) receptors.

Vasoactive intestinal polypeptide (VIP) phase-shifts the rat suprachiasmatic nucleus clock in vitro.

In mammals, the principal circadian pacemaker is housed in the hypothalamic suprachiasmatic nuclei (SCN). The SCN exhibit high levels of vasoactive intestinal polypeptide (VIP) immunoreactivity and two of the three VIP receptors, VPAC(2) and PAC(1), are found in the rat SCN. However, the role of VIP in the SCN remains unclear. In this study, we examined the phase-resetting actions of VIP and selective VIP receptor agonists on the electrical activity rhythm of rat SCN neurons in vitro. Application of VIP during the subjective day did not shift the peak in the firing rate rhythm. However, VIP treatment during the early or late subjective night evoked a small phase delay or a large phase advance, respectively. The phase-advancing effect of VIP was reproduced by the novel VPAC(2) receptor agonist RO 25-1553, but not by pituitary adenylate cyclase-activating peptide (a potent PAC(1) receptor agonist), or by [K15,R16,L27]VIP(1-7)/GRF(8-27), a novel, selective VPAC(1) receptor agonist. These data show that VIP phase-dependently phase-resets the rodent SCN pacemaker in vitro, presumably via the VPAC(2) receptor. As the pattern of phase-shifting evoked by VIP and RO 25-1553 resembles the phase-resetting actions of light on rodent behavioural rhythms, these data support a role for VIP and the VPAC(2) receptor in photic entrainment of the rodent circadian pacemaker.

Fine needle aspiration of thyroid nodules. Determinants of insufficiency rate and malignancy yield at thyroidectomy.

OBJECTIVE: To evaluate patient- and practice-specific determinants of the thyroid nodule fine needle aspiration (FNA) insufficiency rate and malignancy yield at a tertiary-care teaching hospital. STUDY DESIGN: All FNAs of thyroid nodules performed from August 1990 to October 1993 at the Walter Reed Army Medical Center Endocrinology Clinic were reviewed and the results analyzed for correlation with surgical outcome, scintiscanning result and operator experience. Provider-specific factors influencing the FNA insufficiency rate, surgical referral pattern and malignancy yield were evaluated. RESULTS: A total of 504 aspirations in 422 patients with thyroid nodules were included in the analysis. The sensitivity of FNA for detecting malignancy was 80%, specificity was 73.2%, and accuracy was 75.2%. A significant negative correlation was found between recent aspirator experience and the insufficiency rate. Repeat aspiration of nodules previously yielding benign cytology increased the malignancy yield. Surgical excision of nodules with insufficient aspirations gave a low malignancy yield, and aspiration of nodules that were "hot" on scintiscanning rarely yielded false positive FNA results. CONCLUSION: Specific limitations of thyroid nodule FNA include a large number of aspirates containing insufficient cytologic material and a variable malignancy yield. Specific recommendations based on the findings in this report are: the establishment of uniform criteria for judging specimen adequacy, the performance of repeat aspiration on thyroid nodules with previously benign aspirates, the abandonment of scintiscanning in the routine management of thyroid nodules and a conservative approach to clinically indolent nodules repeatedly found to have scant cellularity on FNA. Based on these findings, an algorithm for the diagnostic evaluation of a solid thyroid nodule can be constructed.

Isolation of coronaviruses antigenically indistinguishable from bovine coronavirus from wild ruminants with diarrhea.

Diarrheal feces from three sambar deer and one waterbuck in a wild animal habitat and one white-tailed deer on a wildlife farm in Ohio contained coronavirus particles which were agglutinated by antiserum to bovine coronavirus (BCV) in immune electron microscopy. Three coronavirus strains were isolated in human rectal tumor cells from the feces of the sambar and white-tailed deer and the waterbuck, respectively. Hemagglutination, receptor-destroying enzyme activity, indirect immunofluorescence, hemagglutination inhibition, virus neutralization, and Western blot (immunoblot) tests showed close biological and antigenic relationships among the isolates and with selected BCV strains. Gnotobiotic and colostrum-deprived calves inoculated with each of these isolates developed diarrhea and shed coronavirus in their feces and from their nasal passages. In a serological survey of coronavirus infections among wild deer, 8.7 and 6.6% of sera from mule deer in Wyoming and from white-tailed deer in Ohio, respectively, were seropositive against both of the isolates and selected BCV isolates by indirect immunofluorescence tests. These results confirm the existence of coronaviruses in wild ruminants and suggest that these species may harbor coronavirus strains transmissible to cattle.

Simultaneous inflatable penile prosthesis insertion and corporoplasty for septal chordee attributed to Peyronie's disease.

Impotent patients with Peyronie's disease who qualify for penile prosthesis surgery may pose a reconstructive challenge that can best be resolved at the time of exploration. Restrictive plaques, especially septal chordee, that persist after prosthesis insertion deserve resection. The surgical technique, pathophysiology, and management of postoperative edema facilitated by percutaneous access to the Resipump are described.

Heerfordt syndrome: a cause of facial paralysis.

Heerfordt syndrome is an unusual manifestation of systemic sarcoidosis and is characterized by parotitis, uveitis, and facial nerve paralysis. A case is presented and the clinical manifestations are discussed. Angiotensin converting enzyme assays along with tissue biopsy demonstrating noncaseating granulomas confirm the diagnosis.

Evaluation of amino-oxyacetic acid as a palliative in tinnitus.

Amino-oxyacetic acid (AOAA) was evaluated as a palliative in tinnitus. Sixty-six patients with tinnitus presumed to be of cochlear origin were given either a placebo or 75 mg of AOAA four times a day for 1 week. Response was evaluated by both audiometric measurement of tinnitus loudness and subjective rating by patients of change or no change in tinnitus severity. Because loudness measurements and self-rating have not been shown to be independent, and since the aim of clinical treatment of tinnitus is the alleviation of subjective distress, greater weight was given to the patient's self-rating. A total of 21% of all patients reported a subjective decrease in tinnitus severity, usually within 3 to 4 days after the start of AOAA use. Patients with tinnitus caused by presbycusis or Meniere's disease were the most likely to respond to AOAA treatment with a reduction in tinnitus severity, whereas those with drug-induced tinnitus were the least likely to respond. Nausea and dysequilibrium were the most common side effects of AOAA use. Of the 21% of patients who responded to AOAA, 71% developed some type of side effect. Amino-oxyacetic acid produces a reduction in the severity of tinnitus in about 20% of patients; however, the incidence of side effects makes the drug unacceptable for clinical use.

Histiocytic malignant lymphoma arising in the midfacial soft tissues.

Histiocytic malignant lymphoma arising in the midfacial soft tissues represents an uncommon clinical disorder. We report our experiences with a 63-year-old man with nasal obstruction secondary to a nasal septal mass that developed four weeks after a routine septoplasty. Final pathologic appearance after multiple biopsies was consistent with histiocytic malignant lymphoma. Clinical features, histopathologic findings, therapy, and prognosis are discussed.