Automated detection of the G20210A prothrombin mutation using the LCx microparticle enzyme immunoassay.

BACKGROUND: The prothrombin mutation, a G/A transition at position 20210 in the 3' untranslated region of the prothrombin gene, is associated with an increased risk of deep venous thrombosis and obstetrical complications. Several methods have been developed to detect the mutation; however, given the increased demand for this test in risk factor assessment, the development of simple and efficient screening methods has become necessary. METHODS: We have used a rapid, sensitive, and precise method developed by Abbott Laboratories to detect the prothrombin mutation. The method employs a polymerase chain reaction (PCR) amplification and the Abbot LCx microparticle enzyme immunoassay (MEIA) for detection. This method is able to detect and identify both homozygous and heterozygous genotypes. RESULTS: Two hundred ninety-six patients with a history of deep venous thrombosis, pulmonary embolism, preeclampsia, or cardiovascular disease and 163 control patients were included in this study. The prevalence of the mutation was 5.74% in the high-risk group and 3.06% in the control group. There was complete agreement between the results from the MEIA detection with those obtained using other detection methodologies, namely standard PCR and restriction fragment length polymorphism (RFLP) analysis. CONCLUSIONS: The MEIA detection method of the prothrombin mutation represents a simple, fast, and reliable alternative to standard methods of detection and is well suited for use in routine clinical laboratories. The results of our study confirm others' studies showing a greater incidence of G20210A prothrombin gene mutation in patients with an increased risk of venous thrombosis and pulmonary embolism as well as patients with cardiovascular disease and pregnant women with preeclampsia. It reinforces the necessity of including the screening for prothrombin mutation in populations at risk.

A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa.

OBJECTIVE: To compare the effectiveness of behavioral family systems therapy (BFST) with that of ego-oriented individual therapy (EOIT) as treatments for adolescents with anorexia nervosa. METHOD: Thirty-seven adolescents meeting DSM-III-R criteria for anorexia nervosa were randomly assigned to receive BFST or EOIT, in addition to a common medical and dietary regimen. In BFST, the family was seen conjointly, the parents were placed in control of the adolescent's eating, distorted beliefs were targeted through cognitive restructuring, and strategic/behavioral interventions were used to change family interactions. In EOIT, the adolescent was seen individually, with an emphasis on building ego strength and uncovering the dynamics blocking eating; parents were seen collaterally. Measures administered before, after, and at 1-year follow-up tapped body mass index, menstruation, eating attitudes, ego functioning, depression, and family interactions. RESULTS: BFST produced greater weight gain and higher rates of resumption of menstruation than EOIT. Both treatments produced comparably large improvements in eating attitudes, depression, and eating-related family conflict, but very few changes occurred on ego functioning. CONCLUSIONS: BFST and EOIT proved to be effective treatments for adolescents with anorexia nervosa, but BFST produced a faster return to health.

Pediatricians' experience with and attitudes toward complementary/alternative medicine.

OBJECTIVE: To assess (1) pediatricians' attitudes toward and practice of complementary and alternative medicine (CAM) for their patients; (2) their knowledge, experience, and referral patterns for selected CAM therapies; and (3) their desire for continuing medical education courses on CAM therapies. METHOD: An anonymous, self-report, 25-item questionnaire was mailed to fellows of the Michigan chapter of the American Academy of Pediatrics. RESULTS: Of 860 pediatricians, 348 (40.5%) responded; their median age ranged from 35 to 45 years, 54.3% were men, 67.6% were white, 67.9% were general pediatricians, and 65.2% were trained in the United States. Of the respondents, 83.5% believed their patients use CAM therapies, but 55.1% believed this constituted less than 10% of patients. Of the pediatricians who talked about CAM (53.8%), 84.7% said the discussion was initiated generally by the patient's family. More than half of the physicians (55.2%) said they would use CAM therapies personally, and 50.3% would refer for CAM therapies. Therapies referred for were biofeedback (23.6%), self-help groups (23.3%), relaxation (14.9%), hypnosis (13.8%), and acupuncture or acupressure (10.9%). Of the physicians who responded, 54.1% were interested in continuing medical education courses on CAM therapies. White respondents, US medical school graduates, and general pediatricians were most likely to believe their patients use CAM and discuss or refer for CAM therapies (P<.01). Female pediatricians were most likely to discuss or refer for CAM and to want more continuing medical education on CAM therapies (P<.05). CONCLUSIONS: A majority of pediatricians sampled believed a small percentage of their patients were seeking alternatives to conventional medicine. Half would consider referring patients for CAM, and most were interested in continuing medical education courses on CAM. Larger studies surveying pediatricians, along with more education and research on CAM therapies, need to be considered for the future.

Parent and adolescent perceived need for parental consent involving research with minors.

OBJECTIVE: To assess parents' and adolescents' perceived need for parental consent for minor adolescents to participate in minimal risk research studies based on procedural invasiveness (anonymous surveys, interviews, and blood or urine testing) and sensitivity of the topics (sexuality, drug and alcohol use, and sexually transmitted diseases and human immunodeficiency virus [HIV]). METHODS: An anonymous self-report questionnaire was administered to 100 adolescent-parent pairs at 2 clinical sites (urban and suburban) of Children's Hospital of Michigan in Detroit. RESULTS: By invasiveness of the research procedure, the proportions of parents and adolescents who perceived a need for parental consent were as follows: face-to-face interviews, 62% vs 48%; telephone interviews, 72% vs 46%; blood or urine testing, 77% vs 62%; and blood testing for HIV status, 78% vs 59%. These differences were only significant for telephone interviews and HIV blood testing. For anonymous surveys, a minority of parents (33%) and adolescents (26%) reported that parental consent was needed. Based on sensitivity of the research topics, the proportions of parents and adolescents who perceived a need for parental consent were as follows: sexuality, 60% vs 34%; drug and alcohol use, 56% vs 44%; contraception, 62% vs 46%; and sexually transmitted diseases and HIV testing, 56% vs 52%. These differences were only significant for sexuality. Parents with higher education believed that teens could give their own consent (P < .05). Fifty-seven percent of parents and their teens agreed that parental consent for anonymous surveys was not necessary. For more invasive procedures and more sensitive topics, the percentage of disagreement ranged from 28% to 55.5%. CONCLUSIONS: There is a greater perceived need for parental consent to adolescent participation in research studies among parents than among teens for more invasive procedures and more sensitive topics. These results suggest the need for sensitivity to differing adolescent and parental perceived need for parental consent for a minor adolescent to participate in such studies. Further studies with larger samples are needed to determine what factors influence diverse parent and adolescent opinions.

Value of intraoperative threshold stimulus in predicting postoperative facial nerve function after acoustic tumor resection.

OBJECTIVE: The objective of this study was to determine the predictive value of intraoperative threshold stimulus and postoperative facial nerve outcome in acoustic neuroma surgery. This is a retrospective case review of 116 consecutive procedures to remove acoustic neuromas using either a retrosigmoid or translabyrinthine approach. STUDY DESIGN: Retrospective study. SETTINGS: The Tertiary Referral Center at The California Ear Institute in Palo Alto, California. PATIENTS: These were consecutive presenting patients with acoustic neuroma in the senior author's practice. Patients were not categorized into age, sex, race, or other demographic features. INTERVENTION: All patients had acoustic neuromas detected via magnetic resonance imaging, and they underwent surgery at the hands of the same neurootologic team, Drs. Nissen and Welsh. MAIN OUTCOME MEASURE: The electrophysiological monitoring reports of 81 cases of acoustic tumors. Measures in which intraoperative facial nerve monitoring was performed provided the data for this article. RESULTS: The patients were categorized by postoperative facial nerve function evaluated a minimum of 6 months after surgical removal. Group I was composed of those patients with facial nerve grades of I or II. The median threshold stimulus voltage required to produce measurable facial nerve activity at the root entry zone (REZ) immediately after tumor removal in this group was 0.100 V. Patients in group II had postoperative facial nerve grades of III to VI. Median threshold stimulus in this group was 0.7250 V. The difference in median threshold stimulus voltage at the REZ after tumor removal between these two groups was found to be statistically significant in using the nonparametric Mann-Whitney U test. CONCLUSIONS: The results of this study strongly support the continued use of intraoperative facial monitoring as a predictor of postoperative facial nerve outcome after acoustic tumor surgery.

A multifactorial analysis of facial nerve results in surgery for cerebellopontine angle tumors.

Preserving the function of the facial nerve remains a paramount objective in acoustic neuroma surgery. This study was undertaken to determine the influence of four independent variables on facial nerve outcome by means of a retrospective review of 111 surgical cases: 1) tumor size; 2) use of intraoperative facial nerve monitoring (IFNM); 3) completeness of tumor resection; and 4) surgical approach used. Partial tumor resection appeared to result in improved facial nerve outcome for patients with large tumors. Results indicated that tumor size did not correlate with facial nerve functional outcome, with no statistically significant differences observed among the three size categories. Facial nerve function was not found to depend on selection of either a translabyrinthine (n = 47) or a suboccipital (n = 55) surgical approach in that results were similar for both groups. Outcome data showed a trend in support of the use of IFNM, especially for large tumors, even though the differences between monitored and unmonitored groups were not statistically significant. This study describes the independent impact of the four factors generally thought to affect facial nerve outcome and, in addition, recommends the use of data stratification in reporting facial nerve function results.

Use of the KTP-532 laser in acoustic neuroma surgery.

The potassium titanyl phosphate (KTP-532) laser has been applied to otologic surgery with a proven record of both safety and efficacy. The aim of this study was to demonstrate the use, safety, and advantages of laser dissection in the surgical treatment of acoustic neuromas. The authors' experience with 111 patients in whom laser surgery was used in acoustic neuroma is presented, with emphasis on surgical technique employed and facial nerve functional outcome. The method of laser dissection did not result in deleterious neurologic sequelae or laser-specific complications. In addition, laser dissection afforded certain advantages to traditional techniques, especially in larger tumors. The facial nerve functional outcome as assessed by the House-Brackmann grading system revealed that 90.2% of small tumors, 72.2% of medium tumors, and 75.0% of large tumors achieved satisfactory (grades I and II) functional results. These results compare favorably with the literature describing nonlaser dissection techniques. The observations and results reported in this article demonstrate the safety of the KTP-532 laser in the posterior cranial fossa, and specific advantages that this technology may offer to the surgical armamentarium of the neuro-otologist are outlined.

AIDS knowledge, concerns, and behavioral changes among inner-city high school students.

Knowledge of AIDS, attitudes toward AIDS and condoms, and behavioral changes because of AIDS were studied in 771 students, Grades 9-12 (mean age, 16 years) who completed anonymous questionnaires in gym classes of a New York City high school. Students demonstrated good knowledge of AIDS, with some misconceptions, and significant concerns about AIDS, with some behavioral changes, but most continued to engage in high-risk behaviors. These data indicate that efforts aimed at HIV/AIDS prevention in adolescents must translate knowledge and concerns into behavioral change.

Design and evaluation of a subclassification system for supraglottic laryngeal cancer.

The management of supraglottic laryngeal cancer is predicted upon tumor staging as determined by the American Joint Committee Classification (AJCC). Because of changes in both radiotherapy and surgical treatment, the current AJCC may lack the detail and specificity required for accurate selection of treatment. An expanded classification system should provide predictive information that would aid in clinical decision making. Using the AJCC as a foundation, a subclassification system based upon existing knowledge of laryngeal anatomy, embryology and pattern of tumor spread was developed. This system identifies those cancers that involve subsites deemed to represent regions of increased risk for spread. The validity of this subclassification system and its clinical application was assessed by reviewing 139 cases of supraglottic laryngeal cancer and performing a statistical analysis with respect to treatment outcome. The results of this study support the conclusion that two subpopulations of laryngeal tumors, those with a subsite designation of infrahyoid epiglottis, and those demonstrating fixation of the vocal cord, may benefit from a more aggressive treatment protocol.

The Role of Barrier Contraceptives in Prevention of Pregnancy and Disease in Adolescents.

The advent of HIV infection and a greater understanding of the effects of other viral sexually transmitted diseases have brought condoms back to the forefront in discussions of contraception in both the general press and the medical literature. Development of several newer barrier methods and improved understanding of use of the older methods by adolescents have occurred during the past few years.

CSF otorrhea complicating osteoradionecrosis of the temporal bone.

Osteoradionecrosis of the temporal bone is a well-recognized complication of radiotherapy for head and neck malignancy. There are two mechanisms by which this condition can produce damage to nearby structures and even result in death. Osteoradionecrosis may (1) predispose the patient to an aggressive or chronic infectious process, or (2) cause destruction of tissue by direct necrosis. A review of the literature failed to disclose a cause of CSF otorrhea complicating osteoradionecrosis of the temporal bone. This paper describes a case of skull base osteoradionecrosis, including necrosis of the tympanic membrane, associated with CSF otorrhea. Successful control of this complication was achieved using a translabyrinthine approach to locate the fistula, which originated from the internal auditory canal and was discharging through the middle ear via the oval window. The leak was sealed, the resultant mastoid cavity was obliterated by rotation of a temporalis muscle flap, and the external auditory canal was closed by the Fisch technique.