Multidisciplinary decision-making regarding chemotherapy for lung cancer patients-An age-based comparison.

Optimising decision-making in elderly patients is becoming increasingly urgent. We analysed treatment decisions and course of therapy for patients with lung cancer in different age categories: <65, 65-75, and 75 years and older. About 349 patients with lung cancer (median age 67.8 years), discussed at the multidisciplinary team meeting in the Diakonessenhuis Utrecht, the Netherlands, were reviewed. Multidisciplinary decision-making and subsequent clinical course were extracted from medical files. We found that 39% of eligible patients older than 75 years of age started treatment with chemotherapy compared to 80% of the younger patients (<65 and 65-75). When patients did receive chemotherapy, primary and secondary treatment adaptations were effectuated in 58%: for patients aged <65 in 49%, for patients aged 65-75 and >75 years in 66%. For 44% of all patients treated with chemotherapy, unplanned hospital admissions were required: in 42% for the patients <65, in 52% for those aged 65-75 and in 27% for >75 years. The decision-making process and course of treatment for lung cancer vary per age category. In particular, patients between 65 and 75 years of age might be more frail than initially thought. Age and frailty are important characteristics that need more attention.

Chemotherapy and healthcare utilisation near the end of life in patients with cancer.

The quality of medical care delivered to patients with cancer near the end of life is a significant issue. Previous studies have defined several areas suggestive of aggressive cancer treatment as potentially representing poor quality care. The primary objective of current analysis was to examine chemotherapy and healthcare utilisation in the last 3 months of life among patients with cancer that received palliative chemotherapy. Patients were selected from the hospital administration database of the Diakonessenhuis Utrecht, the Netherlands. Data were extracted from the medical files. A total of 604 patients were included for analysis (median age: 64 years). For 300 patients (50%) chemotherapy was given in the last 3 months (CT+). For 76% (n = 229) of CT+ patients unplanned hospital admissions were made in these last 3 months, compared to 44% (n = 133) of CT- patients (p < .001). Visits to the emergency room in last 3 months were made by 67% (n = 202) of CT+ patients compared to 43% (n = 132) of CT- patients (p < .001). Healthcare consumption was significantly higher in patients who received chemotherapy in the last 3 months of life. Being able to inform our patients about these aspects of treatment can help to optimise both the quality of life and the quality of dying in patients with cancer.

Anatomic Malformations of the Middle and Inner Ear in 22q11.2 Deletion Syndrome: Case Series and Literature Review.

BACKGROUND AND PURPOSE: The 22q11.2 deletion syndrome is characterized by a heterogenic phenotype, including hearing loss. The underlying cause of hearing loss, especially sensorineural hearing loss, is not yet clear. Therefore, our objective was to describe anatomic malformations in the middle and inner ear in patients with 22q11.2 deletion syndrome. MATERIALS AND METHODS: A retrospective case series was conducted in 2 tertiary referral centers. All patients with 22q11.2 deletion syndrome who had undergone CT or MR imaging of the temporal bones were included. Radiologic images were evaluated on predetermined parameters, including abnormalities of the ossicular chain, cochlea, semicircular canals, and vestibule. RESULTS: There were 26 patients (52 ears) with a CT or MR imaging scan available. A dense stapes superstructure was found in 18 ears (36%), an incomplete partition type II was suspected in 12 cochleas (23%), the lateral semicircular canal was malformed with a small bony island in 17 ears (33%), and the lateral semicircular canal and vestibule were fused to a single cavity in 15 ears (29%). CONCLUSIONS: Middle and inner ear abnormalities were frequently encountered in our cohort, including malformations of the lateral semicircular canal.

Ultrasonography and ultrasound-guided fine-needle aspiration biopsy of head and neck lesions: a surgical perspective.

A head and neck ultrasound-guided fine-needle aspiration clinic was set up to determine the role of ultrasound and ultrasound-guided fine-needle aspiration in the evaluation of patients with lesions in this region. One hundred ninety-five lesions were biopsied by ultrasound-guided fine-needle aspiration in 203 patients. Ultrasound detected 2 or more lesions in 14 (48%) of 29 patients with a clinically solitary thyroid nodule. Three (8.8%) of 34 lesions thought to be within the parotid gland were determined to be external. A pronounced learning curve was evident in the technique of ultrasound-guided fine-needle aspiration, particularly for nonpalpable disease. Adequacy of sampling for each 3-month period was 71%, 89%, and 94%, respectively. Seventy-four percent of central aspirations were satisfactory compared to 54% of peripheral aspirations. Ultrasound-guided fine-needle aspiration did not alter the clinical staging of metastatic neck disease in 8 patients having 10 neck dissections but proved useful in detecting nodal recurrence in 3 irradiated necks that did not proceed to surgery. The smallest node to harbor malignancy had 4-mm maximal axial diameter. We conclude that ultrasound and ultrasound-guided fine-needle aspiration are valuable adjuncts to the clinical examination.

Clinical diagnosis of influenza virus infection: evaluation of diagnostic tools in general practice.

BACKGROUND: With the development of new antiviral agents for influenza, the urge for rapid and reliable diagnosis of influenza becomes increasingly important. Respiratory virus infections are difficult to distinguish on clinical grounds. General practitioners (GPs) however, still depend on their clinical judgement. AIM: To evaluate the importance of clinical symptoms in the diagnosis of influenza virus infection. DESIGN OF STUDY: A multicentre questionnaire study. SETTING: Eighty-one patients from 14 general practices. METHOD: Patients with fever and at least one constitutional symptom and one respiratory symptom were included. A questionnaire with the medical history and clinical symptoms was completed and a combined nose-throat swab was taken. Virus culture, rapid culture, and polymerase chain reaction (PCR) amplification were performed on each specimen. Multivariate analysis was used to obtain the best predictive model. RESULTS: By using PCR, an increase was seen in the detection of the viral pathogens compared with the results of culture. In 42 out of 81 patients PCR was positive for influenza. A positive predictive value (PPV) of 75% was observed for the combination of headache at onset, feverishness at onset, cough, and vaccination status during the period of increase influenza activity. Criteria used by the ICHPPC-2 resulted in a PPV of 54%. The PPV for diagnosis made by the GP was 76%. CONCLUSION: Although influenza is difficult to diagnose on clinical grounds, the GPs in this study were able to diagnose influenza as such more accurately on their judgement than by the other criteria.

Plexiform neurofibroma of the submandibular salivary gland in a child.

Plexiform neurofibromas in major salivary glands are rarely described. In the literature, most reported tumours have been present in the parotid gland region. A three-year-old boy with a family history of neurofibromatosis presented with a rapidly growing left submandibular mass. The clinical diagnosis was that of a neurofibroma rather than a primary salivary gland tumour. Resection of the lesion revealed a plexiform neurofibroma involving the submandibular gland. Although these tumours have a neurogenic rather than a salivary gland origin, they must be considered in the differential diagnosis of a salivary gland lesion in a patient with a history of neurofibromatosis.

Angiographic embolization for the treatment of epistaxis: a review of 108 cases.

Ninety-seven patients were referred to the Toronto Hospital (Western Division) between January 1984 and January 1992 for selective angiographic embolization (108 embolizations, including repeat procedures) to control intractable or recurrent severe epistaxis. Eighty-one patients (comprising 94 embolizations) were referred on an emergent basis because of failure of conventional conservative therapy, consisting of anterior and posterior packing. The remaining 16 patients (14 embolizations) were referred electively for recurrent epistaxis. A retrospective review of these cases was performed, with long-term telephone follow-up achieved in over 95% of cases. Embolization safely controlled active hemorrhage in 88% of the emergent cases. The success rate increased to 90% when two cases in which the source of epistaxis was found to be from the internal carotid artery were excluded (because these vessels could not be safely embolized). Of the patients whose epistaxis was initially controlled by embolization, 82% had no further nosebleeds (follow-up time ranged from 2 to 82 months; average, 26.8 months). More than half of the long-term failures were seen in patients with Osler-Weber-Rendu disease. Overall, the mortality rate was 0% and the long-term morbidity rate was 2% (one cerebral vascular accident and one case of skin slough in the territory of the superficial temporal artery.

The economic cost of otitis media in Canada.

The purpose of this study was to estimate the total costs of otitis media (OM) from a societal perspective using a prevalence-based approach to estimate disease related costs for Canadians with OM in 1994. Direct expenditures attributable to OM associated with hospitals, other institutions, physicians, other health professionals, drugs, research and other components of care were assessed, along with estimates of lost productivity due to illness and the workloss of caregivers. The total costs of OM for Canadians were $611.0 million in 1994, with direct and indirect cost components at $470.7 million and $140.3 million, respectively. Over 70% of total OM costs were attributed to children aged 14 years and under ($428.4 million), with direct and indirect costs being $334.1 million and $94.3 million, respectively. This study highlights the scope and magnitude of the economic consequences of OM. The costs calculated may be used to provide guidance in the setting of priorities for research and prevention activities.

Distal airway foreign bodies: Importance of a stepwise approach, knowledge of equipment and utilization of other services' expertise.

Many distal airway foreign bodies present as obstructive atelectasis and may be removed using instruments passed through rigid bronchoscopes. Deeply impacted distal foreign bodies remain problematic and sometimes require thoracotomy. The purpose of this paper is to discuss alternate approaches to avoid open surgical removal. A clinical algorithm is outlined. A young child presented to the hospital with an episode of coughing and oxygen desaturation. A chest radiograph demonstrated a radiopaque foreign body in the right upper lobe with distal atelectasis. The foreign body could not be found using rigid bronchoscopy so a flexible bronchoscope (3.5mm) was used to identify the distal primary tooth that was lodged in the inflamed tertiary segment of the bronchus. The tooth could not be removed using instruments passed through the sideport of the bronchoscope including balloon catheters, ureteral baskets, and biopsy forceps. The catheters were too compliant to reach the upper lobe and the forceps could not engage the tooth. A decision was made to treat the child with steroids and attempt removal 48 h later. The inflammation had resolved and the tooth had shifted positions to a more accessible left lower lobe tertiary segment. Using fluoroscopy with guide wires through the endotracheal tube, the tooth was removed. Tools used by different services are available as well to retrieve foreign bodies and may obviate the need for thoracotomy. Steroids decreased swelling allowing better access to the foreign body.

Electrical coupling of longitudinal and circular intestinal muscle.

Space constants (lambda) were determined for longitudinal-circular muscle strips of cat jejunum by the partition method. Pulses of hyperpolarizing current spread along the major axes of circular muscle cells. In the absence of electrical coupling lambda measured from the longitudinal side of the strips should have been approximately 20 times shorter than lambda measured from the circular side. Median values were found to be statistically the same, 2.4 mm for the longitudinal side (n = 13) and 2.9 mm for the circular (n = 25). Methyl blue, iontophoretically injected into cells on the longitudinal side after recording large hyperpolarizing responses, was found in muscle cells located superficially in the longitudinal layer. The radial lambda for longitudinal muscle, determined from the change in magnitude of the hyperpolarizing response as the microelectrode was advanced through the layer, was 0.27 mm. This is too large to cause differences in depth of recording to significantly affect the circumferential lambda in this layer. These data provide evidence for a high degree of electrical coupling between the two muscle layers of cat jejunum.

Socioeconomic impact of otitis media in North America.

OBJECTIVE: Otitis media (OM) is a common and expensive disease with estimated cost to the health care system in the U.S.A. estimated at 3 to 4 billion dollars and to that of Canada at 600 million dollars per year. Despite the high prevalence rates reported in North America, there remains little censensus about which of the various treatment strategies (medical or surgical) is most clinically effective, which is most cost effective, or which has the most economic and societal impact. Few studies have been conducted comparing the various treatment strategies or analyzing outcome measurement of physiologic end-points relative to the various treatments and quality-of-life issues. This article addresses these problem areas and gives recommendations and guidelines for consideration in the treatment of OM, as well as a review of the literature available.

Accuracy and usefulness of radiographic assessment of cervical neck infections in children.

OBJECTIVE: To determine the accuracy and usefulness of computed tomography (CT) in diagnosis and management of lateral and deep neck infections METHODS: An 11-year retrospective review of 110 children (age range 1 months to 17 years) was conducted at a tertiary care children's hospital. RESULTS: Fifteen patients treated medically (8 with cellulitis, 7 with early abscess) improved. Of the remaining 95 patients who had 107 cervical sites drained surgically, CT predicted accurately operative findings in 81 (76%) cases (72 with abscess, 9 with cellulitis). In the 26 (24%) cases with discrepancy between CT interpretation and operative findings, the most common problem was differentiating early abscess from cellulitis with 18 false positives (no abscess at surgery). In 8 cases, CT diagnosis other than abscess was made (4 cellulitis, 1 inflammatory mass, 1 hematoma, 1 lymphangioma, and 1 tumour); however, when the patients were operated on because of lack of improvement, an abscess was found. CONCLUSIONS: Although CT is helpful both in determining the presence and location of neck infections in children, the CT scan is less helpful in differentiating abscess from lymphadenitis, cellulitis, and some complex cervical masses.

Simultaneous detection of influenza viruses A and B using real-time quantitative PCR.

Since influenza viruses can cause severe illness, timely diagnosis is important for an adequate intervention. The available rapid detection methods either lack sensitivity or require complex laboratory manipulation. This study describes a rapid, sensitive detection method that can be easily applied to routine diagnosis. This method simultaneously detects influenza viruses A and B in specimens of patients with respiratory infections using a TaqMan-based real-time PCR assay. Primers and probes were selected from highly conserved regions of the matrix protein gene of influenza virus A and the hemagglutinin gene segment of influenza virus B. The applicability of this multiplex PCR was evaluated with 27 influenza virus A and 9 influenza virus B reference strains and isolates. In addition, the specificity of the assay was assessed using eight reference strains of other respiratory viruses (parainfluenza viruses 1 to 3, respiratory syncytial virus Long strain, rhinoviruses 1A and 14, and coronaviruses OC43 and 229E) and 30 combined nose and throat swabs from asymptomatic subjects. Electron microscopy-counted stocks of influenza viruses A and B were used to develop a quantitative PCR format. Thirteen copies of viral RNA were detected for influenza virus A, and 11 copies were detected for influenza virus B, equaling 0.02 and 0.006 50% tissue culture infective doses, respectively. The diagnostic efficacy of the multiplex TaqMan-based PCR was determined by testing 98 clinical samples. This real-time PCR technique was found to be more sensitive than the combination of conventional viral culturing and shell vial culturing.

Applicability of a real-time quantitative PCR assay for diagnosis of respiratory syncytial virus infection in immunocompromised adults.

Respiratory syncytial virus (RSV) accounts for the majority of respiratory virus infections, producing high mortality rates in immunocompromised patients with hematologic malignancies. The available methods for the rapid detection of RSV by antigen detection or PCR either lack sensitivity, require complex laboratory manipulation, or have not been evaluated in this patient population. To assess the applicability of a TaqMan-based real-time PCR technique for the detection of RSV A and B in immunocompromised adults, we developed a rapid, sensitive detection method that simultaneously detects RSV A and B and can be applied in routine diagnostics. The specificity of the assay was assessed using a panel of reference strains of other respiratory viruses and RSV. Electron microscopy-counted stocks of RSV A and B were used to develop a quantitative PCR format. Eleven copies of viral RNA could be detected for RSV A strain Long, and 14 copies could be detected for RSV B strain 9320, corresponding to 50% tissue culture infective doses of 0.86 and 0.34, respectively. The assay was evaluated on 411 combined nose and throat swabs derived from immunocompromised adults with or without signs of respiratory tract infection. The diagnostic efficacy of the TaqMan PCR determined on the clinical samples showed that this real-time PCR technique was substantially more sensitive than the combination of conventional viral culture and shell vial culture. None of the clinical specimens derived from patients without signs of respiratory illness were found to be positive for RSV by real-time TaqMan PCR.