[Measuring the willingness of chronic pain patients to change pain management behavior - a study on the transtheoretical model]. / Erfassung der Bereitschaft zur Anderung des Bewältigungsverhaltens bei chronischen Schmerzpatienten. Einse Studie zum Transtheoretischen Modell.

RESEARCH QUESTION: The transtheoretical model (TTM) describes the willingness of behavior change as a process characterized by six stages: precontemplation, contemplation, preparation, action, maintenance, and termination. This study investigates the possibility to apply the TTM to the treatment of chronic pain patients. The main goal is the development of items for a self-administered instrument, which documents the willingness to use cognitive-behavioral methods for pain management independently. With this instrument a treatment can be assigned according to the patient's motivation in order to improve outcomes of pain management programs. METHODS: Based on TTM theory 56 items were developed and adminstered to a sample of 118 chronic pain patients, who were recruited via different facilities for pain therapy. Item- and factor analysis were conducted for determining psychometrical attributes of items and latent scales. RESULTS: Analyses resulted in four consistent scales and accordingly four distinctive stages: precontemplation, preparation, action, and maintenance, which showed sufficiently high indices of homogeneity and discriminant validity. The relationships between scale scores and sociodemographic and pain related variables proved to be in accordance to the theory. CONCLUSIONS: The results show transferability of the TTM to pain management in general. Two stages, contemplation and termination, could not be identified yet. Mainly termination seems not to be existent in the context of pain management. A further study should confirm these findings before therapeutical interventions can be assigned more specifically by the motivational preparedness.

P53 and cyclin D1 staining patterns of malignant and premalignant oral lesions in age-dependent populations.

OBJECTIVE: Recent epidemiologic studies have identified a trend of increasing cancer incidence in younger patients. The purpose of this study was to determine whether this might be reflected by different molecular mechanisms for tumor development. STUDY DESIGN: Dysplastic and malignant oral lesions from age-distinct patient populations were immunohistochemically analyzed for expression of p53 and cyclin D1. Chi-square analysis was used to determine statistical significance. RESULTS: Eighty-two percent of "older" and 75% of "younger" carcinomas stained positively with p53; 63% of carcinomas in the older population and 55% of carcinomas in the younger population showed cyclin D1 positivity. Dysplasias showed similar cyclin D1 staining in both groups. Interestingly, 100% of "younger" dysplasias stained positively for p53, whereas 35.3% of "older" dysplastic lesions showed immunoreactivity. Staining of carcinomas was not statistically significant, whereas p53 staining of dysplasias proved highly significant (P < .025). CONCLUSIONS: p53 immunoreactivity is detectable at an earlier stage of carcinogenesis in younger patients than in the traditional risk population for oral cancer.

Mucoepidermoid carcinoma of the major salivary glands: clinical and histopathologic analysis of 234 cases with evaluation of grading criteria.

BACKGROUND: The authors had previously conducted an investigation of minor salivary gland mucoepidermoid carcinoma, in which they demonstrated that certain clinical and histopathologic features were useful in predicting biologic outcome. The current study investigated the usefulness of these features in determining the prognoses of patients with mucoepidermoid carcinomas of the major salivary glands. METHODS: Clinical data and 15 histopathologic features were compared in 4 patient groups based on outcome after initial treatment. The outcome groups were 1) survival without disease, 2) survival with tumor recurrence only, 3) survival with metastasis, and 4) death related to tumor. A numeric score was assigned to each unfavorable histopathologic feature. Low grade tumors had scores of 0-4. Intermediate grade tumors scored 5 or 6. High grade tumors had scores higher than 6. RESULTS: Most patients (75%) were tumor free after the initial treatment. Twenty-one patients (9%) had local recurrence only, 12 (5%) demonstrated metastasis and survived, and 25 patients (11%) died of their disease. CONCLUSIONS: Clinical features associated with metastasis or death were more advanced age, tumor size, and preoperative symptoms. Histopathologic features that correlated with poor outcome were cystic component less than 20%, 4 or more mitotic figures per 10 high-power fields, neural involvement, necrosis, and anaplasia. All five of these histopathologic features demonstrated statistical prognostic significance when parotid gland tumors from Groups 1 and 4 were compared (P < 0.001). The point-based grading system demonstrated a statistically significant correlation with outcome for parotid tumors but not for submandibular tumors. The authors' findings indicate that patients with tumors of equal histopathologic grade have a better prognosis when their tumors are in the parotid gland than when their tumors are in the submandibular gland. Six of eight submandibular tumors that metastasized or resulted in death were low grade lesions, and none were high grade.

Salivary gland cystadenocarcinomas. A clinicopathologic study of 57 cases.

Current classification schemes for salivary gland neoplasms categorize cystadenocarcinomas on the basis of a recurring histomorphologic pattern of cystic, and often, papillary growth without features of other specific types of salivary gland tumors. To ascertain the clinicomorphologic spectrum and biologic behavior of this tumor, the clinicopathologic features of 57 cystadenocarcinomas from the files of the Armed Forces Institute of Pathology were studied. Excluding five Veterans Administration military cases, men and women were equally affected. Patients ranged in age from 20 to 86 years (mean, 58.8; median, 64), and patients aged over 50 years accounted for 71% of cases. Thirty-seven tumors (65%) occurred in major salivary glands, 35 in the parotid, and two in the sublingual glands. The 20 minor salivary gland tumors (35%) involved, in descending order, the lips, buccal mucosa, palate, tongue, retromolar area, and floor of mouth. Grossly, the lesions were cystic or multicystic masses that ranged in size from 0.4 to 6.0 cm. Microscopically, all tumors demonstrated an invasive, cystic growth pattern, and 75% had a conspicuous papillary component. The predominant cell type varied among tumors and included small cuboidal cells (35 cases), large cuboidal cells (nine cases), and tall columnar cells (seven cases). Six cases exhibited an admixture of cell types. Ruptured cysts with hemorrhage and granulation tissue were common. All 40 patients with follow-up data were either alive or had died of other causes and were free of tumor a mean interval of 59 months after their initial surgery. Three tumors recurred locally (mean interval, 76 months). Three tumors were metastatic to regional lymph nodes at the time of diagnosis, and one patient developed a regional lymph node metastasis after 55 months. Salivary gland cystadenocarcinomas represent a distinct group of malignancies that have an indolent biologic behavior.

An immunohistochemical analysis of anti-amylase antibody reactivity in acinic cell adenocarcinoma.

In many salivary acinic cell adenocarcinomas, well-differentiated serous acinar-type cells may be few and inconspicuous. In these cases it may be difficult to distinguish acinic cell adenocarcinoma from other types of salivary gland neoplasms such as cystadenocarcinoma. The usefulness of antisalivary amylase antibody immunohistochemical staining as a diagnostic aid was assessed on paraffin-embedded tissue sections from 27 typical acinic cell adenocarcinomas. Only 4 of 27 tumors showed reactivity in tumor cells. We conclude that anti-amylase antibody is of limited value in the recognition of acinic cell adenocarcinoma when light morphologic features are insufficient for diagnosis.

Atypical features in salivary gland mixed tumors: their relationship to malignant transformation.

Although criteria for distinction between the benign and malignant elements in carcinoma ex mixed tumor have been adequately described, there have not been any attempts to identify clinical or histologic features in benign mixed tumors that indicate increased risk of malignant change. For this reason, 65 mixed tumors of the major and minor salivary glands that exhibited atypical histologic features were examined in an attempt to analyze which, if any, of these features might indicate a greater likelihood of malignant transformation. The atypical features evaluated were hypercellularity, capsule violation, hyalinization, necrosis, and cellular anaplasia. The mitotic rate was also analyzed. The age of the patient, and the site, size, and prediagnostic duration of the tumor were recorded and, together with the histologic findings, were correlated with follow-up information. Nine (13.8%) of the 65 tumors underwent malignant transformation. Five of these patients died of the tumor, two others had distant metastases and were alive with the disease, and two were free of disease. Benign mixed tumors that showed prominent zones of hyalinization or at least moderate mitotic activity were more likely to develop carcinoma than those that did not. chi 2 analysis indicated that only hyalinization was significant (P < 0.05), but, with Fisher's exact test (two-tailed), this and all of the other features evaluated revealed a P value greater than 0.05. The other atypical features failed to correlate with malignant change. Clinical findings at the initial diagnosis that indicated a greater likelihood of malignant transformation were occurrence in the submandibular gland, older patient age, and large tumor size.

Cica-Care gel sheeting in the management of hypertrophic scarring.

A prospective, controlled clinical trial was undertaken to assess the efficacy and safety of two types of silicone gel, Silastic Gel Sheeting (SGS) and Cica-Care (CC), in the management of hypertrophic scars. Forty-two patients were randomly assigned to SGS and CC groups and their hypertrophic scars were divided into treated and control areas. Extensometric measurements were made at monthly intervals for 6 months and significant improvement of the treated areas relative to the control areas was observed. The two gels were not significantly different in efficacy or safety, but CC, being more adhesive and more comfortable than SGS, has advantages in ease of use and patient acceptability.

Bacteriophages from Bombyx mori.

Preparations of silkworm larvae contained two large phages with contractile tails (Myoviridae). One phage was active on Pseudomonas paucimobilis. The other, not cultivated, was one of the largest viruses known.

Tumor-associated lymphoid proliferation in the parotid gland. A potential diagnostic pitfall.

A substantial proportion of neoplastic and nonneoplastic parotid diseases have a prominent lymphoid component. The lymphoid element in lesions such as papillary cystadenoma lymphomatosum, sebaceous lymphadenoma, and lymphoepithelial carcinoma are readily recognized as a required diagnostic element. However, when other types of benign and malignant salivary gland neoplasms demonstrate tumor-associated lymphoid proliferation, the tumor may be either misclassified or misinterpreted as metastatic disease. Examples of primary benign and malignant parotid neoplasms exhibiting tumor-associated lymphoid proliferation are documented and illustrated. Other parotid lesions that may have a lymphoid element include sialadenitis, cysts with associated lymphoid tissue, parenchymal neoplasms with an expected lymphoid component or those that arise within an intraparotid lymph node, autoimmune disease, malignant lymphoma, and metastatic disease. An approach to recognition and separation of these entities is discussed.

Immunohistochemical analysis of basal cell adenocarcinoma.

Basal cell adenocarcinoma is a recently defined category of salivary gland neoplasms. As the terminology implies, this group of tumors has many histopathologic features that are similar to the more well-known basal cell adenomas. To better characterize these tumors, 23 basal cell adenocarcinomas were reviewed and compared with 11 basal cell adenomas with the use of light microscopic and immunohistochemical methods. Evaluation of cytokeratin, S-100 protein, glial fibrillary acidic protein, carcinoembryonic antigen, epithelial membrane antigen, smooth muscle actin, vimentin, B72.3, Ber-EP4, and milk fat globulin immunoreactivity was performed. Parallel to the morphologic similarity, the immunoprofiles of the basal cell adenocarcinoma and basal cell adenoma were quite similar. Both tumors showed reactivity patterns indicative of ductal epithelial and myoepithelial differentiation. In addition, reactivity to some polymorphic epithelial mucins was observed, which suggested glandular differentiation. The identification of antigens found normally in myoepithelial and epithelial cells supports the concept that these tumors are derived from pluripotential salivary gland epithelial cells. The comparable immunohistochemical profiles imply evolvement from similar cell lines and lead us to conclude that distinction between the two is not possible on the basis of these findings.

Mucoepidermoid carcinoma of intraoral salivary glands. Evaluation and application of grading criteria in 143 cases.

The histopathologic criteria most useful for grading of mucoepidermoid carcinomas are controversial. To identify those histologic features most important in the grading of intraoral mucoepidermoid carcinomas, 143 cases of this disease with clinicopathologic correlations were studied. Twelve histopathologic features of each tumor and their clinical presentation were correlated with patient outcome. Seven patients died of disease, 5 had regional metastases only, 10 had recurrences only, and 121 had no additional problems. Clinical features suggesting aggressive behavior were short duration, presence of clinical symptoms, and location of tumor in the tongue and floor of the mouth. The histopathologic features that indicated high-grade behavior were an intracystic component of less than 20%, four or more mitotic figures per ten high-power fields, neural invasion, necrosis, and cellular anaplasia. The simultaneous assessment of these features showed improved prognostic correlation over individual parameters. A quantitative grading system was devised using these features. Tumors with a point score of 0 to 4 were considered low grade, and none of 122 patients with scores in this range died of their tumor, although 9 had recurrences only and 3 had regional metastases. Point scores of 7 or above indicated highly aggressive behavior. Six of ten patients with these high scores died of tumor. Most of these six patients had recurrences and regional metastases, and all had distant metastases. Two other patients had regional metastases only. Scores of 5 to 6 were considered intermediate between low-grade and high-grade scores because only 1 of 13 patients with these scores died of disease. Three of the five patients with regional metastasis had low-grade tumors, indicating the inability of the grading system to identify them. Nonetheless, with an average follow-up on these patients of 10 years after treatment of the metastasis, no patient had additional problems. The relative objectivity of our proposed grading system for intraoral mucoepidermoid carcinomas may help achieve more accurate and consistent grading of these rare tumors.

Juvenile aggressive fibromatosis: report of three cases and review of the literature.

AF is a non-encapsulated, non-metastasizing fibrous tumor that has a tendency for local recurrence in up to 70% of cases. We suspect possible genetic disposition. Microscopically, AF is a poorly circumscribed fibrous tumor that infiltrates surrounding tissues. It presents as a painless, rapidly growing mass with a predilection for bone destruction. Treatment consists of a carefully planned en bloc resection after biopsy and accurate radiologic evaluation of the extent of the tumor. Radiation therapy and chemotherapy can be used as adjuvant therapy in selected patients. Three patients with AF of the head and neck are described, of which two were found to have congenital disorders of mesodermal development.

The graphical representation of clinical trials with particular reference to measurements over time.

Clinical trials are frequently analysed as if they were surveys when they are in fact experiments. In particular the experimental basis of clinical trials is rarely reflected in the graphs which are used to illustrate them. Proposals are made, and illustrated by example, as to how appropriate figures may be devised, both for parallel-group designs and for crossover trials, to illustrate the experimental nature of clinical trials with measurements over time.

Diagnosis of oral hairy leukoplakia by ultrastructural examination of exfoliative cytologic specimens.

Lingual exfoliative cytologic specimens (scrapings) were obtained from 18 patients positive for human immunodeficiency virus with clinical oral hairy leukoplakia. Buccal mucosal scrapings were obtained from 12 of these patients. The specimens were processed for examination by transmission electron microscopy (TEM). Sixteen (89%) of the lingual specimens revealed infection of keratinocytes by herpes-type virus. There was no evidence of virus infection in the 12 buccal mucosal scrapings. Fungal hyphae were seen by TEM in 14 (78%) of the lingual scrapings and two (17%) of the buccal scrapings. One exfoliative specimen and two biopsy specimens were stained for Epstein-Barr virus DNA with a DNA probe. The demonstration of herpes-type virions by TEM in keratinocytes from a lesion clinically suspected to be hairy leukoplakia provides direct, objective diagnosis. Furthermore, use of exfoliative cytologic specimens provides a clinically simple, noninvasive technique.

Prolonged endotoxemia enhances the renal injuries induced by gentamicin in rats.

The aim of this study was to evaluate the role of chronic endotoxemia in the nephrotoxicity of gentamicin (GM). Saline or Escherichia coli lipopolysaccharide (LPS) was administered to conscious rats by continuous intravenous perfusion (1 mg/kg per day for 7 days) from a subcutaneously implanted osmotic pump. Twenty-four hours after surgery (day zero), treatment with saline or GM (15 mg/kg; intraperitoneally, twice a day) was started for 5 days. Levels of LPS in plasma measured by Limulus amoebocyte lysate activity decreased significantly from days 1 through 8. At days 5 and 8, the cortical concentrations of GM were higher in the LPS-perfused and GM-treated group (LPS plus GM) than they were in the saline-perfused and GM-treated group (saline plus GM) (P less than 0.05). Blood urea nitrogen and serum creatinine remained at normal levels throughout the experiment. A significant increase of cortical tubular cell regeneration was observed in the LPS plus GM animals as compared with regeneration observed in the other groups (saline plus saline, LPS plus saline, and saline plus GM), as measured by [3H]thymidine incorporation into DNA. Moreover, histopathological nephrotoxicity scores showed a synergistic toxic effect between LPS and GM. These results demonstrate that chronic perfusion of low doses of LPS potentiates the nephrotoxicity of GM.

Endotoxin increases the nephrotoxic potential of gentamicin and vancomycin plus gentamicin.

To assess the possible role of endotoxin as an amplification factor for experimental nephrotoxicity due to gentamicin plus vancomycin, rats were given continuous intravenous (iv) endotoxin or saline followed by twice-daily intraperitoneal (ip) saline, vancomycin (20 mg/kg ip), gentamicin (15 mg/kg subcutaneously), or both gentamicin and vancomycin. After 5 or 8 days of treatment, functional and histologic parameters of renal function were evaluated: cortical drug levels, tritiated thymidine incorporation into cellular DNA, creatinine clearance, and appearance by light and electron microscopy. In animals not given endotoxin, only rats that received gentamicin plus vancomycin developed measurable abnormalities. Endotoxin did not cause nephrotoxicity in vancomycin-treated rats. However, in endotoxin-infused rats treated with gentamicin or gentamicin plus vancomycin for 8 days, the increase in blood urea nitrogen, decrease in creatinine clearance, and rise in renal cortical DNA synthesis were more severe than those in non-endotoxin-infused rats (P less than .01). In these studies, endotoxin amplified the nephrotoxic potential of gentamicin alone and gentamicin plus vancomycin.

Virus-associated dysplasia (bowenoid papulosis?) of the oral cavity.

We are presenting a case of multifocal, virus-associated dysplasia of the oral cavity. We believe this case represents bowenoid papulosis, which usually is limited to the genital region. The patient, a 21-year-old white man, had recently completed therapy for Hodgkin's disease. An oral examination revealed multiple red 3 to 6 mm macules scattered over the oral mucosa, involving the buccal and labial mucosa, palate, and gingiva. The favored clinical diagnosis was candidiasis. Histologically, the biopsy specimen showed severe epithelial dysplasia. Three additional oral biopsies of different sites were performed and revealed similar histology. Immunohistochemical stains for human papillomavirus were done, and two of four lesions stained positively. Transmission electron microscopy revealed intranuclear viral particles consistent with human papillomavirus. Further questioning and examination of the patient revealed that he had lesions of the penis that were clinically and histologically bowenoid papulosis. In addition, he admitted to oral-genital sex during the period of therapy for Hodgkin's disease. This is the first reported case of oral bowenoid papulosis, and it supports a viral cause for this disease process.

Intrarenal distribution of vancomycin in endotoxemic rats.

We previously observed that the intrarenal distribution of aminoglycosides was modified by Escherichia coli endotoxin in the absence of any major renal physiological disturbance or histological changes. In the present study, we evaluated the role of E. coli endotoxin on the intrarenal distribution of vancomycin. At the beginning of the experiment, female Sprague-Dawley rats were infused intravenously with saline (control) or endotoxin (0.25 mg/kg) during 15 min. Thereafter, saline was constantly infused for the following 4 h. Two hours after the beginning of the infusion, animals were injected intravenously with a single dose of vancomycin (20 mg/kg). The drug levels in serum; renal cortex, medulla, and papilla; and urine were evaluated from 0.08 to 24 h after injection. Analysis of the area under the curve of the drug concentration in the different kidney components versus time showed a higher accumulation of vancomycin in the renal cortex and medulla in the endotoxin-infused rats than in the normal rats (P less than 0.01). Endotoxin was associated with an increase in the half-life in serum (P less than 0.01) and a lower elimination rate constant. The total clearance of vancomycin from plasma was significantly decreased in endotoxin-treated rats (P less than 0.01). These results demonstrate that endotoxin modifies the renal handling of vancomycin.

Metastatic adenocarcinoma of the colon presenting as periradicular periodontal disease: a case report.

Metastases to the jaws account for only 1% of all malignant tumors of the oral cavity. Consequently the diagnosis of metastasis to the mandible requires a high degree of clinical suspicion and the use of a systematic diagnostic approach. In this case report a patient sought treatment for what appeared clinically and radiographically as periradicular periodontal disease. However, because the patient had a medical history of adenocarcinoma of the colon 5 years previously, metastasis to the jaws was included in the differential diagnosis. Metastasis to the jaws may resemble periodontal disease or many of the other benign and malignant conditions that affect the jaws, thus making the correct radiographic diagnosis difficult. Ultimately, histologic evaluation is essential to make a definitive diagnosis.