Extended-spectrum beta-lactamase Escherichia coli and Klebsiella pneumoniae urinary tract infections.

The prevalence of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae urinary tract infections (UTIs) is increasing worldwide. We investigated the prevalence, clinical findings, impact and risk factors of ESBL E. coli/K. pneumoniae UTI through a retrospective review of the medical records of children with UTI aged <15 years admitted to Prince of Songkla University Hospital, Thailand over 10 years (2004-2013). Thirty-seven boys and 46 girls had ESBL-positive isolates in 102 UTI episodes, compared with 85 boys and 103 girls with non-ESBL isolates in 222 UTI episodes. The age of presentation and gender were not significantly different between the two groups. The prevalence of ESBL rose between 2004 and 2008 before plateauing at around 30-40% per year, with a significant difference between first and recurrent UTI episodes of 27.3% and 46.5%, respectively (P = 0.003). Fever prior to UTI diagnosis was found in 78.4% of episodes in the non-ESBL group and 61.8% of episodes in the ESBL group (P = 0.003). Multivariate analysis indicated that children without fever (odds ratio (OR) 2.14, 95% confidence interval (CI) 1.23-3.74) and those with recurrent UTI (OR 2.67, 95% CI 1.37-5.19) were more likely to yield ESBL on culture. Congenital anomalies of the kidney and urinary tract were not linked to the presence of ESBL UTI. In conclusion, ESBL producers represented one-third of E. coli/K. pneumoniae UTI episodes but neither clinical condition nor imaging studies were predictive of ESBL infections. Recurrent UTI was the sole independent risk factor identified.

Disparity in utilization and expectation of community-based maternal health care services among women in Myanmar: a cross-sectional study.

BACKGROUND: Aim of this study is to assess women's utilization and expectation of community-based antenatal and delivery care services in Myanmar and determine associated factors for disparity of services received with services women expected to receive. METHODS: A cross-sectional survey was conducted among 6-month postpartum women in three townships of Myanmar during May-September 2016. Associated factors for the services with disparity were identified using multinomial logistic regression models. RESULTS: Of 1743 women, the percentages of antenatal care (ANC) attended by a skilled provider, at least four ANC visits, and early ANC were 89, 60 and 36%, respectively. The percentage of non-facility delivery was 65%. Many ANC services received and services expected to receive had lower than 80% coverage. Services with significant disparity included blood hemoglobin and urinary protein testing, and iron supplementation. Low access to ANC, women's socio-economic status, pregnancy and delivery complications, and out-of-pocket cost were associated with disparity of these services. CONCLUSION: Utilization and expectation of community-based ANC services and facility delivery is low in Myanmar. Disparities of the services received with the services women expected to receive were common in ANC. Improving women's expectations on essential services during pregnancy is needed as well as strengthening community participation.

Progress and challenges in improving maternal health in the Tibet Autonomous Region, China.

BACKGROUND: The maternal mortality ratio (MMR) of the Tibet Autonomous Region (hereinafter "Tibet") is still five times higher than the national average. This study aims to identify the successes and pitfalls of the health system that might be related to the high mortality rate based on the WHO health system building blocks, focusing on human resources for health and health infrastructure and the impact on maternal health and outcomes. METHODS: Sources of information include China's central government and Tibet's local government policies and regulations, health statistical yearbooks, maternal and child health routine reporting system, and English and Chinese online research articles. Joinpoint analysis was applied for MMR and maternal health service trends, and correlation test was used to test the relationship between maternal health services and outcomes. RESULTS: Between 2000 and 2015, public health spending in Tibet increased 67-fold, the hospital delivery rate increased 70.1%, and the MMR dropped from 466.9 to 100.1 per 100,000 live births. However, the total number of health workers, qualified medical doctors, and registered nurses per 1,000 people were 4.4, 1.4, and 1.0, respectively, much lower than the national average (5.8, 1.8, and 2.4). In Tibet, there were 80 basic and 16 comprehensive emergency obstetric care (EOC) centers. On average, there were 12 basic and 2.5 comprehensive EOC centers per 500,000 of the population. Though it met the WHO's recommendation, it might remain inadequate in the low population density of the area like Tibet. CONCLUSION: The shortage of health professionals and EOC centers and health information in predominantly remote rural areas with a scattered population still needs to be rectified.

Adiposity rebound from three to six years of age was associated with a higher insulin resistance risk at eight-and-a-half years in a birth cohort study.

AIM: The association between adiposity rebound and insulin resistance in middle childhood has seldom been studied. We examined the effect of body mass index (BMI) velocity and early adiposity rebound on the insulin resistance of prepubertal children. METHODS: BMI data from a longitudinal follow-up of a birth cohort in Thailand were used. The homoeostatic model assessment of insulin resistance (HOMA-IR) was calculated from 12-hour fasting plasma glucose and serum insulin at eight-and-a-half years of age. BMI velocity was calculated from four periods: zero to one, one to three, three to six and six to eight-and-a-half years of age. A multiple linear regression model was used to assess the association of BMI velocity during these four periods and insulin resistance at the age of eight-and-a-half years. RESULTS: In 814 children - 76.7% of the initial cohort - BMI velocities between years one to three, three to six and six to eight-and-a-half years were positively associated with HOMA-IR levels after adjusting for demographic, behavioural and socio-economic factors. Children who had BMI gains between three and six years had mean HOMA-IR values that were 43% higher than those who did not. CONCLUSION: BMI velocity during early and middle childhood, and early adiposity rebound between three and six years, was associated with a higher insulin resistance risk at eight-and-a-half years.

Molecular epidemiology and spatiotemporal analysis of hospital-acquired Acinetobacter baumannii infection in a tertiary care hospital in southern Thailand.

BACKGROUND: Acinetobacter baumannii is a major hospital-acquired pathogen in Thailand that has a negative effect on patient survival. The nature of its transmission is poorly understood. AIM: To investigate the genotypic and spatiotemporal pattern of A. baumannii infection at a hospital in Thailand. METHODS: The medical records of patients infected with A. baumannii at an 800-bed tertiary care hospital in southern Thailand between January 2010 and December 2011 were reviewed retrospectively. A. baumannii was identified at the genomospecies level. Carbapenemase genes were identified among carbapenem-resistant isolates associated with A. baumannii infection. A spatiotemporal analysis was performed by admission ward, time of infection and pulsed-field gel electrophoresis (PFGE) groups of A. baumannii. RESULTS: Nine PFGE groups were identified among the 197 A. baumannii infections. All A. baumannii isolates were assigned to International Clonal Lineage II. blaOXA-23 was the most prevalent carbapenemase gene. Outbreaks were observed mainly in respiratory and intensive care units. The association between PFGE group and hospital unit was significant. Spatiotemporal analysis identified 20 clusters of single PFGE group infections. Approximately half of the clusters involved multiple hospital units simultaneously. CONCLUSIONS: A. baumannii transmitted both within and between hospital wards. Better understanding and control of the transmission of A. baumannii are needed.

An audit of the management of childhood-onset growth hormone deficiency during young adulthood in Scotland.

BACKGROUND: Adolescents with childhood onset growth hormone deficiency (CO-GHD) require re-evaluation of their growth hormone (GH) axis on attainment of final height to determine eligibility for adult GH therapy (rhGH). AIM: Retrospective multicentre review of management of young adults with CO-GHD in four paediatric centres in Scotland during transition. PATIENTS: Medical records of 130 eligible CO-GHD adolescents (78 males), who attained final height between 2005 and 2013 were reviewed. Median (range) age at initial diagnosis of CO-GHD was 10.7 years (0.1-16.4) with a stimulated GH peak of 2.3 µg/l (0.1-6.5). Median age at initiation of rhGH was 10.8 years (0.4-17.0). RESULTS: Of the 130 CO-GHD adolescents, 74/130(57 %) had GH axis re-evaluation by stimulation tests /IGF-1 measurements. Of those, 61/74 (82 %) remained GHD with 51/74 (69 %) restarting adult rhGH. Predictors of persistent GHD included an organic hypothalamic-pituitary disorder and multiple pituitary hormone deficiencies (MPHD). Of the remaining 56/130 (43 %) patients who were not re-tested, 34/56 (61 %) were transferred to adult services on rhGH without biochemical retesting and 32/34 of these had MPHD. The proportion of adults who were offered rhGH without biochemical re-testing in the four centres ranged between 10 and 50 % of their total cohort. CONCLUSIONS: A substantial proportion of adults with CO-GHD remain GHD, particularly those with MPHD and most opt for treatment with rhGH. Despite clinical guidelines, there is significant variation in the management of CO-GHD in young adulthood across Scotland.

Important roles of public playgrounds in the transmission of hand, foot, and mouth disease.

Intra-home and kindergarten transmissions were the reported major modes of hand, foot, and mouth disease (HFMD) transmission in preschool children. However, infection at home is not common and 65-80% of cases do not attend preschool. We conducted a matched case-control study to explore the role of public playgrounds in the transmission of HFMD in addition to direct and indirect exposure to HFMD patients. We used 156 hospital source cases and 156 community source controls. Univariate analysis was followed by conditional logistic regression with attributable fraction computed. Adjusted odds ratios were 11·70 [95% confidence interval (CI) 1·26-109·40] for having HFMD cases in the same class, 14·19 (95% CI 3·55-56·74) for having HFMD cases within the 20 nearest neighbourhoods, 6·03 (95% CI 2·84-12·80) for exposure to public playgrounds, 2·13 (95% CI 1·05-4·32) for finger sucking and 0·29 (95% CI 0·11-0·78) for hand washing with soap before meals. The attributable fractions for the first four risk factors were 6·4%, 20·9%, 57·2% and 27·5%, respectively, while the population prevented fraction for hand washing with soap before meals was 18·7%. Based on our findings, hand washing with soap should be advocated. Health education could include topics which underline the precautions which need to be taken and the advice given regarding avoiding the use of public playgrounds during epidemic periods, especially when children have been getting sick.

Safety and efficacy of intensive intraoperative glycaemic control in cardiopulmonary bypass surgery: a randomised trial.

BACKGROUND: This study aimed to determine the safety and efficacy of intraoperative intensive glycaemic treatment with modified glucose-insulin-potassium solution by hyperinsulinemic normoglycaemic clamp in cardiopulmonary bypass surgery patients. We hypothesised that the treatment would reduce infection rates in this group of patients. METHODS: A prospective, randomised, double-blind trial was conducted in cardiopulmonary bypass surgery patients. A total of 199 adult patients (out of a planned 400) were randomly allocated to intensive or conventional treatment with target glucose levels of 4.4-8.3 mmol/l and < 13.8 mmol/l, respectively. The primary outcomes were clinical infection and cytokine levels, including interleukin (IL)-6 and IL-10. The secondary outcomes were morbidity and mortality. RESULTS: The study was terminated early because of safety concerns (hypoglycaemia). The clinical post-operative infection rate was 17% in the intensive group and 13% in the conventional group (P = 0.53). The proportion of patients with hypoglycaemia was significantly higher in the intensive group (23%) compared with the conventional group (3%) (P < 0.001). Morbidity and mortality rates were similar for both groups. Anaesthetic duration > 2 h (vs. ≤ 2 h), pre-operative IL-6 level > 15 pg/ml (vs. ≤ 15 pg/ml) and post-operative IL-6 level 56-110 pg/ml (vs. ≤ 55 pg/ml) were independent predictors for post-operative infection. CONCLUSIONS: Intraoperative intensive glycaemic treatment significantly increased the risk of hypoglycaemia, but its effect on post-operative infection by clinical assessment could not be determined. Anaesthetic duration, pre-operative and post-operative IL-6 levels can independently predict post-operative infection.

Pediatric lupus nephritis: more options, more chances?

Lupus nephritis (LN) is more common and severe in childhood-onset systemic lupus erythematosus (SLE) than in adults. It is one of the major causes of acute kidney injury (AKI) and chronic kidney disease (CKD) in children. Steroid therapy has been used as the first-line treatment for SLE since 1970, and has improved the survival of SLE patients from ∼ 50% to >80%. Over the years many immunosuppressive drugs, including pulse methylprednisolone, oral cyclophosphamide, pulse intravenous cyclophosphamide, mycophenolate mofitil, rituximab, and tacrolimus, have been combined with prednisolone, further improving survival rates to 90%-95%. However, the effectiveness of these drugs is still uncertain, as most seem very good in the beginning, but in studies examining longer-term follow-up the remission of disease does not remain. Fatal infection is still a major complication of aggressive chemotherapy, and the potential benefits as well as adverse events from each drug need to be considered. Induction of remission is the major aim of therapy, with safe and effective maintenance therapy for long-term remission. The survival rates of many published studies vary widely because of differences in patients and treatment modalities, severity of disease, renal histopathology, racial factors, and duration of follow-up. Finding the optimal treatment for SLE and related co-morbidities is highly challenging, and will likely involve a complex combination of different drugs for different patients in the search for giving them an opportunity to be free from this debilitating disease.

Risk factors for reintubation in the post-anaesthetic care unit: a case-control study.

BACKGROUND: Risk factors for reintubation in post-anaesthetic care units related to anaesthetic processes have not previously been reported. Our goal was to identify risk factors for reintubation in general surgical patients. METHODS: A time-matched, case-control study was conducted on anaesthetic patients between 2001 and 2011. One hundred and sixty-four reintubated patients were compared with 656 randomly selected controls. RESULTS: Independent risk factors for reintubation were age <1 yr vs age 30-49 yr [odds ratio (OR)=16.4, 95% confidence interval (CI)=5.7-47.7], chronic pulmonary disease (OR=2.1, CI=1.1-4.0), preoperative hypoalbuminaemia (OR=4.9, CI=2.4-10), creatinine clearance <24 vs >60 (OR=4.1, CI=1.2-13.4), emergency case (OR=1.8, CI=1.0-3.1), operative time >3 vs <1 h (OR=3.0, CI=1.5-6.2), airway surgery (OR=32.2, CI=13.6-76), head and neck surgery (OR=3.4, CI=1.8-6.2), cardiac surgery (OR=3.8, CI=1.1-13.4), thoracic surgery (OR=6.3, CI=1.9-21.2), cardiac catheterization (OR=2.5, CI=1.1-5.5), ASA physical status III (OR=3.8, CI=1.4-10), and the use of certain types of neuromuscular blocking agent (P<0.001). CONCLUSIONS: Age <1 yr, chronic pulmonary disease, preoperative hypoalbuminaemia, and renal insufficiency were patient factors for reintubation. Emergency case, head and neck, cardiothoracic and airway surgery, and operative time >3 h were operative factors, while certain neuromuscular blocking agents and ASA physical status III were anaesthetic factors for reintubation.

Effect of village income and household income on sanitation facilities, hygiene behaviours and child undernutrition during rapid economic growth in a rural cross-border area, Yunnan, China.

BACKGROUND: The study aimed to examine the effects of village income and household income on child nutrition status through basic sanitation and hygiene behaviours. METHODS: A survey was conducted in a rural cross-border area of Yunnan, China. Data on village income in 2002-2006 and household income in 2002-2007 were obtained from an official report and a household survey respectively. Anthropometric measurement of the children aged 6 months to 5 years (n = 1801) was used to determine their nutrition status. Child caretakers were interviewed about household sanitation facilities and their hygiene behaviours using a structured questionnaire. RESULTS: Households with incomes below the national poverty line decreased from 22% in 2002 to less than 8% in 2007. The coverage of safe drinking water and water-sealed latrines gradually increased, but was still inadequate. The prevalence of stunting and underweight in children was 37% and 17.5% respectively. Village income had a greater positive effect than household income on exclusive breastfeeding, drinking boiled water, handwashing with soap, as well as reducing the prevalence of stunting. Village income at one lag year had the greatest effect on the availability of basic sanitation compared with other lag years, while household income had a small but significant effect through all lag years. CONCLUSIONS: Rapid economic growth is not always followed by improved child nutrition status. Village income has a greater effect than household income on sanitation facilities, hygiene behaviours of caretakers and child nutrition status.

Timing of voiding cystourethrogram after urinary tract infection.

Of the 363 Thai children upon whom a voiding cystouretrogram was performed, a vesicoureteral reflux was detected in 22.8% (17.1%-28.5%) of those for whom it was performed within 7 days (n = 215) of a urinary tract infection diagnosis and in 24.3% (17.4%-31.2%) of those for whom it was performed 7 days (n = 148) after diagnosis. There was no statistically significant difference in reflux prevalence between these two groups.

Management of the neck in patients with T1 and T2 cancer in the mouth.

UNLABELLED: Our aim in this retrospective study was to evaluate the extent of control of metastatic disease in the neck and the survival of patients with T1 and T2 oral cancer. METHODS: All 171 patients with T1 and T2 squamous cell carcinoma (SCC) in the mouth were identified from our computerised database. All had had primary tumours resected and 21 patients with palpable neck nodes had therapeutic neck dissections. Among 150 patients with no palpable nodes, 75 had elective neck dissections, and 75 were observed. The decision to do an elective neck dissection was based on clinical criteria and was not randomised. RESULTS: Cervical nodes contained metastases in 17 of 21 patients who had therapeutic, and 27 of 75 who had elective, neck dissections. Neck metastases developed subsequently in 15 of 75 patients in the observed group, and 9 of these were salvaged by therapeutic neck dissection. The 5-year disease free survival was 19/21 after therapeutic dissection, 72/75 after elective dissection, and 69/75 in the observed group. Patients with cervical nodal metastases had significantly reduced 5-year survival compared with those without (63% and 91%, P = 0.003).

Actin-dependent motility of melanosomes from fish retinal pigment epithelial (RPE) cells investigated using in vitro motility assays.

Melanosomes (pigment granules) within retinal pigment epithelial (RPE) cells of fish and amphibians undergo massive migrations in response to light conditions to control light flux to the retina. Previous research has shown that melanosome motility within apical projections of dissociated fish RPE cells requires an intact actin cytoskeleton, but the mechanisms and motors involved in melanosome transport in RPE have not been identified. Two in vitro motility assays, the Nitella assay and the sliding filament assay, were used to characterize actin-dependent motor activity of RPE melanosomes. Melanosomes applied to dissected filets of the Characean alga, Nitella, moved along actin cables at a mean rate of 2 microm/min, similar to the rate of melanosome motility in dissociated, cultured RPE cells. Path lengths of motile melanosomes ranged from 9 to 37 microm. Melanosome motility in the sliding filament assay was much more variable, ranging from 0.4-33 microm/min; 70% of velocities ranged from 1-15 microm/min. Latex beads coated with skeletal muscle myosin II and added to Nitella filets moved in the same direction as RPE melanosomes, indicating that the motility is barbed-end directed. Immunoblotting using antibodies against myosin VIIa and rab27a revealed that both proteins are enriched on melanosome membranes, suggesting that they could play a role in melanosome transport within apical projections of fish RPE.

Visualization and quantitation of peroxisomes using fluorescent nanocrystals: treatment of rats and monkeys with fibrates and detection in the liver.

Peroxisome proliferation in the liver is a well-documented response that occurs in some species upon treatment with hypolipidemic drugs, such as fibrates. Typically, liver peroxisome proliferation has been estimated by direct counting via electron microscopy, as well as by gene expression, enzyme activity, and immunolabeling. We have developed a novel method for the immunofluorescent labeling of peroxisomes, using an antibody to the 70-kDa peroxisomal membrane protein (PMP70) coupled with fluorescent nanocrystals, Quantum Dots. This method is applicable to standard formalin-fixed, paraffin-embedded tissues. Using this technique, a dose-dependent increase in PMP70 labeling was evident in formalin-fixed liver sections from fenofibrate-treated rats. In formalin-fixed liver sections from cynomolgus monkeys given ciprofibrate, quantitative image analysis showed a statistically significant increase in PMP70 labeling compared to control; the increase in hepatic PMP70 protein levels was corroborated by immunoblotting using total liver protein. An increase in hepatic peroxisome number in ciprofibrate-treated monkeys was confirmed by electron microscopy. An advantage of the Quantum Dot/PMP70 method is that a single common protocol can be used to label peroxisomes from several different species, and many of the common problems that arise with immunolabeling, such as fading and low signal strength, are eliminated.

Influence of condition of surgical margins on local recurrence and disease-specific survival in oral and oropharyngeal cancer.

BACKGROUND: The clearance of surgical margins at the primary site is widely thought to influence the subsequent course of the disease in patients operated on for oral and oropharyngeal carcinoma. In some reports the adverse impact of close or involved margins was not negated by postoperative radiotherapy. These findings, in addition to descriptive histopathological studies, have led some authors to recommend margins of more than a macroscopic clearance of 1cm at certain subsites. We have therefore examined the relation between the condition of surgical margins and local recurrence and disease-specific survival. METHODS: Identical treatment protocols were used to treat two independent groups of patients (Sydney, Australia, n=237; Lanarkshire, n=95) who presented with previously untreated carcinoma of the mouth or oropharynx. All patients were operated on with the primary objective of achieving a macroscopic clearance of 1cm. Postoperative radiotherapy was used according to a protocol. Data about patients were entered into comprehensive computerised databases prospectively. Known clinical and pathological prognostic indicators, in addition to the condition of surgical margins, were analysed to find out if they were predictive of local recurrence and disease-specific survival using the Cox proportional hazard model. RESULTS: Local recurrence was predicted by the presence of perineural invasion at the primary site in both groups. Disease-specific survival was predicted by the presence and extent of regional lymph node metastases in both groups. The condition of surgical margins (clear, close, or involved) did not predict local recurrence, or disease-specific survival on multivariate analysis. CONCLUSIONS: A macroscopic margin of 1cm seems adequate in the surgical management of oral and oropharyngeal carcinoma. For most patients who have close or involved margins the biology of the disease influences the subsequent course irrespective of the width of clearance of tumour.

Docetaxel and carboplatin is an active regimen in advanced non-small-cell lung cancer: a phase II study in Caucasian and Asian patients.

BACKGROUND: The purpose of this study was to report response rates, survival and toxicity in advanced non-small-cell lung cancer (NSCLC) following docetaxel and carboplatin, and to explore potential differences in these end points between Caucasian and Asian patients. PATIENTS AND METHODS: Sixty-eight patients of good performance status with Stage IIIB or IV NSCLC were entered on a phase II study at three sites in Australia and Singapore. Docetaxel 75 mg/m2 and carboplatin AUC 6 were given every 3 weeks. Response to treatment and toxicity were graded by standard criteria. The Kaplan-Meier method was used to estimate survival rates, and subgroups compared by the log-rank test. Cox's proportional hazards regression was used to determine which potentially explanatory variables independently affected the outcome. RESULTS: The response rate was 39% (95% confidence interval 27% to 52%), and 42% in evaluable patients. Response occurred in 65% of Asian and 31% of Caucasian patients (P = 0.01). Ethnicity was the only significant predictor of response in multivariate analysis. The 1-year survival rate was 53%. Performance status (P = 0.021), ethnicity (P = 0.035) and presence of bone or liver metastases (P = 0.011) were independent predictors of overall survival. Neutropenia (grade IV in 73% of patients), febrile neutropenia (26% patients) and diarrhea (grade III/IV in 11% of patients) were the major treatment related toxicities. A high rate (three of six) of febrile neutropenia in Singapore, including one treatment-related death in the initial patients treated, resulted in a reduction in the carboplatin dose to AUC 4.5 at that site. CONCLUSIONS: This regimen is active in advanced NSCLC. The potential impact of ethnicity on efficacy and toxicity of treatment requires further investigation.

Influence of bone invasion and extent of mandibular resection on local control of cancers of the oral cavity and oropharynx.

The aim of this paper was to evaluate the influence of bone invasion on treatment outcome among patients with cancers of the oral cavity and oropharynx and to determine whether or not outcome was influenced by the extent of mandibular resection. A review of 127 prospectively documented patients who were treated with marginal or segmental resection for oral (n = 110) and oropharyngeal (n = 17) cancers was undertaken. There were 97 males and 30 females with a median age of 61 years. Clinical T stages were: T1 17 patients, T2 33, T3 22, T4 55. Median followup was 4 years. A total of 94 patients underwent marginal resections and 33 underwent segmental resections. Histological bone invasion was present in 17 patients (16%) in the marginal resection group and 21 patients (64%) in the segmental group (P<0.05). Soft tissue surgical margins were positive in 11 patients (12%) in the marginal group and in seven patients (21%) in the segmental group (P=not significant). Local control did not correlate significantly with T stage, the extent of mandibular resection or the presence of histological bone invasion, but was significantly influenced by positive soft tissue margins (P<0.01). Among patients with bone invasion, the local control rate was higher following segmental resection when compared to marginal resections (87% vs 75%) but this was not statistically significant. Survival was significantly influenced by positive soft tissue margins but not bone invasion or the type of resection. We conclude that bone invasion alone did not predict for local control or survival rates among patients with oral and oropharyngeal cancers. Involved soft tissue margins were highly predictive of local recurrence and decreased survival. Conservative resection of the mandible is safe as long as marginal mandibulectomy does not lead to compromise of soft tissue margins. Segmental resection should be reserved for patients extensive bone invasion or those with limited invasion in a thin atrophic mandible.

Incidence of cervical node involvement in metastatic cutaneous malignancy involving the parotid gland.

BACKGROUND: The parotid lymph nodes represent an important group of nodes at risk for metastatic involvement from cutaneous malignancies of the head and neck. When treating patients with metastatic disease in the parotid gland it has been our custom to also remove the lymph nodes of the neck on the basis that these nodes represent other nodal groups at risk for metastatic involvement. The aim of this study is to determine the incidence of cervical node involvement among patients with clinical metastatic SCC or melanoma of the parotid to determine whether treatment of the clinically negative neck is warranted. METHODS: The study group consists of 123 prospectively accessioned patients with clinical metastatic cutaneous squamous cell carcinoma (SCC) (n = 73) or melanoma (n = 50) involving the parotid gland and a minimum of 2 years of follow up, irrespective of the clinical status of the neck. RESULTS: Among 73 patients with metastatic SCC in the parotid, 19 (26%) had clinical neck involvement, and 16 of these were pathologically positive (84%). A total of 37 patients had elective neck dissections, and 13 were pathologically positive, which is an overall rate of 52% neck involvement among patients having neck dissection. Among 50 patients with metastatic melanoma in the parotid, 19 (38%) patients were initially seen with clinical neck disease, and all were pathologically positive. Among 31 patients with clinically negative necks, 26 had neck dissections and seven had positive nodes (27%). Overall, 58% of patients with melanoma who had a neck dissection had positive nodes. CONCLUSION: Patients with metastatic cutaneous SCC and melanoma involving the parotid gland had a high incidence of clinical (26% and 38%, respectively) and occult neck disease (35% and 27%). Treatment of the clinically negative neck in the presence of clinical metastatic parotid cancer should be considered to reduce the likelihood of failure in cervical nodes, to define the extent of disease, and to assist with patient selection for adjuvant therapy.