Diagnostic Accuracy and Scope of Intraoperative Transoral Ultrasound and Transoral Ultrasound-Guided Fine-Needle Aspiration of Retropharyngeal Masses.

The use of transoral sonography-guided fine-needle aspiration for intraoperative localization of retropharyngeal masses has been described by Fornage et al. The purpose of this study was to assess the accuracy of this technique. We reviewed the images and medical records of 26 patients with a retropharyngeal lesion suspicious for a metastatic lymph node of Rouviere identified on CT and/or PET/CT. There were 14 patients with a history of thyroid cancer, 7 with mucosal squamous cell carcinoma, 1 with renal cell carcinoma, 1 with parotid acinic cell cancer, 1 with metastatic colon adenocarcinoma, and 2 with no history of cancer. Intraoperative transoral sonography was performed using a commercially available endovaginal transducer. A transoral sonography-guided fine-needle aspiration was performed with a 25-cm-long 20-ga Chiba needle through a needle guide attached to the transducer shaft. Cytopathologic results were categorized as malignant, benign, or nondiagnostic. Transoral sonography and transoral sonography-guided fine-needle aspiration were performed in all patients. A diagnostic specimen was obtained in 25 of 26 (96%) patients with a 100% overall accuracy. Twelve patients underwent subsequent transoral resection of the retropharyngeal mass. In each patient, surgical pathology confirmed the fine-needle aspiration biopsy result. In 4 patients, transoral sonography-guided injection of methylene blue was used to facilitate intraoperative localization of the metastatic retropharyngeal mass. Transoral sonography and transoral sonography-guided fine-needle aspiration of suspicious masses in the retropharyngeal space are highly accurate procedures for identification and cytologic evaluation of benign and metastatic lymph nodes of Rouviere and for presurgical localization.

Erythema multiforme after orf virus infection: a report of two cases and literature review.

Orf virus has a worldwide distribution among sheep and goats. The hypersensitivity reaction erythema multiforme (EM) is a known complication of orf infection in humans; however, its occurrence is poorly understood and has not been extensively reviewed. We present two unrelated cases of orf-associated EM, and a review of the literature, highlighting important clinical, epidemiological and immunological aspects of this condition. Orf and its associated complications can occur in rural areas, as well as urban settings, where it is less well-known, through religious or cultural practices involving animal slaughter. Obtaining a history of animal exposures from patients with lesions suspicious for orf and secondary skin eruptions can guide diagnosis and identification of the inciting immune stimulus. Determining the pathophysiology and relative contribution of host and viral factors contributing to EM and other orf-associated hypersensitivity reactions could facilitate the identification of risk factors and inform treatment decisions.

Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer.

BACKGROUND AND PURPOSE: Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer. MATERIALS AND METHODS: This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome. RESULTS: Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence. CONCLUSIONS: In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

Palliative care nurses' experiences of training in cognitive behaviour therapy and taking part in a randomized controlled trial.

BACKGROUND: This article describes the experiences of clinical nurse specialists in a palliative homecare team who took part in a cluster randomized controlled study. The study aimed to determine whether palliative care nurses given basic training in cognitive behavioural therapy (CBT) were able to use core components of this training when treating advanced cancer patients with anxiety or depression. METHOD: Fifteen nurses were randomly allocated to either receive training in cognitive behavioural techniques or to continue their practice as usual. Nurses were interviewed following the CBT training and after the research study. RESULTS: The CBT group reported a positive change in their approach to patients. Nurses felt empowered, more skilled and effective not only to assess and support patients with symptoms of anxiety and depression but also to facilitate change. In addition, nurses placed considerable value on being given a psychological model and set of interventions. CONCLUSIONS: Nurses found taking part in the study demanding in terms of time and commitment; however, the authors conclude that research in the community palliative care setting is feasible.

A cluster randomized controlled trial of cognitive behaviour therapy for common mental disorders in patients with advanced cancer.

BACKGROUND: Cognitive behaviour therapy (CBT) has been shown to reduce psychological morbidity in people with cancer, but no randomized controlled trial (RCT) exists in palliative care. We aimed to determine whether home care nurses could be taught to deliver basic cognitive behavioural techniques and so reduce symptoms of anxiety and depression. METHOD: Clinical nurse specialists (CNSs) at St Christopher's Hospice were randomly allocated to receive training in CBT or continue their usual practice. At the end of the trial, nurses were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Home care patients who scored as possible cases on the Hospital Anxiety and Depression Scale (HADS) entered the trial. Participants received home care nursing visits. Assessments were carried out at baseline, 6, 10 and 16 weeks. RESULTS: Eight nurses received CBT training and seven continued practice as usual. The mean CTFARS scores were 35.9 for the CBT nurses and 19.0 for the controls (p=0.02). A total of 328 patients (54%) were possible cases and 80 entered the trial; most of those excluded were too ill to participate. There was an interaction between group and time: individuals receiving CBT had lower anxiety scores over time [coefficient -0.20, 95% confidence interval (CI) -0.35 to -0.05, p=0.01]. No effect of the training was found for depression. CONCLUSIONS: It is possible to conduct a randomized trial of psychological interventions in palliative care but there is considerable attrition from physical morbidity and mortality. Nurses can learn to integrate basic CBT methods into their clinical practice. This training may be associated with better outcomes for symptoms of anxiety.

Impact of preoperative thyroid ultrasonography on the surgical management of primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (PHPT) with coexisting thyroid disease has been considered a contraindication to minimally invasive parathyroidectomy (MIP). This study assessed the impact of thyroid ultrasonography and guided fine-needle aspiration (FNA) biopsy with cytological review of the aspiration in distinguishing patients eligible for MIP from those requiring open parathyroidectomy with thyroid surgery. METHODS: The records of 194 consecutive patients who had minimally invasive or open parathyroidectomy for sporadic PHPT were reviewed retrospectively. Thyroid ultrasonographic findings and FNA results were compared with surgical and pathology records. RESULTS: A total of 163 patients (84.0 per cent) were eligible for MIP based on ultrasonographic findings with or without FNA results. Ultrasonography detected concurrent thyroid disease in 163 patients (84.0 per cent). Thirty-nine (23.9 per cent) underwent FNA, of whom 16 had benign findings and were eligible for MIP; the remaining 23 had suspicious FNA results and had open parathyroidectomy combined with thyroid surgery. Postoperative thyroid histopathology confirmed malignancy in nine patients, eight of whom had disease detected ultrasonographically. Micronodular thyroid disease (less than 1 cm) accounted for four of nine malignancies. CONCLUSION: Most patients with PHPT are eligible for MIP. Experienced ultrasonographers can diagnose coexisting micronodular and macronodular thyroid disease, and identify patients eligible for MIP.

Psychological services in hospices in the UK and Republic of Ireland.

OBJECTIVE: To evaluate the level of psychological services available to patients and staff in hospices. DESIGN: Questionnaire analysis. SETTING: Hospices in the UK and Republic of Ireland. PARTICIPANTS: 224 hospices. MAIN OUTCOME MEASURES: The availability of professional psychological support for those with advanced disease. RESULTS: Responses were received from 166 hospices (74%). Only 50 hospices (30%) have access to a psychiatrist, whilst 68 (41%) have access to a clinical psychologist and 92 (45%) have neither. Only 21 hospices (12%) have service level agreements with local mental health trusts. Counsellors, complementary therapists and spiritual advisors such as chaplains were more plentiful. CONCLUSIONS: Delivery of the NICE guidelines, especially tier four, may be compromised by limited availability of specialist services. This has implications for the psychological assessment of applicants for voluntary euthanasia under an Assisted Dying Act.

Selenium and prevention of prostate cancer in high-risk men: the Negative Biopsy Study.

Epidemiological and clinical studies suggesting a significant inverse relationship between intake of dietary selenium and overall cancer risk have led to initiation of a randomized, placebo-controlled, phase III clinical trial testing the safety and efficacy of selenized yeast as a chemopreventive agent for prostate cancer. Participants eligible for the 'Negative Biopsy Study', which was initiated in August 1999, are men considered to be at high risk for prostate cancer because of at least one negative sextant prostate biopsy, which was clinically indicated within 1 year of enrollment to the study. After a 30-day run-in period to ensure protocol compliance, participants are randomized to receive either 200 or 400 microg selenized yeast or matched placebo once daily. Primary study endpoints include development of prostate cancer and prostate-specific antigen (PSA) velocity. Secondary biochemical endpoints include change in chromagranin A and alkaline phosphatase. As of 1 June 2003, 514 eligible participants had been enrolled. Randomization schema was effective for selected parameters including age, body mass index, smoking status, baseline PSA and baseline plasma selenium level. Various data, including medical history, family history, and urological symptoms and specimens (including blood and subsequent prostate biopsy samples) had been collected at baseline, and throughout both the intervention and follow-up stages of the protocol. The goal for accrual is 700 evaluable participants.

Selenium and inhibition of disease progression in men diagnosed with prostate carcinoma: study design and baseline characteristics of the 'Watchful Waiting' Study.

Impediment of the promotion and progression stages of carcinogenesis of the prostate could have a profound impact on treatment choice and prognosis for prostate cancer. Efficacious chemopreventive agents that elicit their activity by slowing the processes of progression could make watchful waiting a viable alternative for a large population of men or could delay the necessity for surgery, radiation or other more invasive treatment modalities associated with frequent side effects. Reports from the Nutritional Prevention of Cancer (NPC) study reported that dietary supplementation with selenium significantly reduced the risk of developing prostate cancer. These data led to initiation of the Watchful Waiting Study, a phase II, multi-center, randomized, double-blind, placebo-controlled clinical intervention study testing the effects of two doses of selenized yeast on progression of prostate cancer. Participants are men with biopsy-proven prostate cancer who have elected to forgo therapy and be closely followed by 'watchful waiting' that includes quarterly prostate-specific antigen (PSA) screening. Subjects are randomized to receive 200 or 800 microg of selenized yeast or matched placebo daily. Endpoints include time to disease progression and PSA velocity. Secondary endpoints include time to initiation of therapy as well as biochemical markers of disease progression including chromagranin A and alkaline phosphatase. Immunohistochemical analyses for indicators of apoptosis, proliferation and differentiation will be performed on baseline and subsequent prostate biopsy specimens. This report summarizes the primary objectives, research methods and the randomized subjects in this important clinical trial.

Analysis of cellular release using capillary electrophoresis and matrix assisted laser desorption/ionization-time of flight-mass spectrometry.

In order to increase our understanding of the mechanisms of learning and memory in the central nervous system, it is necessary to know the neurotransmitters and neuromodulators used in the specific neuronal circuits under study. Methods have been developed to identify the peptides released from single neurons and neuronal clusters from the common neuronal model Aplysia californica. Specifically, solid-phase extraction (SPE), capillary electrophoresis (CE) and matrix assisted laser desorption/ionization-time of flight-mass spectrometry (MALDI-TOF-MS) are combined for profiling neuropeptide releasates. A variety of combinations of SPE and CE were coupled off-line with MALDI-TOF-MS to reduce the high physiological salts, to concentrate the analytes, and to reduce the complexity of the mass spectra using separation. With these protocols, peptides and proteins up to 11000 Da were detected in releasates, offering a much wider mass range compared to direct MALDI analysis of the same releasates. A number of expected and unknown neuropeptides, including egg-laying hormone (ELH) and the partially processed delta/gamma-bag cell peptide were observed in the SPE-treated releasates from a single Aplysia-cultured bag cell neuron. However, by adding a CE separation after the SPE step preceding off-line MALDI-TOF-MS detection, the most complete neuropeptide profiles were obtained.

Developmental regulation of TCR delta locus accessibility and expression by the TCR delta enhancer.

We have used gene-targeted mutation to assess the role of the T cell receptor delta (TCR delta) enhancer (E delta) in alphabeta and gammadelta T cell development. Mice lacking E delta exhibited no defects in alphabeta T cell development but had a severe reduction in thymic and peripheral gammadelta T cells and decreased VDJ delta rearrangements. Simultaneous deletion of both E delta and the TCR alpha enhancer (E alpha) demonstrated that residual TCR delta rearrangements were not driven by E alpha, implicating additional elements in TCR delta locus accessibility. Surprisingly, while deletion of E delta severely impaired germline TCR delta expression in double-negative thymocytes, absence of E delta did not affect expression of mature delta transcripts in gammadelta T cells. We conclude that E delta has an important role in TCR delta locus regulation at early, but not late, stages of gammadelta T cell development.

Intrapleural fibrinolytic therapy for complicated pleural effusions.

Intrapleural administration of fibrinolytic agents can be used to degrade the fibrin present in complicated pleural effusions, thus decreasing viscosity of the fluid and enhancing evacuation of the pleural space via chest tube drainage. Patients who may otherwise need surgical intervention could benefit from this treatment. As more knowledge is gained through clinical experience and research studies, patients' outcomes may show major improvement.

Children and loss.

Where possible children should receive help before a bereavement. this article explores children's experiences of grief and examines their needs. It describes ways in which professionals can help parents and children.

Interlaminar shear stresses and laminae separation in a disc. Finite element analysis of the L3-L4 motion segment subjected to axial compressive loads.

STUDY DESIGN: This study analyzed interlaminar shear stresses across the laminae of a ligamentous L3-L4 motion segment. A three-dimensional finite element model of the motion segment was developed and its response in axial compression mode was predicted. OBJECTIVES: The contributions of "mechanical" factors in producing laminae separation in a disc are not well understood, especially when the nucleus is still gel-like in appearance (stage 1 of disc degeneration). All types of stresses are likely to contribute to laminae separation. The authors believe it is partially due to the interlaminar shear stresses at the laminae interfaces in specific regions of an intact disc because the disc is a composite structure. The effects of anular tears on the interlaminar shear stresses were also investigated. These tears can be circumferential or radial in nature, and commonly occur in the aged, degenerated disc. SUMMARY OF BACKGROUND DATA: A large number of biomechanical studies dealing with the role of the disc vis-a-vis other spinal components have been reported in the literature. The role of mechanical factors, however, in producing laminae separation, especially when the nucleus is still gel-like in appearance (stage 1 of disc degeneration), is not entirely clear. METHODS: A three-dimensional nonlinear finite element model of an intact L3-L4 lumbar motion segment, based on the use of a special type of element for the disc anulus, was created to investigate the interlaminar shear stresses in the anulus. The effects of radial "out-in," radial "in-out," and "circumferential" injuries were analyzed. Injury was modeled as element removal in the posterolateral portion of the disc. Models subjected to axial compressive loads, ranging from 200 N to 2000 N, were analyzed. In addition to the interlaminar shear stresses, disc bulge, and displacements including coupled motions were predicted. RESULTS: The theoretical disc bulge predictions for the radial in-out injury case were in agreement with the disc bulge data obtained experimentally. Displacements, disc bulge, and coupled motions increased with injury, as expected. The interlaminar shear stresses were highest in the posterolateral portions of the intact disc model. Interlaminar shear stresses, in general, increased with injury. Also, a slight increase in circumferential injury was sufficient to see a substantial increase in interlaminar shear stresses. CONCLUSIONS: The interlaminar shear stresses being higher in the posterolateral regions of the intact disc reinforces that, from clinical studies, tears originate in the posterolateral portion of the disc. The large interlaminar shear stresses, caused by asymmetry in the disc structure due to injury, along with chemical and structural changes in the disc with age, may be an important cause of further degeneration through laminae separation. This is the case for traditional composite laminates. This study points out the importance of interlaminar shear stresses to gain further understanding of the role of mechanical factors in producing disc degeneration, especially delamination of the anulus. Clinical relevance of the findings and possible relationship to the aging process are explored.

Role of the social worker in palliative care.

The role of the social worker in the palliative care team is defined by five main functions--assessment, counselling, liaison with local resources and agencies, training and development activities, and staff support. The difference between the social work task, which may be undertaken by any member of the palliative care team, and the social work role is emphasized. Social workers bring to the team particular skills in working with families, children and groups. Their training helps them to locate the patient and family within a social and cultural context and thus to exploit resources which may help the family to resolve the difficulties they face. A method of family assessment is explored and a case study illustrates a family intervention including direct work with children.

Imaging of the normal spine, developmental anomalies, and trauma of the spine and extremities.

Many significant papers in the current literature have considered the spectrum of developmental and traumatic alterations in the spine. The increasing role of MR and CT imaging is stressed as well as the continued importance of conventional radiography. The distinguishing features and pathology of developmental anomalies and traumatic injuries and the importance of accurate and complete diagnosis are discussed. This review includes articles that emphasize imaging of the normal spine, congenital anomalies, and trauma of the spine and extremities.

Easily missed trauma of bones and ligaments.

While most fractures and dislocations are easily detected by radiographic and physical examination, some traumatic events are overlooked because the normal radiographic anatomy is not appreciated. Furthermore, certain routine radiographic views are inadequate to detect specific injuries. "Chip" or "sprain" fractures are often considered minor injuries when they actually connote significant injury to ligaments and capsules. These injuries are usually dismissed by the primary care physician, who does not believe them serious enough to warrant consulting an orthopedic surgeon. However, some are also overlooked by radiologists and orthopedic surgeons. If these injuries are not treated adequately, permanent loss of function or death may result. With these thoughts in mind, we will describe some of these injuries and discuss the radiographic anatomy, the knowledge of which should preclude some of the serious mistakes of diagnosis.