Management of lung cancer patients' quality of life in clinical practice: a Delphi study.

BACKGROUND: The assessment of health-related quality of life (HRQoL) has seen exponential growth in oncology clinical trials. However, the measurement of HRQoL has yet to be optimised in routine clinical practice. This study aimed at exploring the operationalisation of HRQoL in clinical practice with the goal of reaching a consensus from a panel of physicians. MATERIALS AND METHODS: Physicians involved in the management of lung cancer patients in France were recruited to participate in a Delphi study. The study involved three rounds of iterated queries to gain consensus on management aspects of HRQoL, including timing of discussion on HRQoL, which specific domains of HRQoL should be discussed, and what was the most appropriate method of assessment. The threshold adopted for consensus was at least 70% agreement among physicians. A scientific committee reviewed results following each round of the Delphi study. RESULTS: A representative panel of 60 physicians participated in this study. Consensus was obtained for HRQoL management at all time points in the patient care pathway. Panellists agreed that HRQoL discussions should occur during routine visits and hospitalisation. The involvement of patients' relatives was also recognised as important, except when discussing side-effects and involvement of a multidisciplinary team. There was a lack of consensus on a systematic assessment for all patients at each visit and no consensus on how HRQoL should be measured in clinical practice. CONCLUSIONS: HRQoL discussions are considered an integral part in the management of lung cancer patients, and are deemed key to success in patient-physician interaction. Further research is required to harmonise how best to implement HRQoL assessment.

Botulinum toxin therapy for pain and inflammatory disorders: mechanisms and therapeutic effects.

Botulinum toxin (BTX) injections are a well-recognised therapeutic modality for the treatment of regional involuntary muscle disorders and recently BTX has been used for treatment of pain and inflammatory disorders. The primary purpose of this review is to discuss the mechanism of action of therapeutic BTX in light of both the traditional understanding of BTX pharmacological effects as well as new observations. The review will deal with clinical observations and relevant animal experimentation. The data and hypotheses presented are not only relevant to botulinum toxin technology but will certainly prove important in the basic mechanisms of some of the diseases where botulinum toxin has been successfully applied. BTX used clinically comprises botulinum neurotoxin (BoNT) complexed with non-toxic proteins. The non-toxic components of the BTX complexes stabilise the labile BoNT during purification and formulation as a therapeutic. The complex proteins may also have unrecognised clinical significance such as slowing diffusion in tissues or imparting stability. The mechanisms of BTX formulations acting on SNARE proteins are briefly reviewed providing a basis for BTX clinical applications. The potential for design of improved botulinum toxins and formulations is addressed.

Analysis of pain and endoscopic sinus surgery for sinusitis.

This prospective clinical descriptive study was designed to see whether patients who had endoscopic sinus surgery for sinusitis had relief of pain, and whether they had new pain postoperatively. The sample was 252 consecutive patients who underwent endoscopic sinus surgery after presenting with inflammatory sinus disorders meeting specific clinical definitions of sinusitis and criteria for surgically treatable sinus disorders developed by the treating surgeon. Of the 252 consecutive endoscopic sinus surgery patients, 106 (42%) had no preoperative pain and 146 (58%) patients had preoperative sinus pain. At 6- to 12-month postoperative evaluations, patients with no preoperative pain did not develop any new postoperative pain. Among the 146 patients with preoperative pain, 82 (56%) had no pain, residual symptoms, or further sequelae, and were considered cured; 42 (29%) reported a marked improvement of pain or discomfort; 9 (6%) had the same degree of pain or discomfort as before; 3 (2%) reported worse pain or discomfort; and 10 (7%) reported new pain or discomfort. These results suggest that the application of consistent definitions and clinical criteria for various forms of surgically treatable sinusitis will more likely predict improvement of pain and discomfort following surgical treatment. The risk of developing new pain and discomfort following endoscopic sinus surgery in individuals without preoperative pain or discomfort is negligible. The risk of worsening pain or new pain was less than 10% in patients with preoperative pain. Ongoing efforts such as the International Conference on Sinus Disease in the development of consistent terminology, staging, and therapy, and future modifications from additional clinical experience, should result in more predictable and effective care in the surgical treatment for pain of sinus disease.

Treatment of chronic paranasal sinus pain with minimal sinus disease.

A common problem for otolaryngologists are patients who present with recurrent, persistent sinus pain that appears out of proportion to the findings on physical examination. Often these patients have a history of recurrent sinusitis that required antibiotics or surgical intervention. Many have had repeated surgical procedures because of this pain. Other common past medical histories may include allergic rhinitis, facial trauma, or dental disease. Patients who have experienced documented acute sinusitis in the past will often present de novo with similar symptoms, but lack any objective evidence of a new active sinus infection. However, the diagnosis of sinusitis is not clearly removed from the patient's or clinician's mind, and the patient is further frustrated by the lack of adequate diagnosis, treatment, and resolution of symptoms. These patients may or may not be experiencing an upper respiratory tract infection or allergy with nasal drainage. Often, they are emotionally distraught from recurrent and persistent pain, the lack of resolution of their symptoms, dependency on narcotics and other analgesics, multiple consultations with a variety of clinicians, and the impingement of their symptoms on employment, interpersonal relationships, and societal and family obligations. If sinusitis is not found to be present, the otolaryngologist must help the patient understand this point, reassure him or her that the otolaryngologist will still be vigilant for the development of sinusitis, and refocus the history and workup for some other cause of the recurrent and persistent paranasal pain. We review various treatment approaches to paranasal pains that are not the result of sinusitis.

Cluster headache presenting with orbital inflammation.

Acute, noninfectious orbital inflammations often defy a specific diagnosis despite a thorough medical evaluation and are grouped in the nonspecific diagnostic category of idiopathic inflammation of the orbit (pseudotumor). An atypical case of cluster headache presenting with intermittent migratory facial swelling and orbital inflammation, and 3 mm of exophthalmos simulating idiopathic orbital inflammation is presented. Although periobital pain is a frequent finding in patients suffering from cluster headaches, to the authors' knowledge this is the first reported case of orbital inflammation with cluster headache. After unsuccessful treatment directed at potential infectious and inflammatory causes, the patient responded well to methysergide, an established treatment for cluster headaches. A review of the known mechanism for this disorder, peripheral and central nervous system mechanisms of pain, and migratory angioedema reveals overlapping pathophysiology, clinical findings, and associated symptoms.

Acquired QT interval changes and neck dissections.

STUDY OBJECTIVE: To determine if acquired long QT syndrome following right or left, radical or modified, neck dissections result in malignant arrhythmias or deaths. DESIGN: Prospective study. SETTING: Inpatient head and neck service of the Massachusetts Eye and Ear Infirmary. PATIENTS: 69 patients who underwent extensive neck surgery, without congenital long QT syndrome, medications known to prolong the QT interval, preoperative ventricular arrhythmias, or electrolyte abnormalities. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Preoperative and postoperative electrolytes were evaluated. Preoperative and postoperative electrocardiograms and QT intervals were evaluated. Continuous intraoperative and 10- to 12-hour postoperative monitoring of lead II or V5 were evaluated. Twenty-six patients (Group 1) underwent either right radical neck dissection or modified right radical neck dissection, 25 patients (Group 2) underwent either left radical neck dissection or modified left neck dissection, and 18 patients (Group 3) underwent extensive neck surgery without radical or modified neck dissection. Postoperatively, 38 patients (19 Group 1, 11 Group 2, and 8 Group 3 patients) developed a QT interval corrected for heart rate (QTc) of greater than 440 milliseconds. Repeated measures analysis of variance, comparing preoperative and postoperative QTc showed a statistically significant preoperative to postoperative change, but no significant difference among the three groups. No malignant arrhythmias or deaths were recorded in any of the three groups. CONCLUSIONS: Acquired long QT syndrome following radical neck dissection, without congenital, metabolic, or pharmacologic disturbance, is unlikely to trigger malignant arrhythmias, as previously reported for right radical neck dissection.

The use of propofol and mivacurium anesthetic technique for the immediate postoperative adjustment of sutures in strabismus surgery.

PURPOSE: Adjustable suture techniques have become increasingly popular over the last decade and may reduce the re-operation rate after strabismus surgery. The adjustment usually is made in the hospital or office 5 to 24 hours after surgery, when the patient has fully recovered from general anesthesia. The ability to perform suture adjustment in the operating room, immediately after completion of surgery, would be an attractive alternative with respect to patient monitoring, sterility, comfort, and timing. The purpose of this study is to compare the alignment of patients in the operating room adjusted immediately after surgery with their alignment the morning after surgery. METHODS: Patients with strabismus who have good vision in each eye and who were judged to be appropriate candidates for adjustable sutures were invited to enroll in a study using propofol and mivacurium total intravenous anesthetic technique. Patients underwent strabismus surgery in which one or more muscles were placed on adjustable sutures. Immediately after extubation, these patients were awakened in the operating room, assisted in sitting upright, and asked to fixate on a 20/400 Snellen E target on the operating room wall. Sutures were adjusted, when necessary, to obtain the desired postoperative alignment. Prism and alternate cover measurements, taken after the sutures were permanently tied, were compared with measurements taken the morning after surgery. RESULTS: Twenty-nine patients qualified for inclusion. Measurements of horizontal and vertical alignment in the operating room were all within 12 prism diopters (PD) of the measurements taken 18 to 24 hours after surgery (mean variation, 4 PD horizontally and 2 PD diopters vertically). The measured deviation changed less than or equal to 6 PD horizontally in 78% of patients and less than or equal to 3 PD vertically in 70% of patients. CONCLUSION: For some adult patients with strabismus, a total intravenous general anesthesia technique using an infusion of propofol and mivacurium may provide the opportunity for accurate suture adjustment in the operating room, immediately after completion of surgery.

Determinants and impact of headache after acoustic neuroma surgery.

Headache after acoustic neuroma surgery is known to occur clinically, but has not been studied systematically until recently. In the present study, 155 patients were surveyed regarding their experience of headache and associated symptoms following resection of an acoustic neuroma: 73 percent (n = 98) of patients undergoing suboccipital resection of an acoustic neuroma and 53 percent (n = 8) of patients undergoing translabyrinthine resection of acoustic neuroma complained of headache following surgery. The average pain intensity was greater for the suboccipital approach. Only 9 percent (n = 14) reported troublesome or frequent headaches preoperatively. Headache was described most often as tension type, with episodic acute exacerbations mimicking migraine. Clinical observations suggest that most patients are treated successfully with various combinations of reassurance, tricyclic antidepressants, nonsteroidal anti-inflammatory medications, trigger-point injections, adjunctive stress management techniques (relaxation), and physical therapy. The impact of recurrent headache on work and recreational function is notable. Several possible pathophysiological and biopsychosocial models are proposed to account for the prevalent headache problem. Although spontaneous resolution usually occurs over time, additional study is needed to determine the natural history of postoperative headache once it occurs.