Citations

Object The authors describe the unique occurrence of nodular enhancement within the fundus of the internal auditory canal (IAC) lateral to the preoperative radiological tumor margin following gross-total vestibular schwannoma (VS) resection. Methods The nature of the study was a retrospective chart review of records. The authors reviewed the cases of all patients who underwent microsurgical resection of a VS between January 2000 and January 2010 at a single tertiary referral center. Patients with incomplete resection, neurofibromatosis Type 2, and those with fewer than 2 postoperative MR images available for review were excluded. Postsurgical patients with IAC enhancement located lateral to the preoperative imaging–delineated tumor margin were identified. Lesion morphology was characterized on serial MR imaging studies. Clinical follow-up and outcomes were recorded. Results Over the past decade, 350 patients underwent microsurgical VS resection. Of these, 16 patients met study criteria and were found to have postsurgical enhancement in the distal aspect of the IAC lateral to the imaging limits of the preoperative tumor margin on the first postoperative MR imaging study (37.5% women, median age 45 years). Initial MR imaging was performed at a mean of 3.1 months following surgery, and the mean radiological follow-up duration was 39.8 months (range 16.4–101.9 months). None of the 16 patients developed recurrence during the follow-up course. Conclusions In contrast to previous publications that have reported a high rate of recurrence in cases involving nodular enhancement within the original tumor bed, postoperative enhancement in the IAC lateral to the original tumor margin appears to carry much less risk for tumor recurrence. These findings may be helpful when counseling patients on the recommended frequency of postoperative follow-up imaging.

Object Glossopharyngeal neuralgia (GPN) is a rare pain disorder characterized by severe, stabbing pain of the ear, posterior tongue, and throat. The authors report their early experience of using stereotactic radiosurgery (SRS) as an alternative to posterior fossa surgery for patients with medically resistant GPN. Methods Five patients (3 men, 2 woman) with medically resistant GPN underwent Gamma Knife surgery. The radiosurgical target was the distal portion of the glossopharyngeal and vagus nerves at the jugular foramen (glossopharyngeal meatus). The maximum radiation dose in all cases was 80 Gy. The median follow-up after radiosurgery was 13 months (range 2–19 months). Results Three patients became pain-free at 2 days, 3 days, and 2 weeks, respectively, and were able to discontinue the medications taken preoperatively for their pain. None of these patients have suffered recurrent pain since becoming pain free. Two patients experienced no benefit from the procedure and underwent posterior fossa surgery 2 and 5 months after SRS. Both of these patients continued to have pain after posterior fossa surgery. One of these patients was later discovered to have a head and neck cancer as the cause of his pain. No patient developed hoarseness or dysphagia after radiosurgery. Conclusions This preliminary experience demonstrates that SRS is an option for patients with medically resistant GPN. Additional follow-up and a larger number of patients are needed to demonstrate the long-term safety and optimal radiation dosimetry for this indication.

The introduction of flow diverters for treatment of intracranial aneurysms represents a major paradigm shift in the treatment of these lesions. The theoretical hallmark of flow diverters is the treatment of the diseased segment harboring the aneurysm instead of treating the aneurysm itself. Flow diverters are designed to induce disruption of flow near the aneurysm neck while preserving flow into parent vessel and adjacent branches. After flow diversion, intra-aneurysmal thrombosis occurs, followed by shrinkage of the aneurysmal sac as the thrombus organizes and retracts. Preliminary clinical series document effective treatment of wide-neck and/or large and giant aneurysms with acceptable complication rates. However, several questions remain unanswered related to the incidence and mechanisms of aneurysm rupture after treatment with flow diverters, fate of small perforating vessels, and long-term patency rates.

Abstract Systemic therapy has led to a median survival time for patients with advanced colorectal cancer (CRC) almost fourfold longer than that expected with best supportive care, an outcome achieved through combining chemotherapeutic and targeted biologic agents. Although the latter can include anti–epidermal growth factor receptor antibodies, such as cetuximab and panitumumab, we now have strong evidence that patients whose tumors harbor mutated KRAS will not benefit from this class of agent. Acceptance of the reliability and importance of the KRAS data took several years to evolve, however, for a variety of reasons. The timeline from the presentation and publication of small, retrospective phase II studies to widespread acceptance of the KRAS predictive value and changes in behavior—specifically, modifications of ongoing national trials in advanced/metastatic CRC, changes in national guidelines and practice patterns, and adjustments to the labeled indications for the monoclonal antibodies—was lengthy. In this commentary, we discuss whether or not the process of data disclosure regarding KRAS status and treatment of advanced CRC patients was effective in permitting timely decisions regarding ongoing publicly funded clinical trials and whether or not such decisions were rational and ethical. The overall goals are to highlight lessons learned regarding early disclosure of clinical trial results, as well as vetting and adoption of new scientific data, and to propose modifications for handling similar situations in the future.

Objectives: Poor mental health is a major source of distress, disability, and social burden in older adults. The objective of this study was to determine if activity limitation and healthcare access are associated with frequent mental distress (FMD) in adults 65 years and older. Methods: Of the 123 427 study participants aged 65 years or older, 120 445 participants responded to the Behavioral Risk Factors Surveillance System (BRFSS) survey question on number of mentally unhealthy days. Participants who reported having 14 or more mentally unhealthy days during the past 30 days were considered as having FMD. Activity limitation, avoidance of medical care due to cost, and availability of personal doctor were examined for their association with FMD in multivariable logistic regression analysis. Age, sex, race/ethnicity, marital and employment status, emotional support, and life satisfaction were included as potential confounders. Results: The prevalence of FMD in this study population was 6.5% (95% CI = 6.3-6.8) with estimates significantly greater among women (7.2%, 95% CI = 6.9-7.6) as compared to men (5.5%, 95% CI = 5.1-6.0). The odds of FMD were more than 2-fold elevated for those who reported activity limitations due to physical, mental, or emotional problems (adjusted OR = 2.59, 95% CI = 2.33-2.87), and among those who reported health care cost as a barrier to see a doctor (adjusted OR = 2.14, 95% CI = 1.75-2.61). There was no significant relationship between availability of personal doctor and FMD observed in the study. Conclusions: The findings of this study showed that activity limitation and cost of medical care are associated with FMD in the US elderly population.

Background— Left atrium (LA) enlargement is common in organic mitral regurgitation (MR) and is an emerging prognostic indicator. However, outcome implications of LA enlargement have not been analyzed in the context of routine clinical practice and in a multicenter study. Methods and Results— The Mitral Regurgitation International DAtabase (MIDA) registry enrolls patients with organic MR due to flail leaflets, diagnosed in routine clinical practice, in 5 US and European centers. We investigated the relation between LA diameter and mortality under medical treatment and after mitral surgery in 788 patients in sinus rhythm (64±12 years; median LA, 48 [43 to 52] mm). LA diameter was independently associated with survival after diagnosis (hazard ratio, 1.08 [1.04 to 1.12] per 1 mm increment). Compared with patients with LA <55 mm, those with LA ≥55 mm had lower 8-year overall survival ( P <0.001). LA ≥55 mm independently predicted overall mortality (hazard ratio, 3.67 [1.95 to 6.88]) and cardiac mortality (hazard ratio, 3.74 [1.72 to 8.13]) under medical treatment. The association of LA ≥55 mm and mortality was consistent in subgroups. Similar excess mortality associated with LA ≥55 mm was observed in asymptomatic and symptomatic patients ( P for interaction, 0.77). In patients who underwent mitral surgery, LA ≥55 mm had no impact on postoperative outcome ( P >0.20). Mitral surgery was associated with greater survival benefit in patients with LA ≥55 mm compared with LA <55 mm ( P for interaction, 0.008). Conclusions— In MR caused by flail leaflets, LA diameter ≥55 mm is associated with increased mortality under medical treatment, independent of the presence of symptoms or left ventricular dysfunction.

We performed a pathologic study with further using an immunohistochemical technique (using anti-p63 and anti-CK5) on tissues obtained by open lung biopsy from 18 patients with previous exposure to sulphur mustard (SM) as case group and 8 unexposed patients (control group). The most frequent pathologic diagnosis was constrictive bronchiolitis ( 44.4 % ), followed by respiratory ( 22.2 % ) and chronic cellular bronchiolitis ( 16.7 % ) in the case group, and hypersensitivity bronchiolitis ( 50 % ) in the control group. The pathologic diagnoses were significantly different in the case and control groups ( P = 0.042 ). In slides stained by anti-p63 and anti-CK5, the percent of stained cells and the mean number of epithelial cells were lower in the case group in comparison to the control group. This difference was significant for the mean number of cells stained by anti-CK5 ( P = 0.042 ). Furthermore, there was a significant correlation between pathologic diagnosis and total number of cells and mean number of cells stained with anti-p63 and anti-CK5 ( P value = 0.002, <0.001, 0.044). These results suggest that constrictive bronchiolitis may be the major pathologic consequence of exposure to SM. Moreover, decrease of p63 in respiratory tissues affected by SM may suggest the lack of regenerative capacity in these patients.

Long‐chain acyl‐coenzymes A (acyl‐CoAs) (LCACoA) are the activated forms of long‐chain fatty acids and serve as key lipid metabolites. Excess accumulation of intracellular LCACoA, diacylglycerols (DAGs) and ceramides may create insulin resistance with respect to glucose metabolism. We present a new method to measure LCACoA concentrations and isotopic enrichment of palmitoyl‐CoA ([U‐ 13 C]16‐CoA) and oleoyl‐CoA ([U‐ 13 C]18:1‐CoA) using ultra‐performance liquid chromatography/tandem mass spectrometry (UPLC/MS/MS) to quantitate seven different LCACoA (C14‐CoA, C16‐CoA, C16:1‐CoA, C18‐CoA, C18:1‐CoA, C18:2‐CoA, C20‐CoA). The molecules are separated on a reversed‐phase UPLC column using a binary gradient with ammonium hydroxide (NH 4 OH) in water and NH 4 OH in acetonitrile (ACN). The LCACoA are quantified using selected reaction monitoring (SRM) on a triple quadrupole mass spectrometer in positive electrospray ionization (ESI) mode. All LCACoA ions except enriched palmitate enrichment of palmitoyl‐CoA ([U −13 C]16‐CoA) and oleoyl‐CoA ([U −13 C]18:1‐CoA) using ultra‐performance liquid chromatography/mass spectrometry (UPLC/MS/MS) to quantitate seven different LCACoA (C14‐CoA, C16‐CoA, C16:1‐CoA, C18‐CoA, C18:1‐CoA, C18:2‐CoA, C20‐CoA). The molecules are separated on a reversed‐phase UPLC column using a binary gradient with ammonium hydroxide (NH 4 OH) in water and NH 4 OH in acetonitrile. The LCACoA are quantified using selected reaction monitoring (SRM) on a triple quadrupolemass spectrometer in positive electrospray ionization (ESI) mode. All LCACoA ions except enriched palmitate and oleate were monitored as [M + 2 + H] + and [U 13 C]16‐CoA and [U 13 C]18:1‐CoA were monitored as [M + 16 + H] + and [M + 18 + H] + , respectively. The method is simple, sensitive and efficient (run time as short as 5 min) and allowed us to measure the concentration and detect enrichment in intramyocellular [U 13 C]16‐CoA and [U 13 C]18:1‐CoA during a low dose intravenous infusion of [U 13 C]palmitate and [U 13 C]oleate in adults undergoing either a saline control experiment or an insulin/glucose infusion experiment. This technique should allow investigators to measure the trafficking of extracellular fatty acids to the intracellular LCACoA pool. Copyright © 2011 John Wiley & Sons, Ltd.