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Purpose This study evaluates the temporal evolution of the spatial relationship between the pituitary adenoma transsphenoidal surgical cavity and the adjacent optic chiasm and discusses implications on timing and choice of radiotherapy modality. Methods This retrospective observational review analyzed factors that might influence the postoperative relationship between the surgical cavity and the optic chiasm, including tumor type, craniocaudal tumor and resection cavity dimensions, the preoperative distance between tumor and the optic chiasm, the presence of cavernous sinus invasion, and the choice of intraoperative packing material. Changes observed on magnetic resonance imaging in the preoperative, immediate (within 72 h), and delayed (≥3 months) postoperative periods were compared. Results Sixty-five patient histories were analyzed. Preoperatively, the pituitary adenoma was apposed to the optic chiasm in 43 patients (66%). Postoperatively, 34 patients (52%) in the immediate postoperative period and 54 patients (83%) in the delayed postoperative period had a distance ≥2 mm between the resection cavity and the optic chiasm. This distance provides a greater margin of safety with adjuvant radiosurgery. Preoperative tumor size showed a strong association with postoperative descent of the optic chiasm. Conclusions Preoperative tumor size and degree of mass effect on the optic chiasm predict postoperative changes. In this study, the distance between the resection cavity and the optic chiasm was greater at ≥3 months postoperatively than in the immediate postoperative period, regardless of preoperative mass effect, indicating radiotherapy planning should be deferred to ≥3 months postoperatively when not precluded by aggressive histological characteristics that necessitate more immediate treatment. Precis To investigate the temporal relationship between the postoperative sellar surgical cavity and the adjacent optic apparatus after transsphenoidal resection of pituitary adenomas and the implications for radiotherapy.

Volunteer Recovery Support for Adolescents (VRSA) is a novel recovery monitoring and support service for youth after discharge from residential treatment for substance use disorders. Study methods and results of a randomized controlled study are presented in a companion paper and provide evidence that VRSA improves pro recovery peer and activity involvement, decreases substance use and related problems, and increases early full remission (Godley et al., under review). This paper describes the VRSA model, how fidelity was monitored, methods used to recruit, retain, train, and supervise volunteers, how well volunteers were able to implement the model, and how adolescents responded to VRSA. As evidenced by successful recruitment of volunteers to cover caseload needs, positive rates of volunteer retention, and favorable recovery support session completion rates, VRSA is a flexible, potentially low-cost model for providing extended recovery support services that is both feasible and acceptable to adolescents. Future research is needed to identify variables that predict volunteer commitment and to investigate if matching gender, race/ethnicity, or other variables affect results.

Objective Visual field (VF) outcomes are commonly reported in neurosurgical case series; however, substantial variability can exist in VF testing and outcome reporting. We aimed to evaluate the challenges of VF testing and to develop detailed recommendations for VF outcome reporting by analyzing results from an ongoing, multicenter study of transsphenoidal pituitary surgery. Methods VF testing results were collected during a prospective, multicenter clinical trial evaluating patient outcomes after transsphenoidal surgery for nonfunctioning pituitary adenomas (TRANSSPHER). Two independent ophthalmologists reviewed reliability and outcomes of all VF studies. Preoperative and postoperative VF studies were evaluated individually and as preoperative/postoperative pairs. Results Suboptimal perimetry field settings were reported in 37% of VF studies. Automated reliability criteria flagged 25%–29% of VF studies as unreliable, whereas evaluation by 2 independent ophthalmologists flagged 16%–28%. Agreement between automated criteria and raters for VF reliability was inconsistent (κ coefficients = 0.55–0.83), whereas agreement between the 2 raters was substantial to almost perfect (κ coefficients = 0.78–0.83). Most patients demonstrated improvement after surgery (rater 1, 67%; rater 2, 60%), with substantial rater agreement on outcomes for paired examinations (κ coefficient = 0.62). Conclusions VF outcome studies demonstrated significant variability of test parameters and patient performance. Perimetry field settings varied among patients and for some patients varied preoperatively versus postoperatively. Reliance on automated criteria alone could not substitute for independent ophthalmologist review of test reliability. Standardized guidelines for VF data collection and reporting could increase reliability of results and allow better comparisons of outcomes in future studies.

Background Alcohol and other drug (AOD) problems confer a global, prodigious burden of disease, disability, and premature mortality. Even so, little is known regarding how, and by what means, individuals successfully resolve AOD problems. Greater knowledge would inform policy and guide service provision. Method Probability-based survey of US adult population estimating: 1) AOD problem resolution prevalence; 2) lifetime use of “assisted” (i.e., treatment/medication, recovery services/mutual help) vs. “unassisted” resolution pathways; 3) correlates of assisted pathway use. Participants (response = 63.4% of 39,809) responding “yes” to, “Did you use to have a problem with alcohol or drugs but no longer do?” assessed on substance use, clinical histories, problem resolution. Results Weighted prevalence of problem resolution was 9.1%, with 46% self-identifying as “in recovery”; 53.9% reported “assisted” pathway use. Most utilized support was mutual-help (45.1%,SE = 1.6), followed by treatment (27.6%,SE = 1.4), and emerging recovery support services (21.8%,SE = 1.4), including recovery community centers (6.2%,SE = 0.9). Strongest correlates of “assisted” pathway use were lifetime AOD diagnosis (AOR = 10.8[7.42–15.74], model R2 = 0.13), drug court involvement (AOR = 8.1[5.2-12.6], model R2 = 0.10), and, inversely, absence of lifetime psychiatric diagnosis (AOR = 0.3[0.2–0.3], model R2 = 0.10). Compared to those with primary alcohol problems, those with primary cannabis problems were less likely (AOR = 0.7[0.5–0.9]) and those with opioid problems were more likely (AOR = 2.2[1.4-3.4]) to use assisted pathways. Indices related to severity were related to assisted pathways (R2 Conclusions Tens of millions of Americans have successfully resolved an AOD problem using a variety of traditional and non-traditional means. Findings suggest a need for a broadening of the menu of self-change and community-based options that can facilitate and support long-term AOD problem resolution.

Background: It has been long established that achieving recovery from an alcohol or other drug use disorder is\ud associated with increased biobehavioral stress. To enhance the chances of recovery, a variety of psychological,\ud physical, social, and environmental resources, known as “recovery capital”, are deemed important as they can\ud help mitigate this high stress burden. A 50-item measure of recovery capital was developed (Assessment of\ud Recovery Capital [ARC]), with 10 subscales; however, a briefer version could enhance further deployment in\ud research and busy clinical/recovery support service settings. To help increase utility of the measure, the goal of\ud the current study was to create a shorter version using Item Response Theory models.\ud Method: Items were pooled from the original treatment samples from Scotland and Australia (N=450) for scale\ud reduction. A reduced version was tested in an independent sample (N =123), and a Receiver Operating\ud Characteristic Curve was constructed to determine optimal cut-off for sustained remission (> 12 months abstinence).\ud Results: An abbreviated 10-item measure of recovery capital captured item representation from all 10 original\ud subscales, was invariant across participant’s locality and gender, had high internal consistency (α= .90),\ud concurrent validity with the original measure (rpb =.90), and predictive validity with sustained remission using\ud a cut-off score of 47.\ud Conclusion: The brief assessment of recovery capital 10-item version (BARC-10) concisely measures a single\ud unified dimension of recovery capital that may have utility for researchers, clinicians, and recovery support\ud services.

A sample of 904 physicians consecutively admitted to 16 state Physicians' Health Programs (PHPs) was studied for 5 years or longer to characterize the outcomes of this episode of care and to explore the elements of these programs that could improve the care of other addicted populations. The study consisted of two phases: the first characterized the PHPs and their system of care management, while the second described the outcomes of the study sample as revealed in the PHP records. The programs were abstinence-based, requiring physicians to abstain from any use of alcohol or other drugs of abuse as assessed by frequent random tests typically lasting for 5 years. Tests rapidly identified any return to substance use, leading to swift and significant consequences. Remarkably, 78% of participants had no positive test for either alcohol or drugs over the 5-year period of intensive monitoring. At post-treatment follow-up 72% of the physicians were continuing to practice medicine. The unique PHP care management included close linkages to the 12-step programs of Alcoholics Anonymous and Narcotics Anonymous and the use of residential and outpatient treatment programs that were selected for their excellence.

The addiction field's failure to achieve consensus on a definition of “recovery” from severe and persistent alcohol and other drug problems undermines clinical research, compromises clinical practice, and muddles the field's communications to service constituents, allied service professionals, the public, and policymakers. This essay discusses 10 questions critical to the achievement of such a definition and offers a working definition of recovery that attempts to meet the criteria of precision, inclusiveness, exclusiveness, measurability, acceptability, and simplicity. The key questions explore who has professional and cultural authority to define recovery, the defining ingredients of recovery, the boundaries (scope and depth) of recovery, and temporal benchmarks of recovery (when recovery begins and ends). The process of defining recovery touches on some of the most controversial issues within the addictions field. © 2007 Elsevier Inc. All rights reserved.

Addition of the endoscope to the transsphenoidal approach for resection of sellar lesions can improve visualization by providing better illumination and wider views of the surgical field. This article describes the indications, instrumentation, and operative techniques for endoscopic-assisted transsphenoidal surgery

Many complex ethical issues arise in the day-to-day conduct of longitudinal studies of addiction treatment. These issues are rooted, in part, in the sustained and potentially ambiguous relationship between research staff and study participants, the frequently changing clinical and legal status of study participants, the assertive methods required to generate high follow-up rates, and the numerous systems of care and control in which participants are involved. To identify common ethical issues that arise in such studies, the authors conducted individual and group interviews with seasoned members (case trackers, field trackers, interviewers, and supervisors) of the research team. The ethical dilemmas identified through these interviews fell into seven broad arenas: (1) informed consent for research participation, (2) confidentiality and information disclosure, (3) relationship boundaries between study participants and research staff, (4) duty to warn/report responsibilities, (5) questions of autonomy and privacy, (6) issues related to compensation for research participation, and (7) data integrity. Case studies that illustrate common ethical dilemmas within each of these seven areas are presented and discussed. Ethical dilemmas in the study of addiction treatment can be effectively managed via ethically informed research protocols, staff training in ethical decision-making, monitoring and supervision, and collective debriefing of critical events.

Purpose To report the success rate of endoscopically assisted balloon dacryoplasty (EADCP) for treatment of acquired incomplete nasolacrimal duct obstructions (NLDOs). Design Retrospective, noncomparative case series. Participants Records of patients treated for incomplete NLDOs with EADCP by one of the authors (WLW) were reviewed. Diagnosis of incomplete NLDO was based upon subjective complaints of tearing, dye disappearance testing, clinical evidence of epiphora, and nasolacrimal duct irrigation. Endoscopically assisted balloon dacryoplasty was performed for incomplete obstructions identified. Methods One hundred forty-two nasolacrimal systems in 103 patients with incomplete NLDOs underwent EADCP for treatment of incomplete obstructions. A 3×15-mm balloon was utilized in all procedures, with silicone lacrimal tubes placed in 131 systems. Patients received postoperative topical antibiotic–steroid drops for 2 weeks and a 1-week tapering dosage of systemic methylprednisolone. Main outcome measures Patients were assessed at their last postoperative visit by nasolacrimal system irrigation, dye disappearance testing, and subjective complaints of epiphora. Results Eighty systems (56%) experienced complete resolution of symptoms after surgery. Forty-eight additional systems (34%) showed improvement but still experienced periodic epiphora. Fourteen systems (10%) showed no improvement. The average time before follow-up was 7.5 months. Conclusion Endoscopically assisted balloon dacryoplasty as a treatment for incomplete NLDOs provides complete relief or substantial improvement in a significant percentage of patients. Nasal videoendoscopy adds significantly to the understanding of this procedure and its potential for success. Endoscopically assisted balloon dacryoplasty should be considered an appropriate treatment option for selected patients with incomplete NLDOs.

Objectives To determine the long-term outcome of patients presenting with synchronous lymphoma and severe liver dysfunction and to describe the outcome of patients treated with initial mechlorethamine-based therapy used as a bridge to more conventional chemotherapy. Patients and Methods We reviewed the clinical course of all patients diagnosed as having lymphoma who presented with severe liver dysfunction and received intravenous mechlorethamine between September 1988 and February 2003 at the Mayo Clinic in Rochester, Minn. Results Forty-one patients were identified, 33 (80%) of whom had newly diagnosed, previously untreated lymphoma. Thirty-seven (90%) had non-Hodgkin lymphoma, and 4 (10%) had Hodgkin disease. Thirty-four patients (83%) had stage IV disease, and 31 (84%) of 37 had an intermediate-high International Prognostic Index. The median total bilirubin level before therapy was 10.7 mg/dL (range, 2.5–30.2 mg/dL), and the median alkaline phosphatase level was 982 U/L (range, 233–3415 U/L). In addition to mechlorethamine, 34 patients (83%) received concomitant corticosteroids, and 12 (29%) received concomitant rituximab. Twenty-two patients (54%) had sufficient improvement in liver function to receive subsequent standard chemotherapy. Nine patients (22%) are alive and disease-free at a median of 31 months (range, 4 to ≥87 months) after mechlorethamine treatment. Factors associated with improved overall survival included improvement in bilirubin levels ( P P =.001). Conclusion Mechlorethamine, high-dose corticosteroids, and rituximab are useful therapeutic interventions for this unique group of patients with lymphoma and severe liver dysfunction. Substantial clinical improvement and long-term survival are possible.

Purpose To determine the clinical efficacy and morbidity of combined endoscopic transnasal medial and inferior wall orbital decompression performed in conjunction with transcutaneous lateral orbital decompression. Design Retrospective noncomparative case series. Participants Thirty-four subjects (64 orbits) underwent combined orbital decompression procedures for treatment of Graves' orbitopathy. Intervention Transnasal endoscopic medial wall and floor with simultaneous transcutaneous lateral orbital decompression. Main outcome measurements Ocular motility, visual acuity, and exophthalmometry. Results No new ocular motility disturbances occurred. There was a mean gain of 0.7 Snellen lines in acuity (range +9 to −10 lines). A mean proptosis reduction of 4.2 mm was observed (range 1–9 mm). Conclusions Combined endoscopic transnasal medial and inferior orbital wall decompression done in conjunction with transcutaneous lateral orbital decompression carries a low risk of morbidity, including new onset motility disorders, and yields anatomic retropulsion of the globe that is comparable to other methods.

Purpose: Extranodal marginal zone B-cell lymphoma (low-grade B-cell lymphoma of mucosa-associated lymphoid tissue [MALT] type) is a distinctive type of lymphoma that usually arises in association with mucosa or other epithelial structures and has an indolent clinical course. The frequency and clinical features of MALT lymphomas in the ocular adnexa have not been well studied. Methods: The authors examined the clinicopathologic features of ocular adnexal lymphoma, identified a subset of cases with MALT characteristics, and determined patient outcome. Results: The 42 patients, 16 men and 26 women age 35-89 years (mean, 64) were followed an average of 4.8 years. Thirty-two patients had ocular adnexal involvement at presentation (primary ocular adnexal lymphoma) and 10 had a history of lymphoma that relapsed in the orbit (secondary ocular adnexal lymphoma). In the primary group, 23 patients had lymphoma confined to the ocular adnexa, 3 had a single lesion that invaded adjacent structures, and 6 had distant spread at the time of presentation. Twenty-five patients achieved a complete remission. Nine patients, including 6 patients whose disease was localized initially, had progression or relapse of disease in distant sites. At last follow-up, 21 patients were free of disease, 9 were alive with disease and 2 had died of lymphoma. In the secondary group, at last follow-up, 1 patient had died of other causes, free of lymphoma, 3 patients were alive with disease and 5 had died of lymphoma (outcome not known in 1 case). Using the recently described revised European-American lymphoma classification, we found 16 MALT lymphomas, 8 diffuse large B cell, 12 follicular center, 3 mantle cell, 1 B-small lymphocytic lymphoma, and 2 unclassifiable low-grade lymphomas. The most common type of primary lymphoma was MALT type (15 of 30 classifiable cases), and the most common secondary lymphoma was follicular center (6 of 10). No increased frequency of conjunctival or lacrimal gland involvement by MALT lymphomas was found. All 33 lymphomas with immunophenotyping were of B lineage. Conclusions: Ocular adnexal lymphomas are 8-cell tumors that develop in older adults, predominantly among women. Primary orbital lymphomas have a favorable prognosis; a high proportion of them have MALT characteristics.

Purpose To report a series of lacrimal complications associated with a specific type of lacrimal plug (Herrick Lacrimal Plug; Lacrimedics Incorporated, Rialto, CA.) Design Retrospective, noncomparative case series and survey. Methods Members of the American Society of Ophthalmic Plastic and Reconstructive Surgery were asked to submit personally treated cases of patients referred for treatment of complications after placement of a Herrick Lacrimal Plug. Main outcome measures Failure of the device to be removed by simple lacrimal irrigation. Results The clinical courses of 41 patients were analyzed. Patients ranged in age from 19 to 81 years, and all had symptomatic epiphora related to the presence of the lacrimal plug. Several interventions were used to treat lacrimal obstruction. Nasolacrimal duct probing with irrigation was used in 15 lacrimal systems, whereas six systems were probed and subsequently stented with silicone tubing. Eyelid margin cutdown was used in eight cases. Balloon dacryoplasty was performed in three systems, dacryocystorhinostomy in 18 instances, and conjunctivodacryocystorhinostomy in two patients. Conclusions The Herrick lacrimal occlusion device sometimes cannot be removed by simple irrigation and is capable of inducing permanent, irreversible, symptomatic lacrimal drainage system obstruction.

We saw two infants with the unusual combination of oculomotor nerve palsy, facial capillary hemangioma, cerebellar hypoplasia, and apparent gaze palsy. Systematic imaging of children with congenital oculomotor nerve palsy may lead to the recognition of more associated neurologic abnormalities that are not clinically apparent, as was the case in our patients.

To document the change in drainage of tears that occurs with blinking, the authors evaluated 17 lacrimal systems of 12 individuals with dacryoscintigraphy. A significant difference in tear drainage was found by keeping the eyelids closed during the first 2 minutes after drop placement (P less than 0.03), but not from 2 to 5 minutes (P greater than 0.4). Retardation of tear drainage after droplet placement can be achieved by simple eyelid closure for 2 minutes.

In a patient who had fever and cytopenias but no peripheral lymphadenopathy, bone marrow biopsy revealed findings consistent with Hodgkin's disease. Subsequently lymph node biopsy specimens showed lymphoma with features more consistent with peripheral T-cell lymphoma. The clinical features of this patient were those that have been ascribed to an atypical clinical form of Hodgkin's disease. This case illustrates the inadequacy of bone marrow examination as the sole criterion for establishing an initial diagnosis of Hodgkin's disease, particularly in relationship to the newly recognized pleomorphic variants of T-cell malignant lymphoma.

A solitary extramedullary lymphoid neoplasm had characteristics of plasma cell precursors or plasmablasts. Conventional microscopic study classified this tumor as a diffuse large cell lymphoma of "immunoblastic sarcoma" type. Immunologic cell surface markers could not be detected, but cytoplasmic immunoglobulin G (IgG)-kappa was demonstrated by immunoperoxidase technic, and IgG was present in the supernatant of the tumor tissue culture. The distinction between lymphoid and plasma cellular neoplasms is made.

An erythrophagocytic neoplastic infiltration of the bone marrow which resembled malignant histiocytosis was found in an elderly man who, when initially examined, had fever and cytopenias. Results of cytochemical and immunologic studies were consistent with an acute lymphocytic leukemia in which the lymphoblasts showed the simultaneous expression of lymphoid stem cell and B-cell markers. Chromosome analysis revealed an abnormal clone with a deletion of part of the long arm of chromosome 20. This case illustrates (1) the occurrence of striking erythrophagocytosis by lymphoblasts at the time of initial presentation of a patient with acute lymphocytic leukemia, (2) the fact that abnormalities of chromosome 20 can occur in patients with acute lymphocytic leukemia, and (3) the capability of lymphoid malignant lesions to show the simultaneous expression of antigens that are characteristic of different stages of lymphoid differentiation.

A series of seventy-six secondary flexor tendon grafts to the fingers have been presented for evaluation. In all instances the initial disability had resulted from injury in “no man's land.” This evaluation indicates that cooperation of the patient and the preoperative condition of the hand are the most significant factors in predicting results.