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In the philosophical traditions of both the East and West, one encounters the idea that human beings may attain the good life by satisfying a small number of basic needs.

To evaluate the efficacy and ocular safety of bromfenac ophthalmic solution 0.09% dosed once daily for the treatment of ocular inflammation and pain following cataract extraction with posterior chamber intraocular lens implantation.A total of 455 subjects (455 study eyes: 230 bromfenac, 225 placebo) were enrolled in two randomized double-masked, placebo-controlled, clinical trials at 64 ophthalmology clinics in the United States. Subjects were randomized to receive either bromfenac 0.09% or placebo dosed once daily. Dosing began 1 day before cataract surgery (Day -1), continued on day of surgery (Day 0), and for 14 days following surgery. Evaluations were completed on Days 1, 3, 8, 15 and 22. The primary efficacy endpoint was cleared summed ocular inflammation score (SOIS) by Day 15. The secondary efficacy endpoint was the number of subjects who were pain-free at Day 1.The bromfenac 0.09% group was significantly higher compared to the placebo group in the primary endpoint of the proportion of subjects who had cleared ocular inflammation by Day 15 (P0.0001). The mean SOIS for the bromfenac 0.09% group was lower than the placebo group at Days 3, 8, 15, and 22 (P0.0001). More bromfenac 0.09% subjects were pain free at Days 1, 3, 8, and 15 (P0.0001). Fewer subjects in the bromfenac 0.09% group withdrew from the clinical trials due to lack of efficacy at Day 15 (P0.0001). Fewer adverse events were reported in the bromfenac 0.09% group than the placebo group. Limitations included advanced age, female predominance, and surgical nuances among cataract surgeons, making cross-trial comparisons difficult.Bromfenac ophthalmic solution 0.09% dosed once daily is clinically safe and effective for the treatment of ocular inflammation and the reduction of ocular pain associated with cataract surgery.

Clin. Otolaryngol. 2010, 35, 402–408 Objectives: To investigate the prognostic significance of positive margin and disease course in partial laryngectomy for advanced laryngeal carcinoma and radiation failure. Design: Retrospective case control study. Setting: A major tertiary referral centre. Participants: Patients who underwent partial laryngectomy for advanced laryngeal carcinoma or for radiation failure with at least 2 years of follow-up. Main outcome measures: Margin status versus primary treatment and salvage treatment versus disease-free survival and overall survival. Results: Twenty nine patients with sufficient follow-up data were found. Twelve patients had histological positive margin. Five of the 12 patients with a histological positive margin failed surgery as did four patients with clear margins. A positive margin had no effect on disease-free survival (P = 0.287) but was associated with poorer overall survival (P = 0.051). Of 11 patients treated primarily with surgery, recurrence was documented in one of eight with a positive margin and none of three with clear margins. Of 18 patients who underwent surgery secondary to radiation failure, recurrence was documented in all four with a positive margin and 4 of 14 with negative margins. Extended frontolateral resection, performed only in radiation failures, was associated with worse disease-free survival. Conclusions: Non-irradiated patients with involvement of a single margin after partial laryngectomy may be spared total laryngectomy if adjuvant radiation is administered. Patients who fail radiation should undergo radical partial laryngectomy, with conversion to total laryngectomy in those with a positive margin.

To shed light on the discrepancy between the advanced stage at presentation and high recurrence rate of well-differentiated thyroid cancer in children and the overall good survival.The files of 75 children with well-differentiated thyroid cancer treated from 1954 to 2001 in a major tertiary-care hospital were reviewed for disease course, management, and outcome.Sixty patients (80%) had positive neck metastases with involvement of central compartment lymph nodes in all, lateral neck nodes in 36, and distant metastases in 4. Sixty-seven patients underwent total thyroidectomy with adjuvant radioiodine treatment and 8 underwent hemithyroidectomy; all had concomitant neck treatment. The rate of local (5%) and neck (9%) recurrence was similar to the total rate reported in adults. Total thyroidectomy led to a significantly lower recurrence rate (7.5%) than hemithyroidectomy (38%; P0.005). Type of neck dissection did not affect recurrence or appearance of distant metastases. All deaths (n = 2) were due to distant metastases, whereas 30% of adult deaths are due to local or neck disease.The treatment of choice for well-differentiated thyroid cancer in young patients is total thyroidectomy. Neither regional disease at presentation nor recurrences affect survival.

Purpose: The standard treatment for patients with early glottic carcinoma in Israel has been radiotherapy. In recent years, encouraging results with laryngo-microscopic carbon dioxide laser surgery as a treatment for early glottic carcinoma has changed our treatment strategy. We conducted a retrospective study to investigate the results of carbon dioxide laser excisional technique for early glottic carcinoma (T1, T2). Materials and Methods: Twenty-six had squamous cell carcinoma (SCC), (21 patients with T1 and 5 patients with T2 lesions), 3 had carcinoma in situ, (CIS) and 3 had verrucous carcinoma (VC). Results: All patients were free of disease after salvage treatment at the most recent follow-up. Conclusions: Careful patient selection with endoscopic staging and strict follow-up are essential to secure good results in the treatment of carbon dioxide laser for early laryngeal carcinoma. (Am J Otolaryngol 2003;24:28-33. Copyright 2003, Elsevier Science (USA). All rights reserved.)

Objective:To identify the prognostic significance of specific lymph node related characteristics for disease persistence and recurrence in patients with pre- or intra-operative evidence of neck metastases and no other risk factors.Method and resultsSixty-eight patients were identified; 50 per cent had persistent or recurrent disease. All underwent the same treatment strategy. There were no statistically significant differences in any of the patient- or tumour-related parameters when patients with and without persistence or recurrence were compared. Patients with recurrent or persistent disease had significantly larger (>3 cm) metastatic lymph nodes, but there were no differences regarding other lymph node related parameters (i.e. number, extracapsular extension, number of lymph nodes with extracapsular extension, and central vs lateral neck location). On multivariate analysis, however, none of the parameters were predictive of persistent or recurrent disease.Conclusion:In papillary thyroid carcinoma patients with no other risk factors, pre- or intra-operative evidence of cervical metastases was associated with a very high rate of disease persistence or recurrence. Specific lymph node characteristics were not shown to have prognostic significance.

We retrospectively evaluated the management of supraglottic carcinoma at our centre during the last 35 years to determine the preferred mode of treatment. A review of the medical records yielded 114 patients with supraglottic T 1 and T 2 carcinoma who were diagnosed and treated in the Departments of Otolaryngology, Head and Neck Surgery, and Oncology between 1959 and 1993. Of these, 47 (41.2%) had T 1 carcinoma (stage I) and 67 (58.8%) T 2 (stage II). Treatment varied among radiotherapy, surgery, or combined radiotherapy and surgery. Twelve patients underwent elective neck dissection, one of whom (8.3%) was found to have occult metastases. Local failures were noted in 22 patients (11 T 1 : 11 T 2 ), three of whom also had neck metastases. All except one T 2 patient received radiotherapy. Radiotherapy yielded the best survival rates for T 1 disease as combined therapy did for T 2 . Five-year recurrence rates for T 1 patients were 35% for those treated by radiotherapy and 42% for those treated with combined therapy; corresponding figures for T 2 patients were 39% and 28%. We suggest that patients with T 1 supraglottic carcinoma be managed with radiotherapy and patients with T 2 with combined therapy. We believe there is no need for elective neck dissection, especially in T 1 .

Emotionally arousing material is typically better remembered than neutral material. Since norepinephrine and cortisol interact to modulate emotional memory, sex-related influences on stress responses may be related to sex differences in emotional memory. Two groups of healthy women – one naturally cycling (NC women, N = 42) and one using hormonal contraceptives (HC women, N = 36) – viewed emotionally arousing and neutral images. Immediately after, they were assigned to Cold Pressor Stress (CPS) or a control procedure. One week later, participants received a surprise free recall test. Saliva samples were collected and later assayed for salivary alpha-amylase (biomarker for norepinephrine) and cortisol. Compared to NC women, HC women exhibited significantly blunted stress hormone responses to the images and CPS. Recall of emotional images differed between HC and NC women depending on noradrenergic and cortisol responses. These findings may have important implications for understanding the neurobiology of emotional memory disorders, especially those that disproportionately affect women.

Pattern separation, the process by which similar experiences can be stored as distinct memories, has been ascribed to the dentate gyrus (DG) of the hippocampus. The DG is the target of noradrenergic modulation directly and indirectly via the basolateral amygdala. We tested the hypothesis that noradrenergic activation (tested using salivary alpha-amylase) potentiates DG function, enhancing pattern separation, by showing participants fearful stimuli in a pre-training task and then testing their capacity for pattern separation in a later test. Consistent with our hypothesis, we found that increased levels of salivary alpha-amylase were positively correlated with enhanced pattern separation performance even after accounting for general enhancements in recognition.

Post-trial pharmacological activation of the noradrenergic system can facilitate memory consolidation. Because exercise activates the locus coeruleus and increases brain norepinephrine release, we hypothesized that post-trial exercise could function as a natural stimulus to enhance memory consolidation. We investigated this in amnestic mild cognitive impairment (aMCI) and cognitively normal elderly individuals by examining the effects of an acute bout of post-learning, aerobic exercise (6 minutes at 70% VO2 max on a stationary bicycle) on memory for some emotional images. Exercise significantly elevated endogenous norepinephrine (measured via the biomarker, salivary alpha-amylase) in both aMCI patients and controls. Additionally, exercise retrogradely enhanced memory in both aMCI patients and controls. Acute exercise that activates the noradrenergic system may serve as a beneficial, natural, and practical therapeutic intervention for cognitive decline in the aging population.

To investigate the prognostic significance of positive margin and disease course in partial laryngectomy for advanced laryngeal carcinoma and radiation failure.Retrospective case control study.A major tertiary referral centre.Patients who underwent partial laryngectomy for advanced laryngeal carcinoma or for radiation failure with at least 2 years of follow-up.Margin status versus primary treatment and salvage treatment versus disease-free survival and overall survival.Twenty nine patients with sufficient follow-up data were found. Twelve patients had histological positive margin. Five of the 12 patients with a histological positive margin failed surgery as did four patients with clear margins. A positive margin had no effect on disease-free survival (P = 0.287) but was associated with poorer overall survival (P = 0.051). Of 11 patients treated primarily with surgery, recurrence was documented in one of eight with a positive margin and none of three with clear margins. Of 18 patients who underwent surgery secondary to radiation failure, recurrence was documented in all four with a positive margin and 4 of 14 with negative margins. Extended frontolateral resection, performed only in radiation failures, was associated with worse disease-free survival.Non-irradiated patients with involvement of a single margin after partial laryngectomy may be spared total laryngectomy if adjuvant radiation is administered. Patients who fail radiation should undergo radical partial laryngectomy, with conversion to total laryngectomy in those with a positive margin.

A plethora of evidence from the animal and human literature suggests that emotionally arousing material is often remembered better than is neutral material, and that this effect critically involves noradrenergic activation during and soon after exposure to the emotional material. A crucial prediction of this hypothesis is that endogenous adrenergic activation should relate positively and selectively to memory for emotional events in humans. Salivary alpha-amylase (sAA), a biomarker for adrenergic activity was measured in response to viewing a series of mixed emotional and neutral images to test this prediction in healthy men and women. One week after viewing these images subjects returned for a surprise free recall test. Endogenous noradrenergic activation, defined as an increase in sAA immediately after versus before slide viewing, occurred in 24 of 67 subjects. Regression analysis of the data revealed a significant positive correlation between the increase in sAA and the percentage of emotional pictures recalled. No correlation existed in the same subjects between sAA and the percentage of neutral pictures recalled. Additionally, the difference between these two correlations closely approached significance. The findings therefore demonstrate a relationship between a measure of endogenous noradrenergic activation and long-term memory performance in humans. The results support the view that adrenergic activation underlies enhanced memory for emotional material in humans, namely, that endogenous adrenergic activation in response to an emotional event should predict long-term memory for the event. The selectivity of the relationship for emotional, and not neutral, material supports the view derived from earlier research that stress activation does not necessarily enhance memory for all aspects of an emotional event; rather, that it acts disproportionately to influence memory for the more emotional aspects of an event. These findings are the first involving human subjects to indicate that the degree of endogenous noradrenergic activation in response to emotionally arousing stimuli predicts the strength of long-term memory for those stimuli.

Purpose To assess the safety and efficacy of peripheral 360-degree laser retinopexy as prophylaxis against rhegmatogenous retinal detachment (RRD) in eyes having pars plana vitrectomy (PPV) for the removal of retained cataract fragments. Setting Private practice, Callahan Eye Foundation Hospital, University of Alabama at Birmingham, and Helen Keller Foundation for Research and Education, Birmingham, Alabama, USA. Methods This retrospective analysis comprised a consecutive series of patients who had PPV with 360-degree laser retinopexy for retained cataract fragment removal between January 1, 1995, and December 31, 2000. All laser treatments were applied with indirect ophthalmoscope delivery. Results In 78 eyes of 78 patients, the mean interval between cataract surgery and PPV with 360-degree laser retinopexy prophylaxis was 14 days. One (1.3%) of 78 eyes had postoperative RRD during a mean follow-up of 6 years. No laser-related complications occurred. Conclusions The incidence of RRD after PPV with 360-degree laser retinopexy prophylaxis was 1.3%, a significant reduction from the average 8.2% RRD rate in the literature ( P = .024). Although future prospective trials are indicated, the results suggest that 360-degree laser retinopexy prophylaxis could significantly reduce the incidence of this visually disabling complication.

Bilateral vocal fold immobility in adduction usually creates severe dyspnoea. Many surgical procedures have been established to improve the airway insufficiency in affected patients.Over the last six years 22 patients with bilateral vocal fold immobility in our department have undergone CO2 laser posterior ventriculocordectomy with partial arytenoidectomy (PVCPA). None had dyspnoea or a disturbance in the immediate post-operative period or during follow up, which ranged from five months to six years. Only one patient required a second procedure.Laser PVCPA appears to be an effective and reliable method for the treatment of bilateral vocal fold immobility in selected patients.

Though most hemangiomas do not need treatment, a significant minority are associated with complications and external deformities that demand intervention. Steroids play an important role in therapy, but not infrequently afford only partial and temporary benefit. Thanks to improvements in the surgical approach and equipment, hemostasis control devices and laser techniques, we can now treat patients who would otherwise go untreated. Moreover, in certain cases, we can now recommend earlier intervention, saving patients from years of living with deformities and the concomitant psychosocial problems. Vascular anomalies of the head and neck include venular, venous and arteriovenous malformations. These lesions are slow growing vascular ectasia that never involute spontaneously and almost always require intervention. Treatment includes laser therapy, injection of sclerosing agents, embolization through angiography and surgery, which in many cases is the only definitive treatment. We present the current treatment approach and describe our experience in the treatment of 16 patients.

Kimura's disease is a rare angiolymphoid proliferative disorder of soft tissue characterized by subcutaneous swelling and a predilection for the head and neck. There are usually enlarged regional lymph nodes, eosinophilia and elevated sedimentation rate and IgE levels. A 26-year-old women with subcutaneous masses in the submandibular area is reported. The diagnosis of Kimura's disease versus angiolymphoid hyperplasia is discussed.

The facial and vestibulocochlear nerves emanate from the brain stem and then run parallel to each other within the internal auditory canal prior to their more peripheral distribution. Although anatomic connections between the facial and cochlear nerves have been described, reports outlining facial-vestibular anastomoses are few and may be found primarily in the non-English literature. The present study documents the existence of vestibulofacial neural connections as part of an anatomic dissection of 17 fresh human temporal bones.

Seventy-three patients with lip carcinoma were treated from 1970 to 1988 inthe Otolaryngology Department of the Beilinson Medical Center. The most common histological type was squamous cell carcinoma which occurred in 68 patients; four tumours were basal cell carcinoma and one acinic cell carcinoma. Carcinoma of the lip is more frequent in males. Nevertheless, the frequency of carcinoma in females in our series was substantially higher than the average reported in the literature. Forty-nine patients were treated surgically and 24 patients were treated by irradiation. Analysis of the results among thosetreated by surgery and those treated by irradiation shows a difference in tumour local control which was statistically significant (p = 0.025). Surgical treatment is recommended because of the advantage of tumour margin assessment, avoidance of radiotherapy complications and rapid rehabilitation. Two rare cases of carcinoma of the lip in young patients (age under 20 years) are presented.

Reactive arthritis, also called Reiter's syndrome, is the most common type of inflammatory polyarthritis in young men. It is sometimes the first manifestation of human immunodeficiency virus infection. An HLA-B27 genotype is a predisposing factor in over two thirds of patients with reactive arthritis. The syndrome most frequently follows genitourinary infection with Chlamydia trachomatis, but other organisms have also been implicated. Treatment with doxycycline or its analogs sometimes shortens the course or aborts the onset of the arthritis. Reactive arthritis may also follow enteric infections with some strains of Salmonella or Shigella, but use of antibiotics in these patients has not been shown to be effective. Reactive arthritis should always be considered in young men who present with polyarthritis. Symptoms may persist for long periods and may, in some cases, cause long-term disability. Initial treatment consists of high doses of potent nonsteroidal anti-inflammatory drugs. Patients with large-joint involvement may also benefit from intra-articular corticosteroid injection.

Thyroid cancer is the third most common solid tumor in children and adolescents. A review was made of the data on 540 such patients reported from nine large centers renowned for their experience with thyroid cancer. In respect to the pathogenesis the only factor conclusively known to promote development of thyroid cancer in the pediatric age group is irradiation, as documented by the Chernobyl experience. The evidence indicates that thyroid carcinoma in the pediatric age group is a biologically independent and more aggressive entity than in adults; paradoxically the prognosis is good. In the great majority of cases the only presenting sign was a neck mass. In a high percentage (60-80%) there were also palpable lymph nodes. The findings regarding lung metastases were not clear-cut: in most series they were present in about 10%, with a high of 28% in one group and a low of 5% in another group. Papillary carcinoma or the follicular variant of papillary carcinoma were the dominant histologic types, pure follicular carcinoma being found much less frequently than among adults with thyroid cancer. Despite the relatively advanced stage of the disease upon diagnosis, only 13 patients died of the disease, 12 to 33 years postoperatively. Recurrence rates ranged between 10% to 35%, with involvement of the lateral neck, thyroidal bed or distant sites 3 to 33 years after treatment; most failures responded to further surgery or radioactive iodine. There is almost general agreement that surgical intervention should consist of total or near total thyroidectomy despite the high rates of recurrent laryngeal nerve paralysis and hypocalcemia. In regard to neck metastases less than radical surgery has proved during the years to be sufficiently effective. Radioactive iodine, used by all at some stage of management for treatment purposes, should be used prophylactically only after due consideration in view of possible teratogenicity.

Thyroid cancer is a rare but intriguing malignancy when it occurs in childhood and adolescence. In this retrospective study 58 young patients with thyroid cancer treated at the Rabin Medical Centre are presented. We found that thyroid carcinoma in children presented in a more advanced stage than in adults, and the incidence of regional metastases at the time of presentation is higher. Nevertheless, the biological behaviour of the tumour is more benign. We believe that near-total thyroidectomy is the treatment of choice in this age group for disease limited to the gland, and total thyroidectomy with perithyroidal neck dissection should be performed in patients with nodal disease. For follow-up, we recommend physical examination with measurement of thyroglobulin and TSH levels, ultrasound examination of the neck and chest radiography.

Over a period of 32 years, 56 patients with inverted papilloma of the nasal cavity and paranasal sinuses were diagnosed and treated at Beilinson Medical Center, Israel. Four patients (7%) had an associated malignancy. Several surgical approaches were used: limited intranasal excision in 5 patients with an 80% failure rate, a Caldwell-Luc approach in 21 patients with a 48% recurrence rate, and lateral rhinotomy with medial maxillectomy in 18 patients with only a 22% failure rate; a selected group of 9 patients underwent an endoscopic procedure, with a 22% recurrence rate. Our results and a review of 19 published reports suggest that medial maxillectomy via lateral rhinotomy remains the treatment of choice for most cases of inverted papilloma. The role of endoscopic excision in selected patients is discussed.

Rhinocerebral mucormycosis is a fulminating, devastating fungal disease, usually associated with debilitating diseases such as diabetes mellitus, leukaemia and immunosuppressive conditions. Ten patients with this rare disease have been treated over the past 14 years at the Beilinson Medical Centre. Nine patients had an underlying debilitating disease and one patient had latent diabetes mellitus which was diagnosed only after presentation of mucormycosis. Only two of the 10 patients survived. Early aggressive surgical debridement, together with amphotericin B and correction of underlying metabolic acidosis were found to be important factors associated with survival.

This study reviews the records of 56 patients with early glottic carcinoma involving the anterior commissure (T1N0M0) who were treated between 1958 and 1988 at Beilinson Medical Center. Five- and 10-year survival rates were 82% and 60%, respectively. Most failures were local (15 patients). In addition, three patients who were treatment failures had neck lesions (regional failure) and one had lung lesions (distant metastases). All 56 patients received irradiation as the only mode of initial treatment. The effectiveness of irradiation for anterior commissure lesions is therefore evaluated. The study supports previous reports suggesting that glottic carcinoma involving the anterior commissure is associated with a high rate of treatment failure.

Treatment of thyroidal oxyphilic (Hurthle cell) tumors is controversial due to difficulties in grading tumor malignancy. We classify these tumors into 3 histological subtypes: adenomas, atypical adenomas, and carcinomas. The purpose of this study was to find out whether this classification is a useful criterion for determination of the extent of surgery. Our retrospective study included 5 cases of adenoma, 2 of atypical adenoma and 13 of carcinoma. All histological specimens were revised and were stained immunohistochemically for thyroglobulin. All specimens were positive for thyroglobulin; staining for factor VIII was performed in cases in which the tumor had penetrated into blood vessels. Hemithyroidectomy was used for typical adenomas, while atypical adenomas were treated as carcinomas and total thyroidectomy was performed. 5 patients were treated with radioactive iodine. Taking into account the clinical results, we conclude that histological subtype is a useful guide for proper surgical management. Hemithyroidectomy is proper therapy for adenomas. The management of atypical adenomas was not determined as all were treated as carcinomas.

Because of the limitations of periodic 131I whole-body scans, including suspension of substitution therapy, questionable sensitivity and low yield in detecting metastases in patients who have undergone thyroidectomy, serum thyroglobulin and 131I whole-body scans were evaluated for sensitivity in detecting local, regional or distant metastases in 261 patients with differentiated thyroid carcinoma after total thyroidectomy and ablation.A noncompetitive immunoradiometric assay was used for serum thyroglobulin determination. An 131I whole-body scan was obtained after replacement therapy had been suspended for 6 wk or when TSH reached levels higher than 50 microU/ml. In patients who underwent radiological procedures with iodinated contrast media, the waiting period before the 131I whole-body scan was no less than 10 wk.Of the 58 patients with proven metastases who were followed for 12 yr (mean 7 +/- 3.3 yr), 51 (88.4%) had high serum thyroglobulin assays performed while under full replacement therapy and 32 (55%) showed clear 131I whole-body scan localization. There were no instances of positive whole-body scans and negative serum thyroglobulin.In patients treated with 131I, serum thyroglobulin assay was an excellent method to assess treatment. Patients with metastatic disease and negative whole-body scans with or without serum thyroglobulin exhibited a trend toward higher mortality. This trend may also indicate that the lack of 131I trapping and low thyroglobulin is a sign of metabolic dedifferentiation of otherwise histologically differentiated thyroid tumors.

A review of 48 cases of anaplastic cell carcinoma of the thyroid gland treated in the Department of E.N.T. of Beilinson Medical Center revealed more than 90% of the patients to be over 50 years of age. Twenty-five percent of the patients showed, histologically, areas of transition from differentiated carcinoma (either papillary or follicular) into anaplastic carcinoma. The patients were treated by surgery and/or irradiation and/or chemotherapy. Twenty-seven patients underwent subtotal or total thyroidectomy and 21 patients underwent biopsy or partial thyroidectomy. The survival rate was very poor, two-year survival rate was 28%. Twenty-eight of the patients (58%) died within one year of diagnosis.

The tongue is an unusual site for metastases of cutaneous malignant melanoma. A review of the literature revealed only 16 such cases. The discovery of metastases in the tongue usually indicates widespread dissemination of the melanoma and a terminal phase of the disease. Two patients with metastatic malignant melanoma of the tongue are presented. The primary tumors were excised 10 and four years respectively prior to the discovery of the lingual metastases. In one of the patients the lingual metastasis was the first evidence of a disseminated stage of the disease. The histopathological differentiation between primary and secondary melanoma of the tongue is discussed. Such differentiation may have an important therapeutic implication.

We describe a new technique for the direct injection of Teflon into a paralyzed vocal cord for purposes of augmentation.

We have lately treated six infants hospitalized in our hospital for persistent vomiting and failure to thrive with no overt explanation for their condition. Examination of the ears of these infants revealed various degrees of serous otitis media. They all had myringostomies and insertion of ventilation tubes after which they stopped vomiting and gained in weight. We wish to revive the often overlooked association between protracted vomiting and middle ear effusion. It seems that minimal degrees of middle ear effusion may cause vomiting and patients with this condition may benefit from ventilation tubes.

Studies of tissue respiration and oxidative phosphorylation of homogenates in the liver of white rats indicated that the 3-day hypokinesia is associated with a decreased rate of endogenic respiration and an increased amythal-resistant respiration. On the 10th day, there occurs a sharp increase of the oxidation rate of the endo- and exogenic substrates and the separation of oxidative phosphorylation takes place. During 30-day immobilization, the homogenate respiratory activity again decreases while on the 70-140th days of an exposure the oxidation rate of endo- and exogenic substrates increases with an increased effect of endogenic succinate on the hepatocyte energy metabolism. The possible mechanism disturbances in the liver of immobilized animals are discussed.

Of the 720 patients with thyroid cancer we saw from 1953 to 1989, 49 were younger than 20 years at diagnosis, and the female/male ratio was 4.4:1. The histologic type was papillary in 34, follicular in 14 and medullary in 1. Initial treatment in 41 was total or near-total thyroidectomy, and in 8 hemithyroidectomy. 23 underwent neck dissection in addition to thyroidectomy. 49% of those who underwent total thyroidectomy had foci of bilateral thyroid carcinoma on serial histological section. Local and distant relapse of thyroid carcinoma occurred in 4 of the 8 who underwent hemithyroidectomy, but in only 1 of the 41 who underwent total thyroidectomy. Our recommendations include total thyroidectomy, radioiodine therapy, and modified neck dissection when neck metastases are presented.

Between 1958 and 1983 at Beilinson Medical Center, Petah Tiqva, Israel, 75 patients were diagnosed as having squamous cell carcinoma of the body of the tongue. Of these, 42 were male and 33 female and the average age at the time of diagnosis was 61.6 years. 29.33% were in clinical stage I, 36% in stage II, 26.67% in stage III and 8% in stage IV. Fifteen patients underwent only surgery, nine received only irradiation and 51 received combined treatment. The 5-year survival rate was 68.3% with a significant difference between that for stage I (90%) and stage II (83.7%) and that for stages III and IV (43.07% and 0%, respectively) (P less than 0.001). Among the 24 with recurrence of the malignancy, 20 died despite treatment and four patients died of causes unrelated to the malignancy. From this experience it was concluded that local excision of the tumor should be performed only in stage I patients and that in stage II patients prophylactic treatment of the neck (neck dissection and irradiation) should be undertaken because of the high incidence of occult metastases.

Malignant skin neoplasms of the auricle and peri-auricular region constitute only 6% of all skin cancers. However, rates of recurrence and metastasis are higher than for other cutaneous malignancies. Of 81 patients with malignant skin neoplasms of the auricle, 53.1% had basal cell carcinoma, 39.5% squamous cell carcinoma and 7.4% malignant melanoma. The neoplasms were 4 times more common in men (more than in other series), and more common in those of Ashkenazi origin (75% of the patients) and in the elderly (peak incidence in the 7th decade). All patients were treated surgically, and 21 were also irradiated. In 4 with cervical metastases neck dissection was performed. The recurrence rate for all neoplasms was 12.4% and the rate of metastases to regional lymph nodes from squamous cell carcinoma, 12.5%. There was a marked correlation between positive margins after surgical excision and rates of recurrence and regional metastases. Malignant skin neoplasms of the auricle should be regarded as high risk lesions which often recur and/or metastasize. Therefore, it is recommended to excise the tumors adequately so as to get negative margins, and to follow-up with careful, frequent evaluation.

This paper presents data suggesting that tissue homogenates can be used to assess mitochondrial oxidation. The effect of hypokinesia of various duration on tissue respiration and oxidative phosphorylation of rat kidneys was investigated for the first time. It was found that 3-day hypokinesia led to a decrease of tissue respiration due to a lower contribution of endogenous fatty acids; 10-day hypokinesia caused activation of tissue respiration on endogenous and exogenous pyridine and flavoprotein-dependent substrates; 30-, 70- and 140-day hypokinesia brought about changes in energy formation at the expense of inhibition of respiratory activity of preparations and uncoupling of oxidative phosphorylation. Mechanisms of the above disturbances in energy metabolism reactions of kidneys are discussed.

Metastases to the mandible are very rare and account for only 1% of all oral tumors. The most common primary in such cases is the breast. Only 20 cases of metastases to the mandible of tumors of the large bowel have been reported. We present the case of a 59-year-old woman with metastatic disease of the mandible in whom the primary tumor was an adenocarcinoma of the sigmoid. Metastases to the oral cavity and mandible should be included in the differential diagnosis of gingival or mandibular lesions in a patient with a previous or current malignancy.

Objective. —To study the epidemiology of childhood pneumococcal invasive infections in Israel as a background for immunization programs. Design. —A 2-year (October 1988 through September 1990) prospective, nationwide surveillance of all invasive pediatric pneumococcal infections. Setting. —All 25 medical centers hospitalizing children in Israel, including all laboratories performing blood cultures from pediatric patients. Patients. —Infants and children aged 0 to 12 years visiting the pediatric emergency department or hospitalized in pediatric departments were included ifStreptococcus pneumoniaewas isolated from blood or cerebrospinal fluid. Results. —Four hundred sixty-nine invasive infections were diagnosed. Pneumonia, bacteremia without apparent focus, meningitis, and cellulitis were found in 39%, 37%, 17%, and 3%, respectively. The annual incidence was 42 per 100000 for children younger than 5 years of age (104 per 100000 for those Conclusions. —Pneumococcal invasive infections are common in children in Israel and carry considerable morbidity. (JAMA. 1992;268:3328-3332)