Course Of Conservative Treatment Research Articles

Spontaneous Osteonecrosis as a Cause of Knee Pain in an Older Active Woman

The patient was a 63 year old woman with a chief complaint of worsening right knee pain, which began 6 weeks prior while walking down a steep incline. Prior to symptom onset, the patient ran 6.5 km daily. The patient’s symptoms initially presented as tightness in the posterior aspect of the knee, but changed to a constant varying ache along the medial aspect of the knee with occasional sharp pain during ambulation. The patient also reported night pain and as well as morning stiffness. Radiographic findings were significant for mild degenerative changes with minimal medial joint space narrowing for the right knee (Figure 1). The patient was treated with a corticosteroid injection, which only provided temporary minimal relief. Magnetic resonance imaging was subsequently ordered and revealed findings consistent with spontaneous osteonecrosis of the medial femoral condyle (Figure 2), which is a distinct form of osteonecrosis and usually demonstrates a subchondral fracture identifiable on magnetic resonance imaging. This can affect males or females but it more commonly affects older women and is typically characterized by the sudden onset of knee pain [1]. In general, the lesion is more commonly located in a femoral condyle and it is not usually associated with systemic disorders or previous corticosteroid therapy [1]. The patient attempted a course of conservative treatment including protected weightbearing with hyaluronic acid, and physical therapy. However, the patient did not respond to conservative management and is awaiting unicompartmental knee arthroplasty. Note: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the US Air Force or Department of Defense.

Symptom Severity and Conservative Treatment for Carpal Tunnel Syndrome in Association With Eventual Carpal Tunnel Release

To study the relationship between the severity of carpal tunnel syndrome (CTS) symptoms and surgery for CTS and the relationship between conservative treatments and surgery for CTS. A secondary analysis of baseline to 6-month data from a randomized controlled trial, which examined the effectiveness of orthosis/stretch combinations on the symptoms of CTS, was conducted for a total of 96 participants with CTS. Participants completed the Carpal Tunnel Questionnaire and posttreatment surveys. Statistical analyses included exploration of correlates of progression to surgery for CTS and logistical regression to examine the association between conservative treatments and CTS symptoms and progression to surgery for CTS. Twenty-one participants received surgery for their CTS, and 31 participants received 1 or more conservative treatments. Severity of baseline CTS symptoms and additional treatments were indicators of progression to surgery. The randomized controlled trial intervention was inversely associated with progression to surgery. CTS that does not respond to an initial course of conservative treatment may not improve with additional treatments. More than half of the participants who received additional conservative treatment still progressed to surgery. Current intervention guidelines for CTS provide limited guidance as to the best methods to efficiently treat CTS. CTS is a costly and high-burden disorder, resulting in reduced quality of life. Research should examine when and for whom conservative care is an effective choice and the association between conservative care and the eventual need for CTS surgery.

Conservative management of femoroacetabular impingement (FAI) in the long distance runner

Femoroacetabular impingement (FAI) is one cause of anterior hip pain that may occur in a long distance runner. By definition FAI is due to bony abutment of the femoral neck and the acetabulum. This occurs primarily with end-ranges of hip flexion and adduction. An understanding of running mechanics and performing a thorough examination will help the clinician provide an appropriate intervention for these athletes. A course of conservative treatment that includes patient education, manual therapy and strengthening should be tried prior to surgical management.

Conservative management of a 13-year-old boy with postintubation tracheal injury

Injuries to the trachea can occur in the event of accidental trauma or complications from various medical procedures. Postintubation tracheal injury can be a critical issue; it needs to be recognized as soon as possible because it can be life threatening. The mortality rate of postintubation tracheal injury is as high as 22%. Management has traditionally consisted of surgery, but more and more case reports describe successful recovery after a course of conservative treatment. We present the case of a 13-year-old boy who was transferred to our pediatric intensive care unit with progressive subcutaneous emphysema after emergent endotracheal intubation. This patient was found cyanotic and unconscious in his bed at home. His mother started chest compression at the behest of an emergency medical technician over the phone. The boy had pulseless ventricular tachycardia and ventricular fibrillation during transportation and received endotracheal intubation immediately. After 40 minutes of cardiopulmonary resuscitation, he regained spontaneous circulation. Progressive subcutaneous emphysema was palpable from neck to trunk, and the sound of the boy’s breathing was subdued on his right side. A computed tomography scan showed a pouch-like lesion with rupture at the right side of the middle to lower part of his trachea, as

The potential impact of various diagnostic strategies in cases of chronic pain syndromes associated with lumbar spine degeneration

PurposeTo study the possible effects of various diagnostic strategies and the relative contribution of various structures in order to determine the optimal diagnostic strategy in treating patients with noncompressive pain syndromes.Study designProspective, nonrandomized cohort study of 83 consecutive patients with noncompressive pain syndromes resistant to repeated courses of conservative treatment. The follow-up period was 18 months.ResultsNucleoplasty was effective in cases of discogenic pain; the consequences related to false positive results of the discography were significant. The most specific criterion was 80% pain relief after facet joint blocks, whereas 50% pain relief and any subjective pain relief were not associated with a significant increase in the success rate. A considerable rate of false negative results was associated with 80% pain relief, whereas 50% pain relief after facet joint blocks showed the optimal ratio of sensitivity and specificity. Facet joint pain was detected in 50.6% of cases (95% confidence interval 44.1%–66.3%), discogenic pain in 16.9% cases (95% confidence interval 9.5%–26.7%), and sacroiliac joint pain in 7.2% cases (95% confidence interval 2.7%–15%). It was impossible to differentiate the main source of pain in 25.3% of cases.ConclusionIt is rational to adjust the diagnostic algorithm to the probability of detecting a particular pain source and, in doing so, reduce the number of invasive diagnostic measures to evaluate a pain source. False positive results of diagnostic measures can negatively affect the overall efficacy of a particular technology; therefore, all reasons for the failure should be studied in order to reach an unbiased conclusion. In choosing diagnostic criteria, not only should the success rate of a particular technology be taken into consideration but also the rate of false negative results. Acceptable diagnostic criteria should be based on a rational balance of sensitivity and specificity.

PM.93 A Complicated Case of Giant Vulval Condylomata in Pregnancy

Anogenital warts are one of the most common sexually transmitted diseases in the UK caused by HPV infection.1 2 The condition is not purely benign with significant symptoms present in...

Surgical Management of C5 Palsy Resulting from Posterior Spinal Decompression for the Treatment of Cervical Spondylotic Myelopathy

Objective: To assess the feasibility of anterior cervical procedures in the treatment of C5 palsy occurring after posterior cervical decompression procedures done for the treatment of cervical spondylotic myelopathy. Introduction: In this study we hypothesized that anterior cervical decompression would benefit these patients through widening the cervical foramen, directly by rongeurs and drills and indirectly by placing an intervertebral spacer (cervical cage). The aim of the study is to assess whether a more proactive approach would benefit these patients. Materials and methods: Between January 2005 and September 2011, 200 posterior cervical procedures have been done by the authors, for the treatment of cervical spondylotic myelopathy (CSM). The procedures done were laminectomy with or without instrumentation. Forty cases developed C5 palsy postoperatively (20%). 20 cases (50%) presented immediate postoperatively and the rest presented during the first week postoperatively. All the cases started a course of conservative treatment of steroids, analgesics and physiotherapy. Thirty patients (75%) improved on conservative treatment. Ten patients did not improve after more than one year of conservative management. Two cases had a single level anterior cervical discectomy and cage fusion (ACDF), 3 cases had single level ACDF with plate fixation and 3 cases had 2 levels ACDF with plate fixation. Two cases had 3 levels ACDF with interbody fusion and plate fixation. The operative choice was made in order to increase the lordotic curve and the foraminal diameter. Results: Immediately postoperatively all patients had improved radicular pain. Assessment of the motor power was made immediately postoperative and 3 months afterwards with continuous physiotherapy. There was no change in the C5 palsy in all cases on the immediate postoperative examination, whereas all cases showed improvement of at least 2 grades in the 3 months postoperative visits. All patients at the final follow up had an MMT (Manual Muscle Test) grade of at least 3. Six patients reached an MMT grade of 4 or more. One case had recurrent myelopathy 9 months after 3 levels ACDF and fixation. His MRI showed adjacent segment degeneration at a higher level and had led to myelopathy. He improved on conservative treatment. Two cases died during follow up period: one at 10 months postoperatively from complications of massive myocardial infarction and the other one 15 months postoperatively from bronchogenic carcinoma diagnosed 7 months after surgery. Conclusion: Postoperative C5 palsy following posterior decompression for cervical spondylotic myelopathy is not an uncommon occurrence and the majority of cases will respond to conservative treatment. Anterior decompression procedures may offer a safe and effective solution for those few patients who do not respond to a prolonged period of conservative management.

COMPLEX TREATMENT OF PATIENT WITH MULTIPLE FRACTURES OF THE VERTEBRAE IN THE THORACIC SPINE

The authors presented an example of a complex treatment of pediatric patient with multiple fractures of the vertebrae in the thoracic spine. The child was operated on the burst fracture of a Th5 vertebra. Due to the presence of vertebral compression fractures Th8 a course of conservative treatment by the orthosis in hyperextension brace. Follow-up was 15 months.

Clinical Outcomes Analysis of Conservative and Surgical Treatment of Patients With Clinical Indications of Prearthritic, Intra-articular Hip Disorders

To describe outcomes of the conservative treatment of patients who had the clinical presentation of a prearthritic, intra-articular hip disorder, including acetabular labral tears, developmental hip dysplasia, and femoroacetabular impingement. Prospective observational clinical outcomes study. Outpatient orthopedic clinic at a tertiary university hospital. Patients presenting with prearthritic, intra-articular hip disorders were recruited. Fifty-eight consecutive patients were enrolled; 6 were lost to follow-up, and 52 subjects completed the study. Patients were recruited on the basis of symptoms, distribution of pain, and the findings of a physical examination. Radiographic measurements of the hip were obtained for all subjects to describe the presence or absence and extent of deformity and/or osteoarthritis. All subjects completed a directed course of conservative treatment. After 3 months of conservative care, subjects with continued limitations, reduction of symptoms with a diagnostic intra-articular hip injection, and a surgically amenable lesion found on a magnetic resonance arthrogram proceeded to surgery. Numeric Pain Score (0-10), Short Form-12, Modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, Nonarthritic Hip Score, Baecke Questionnaire of Habitual Activity, and patient choice to have surgery. Fifty-eight patients (9 men and 49 women) with a mean age of 35 ± 11 years (range, 18-50 years) enrolled in the study. Fifty-two subjects completed the study. Twenty-three subjects (44%) reported satisfaction with conservative care. Twenty-nine subjects (56%) chose to have surgery. Both groups demonstrated equally significant improvement (P value ranges: P = .03 to P = .0001) in all outcome measures from baseline to 1-year follow-up. Subjects who chose surgery had higher baseline activity scores compared with the conservative treatment group (P = .02). All subjects with signs and symptoms of prearthritic, intra-articular hip disorders who were treated with conservative treatment alone and with conservative treatment followed by surgery demonstrated significant improvement in pain and functioning from baseline to 1 year. Forty-four percent of patients improved with conservative care alone, and 56% chose to have surgery after receiving conservative care. Persons with more active lifestyles were more likely to choose surgery. These data suggest that a trial of conservative management for persons with prearthritic, intra-articular hip disorders should be considered before engaging in surgical intervention.

Arteriovenous Malformation Incidentally Found by Ultrasonography in a Thigh Hematoma after Contusion

Vascular malformations in extremities are difficult to detect in cases of minor trauma. The authors report a case of an arteriovenous malformation (AVM) incidentally found by ultrasonography in a contusion. After a slip down, a 52-year-old man who had undergone total arthroplasty in both hips 10 years earlier complained of an ovoid right hip swelling that had gradually increased in size. Suspecting a simple cyst or hematoma, the swelling was examined by ultrasonography, which revealed a subcutaneous hematoma with arterial flow connected to muscle. Arteriography revealed an AVM around the right hip joint. Due to the presence of multiple arteriovenous shunts, a conservative treatment course was adopted and after 3 weeks of treatment the swelling almost completely resolved. It appears that the small AVM may have existed congenitally before hip surgery and the contusion over the AVM had led to hematoma rather than an arteriovenous fistula. The authors emphasize the usefulness of ultrasonography for the diagnosis of posttraumatic swelling.

Natural Course of Perihemorrhagic Edema After Intracerebral Hemorrhage

There is only limited knowledge on the time course of perihemorrhagic edema (PHE) after intracerebral hemorrhage (ICH). We aimed to investigate the chronological PHE course and its relation to in-hospital mortality in a large retrospective ICH cohort. Patients with supratentorial ICH treated at our institution between 2006 and 2009, who had received at least 3 CT scans in the course of conservative treatment, were included in the present analysis. PHE at Days 1, 2, 3, 4 to 6, 7 to 11, 12 to 16, 17 to 21, and >22 was assessed using a threshold based semiautomatic volumetric algorithm. A chart review was performed to achieve data on duration of stay, ventilation, treatment with external ventricular drains, and in-hospital mortality. Two hundred nineteen patients aged 69.9±10.5 years with deep (n=103) or lobar (n=116) ICH were included in the study. Mean ICH volume was 35.7±31.5 mL. Mean absolute PHE volume significantly increased from initially 32.6±29.9 mL to 63.7±46.7 mL at Days 7 to 11. No significant changes were observed at later time points. ICH volume was strongly correlated with absolute PHE volume (ρ=0.8, P<0.001) and inversely correlated with relative PHE (ρ=-0.4 to -0.5, P<0.001). Increase in absolute PHE between Days 1 and 3 was significantly predictive for in-hospital mortality (P=0.014, ExpB=1.04). PHE develops early after ICH and doubles within the first 7 to 11 days after the initial bleeding event. This additional mass effect may contribute to secondary clinical deterioration and mortality, especially in larger ICH. Because of its inverse correlation with ICH volume, relative PHE may not be suitable for analyses considering the clinical impact of PHE.

Surgical Treatment for Multiple Unstable Uncomplicated Spinal Fractures in Children

Objective. To appreciate peculiarities and efficacy of surgical treatment of children with multiple unstable uncomplicated fractures of thoracic and lumbar vertebrae. Material and Methods. Thirty-nine patients aged of 10 to 17 years with unstable uncomplicated spinal injuries were operated on, including 12 patients with fractures in thoracic spine, and 27 — in lumbar. Two fractured vertebrae were adjacent in 31 cases, and in 8 cases, one or more motion segments divided them. Twenty-two patients were admitted to the hospital in the nearest hours or days after the trauma, 6 — in 1—1.5 months, and 11 patients — after partial or complete course of conservative treatment during 2—24 months. Results. Long-term follow-up period varied from 9 months to 9 years. Vertebral body height restoration, fracture consolidation, and posterior fusion formation in patients operated on immediately or within first months after trauma were achieved in 1—1.5 years. Patients with late surgery presented anterior and posterior fusion in 1.5—2 years after surgery. Conclusion. The choice of treatment for multiple and multilevel vertebral fractures in children should be determined by the nature and term after the injury onset considering the number of injured vertebrae, their localization, and injury severity.

The acute adhesive small-bowel obstruction timing of surgical intervention、 indications and prognosis

Objective To investigate the acute adhesive small-bowel obstruction timing of surgical intervention、indications and prognosis. Methods A retrospective analysis of 48 cases of acute adhesive smallbowel obstruction of the clinical data, surgical timing and indications, which were treated from January 2000 to July 2009.Results 41 patients cured,5 cases improved, two deaths from septic shock, postoperative pulmonary infection in 10 cases,8 cases of wound infection, intra-abdominal residual abscess in 5 cases, short bowel syndrome in 3 cases,2 cases of renal insufficiency, which were cured through combined treatment. Conclusion Acute adhesive intestinal obstruction in a conservative course of treatment should be to discover clues of early intestinal strangulation, decisive decision to surgical treatment, timing of surgery are advised to be early, not late.Being loose instead of strict in surgical indications is the important measures to improve the clinical cure rate and reduce complications and mortality. Key words: Acute adhesive small intestinal obstruction; Surgical timing ; Surgical indication

Hypertriglyceridemic acute pancreatitis during pregnancy: Prevention with diet therapy and ω-3 fatty acids in the following pregnancy

Acute pancreatitis complicating pregnancy is rare and has previously been associated with high mortality rates. We report a case of repeated hypertriglyceridemia during pregnancy. During the patient's first pregnancy, acute pancreatitis was elicited in the third trimester by pregnancy-induced hypertriglyceridemia. The patient was treated successfully with a conservative treatment course. The hypertriglyceridemia recurred during her second pregnancy. She carried the pregnancy to term without incident while maintaining a diet low in fat diet and high in ω-3 fatty acids. Early diagnosis and intensive treatment can help to preserve the lives of the patient and the fetus. Prophylactic diet therapy and ω-3 fatty acids may prevent recurrent hypertriglyceridemia during pregnancy.

Conservative Management of Pediatric Nephrolithiasis Caused by Melamine-Contaminated Milk Powder

In this article we report our experience with the diagnostic screening and management of children with melamine-induced nephrolithiasis. A total of 1091 children younger than 4 years who had been exposed to melamine-contaminated formula from September 17 to October 12, 2008, were screened for nephrolithiasis at the department of pediatrics at Shenzhen Nanshan Hospital in China. During the clinical examination, each patient's demographic characteristics were recorded together with the details of his or her milk-consumption profile during the contamination scare and any clinical signs of poisoning. Urinary stones were detected by B-ultrasonography, and renal status was examined by a routine urine test panel and a renal function test. When urinary stones were detected, patients were ordered to cease consumption of the suspected formula, and a conservative treatment course was adopted, including infusion of fluids, urinary alkalinization, increased water consumption, and diuresis. Of the 1091 children screened, 12 (1.1%) were diagnosed with kidney stones. They had been exposed to the contaminated milk from 1 to 24 months. Eleven (91.7%) of these 12 patients had consumed milk with a high level of melamine content (955-2563 ppm); 1 patient (8.3%) had consumed milk with a low-level melamine content (6.2-17.0 ppm). Six patients exhibited dysuria; the remaining 6 patients were asymptomatic. All 12 patients had normal renal function, although 4 had proteinuria, and 1 had hematuria. The kidney stones were resolved within 3 to 5 days of commencing treatment in all 12 cases. Nephrolithiasis was associated with high melamine-exposure levels. A combination of B-ultrasonography and urinalysis is suitable for screening for pediatric nephrolithiasis caused by melamine poisoning. The condition can be resolved with a conservative treatment approach in patients without serious clinical symptoms who have normal kidney function.

RUPTURE OF A SPINAL ARTERY ANEURYSM ATTRIBUTABLE TO EXACERBATED SJöGREN SYNDROME

Presentation of a patient with acute subarachnoid hemorrhage from a ruptured spinal artery aneurysm attributable to exacerbated Sjögren syndrome. A 46-year-old woman with symptoms of exacerbated Sjögren syndrome experienced the acute onset of extreme headache accompanied by nuchal rigidity. A computed tomographic scan revealed subarachnoid hemorrhage. Angiography showed an isolated aneurysm of a branch of the right vertebral artery that was a feeding artery of the anterior spinal artery. Neither operative clipping nor endovascular coiling of the aneurysm was reasonable, owing to the high risk of occluding the anterior spinal artery during the intervention. Further diagnostic measures confirmed Sjögren syndrome and revealed cryoglobulinemic vasculitis, membranoproliferative glomerulonephritis with acute renal failure, Hashimoto thyroiditis, and acute hydrocephalus. In the course of conservative treatment, the patient recovered completely from the subarachnoid hemorrhage. One year after treatment with glucocorticoids and immunosuppressive agents, both the aneurysm and the vasculitis could no longer be detected on conventional angiography. Generally, spinal artery aneurysms are exceptionally rare, and few cases of rupture with subsequent subarachnoid hemorrhage have been published. We report on a ruptured spinal aneurysm attributable to Sjögren syndrome-associated cryoglobulinemic vasculitis. Conservative treatment with glucocorticoids and immunosuppressive agents led to resolution of the vasculitic spinal aneurysm.

Scapular winging: anatomical review, diagnosis, and treatments

Scapular winging is a rare debilitating condition that leads to limited functional activity of the upper extremity. It is the result of numerous causes, including traumatic, iatrogenic, and idiopathic processes that most often result in nerve injury and paralysis of either the serratus anterior, trapezius, or rhomboid muscles. Diagnosis is easily made upon visible inspection of the scapula, with serratus anterior paralysis resulting in medial winging of the scapula. This is in contrast to the lateral winging generated by trapezius and rhomboid paralysis. Most cases of serratus anterior paralysis spontaneously resolve within 24 months, while conservative treatment of trapezius paralysis is less effective. A conservative course of treatment is usually followed for rhomboid paralysis. To allow time for spontaneous recovery, a 6–24 month course of conservative treatment is often recommended, after which if there is no recovery, patients become candidates for corrective surgery.

Percutaneous drainage and continuous irrigation in patients with severe pyogenic spondylitis, abscess formation, and marked bone destruction

The use of percutaneous suction aspiration has recently become viewed as an effective management strategy for pyogenic spondylitis unresponsive to conservative treatment. What remains unclear is whether it can be effective for severe pyogenic spondylitis in which abscess formation or marked bone destruction is present. The authors undertook a study to clarify answers to this question. The authors evaluated clinical and radiographic/neuroimaging data obtained in five patients with severe pyogenic spondylitis, extensive abscesses, and marked bone destruction. These patients had undergone percutaneous drainage and continuous irrigation because open surgery was considered contraindicated in light of their poor general health. The mean period during which continuous irrigation was applied was 9 days (range 7-11 days), and the mean period during which the drainage tube was in place was 19 days (range 13-38 days). All patients suffered from back pain, which was relieved by the percutaneous technique in four patients after a mean of 8 days. The abscesses and inflammation resolved in all patients. Progressive osseous destruction was not observed, and open surgery was performed in only one patient in whom back pain persisted as a result of spinal instability. After an unsuccessful course of conservative treatment, severe pyogenic spondylitis with abscess formation or marked bone destruction was successfully treated using percutaneous drainage and continuous irrigation. Based on their results, the authors believe that this procedure can be used in patients with severe pyogenic spondylitis that was unresponsive to conservative treatment, particularly in those whose general health is poor.

The response of chronic gastritis to conservative treatment.

Abstract Gastroscopy and gastric biopsy have been carried out in human subjects before and after a course of conservative treatment for gastric ulceration or postgastrectomy dyspepsia due to gastritis. In the healing gastric ulcer the surrounding mucosa returns to histological normality, but in the postgastrectomy patient there is a persistent chronic gastritis around the stoma. In the gastric ulcer patient the cause of the gastritis may be the action of acid-pepsin on mucosa sensitized by bile reflux. In the postgastrectomy cases persistent gastritis may be due to the refluxing fluid itself causing the irritation, or to the absence of a protective effect exerted by the pyloric gland area.

Spotlight

Janowska-Wieczorek et al., pp.752–760 Fragments of the plasma membrane shed by cells are suspected to participate in intercellular signaling. These fragments, called microvesicles, contain proteins similar, but not identical, to those in the membrane of the originating cells. Platelets release microvesicles when stimulated by agonists or exposed to high-stress shear forces, and these platelet-derived microvesicles (PMV) regulate proliferation, survival, and adhesion of human normal and malignant hematopoietic cells. Experimental metastases can be reduced by decreasing the blood platelet concentration, and increased by transfusion of platelets. Janowska-Wieczorek and colleagues suspected that PMV could spur lung cancer cells to grow and metastasize. They investigated the transfer of platelet-derived surface molecules to lung cancer cells in vitro as well as the direct biologic effect of PMV on the cancer cells. They report that PMV interact with lung cancer cells and increase their metastatic and angiogenic potential. Not only do the microvesicles chemoattract the cancer cells, they stimulate various signaling pathways, including some involved in proliferation and vascularization. In addition, the authors showed that in mice, lung carcinoma cells covered with PMV spawned more metastatic loci in the lungs and spread to the bone marrow in greater numbers than did cancer cells without PMV. These results help to explain the aggravating effect of platelets on cancer. The authors suggest that PMV play a key role in mediating communication between platelets and cancer cells, but that more work will be critical to determine exactly which components do the talking, and potentially exploit them for new therapeutic approaches. Chin et al., pp.789–797 Although head and neck cancer can be successfully treated when detected early, the survival rate is not high, because most cases are only discovered after the disease has advanced. Treatment usually incorporates surgery, radiotherapy, and chemotherapy. Although surgery has the best outcome, its unpleasant side effects make it undesirable if the disease is likely to recur despite treatment. Having a marker that identified which cancers were most likely to recur would greatly help physicians choose the most appropriate course of treatment. To find such a marker, Chin and colleagues compared the expression of more than 13,000 genes in cancerous and normal tissue. They found that, among others, the protein SPARC (osteonectin) is consistently elevated in head and neck cancers. SPARC is known to be overexpressed in other tumors as well, but has never been associated with head and neck cancer previously. The authors also examined gene expression in relation to clinical outcome in a number of patients. SPARC turned out to be a strong indicator of a short disease-free interval and poor prognosis. The association became even stronger when combined with two other extracellular matrix proteins identified, PAI-1 and uPA. This study marks that matched tissue samples have been analyzed for prognostic markers, and identified markers have been verified with clinical data and prognosis. These markers could potentially help determine whether a conservative course of treatment is warranted, and may even serve as early warning indicators of recurrence. Ding et al., pp.803–810 Nonsteroidal anti-inflammatory drugs (NSAIDs) have shown some anticancer activity in many types of human cancers. These drugs act on cyclooxygenases (COX), and because COX-2 is often overexpressed in cancer cells, NSAIDs are thought to impair cancer growth by targeting COX-2. Ding and colleagues investigated the role of one such drug, celecoxib, in pre-malignant and malignant oral cell culture. Previous evidence has suggested that celecoxib could prompt apoptosis through pathways independent of COX-2, so the researchers evaluated second-generation celecoxib derivatives that lacked COX-2 inhibitory activity. They report that cells exposed to these derivatives pause in the G2/M phase of the cell cycle. The derivatives also induced apoptosis with greater potency than celecoxib did. Although earlier work with prostate cancer cells had described a pathway by which these derivatives boosted apoptosis, the current work shows that, in oral cells, derivative-induced apoptosis occurs independently of that pathway. The results suggest that celecoxib derivatives can take advantage of a variety of molecular mechanisms to inhibit growth and promote apoptosis in many cell types. Although results obtained in vitro may not always reflect tumor responses in vivo, the current work provides a reasonable model for designing celecoxib compounds with potential for use in chemoprevention and chemotherapy.