Surveillance of Infectious Disease Occurrences in the Community: An Analysis of Symptom Presentation in the Emergency Department

OBJECTIVES: To determine the effectiveness of a simulated emergency department (ED)-based surveillance system to detect infectious disease (ID) occurrences in the community. METHODS: Medical records of patients presenting to an urban ED between January 1, 1999, and December 31, 2000, were retrospectively reviewed for ICD-9 codes related to ID symptomatology. ICD-9 codes, categorized into viral, gastrointestinal, skin, fever, central nervous system (CNS), or pulmonary symptom clusters, were correlated with reportable infectious diseases identified by the local health department (HD). These reportable infectious diseases are designated class A diseases (CADs) by the Ohio Department of Health. Cross-correlation functions (CCFs) tested the temporal relationship between ED symptom presentation and HD identification of CADs. The 95% confidence interval for lack of trend correlation was 0.0 +/- 0.074; thus CCFs > 0.074 were considered significant for trend correlation. Further cross-correlation analysis was performed after chronic and non-community-acquirable infectious diseases were removed from the HD database as a model for bioterrorism surveillance. RESULTS: Fifteen thousand five hundred sixty-nine ED patients and 6,489 HD patients were identified. Six thousand two hundred eight occurrences of true CADs were identified. Only 87 (1.33%) HD cases were processed on weekends. During the study period, increased ED symptom presentation preceded increased HD identification of respective CADs by 24 hours for all symptom clusters combined (CCF = 0.112), gastrointestinal symptoms (CCF = 0.084), pulmonary symptoms (CCF = 0.110), and CNS symptoms (CCF = 0.125). The bioterrorism surveillance model revealed increased ED symptom presentation continued to precede increased HD identification of the respective CADs by 24 hours for all symptom clusters combined (CCF = 0.080), pulmonary symptoms (CCF = 0.100), and CNS symptoms (CCF = 0.120). CONCLUSIONS: Surveillance of ED symptom presentation has the potential to identify clinically important ID occurrences in the community 24 hours prior to HD identification. Lack of weekend HD data collection suggests that the ED is a more appropriate setting for real-time ID surveillance.     

局限性肾癌的外科治疗进展

在过去三十年,随着横断面影像学的发展及在临床上的应用增多,使偶然发现的肾肿块数量不断增加,导致无症状、局限性、肾小肿块发生率随之升高。对于临床上发现的局限性肾癌,长期以来根治性肾切除一直是传统治疗的"金标准",但随着早期肾癌检出率的增高以及许多新技术和新观念的出现,应该对肾癌的治疗方式进行重新评估。     

Determinants of post-intensive care mortality in high-level treated critically ill patients

Objective To assess the predictive ability of preillness and illness variables, impact of care, and discharge variables on the post-intensive care mortality.Setting and patients 5,805 patients treated with high intensity of care in 89 ICUs in 12 European countries (EURICUS-I study) surviving ICU stay.Methods Case-mix was split in training sample (logistic regression model for post-ICU mortality: discrimination assessed by area under ROC curve) and in testing sample. Time to death was studied by Cox regression model validated with bootstrap sampling on the unsplit case-mix.Results There were 5,805 high-intensity patients discharged to ward and 423 who died in hospital. Significant odds ratios were observed for source of admission, medical/surgical unscheduled admission, each year age, each SAPSII point, each consecutive day in high-intensity treatment, and each NEMS point on the last ICU day. Time to death in ward was significantly shortened by different source of admission; age over 78 years, medical/unscheduled surgical admission; SAPSII score without age, comorbidity and type of admission over 16 points; more than 2 days in high-intensity treatment; all days spent in high treatment; respiratory, cardiovascular, and renal support at discharge; and last ICU day NEMS higher than 27 pointsConclusions Worse outcome is associated with the physiological reserve before admission in the ICU, type of illness, intensity of care required, and the clinical stability and/or the grade of nursing dependence at discharge.This study was supported in part, by the Foundation for Research on Intensive Care in Europe (FRICE) and by a grant from the Commission of the European communities (BMH1-CT93-1340)     

死亡相关蛋白激酶在结肠癌耐药中的作用

目的 探讨死亡相关蛋白激酶（DAPK）在结肠癌耐药中的作用.方法 应用免疫组织化学（免疫组化）SP法检测61例结肠癌组织及32例癌旁组织中DAPK的表达.以氟尿嘧啶（5-FU）诱导建立的结肠癌耐药细胞系HCT116/5-FU为模型.通过转染DAPK-siRNA下调DAPK的表达（DAPK-siRNA组）,转染FAM-siRNA（FAM-siRNA组）作为对照;通过过表达载体上调DAPK的表达（DAPK过表达组）.采用实时定量荧光PCR及蛋白质印迹法检测3组的DAPK、多药耐药蛋白（MRP）和P-糖蛋白（P-gp）的mRNA及蛋白表达水平;MTT法及流式细胞法分别测定3组细胞在未经5-FU处理及浓度为8 μg/ml的5-FU处理下的细胞增殖和凋亡情况.结果 DAPK在结肠癌组织中的阳性表达率明显低于癌旁组织[18.0％（11/61）比90.6％（29/32）,P＜0.05].与FAM-siRNA组比较,DAPK-siRNA组细胞中DAPK mRNA水平及蛋白表达水平均明显降低,DAPK过表达组则均显著升高（均P＜0.05）.在5-FU处理下,相比FAM-siRNA组,DAPK过表达组细胞增殖受到明显抑制,细胞凋亡率明显升高（均P＜0.05）;DAPK-siRNA组细胞增殖和细胞凋亡率均无明显变化（均P＞0.05）.与FAM-siRNA组比较,DAPK过表达组两种耐药蛋白的mRNA和蛋白表达水平均明显降低（P＜0.05）,而DAPK-siRNA组与FAM-siRNA组间差异无统计学意义（P＞0.05）.结论 DAPK能够抑制结肠癌耐药细胞的增殖,促进其凋亡,并可能通过抑制MRP和P-gp的mRNA和蛋白表达,来增强结肠癌细胞对药物的敏感性。     

Vigilancia activa de masas renales pequeñas diagnosticadas en pacientes de edad avanzada o con comorbilidad: en busca de la mejor estrategia de tratamiento

IntroductionAim of this study is to provide our results after long-term active surveillance (AS) protocol for small renal masses (SRMs), and to report the outcomes of patients who remained in AS compared to those who underwent delayed surgical intervention.Patients and methodsWe retrospectively reviewed our database of 58 patients diagnosed with 60 contrast enhancing SRMs suspicious for renal cell carcinoma (RCC). All patients had clinical and radiological follow-up every 6 months. We evaluated the differences between patients who remained on AS and those who underwent surgical delayed intervention.ResultsThe mean age was 75 years, the mean follow-up was 88.5 months. The median initial tumor size at presentation was 2.6 cm, and the median estimated tumor volume was 8.7 cm³. The median linear growth rate of the cohort was 0.7 cm/year, and the median volumetric growth rate was 8.8 cm³/year. Death for metastatic disease occurred in 2 patients (3.4%). No correlation was found between initial tumor size and size growth rate. The mean linear and volumetric growth rates of the group of patients who underwent surgery was higher than in those who remained on surveillance (1.9 vs. 0.4 cm/year and 16.1 vs. 4.6 cm³/year, respectively; P < .001).ConclusionsMost of SRMs demonstrate to have an indolent course and low metastatic potential. Malignant disease could have faster linear and volumetric growth rates, thus suggesting the need for a delayed surgical intervention. In properly selected patients with low life-expectancy, AS could be a reasonable option in the management of SRMs.     

Novel Tools to Improve Patient Selection and Monitoring on Active Surveillance for Low-risk Prostate Cancer: A Systematic Review

Context

Active surveillance (AS) is an alternative to initial radical treatment of low-risk prostate cancer (PCa). Current criteria for selection and follow-up incorrectly exclude some patients eligible for AS and misclassify some who actually harbour significant disease. Better prediction of cancer behaviour at diagnosis would allow less strict monitoring and may improve acceptance of AS.

Objective

To review and critically analyse the literature on the value of novel clinical tools for patient selection and monitoring on AS.

Evidence acquisition

A comprehensive search of the PubMed database until July 10, 2013, was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. Studies assessing novel markers and diagnostics for patient selection for AS and follow-up during AS were included. Studies analysing only classic clinical parameters used in current protocols (prostate-specific antigen, prostate volume, number of (positive) prostate biopsies, percentage malignant tissue, Gleason score) were excluded. This review focuses only on the AS setting and not on predicting insignificant disease in general.

Evidence synthesis

Of 787 studies on AS, 30 were included in this review: 14 on magnetic resonance imaging (MRI), 5 on serum markers, 5 on urinary markers, 4 on histopathology markers, and 2 on germline genetic markers. Several of these markers improve the prediction of tumour volume, tumour grade, or time to active treatment. MRI has a high specificity for low-risk PCa; new serum markers are associated with unfavourable disease. In none of the studies was the new marker used as the primary decision tool. Long-term outcome measures such as mortality were not assessed. The definition of indolent PCa is disputable.

Conclusions

Imaging and serum markers may improve future patient selection for AS and follow-up during AS. Prospective studies should aim to further evaluate the clinical utility of these new markers with respect to longer term outcomes of AS.

Patient summary

We searched the literature for articles reporting new ways to safely monitor low-risk prostate cancer for patients who have not had radical treatment. We found 30 articles. The most promising tools appear to be magnetic resonance imaging scans and various new blood markers. These may be used in the future within active surveillance regimens.     

ERG Protein Expression in Diagnostic Specimens Is Associated with Increased Risk of Progression During Active Surveillance for Prostate Cancer

Background

Compelling biomarkers identifying prostate cancer patients with a high risk of progression during active surveillance (AS) are needed.

Objective

To examine the association between ERG expression at diagnosis and the risk of progression during AS.

Design, setting, and participants

This study included 265 patients followed on AS with prostate-specific antigen (PSA) measurements, clinical examinations, and 10–12 core rebiopsies from 2002 to 2012 in a prospectively maintained database. ERG immunohistochemical staining was performed on diagnostic paraffin-embedded formalin-fixed sections with a ready-to-use kit (anti-ERG, EPR3864). Men were characterised as ERG positive if a minimum of one tumour focus demonstrated ERG expression.

Outcome measurements and statistical analysis

Overall AS progression was defined as clinical progression: increased clinical tumour category ≥cT2b by digital rectal examination and ultrasound, and/or histopathologic progression: upgrade of Gleason score, more than three positive cores or bilateral positive cores, and/or PSA progression: PSA doubling time <3 yr. Risk of progression was analysed using multiple cause-specific Cox regression and stratified cumulative incidences (Aalen-Johansen method). Curatively intended treatment, watchful waiting, and death without progression were treated as competing events.

Results and limitations

A total of 121 of 142 ERG-negative and 96 of 123 ERG-positive patients had complete diagnostic information. In competing risk models, the ERG-positive group showed significantly higher incidences of overall AS progression (p < 0.0001) and of the subgroups PSA progression (p < 0.0001) and histopathologic progression (p < 0.0001). The 2-yr cumulative incidence of overall AS progression was 21.7% (95% confidence interval [CI], 14.3–29.1) in the ERG-negative group compared with 58.6% (95% CI, 48.7–68.5) in the ERG-positive group. ERG positivity was a significant predictor of overall AS progression in multiple Cox regression (hazard ratio: 2.45; 95% CI, 1.62–3.72; p < 0.0001). The main limitation of this study is its observational nature.

Conclusions

In our study, ERG positivity at diagnosis can be used to estimate the risk of progression during AS. If confirmed, ERG status can be used to individualise AS programmes.

Patient summary

The tissue biomarker ERG identifies active surveillance patients with an increased risk of disease progression.     

Trends in reporting injury as a cause of death among people with epilepsy in the U.S., 1981–2010

PurposeTo examine trends in reporting injury as a cause of death among people with epilepsy in the U.S. during the past three decades.MethodWe analyzed the U.S. multiple causes of death data from death certificates in 1981–2010 to compare rate and odds ratios (OR) of reporting injury as cause of death among cases with vs. without mention of epilepsy across years.ResultsThe trends in reporting epilepsy with and without injury were similar in most age groups but were inconsistent in most external causes of injury. The OR of reporting injury was 1.02 (95% confidence intervals (CI) 0.97–1.07) in 1981–1985 and decreased to 0.52 (95% CI 0.48–0.55) in 2006–2010. The decline in OR was prominent among people aged 15–24 followed by people aged 25–44. For the five external causes of injury, the OR of suffocation and drowning were 6.32 (95% CI 5.91–6.75) and 5.64 (95% CI 5.16–6.16) in 1981–1985 and decreased to 3.03 (95% CI 2.74–3.35) and 2.56 (95% CI 2.18–3.00) in 2006–2010. The OR for poisoning and traffic crashes were 0.70 (95% CI 0.57–0.85) and 0.08 (95% CI 0.07–0.09) in 1981–1985 and 0.21 (95% CI 0.18–0.25) and 0.06 (95% CI 0.05–0.08) in 2006–2010.ConclusionThe risk of fatal injury among people with epilepsy decreased drastically during the past three decades in most age groups and for most external causes of injury except falls. People with epilepsy had lower risks of dying from injury due to poisoning or traffic crashes, had higher risks of dying from suffocation and drowning.     

Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage in Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2

To distinguish the characteristics of ruptured cerebral aneurysm that are suitable for endovascular treatment from those that are not, we evaluated factors that influenced the results of aneurysm embolization in patients with ruptured cerebral aneurysm, based on data from the Japanese Registry of Neuroendovascular Therapy (JR-NET) 1 and 2. The multivariate analysis revealed that young patients, patients with low modified Rankin Scale (mRS) scores before onset, and patients with low World Federation of Neurosurgical Societies (WFNS) grades had good outcome. Compared to proximal internal carotid artery (ICA) aneurysms, the odds ratio of middle cerebral artery (MCA) aneurysms was 1.67, indicating poorer outcome for MCA aneurysms, and patients with small, wide-neck cerebral aneurysms had poor outcome. Patients treated after 15 days had better outcome than during other periods. The timing of treatment, however, did not influence the outcome in patients treated within 14 days. The outcome was poorer when the responsible doctor for the treatment was a specialist or a non-specialist than a supervisory doctor. The outcome of patients treated with bare platinum coils, and three dimensional (3D) rotational angiography was better, and the outcome of patients who completed treatment with body filling was poorer than in patients with complete occlusion. Perioperative hemorrhagic complications, all ischemic complications, and rebleeding occurred in 4.5%, 6.4%, and 1.4% of patients, respectively. All these complications had poor outcome factors on day 30, with odds ratios of 2.72, 2.96, and 25.49, respectively. We must be fully aware of these risk factors and determine indications for the treatment when endovascular treatment is performed as the treatment of choice for ruptured cerebral aneurysm.