Ultrasonography: is it useful in the diagnosis of cancer in thyroid nodules?

The role of ultrasonography (US) in the diagnosis of cancer in thyroid nodules is not well-established. The aim of the present study was to evaluate US performance in predicting cancer in thyroid nodules using a novel approach. Two hundred and eighty-nine patients with thyroid nodular disease were evaluated with clinical, biochemical and cytopathological examinations. Eighty patients with palpable solitary thyroid nodules or multinodular goiters who were to undergo surgery were included, and had a US exam performed by one of us. Some US characteristics of thyroid nodules were associated to cancer: absent halo, hypoechogenicity and microcalcifications, with sensitivity, respectively, of 56, 44 and 56%, and specificity of, respectively, 80, 83 and 94%. These findings were considered positive and were studied in two different combinations: simultaneous, when two or more were positive, and parallel, when any positive finding was present. When positive findings were studied simultaneously, sensitivity ranged 25 to 38% and specificity ranged 89 to 97%. Microcalcifications, associated or not to other findings, were highly specific for thyroid cancer, but they were only present in half of the malignancies. When positive findings were studied in parallel, sensitivity ranged 69 to 81% and specificity ranged 70 to 81%. The parallel combination of hypoechogenicity or microcalcifications or absent halo improved US sensitivity to 81% with an acceptable specificity (70%). This method is potentially useful to help us select patients for surgery when fine-needle aspiration biopsy is repetitively non-diagnostic or select for biopsy incidentally discovered non-palpable nodules.     

Tissue harmonic imaging: is it useful in hepatobiliary and pancreatic ultrasonography?

The introduction of tissue harmonic imaging (THI) could solve problems related to ultrasound in technically difficult patients by providing a marked improvement in image quality. Tissue harmonics are generated by tissue vibration while the transmitted pulse propagates through tissue and are multiples of the fundamental frequency. The harmonic image is obtained by separating the fundamental and harmonic frequencies, the second harmonic, or twice the fundamental frequency, being used for imaging. Through a better spatial resolution, less artifact and an increased visualization of the deep structures, tissue harmonic sonography improves the image quality. In hepatobiliary diseases THI improves the detection and characterisation of focal liver lesions, increases the conspicuity of gallbladder polyps and stones, choledocholithiasis and intrabiliary masses. Visualization of the pancreatic duct, pancreatic calcifications or duct stones is also more accurate with THI. The results with THI are better than those with conventional ultrasonography as the body mass index increases. The limitations of THI can be overcome by the use of the new pulse inversion harmonic imaging.     

Response criteria for rheumatoid arthritis in clinical practice: how useful are they?

OBJECTIVE: To compare the performance of the American College of Rheumatology (ACR), European League Against Rheumatism (EULAR), and simple disease activity index (SDAI) response criteria for rheumatoid arthritis at the individual level in an observational cohort. METHODS: 184 outpatients were followed using a structured protocol. For each patient, the responses according to ACR 20% and 50%, EULAR moderate and good, and SDAI minor and major responses were calculated. For comparison, improvements in health assessment questionnaire (HAQ) score of 0.22 and 0.5 were calculated. The numbers of individuals fulfilling the criteria at each level were compared, and the numbers fulfilling any two sets of response criteria calculated. The EULAR "moderate" and "good" responses were grouped together as "overall," and SDAI "minor" and "major" were merged into SDAI "overall". RESULTS: All 94 ACR 20 responders were found in the EULAR and SDAI "overall" response groups, and 118 of 124 SDAI "overall" responders were found in the EULAR "overall" group. In contrast, of 53 ACR 50 responders, only 34 were found in the EULAR "good" or SDAI "major" group. Among the 56 patients in the EULAR "good" response group, only 26 met the SDAI "major" response. Improvement in HAQ score performed similarly to the other response criteria sets at the group levels. CONCLUSIONS: For individual patients, agreement is good at the level of ACR 20 response, when EULAR overall, SDAI overall, or HAQ 0.22 criteria are applied. Agreement between ACR 50, EULAR good, SDAI major, and HAQ 0.5 response is poor. This should be considered when response criteria are used for clinical decisions.     

Induced sputum for the diagnosis of pulmonary tuberculosis: Is it useful in clinical practice?

BACKGROUND:

Diagnosing pulmonary tuberculosis (PTB) is challenging in patients who are unable to spontaneously expectorate. Published evidence suggests that induced sputum (IS) is the least invasive and most cost-effective method of diagnosis, and should be used before fibre-optic bronchoscopy (FOB).

METHODS:

The medical records of 337 adults treated for PTB in northern Alberta between 1997 and 2007 were reviewed to determine whether local practice patterns reflect the evidence. Microbiological data were collected from the Provincial Laboratory for Public Health. Demographic information was collected from the patients’ charts.

RESULTS:

A total of 8.5% (26 of 307) of PTB patients had IS collected, whereas 35.8% (110 of 307) underwent FOB. Among FOB patients, 56.4% (62 of 110) had no sputum sent before the procedure and 29% (18 of 62) of these patients were smear positive. Only five patients referred for FOB had IS sent previously. There were no demographic factors predictive of IS use, whereas being an inpatient at a teaching facility or having a nodule or mass on chest x-ray was predictive of FOB referral. Because so few IS samples were available, not all patients had spontaneously expectorated sputum, IS and FOB tests performed; thus, the calculated yields were not comparable with one another.

CONCLUSIONS:

Despite published evidence recommending IS collection before FOB referral in suspected PTB patients, clinicians in our health region appeared to prefer early FOB over IS by a large margin. This practice pattern is less cost effective and exposes patients and health care workers to greater risk. Further research is needed to identify the reasons for the underuse of sputum induction.     

Injectable opiate maintenance in the UK: is it good clinical practice?

This paper reviews the current practice of injectable opiate treatment (IOT) in the United Kingdom, i.e. the "British system" of prescribing injectable heroin and methadone, and considers some of the clinical and ethical issues it raises. There is very limited research evidence supporting either the safety or effectiveness of IOT as practised in Britain. In particular there is almost no evaluation of long‐term outcomes of IOT, which is of potential concern given the possibility of some patients remaining indefinitely in IOT, the risk of vascular complications, and its higher cost compared with oral maintenance. It would be easy to assess this controversial intervention as in need of further research. However, striving towards best practice in IOT involves more than generating evidence. The likelihood of a patient receiving IOT in the United Kingdom appears to be influenced more by the personal inclinations of prescribers than by outcome data (if any), or identified community needs for access to IOT. The author asks is this good clinical practice and is it sustainable? The "British system" needs to modernise itself consistent with international paradigms of continuous quality improvement, and the NHS's own agenda of clinical governance.     

Cancer and genes: how will molecular biology reshape our clinical practice?

Cancers develop through a succession of stages marked by the accumulation of genetic events within the cell. The rate of occurrence of these events is influenced by the genetic make-up of the individual (e.g., differences in the metabolism of carcinogens, and in the capacity for DNA repair). Knowledge of these events will help define precise targets for early diagnosis. Molecular profiles of cancers will predict prognosis and guide the selection of appropriate therapy. Genetic differences between cancers and normal cells may at last be exploited to make cancer treatment truly selective. An example in clinical trials is the ‘smart virus’ that replicates in and destroys only cancer cells because of their defective p53 function. An understanding of the genetic background of individuals should allow those at particular risk to be recognised and to develop prevention programmes involving targeted screening or the avoidance of predisposing environmental factors. Here, however, human behaviour and the efficacy of early detection methods are likely to be limiting factors, as is already clear from experience with tobacco smoking and with genes for breast cancer and ovarian cancer.     

Collection of autologous blood for bone marrow donation: how useful is it?

The hospital charts of 495 adult bone marrow (BM) donors to adult patients were reviewed to determine how necessary it is to collect autologous blood for marrow donation. An autologous transfusion was given to 79% of the donors. The median total volume of marrow harvested was 900 ml (range 450-1350 ml). The median number of nucleated cells harvested was 3.2 x 10(8)/kg patient weight (range 0.9-7.4 x 10(8)/kg patient weight). On the morning following the harvest, the median haemoglobin (Hb) concentrations were 104 g/l (79-135 g/l) in the female and 122 g/l (89-151 g/l) in the male donors autotransfused, and 96 g/l (75-127 g/l) in the female and 119 g/l (88-141 g/l) in the male donors not autotransfused. The post-donation Hb was lower than 85 g/l in four and lower than 90 g/l in 25 donors. Of the 25 donors with post-harvest Hb lower than 90 g/l, 23 were females and 14 had received an autologous transfusion. This study shows that, with a few exceptions, it is not necessary to collect autologous blood from healthy BM donors before the marrow harvest. The post-donation Hb concentrations do not decrease to levels detrimental to healthy persons whether autologous blood is transfused or not.     

Six-minute walking performance in patients with moderate-to-severe heart failure; is it a useful indicator in clinical practice?

AIMS: The 6-min walk test has been incorporated into studies on the efficacy of new therapies and into prognostic stratification for chronic heart failure patients. Firm conclusions on the usefulness of the test in clinical practice are still lacking. The aim of this study was to investigate (1) the correlation between walk test performance and standard indices of cardiac function and exercise capacity, and (2) the prognostic value of the walk test with respect to peak VO2 and NYHA class. METHODS AND RESULTS: Three hundred and fifteen chronic heart failure patients (age: 53+/-9 years, NYHA class: II (182), III (133)) underwent a functional evaluation and a 6-min walk test. Of these, 270 were followed-up for a minimum of 6 months (mean 387+/-177 days). Walked distance was 396+/-92 m. There was no significant correlation between distance walked and central haemodynamic data. Functional capacity, as measured by ergometry, correlated moderately with distance walked (duration: r=0.48, peak VO2: r=0.59, anaerobic threshold: r=0.54; all P<0.001). During follow-up, 46 patients died from cardiovascular causes and 12 were urgently transplanted. Either of these events were considered end points of the study. Survival analysis was performed from a continuous walk test and peak VO2 measurements or after categorization of (a) quartile segmentation, (b) cut-off points from the literature and (c) thresholds from receiver operating characteristic curves. At univariate survival analysis (Cox regression), the association of the walk test with survival was of significance (P=0.03, continuous variable), or borderline significance (0.05< or =P< or =0.1, after categorization). Peak VO2 was always significant, independent of the scale used (0.005< or =P< or =0.03). The strongest association was found for NYHA class (P<0.001), which showed the highest sensitivity and specificity for the prediction of the event (0.64 and 0.65, respectively). When walk test performance, continuous or categorized, was entered into a multivariate model with NYHA class or peak VO2, it lost any significant association with survival (P>0.76 in all models with NYHA class and P>0.27 in all models with peak VO2). CONCLUSION: In moderate-to-severe chronic heart failure patients, the 6-min walk test is not related to cardiac function and only moderately related to exercise capacity. Walking performance does not provide prognostic information which can complement or substitute for that provided by peak VO2 or NYHA class. Hence the test is of limited usefulness as a decisional indicator in clinical practice.     

ATP-binding cassette transporters in progression and clinical outcome of pancreatic cancer: What is the way forward?

Pancreatic ductal adenocarcinoma(PDAC) is one of the most aggressive diseases and is characterized by high chemoresistance, leading to the lack of effective therapeutic approaches and grim prognosis. Despite increasing understanding of the mechanisms of chemoresistance in cancer and the role of ATPbinding cassette(ABC) transporters in this resistance, the therapeutic potential of their pharmacological inhibition has not been successfully exploited yet. In spite of the discovery of potent pharmacological modulators of ABC transporters, the results obtained in clinical trials have been so far disappointing, with high toxicity levels impairing their successful administration to the patients. Critically, although ABC transporters have been mostly studied for their involvement in development of multidrug resistance(MDR), in recent years the contribution of ABC transporters to cancer initiation and progression has emerged as an important area of research, the understanding of which could significantly influence the development of more specific and efficient therapies. In this review, we explore the role of ABC transporters in the development and progression of malignancies, with focus on PDAC. Their established involvement in development of MDR will be also presented. Moreover, an emerging role for ABC transporters as prognostic tools for patients' survival will be discussed, demonstrating the therapeutic potential of ABC transporters in cancer therapy.     

Antibodies to Saccharomyces cerevisiae: are they useful in clinical practice?

BACKGROUND/AIMS: Antibodies to Saccharomyces cerevisiae are associated with Crohn's disease. The aim of this study was to assess the sensitivity and specificity of antibodies to Saccharomyces cerevisiae for Crohn's disease in an Italian population and to evaluate their clinical role. METHODOLOGY: Antibodies to Saccharomyces cerevisiae serum levels were assessed in 72 inflammatory bowel disease patients (30 Crohn's disease; 42 ulcerative colitis) and 35 age-matched controls. Patients were divided into subgroups on the basis of disease behavior and clinical feature were evaluated. RESULTS: Antibodies to Saccharomyces cerevisiae sensitivity and specificity for Crohn's disease patients were 50% (31-68) and 91% (77-98), for IgG and 56% (37-64) and 94% (80-99), respectively, for IgA. No correlation was observed between the presence of antibodies to Saccharomyces cerevisiae and clinical features. Antibodies to Saccharomyces cerevisiae were more prevalent in Crohn's disease than in ulcerative colitis patients (IgA: 57% vs. 26%; IgG: 50% vs. 17%; p < 0.05). Interestingly, in Crohn's disease patients, the prevalence of antibodies to Saccharomyces cerevisiae was higher in patients with small bowel involvement than in patients with pure colonic disease (IgA: 66% vs. 17%; IgG: 58% vs. 17%). No difference in antibodies to Saccharomyces cerevisiae prevalence was observed between ulcerative colitis and pure colonic Crohn's disease patients. CONCLUSIONS: Our data show an association between Crohn's disease and antibodies to Saccharomyces cerevisiae. However, it does not seem useful in discriminating between ulcerative colitis and colic Crohn's disease.     

Diagnostic algorithm for HFpEF: how much is the recent consensus applicable in clinical practice?

Heart Failure Reviews - Heart failure with preserved ejection fraction (HFpEF) represents an important cardiovascular entity with increasing prevalence and relatively high mortality. The agreement...     

Staging laparoscopy for proximal pancreatic cancer in a magnetic resonance imaging-driven practice: what's it worth?

BackgroundPreoperative imaging is often inadequate in excluding unresectable pancreatic cancer. Accordingly, many groups employ staging laparoscopy (SL), although none have evaluated SL after preoperative magnetic resonance imaging (MRI). We performed a retrospective, indirect cost-effectiveness analysis of SL after MRI for pancreatic head lesions.MethodsAll MRI scans administered for proximal pancreatic cancer between 2004 and 2008 were reviewed and the clinical course of each patient determined. We queried our billing database to render average total costs for all inpatients with proximal pancreatic cancer who underwent pancreaticoduodenectomy, palliative bypass or an endoscopic stenting procedure. We then performed an indirect evaluation of the cost of routine SL.ResultsThe average costs of hospitalization for patients undergoing pancreaticoduodenectomy, open palliative bypass and endoscopic palliation were: US$26 122.43, US$21 957.18 and US$11 304.00, respectively. The calculated cost of SL without laparotomy was US$2966.25 or US$1538.61 prior to laparotomy. The calculated cost of treating unresectable disease by outpatient laparoscopy followed by endoscopy was US$5943.17. Routine SL would increase our costs by US$76 967.46 (3.6%).ConclusionsStaging laparoscopy becomes cost-effective by diverting unresectable patients from operative to endoscopic palliation. Given the paucity of missed metastases on MRI, the yield of SL is marginal and its cost-effectiveness is poor. Future studies should address the utility of SL by both examining this issue prospectively and investigating the cost-effectiveness of endoscopic vs. surgical palliation in a manner that takes account of survival and quality of life data.     

Calcification in marine molluscs: how costly is it?

Although crucial to our understanding of skeletal evolution in marine invertebrates, the cost of calcification has remained elusive for a simple reason: CaCO3 is an inorganic material. Its cost thus derives solely from the metabolic expenses of accumulating, transporting, and precipitating CaCO3 and cannot normally be separated from other metabolic costs. Traditionally, calcification cost has been ignored and total shell cost has been assumed to derive solely from skeletal organic matrix. The cost estimated here was permitted by the substantial natural variation in shell thickness in two rocky-shore gastropods (Nucella lamellosa and Nucella lapillus). In both the field and laboratory, data from three separate experiments revealed that groups of snails producing extra shell material under a particular set of experimental conditions also consumed extra food. The cost of calcification was estimated by computing the extra energy assimilated per unit extra shell produced at a common rate of tissue growth and then subtracting the cost of the organic matrix. At 1-2 J/mg of CaCO3, the calcification cost reported here is roughly 5% of that for the predominantly proteinaceous organic fraction of molluscan shells on a per-gram basis. This may explain why calcareous microstructures high in organic content have become less common evolutionarily.