National Surgical Patterns of Care for Primary Surgery and Axillary Staging of Phyllodes Tumors

Abstract: Phyllodes tumors (PT) are rare and unique in their suspected stromal and epithelial origin, and their propensity to recur despite surgical resection. Current surgical treatment of PT does not include sampling of regional lymph nodes (LNs) as malignant PT infrequently spread to LNs. We hypothesize that, because of substantial experience with common epithelial lesions of the breast, surgeons are more prone to sample LNs in PT patients. We reviewed national surgical patterns of care of axillary LN sampling for PT using the Surveillance Epidemiology & End Results (SEER) registry. SEER data for LN evaluation are available from 1988. The public‐access SEER data‐base was queried for patients presenting over all 17 registries between 1988 and 2003 with PT of the breast. Data were collated by type of surgery and number of LNs examined, and further analyzed by tumor size of the primary lesion where available; 1,035 cases of PT were identified for the 16‐year period. Patients had a median age of 50 (range 12–96). Of the specimens with SEER grade listed, 117 were well‐differentiated, 186 moderately differentiated, 79 poorly differentiated, and 132 undifferentiated; 612 (59.1%) cases had specific surgical procedures reported: 191 partial, 251 simple, 5 subcutaneous, 154 modified radical, and 6 radical mastectomies, with 5 mastectomies (NOS) documented. The remainder of cases had surgery that was coded as “undocumented” or unknown. When surveyed by LNs examined, 25.5% of patients (n = 264) underwent some degree of regional lymphadenectomy; the median number of LNs examined in these patients was 7 (range 1–37). Of all PT patients, 9.0% of patients underwent axillary sampling of 10 LN or more. Only nine patients (3.4%) had positive LNs. When assessing axillary sampling rate by tumor size, smaller lesions were less likely to undergo sampling than larger lesions (19.3% for lesions <2 cm, 20.5% for lesions 2–4.9 cm, 27.9% for 5–9.9 cm); although this was nonsignificant. In spite of the lack of supporting data for LN examination axillary staging continues to be performed for many cases of PT.     

Recurrence patterns of squamous cell carcinoma of the penis: recommendations for follow-up based on a two-centre analysis of 700 patients

BACKGROUND: Current follow-up recommendations for patients with penile carcinoma are based on small numbers of patients. OBJECTIVES: To give further insight into the recurrence patterns of penile carcinoma in different treatment settings and provide recommendations for follow up. DESIGNS, SETTING, AND PARTICIPANTS: In this retrospective study, we analysed 700 patients from two referral centres for penile carcinoma for recurrences. MEASUREMENTS: Recurrences were categorized as local, regional, or distant. The rate of local recurrences was compared between patients undergoing penile-preserving treatments and partial/total amputation. Regional recurrences were compared between patients surgically staged as pN0 or pN+ and clinically node-negative (cN0) patients subjected to a wait-and-see policy. The total recurrence rate, type of recurrence, time to recurrence, and survival were calculated. RESULTS AND LIMITATIONS: 205 out of 700 patients (29.3%) had a recurrence, consisting of 18.6% local, 9.3% regional, and 1.4% distant recurrences. Of the recurrences, 92.2% occurred within 5 yr after primary treatment. All regional and distant recurrences occurred within 50 and 16 mo, respectively. The local recurrence rate was 27.7% after penile-preserving therapy and 5.3% after amputation. The regional recurrence rate was 2.3% in patients staged as pN0, 19.1% in patients staged as pN+, and 9.1% in patients undergoing a wait-and-see policy. The 5-yr disease-specific survival was 92% after a local recurrence and 32.7% after a regional recurrence. All patients with a distant recurrence died within 22 mo. Although the number of analysed patients is substantial, the results do not necessarily reflect those of other centres using different techniques for the management of penile carcinoma. CONCLUSIONS: Patients undergoing penile-preserving therapy, patients surgically staged as pN+, and those undergoing a wait-and-see policy for the nodal status are at high risk of developing a recurrence. Follow-up recommendations are provided based on the risk and impact on survival of a recurrence.     

The efficacy of drugs for the treatment of LUTS/BPH, a study in 6 European countries

OBJECTIVES: This paper profiles the usage and effectiveness of various LUTS/BPH drugs in real-life practice. METHOD: The TRIUMPH study recorded the treatment and outcomes of 2351 newly-presenting LUTS/BPH patients in 6 European countries over a 1-year follow-up period. At each visit the clinician recorded the treatment, co-morbidities, complications and drugs prescribed, and the patient completed an IPSS questionnaire. The results were analysed using change in IPSS as the primary outcome measure. RESULTS: Over the study period 74.9% of patients were prescribed medication, the majority (83% of those medicated) were prescribed only a single drug. Tamsulosin was the most commonly prescribed drug in all countries (38% of medicated cases), although with national variation from 24% in Poland to 70% in Italy. The alpha-blockers were the most effective, with a mean reduction of 6.3 IPSS points. Finasteride was slightly less effective (4.1 points). Significant improvements were seen in 43% of patients on phytotherapy with Serenoa repens or Pygeum africanum compared to 57% of those on finasteride and 68% on alpha-blockers. The only combination therapy found to produce a statistically significant improvement over the use of individual drugs was finasteride+tamsulosin (8.1 points compared to 6.7 for tamsulosin alone and 4.2 for finasteride alone). CONCLUSIONS: All drug treatments showed some improvement over watchful-waiting for most patients over the study period: the alpha-blockers were found to be the most effective. There were marked national differences in prescribing patterns, both in individual drug choice and in the use of combination therapies.     

Nocturnal electrobioimpedance volumetric assessment in diabetic men with erectile dysfunction before and after tadalafil intake

Nocturnal electrobioimpedance volumetric assessment (NEVA) is a procedure that can measure penile volume changes together with the number and duration of nocturnal erectile events. This study was conducted to evaluate the different NEVA patterns in diabetic patients with erectile dysfunction (ED), and demonstrate the extent to which tadalafil may affect the characteristics of nocturnal penile erections in these patients. Therefore, 38 patients with noninsulin-dependent diabetes and ED participated in this study. They were assessed with history intake including evaluation by the abridged five-item version of International Index of Erectile Function, clinical and psychiatric assessment and NEVA for three consecutive nights where placebo was given on the second night and tadalafil on the third night. In all, 14 potent males were taken as a control group. Data were analyzed using t-test. Results showed normal patterns in only six (16%) patients (central organic group), while abnormal patterns were observed in the remaining 32 (84%) patients (peripheral organic group). These abnormal patterns showed significant decrease in both the number (P=0.0001) and duration (P=0.03) of erectile events compared to those of controls. The percentage of penile blood volume change over baseline also decreased significantly (P=0.0002) relative to controls. Veno-occlusive dysfunction was the main pathology (23 patients, 72%) as suggested by NEVA. Tadalafil did not significantly change basal nocturnal penile tumescence results in either the central organic or control groups, but it did so significantly in the peripheral organic group (P=0.02 for duration change and P=0.01 for % blood volume change). In conclusion, NEVA may suggest some evidence about the pathophysiology of an underlying vasculogenic cause, thus directing towards the next specific step needed for a precise diagnosis. Tadalafil improves nocturnal erections in diabetic patients with peripheral but not central organic impotence.     

Saskatchewan’s Joint Chiropractic Professional Review Committee

Saskatchewan’s Joint Chiropractic Professional Review Committee functions to ensure that clinically necessary services are provided to patients. The committee which has both government (payer) and professional representation is created by the Medical Care Insurance Act in Saskatchewan. Examples of committee concerns include frequent visits by individual patients, high number of patients treated per day, poor record keeping, high service per discrete patient value. The article concludes with some suggestions for how to determine if a practitioner’s pattern of practice is unusual and how to respond if contacted by the committee. The strengths of this form of review process include: the committee has a majority of chiropractors, patterns of practice are compared to that of peers, evaluation of patterns of practice uses random sampling of files to be analysed, and guidelines for practice are set by peers using a consensus process.     

Optimizing prostate cancer detection during biopsy by standardizing the amount of tissue examined per core

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? The main goal of a prostate biopsy is to identify clinically relevant prostate cancer with the lowest possible morbidity from the procedure. Over time, many have tried different variations in the procedure in an attempt to find the optimal methodology for performing prostate biopsies. These changes include better equipment in helping optimize cancer localization, varying the number of cores in efforts to improve cancer detection, and sampling various areas of the prostate to find cancer that might be difficult to identify. To our knowledge we are the first to describe performing prostate biopsies by keeping the sampling size constant and varying the number of cores based on the size of the prostate. The study adds a variation in the current techniques used for prostate biopsies. In certain situations, using a standard number of cores makes obtaining proper sampling of a prostate difficult. We propose a methodology in performing prostate biopsies that will allow for standardization of the tissue per core analysed, thus improving the sampling of the prostate.

OBJECTIVE

? To investigate the effect on cancer detection by varying the number of cores taken for prostate biopsy according to the size of the prostate.

PATIENTS AND METHODS

? A retrospective review of a prospectively registered prostate biopsy database identified 3040 consecutive patients undergoing prostate biopsy at a Veterans Administration Hospital between 1994 and 2008. ? Of 2224 biopsies, 681 (31%) were found to have cancer and 1540 (69%) had negative biopsies. ? Prostate volume to biopsy core ratios (volume/number of cores) were derived and a comparative analysis was performed to determine the impact on cancer detection rates.

RESULTS

? The median prostate volume was significantly smaller for those patients diagnosed with prostate cancer than for those with negative biopsies (33 vs 43 cc, P= 0.01). ? The median number of cores was the same for both groups of patients (median 12, P= 0.66). ? The median transrectal ultrasonography TRUS size/core ratio was 3.5 [interquartile range (IQR) 2.5] for patients with identified cancer as compared with 4.7 (IQR = 3.9) for those with negative biopsies (P= 0.000). ? On multivariable logistic regression analysis TRUS size/core ratio had a significant impact on cancer detection with a relative risk ratio of 1.29 (95% confidence interval, 1.1–1.5, P= 0.001) even when controlled for age, race, prostate volume, digital rectal examination and prostate‐specific antigen level.

CONCLUSIONS

? Prostate cancer detection can be enhanced by individualizing the number of cores performed to a real‐time prostate volume sampling. ? The present study emphasizes that optimal cancer detection rates were observed when a ratio of 3.5 cc per tissue core was achieved. ? Proper prospectively designed studies must be performed to further validate these findings.     

Inter-observer variation in assessment of undescended testis. Analysis of kappa statistics as a coefficient of reliability

In a prospective study the inter-observer variation in the diagnosis of undescended testis was analysed. Two physicians assessed independently the position and motility of the testes of 37 boys referred for undescended testis. The boys were examined in the supine and squatting positions. The observed agreement rate between the observers was 0.90 to 0.97. Using kappa (kappa) statistics, the values were adjusted for the expected chance agreement; kappa values between 0.47 and 0.81 were obtained, slightly higher values for patients in the supine position. Complete agreement on all observations was reached in 13.5% of the patients. Inter-observer variation may be a substantial source of bias in diagnosing the undescended testis and one of the reasons for the varying results in studies of hormonal treatment of this condition. It is also a fact that the number of orchiopexies in some countries exceeds the incidence of this condition.     

The effect of urethral pressure variation on detrusor activity in women

The purposes of this study were to confirm previously described patterns of urethral pressure variation and to establish criteria for their diagnosis. The effect of urethral pressure variation on detrusor activity was also examined. The study involved a retrospective review of the computerized cystometric tracings from a 26-month period. Forty-one patients had artefact-free satisfactory tracings demonstrating urethral pressure variation, detrusor instability and/or gradual detrusor pressure increase. These tracings were stored on a computer program which permitted real-time second-by-second review. Statistical analysis was done using Fisher's exact test and an independentt-test. Three patterns of urethral pressure variation were identified: rapid pressure variation (RPV), gradual pressure variation (GPV) and stress-induced transient urethral relaxation (SITUR). RPV was associated with onset at low bladder volumes (independentt-test,P=0.02) and with detrusor instability (Fisher's exact test,P<0.001). GPV began at high bladder volumes (Fisher's exact test,P<0.001). SITUR was not associated with any specific pattern of urethral pressure variation or detrusor pressure change. Analysis of tracings of the patients with a combination of rapid urethral pressure variation and detrusor instability revealed a statistically significant increased frequency of urethral relaxation as the primary event precipitating an unstable detrusor contraction (Fisher's exact test,P<0.003). In conclusion, three different patterns of urethral pressure variation were identified. Rapid pattern urethral pressure variation is closely associated with detrusor instability. Further study of urethral pressure variation may help to elucidate the pathophysiologic mechanism responsible for idiopathic unstable detrusor contractions.Editorial Comment: This investigation includes very interesting and clinically important findings. The authors describe three patterns of urethral pressure variation and their relation to the detrusor activity. Taking these activities of the urethra into consideration, especially the relationship between detrusor instability and rapid urethral pressure variation, we may select the reasonable and effective therapeutic modality for female urinary incontinence. This study is timely, adding pertinent information for clinical decision-making.     

A limited sampling strategy for the estimation of 12-hour Neoral systemic drug exposure in heart transplant recipients.

BACKGROUND: Therapeutic drug monitoring of cyclosporine in heart transplant patients is used to monitor therapy and prevent rejection. Of the various methods available for performing therapeutic drug monitoring of cyclosporine, the method of limited sampling strategy for area under the concentration-time curve profiling has been used most widely recently. The process of identifying sparse data points to predict area under the concentration-time curve is essentially a variable selection problem, with the variables being the drug concentrations at the various timepoints. Although fitting more variables into a model will typically allow for a better prediction of area under the concentration-time curve, improving the prediction has to be traded-off against the desirability of using as few timepoints as possible. The objective of this study was thus to formulate a model that would provide a good prediction of area under the concentration-time curve based on a limited number of sampling points. METHODS: We studied 15 stable heart transplant patients (11 Chinese and 4 Indians). All patients were receiving Neoral-based immunosuppression. Whole blood samples for area under the concentration-time curve analysis were obtained at the following timepoints: pre-dose (C(0h)) and at 1, 2, 3, 4, 6 and 12 hours (C(1h), C(2h), C(3h), C(4h), C(6h), C(12h), respectively) post-dose during the first dosing interval. The linear trapezoidal rule was used to calculate the area under the concentration-time curve (AUC) from time 0 h to 12 h. Various limited sampling strategies, as well as Keown's formula, which was derived in renal transplant patients and used C(0h) and C(2h), were compared based on their capacity for reducing total error squared. RESULTS: C(4h) was found to be the single most predictive timepoint and explained 95.3% of AUC(0-12) variation. C(0h) and C(12h) explained 60% and 75.7% of the variation in AUC(0-12), respectively. The best 2-variable model identified by stepwise selection procedures included C(1h) and C(4h) as predictors, explaining 97.3% of the variation in total area under the concentration-time curve from time 0 h to 12 h. Using Keown's algorithm, the R(2) was only 80.9%. CONCLUSION: We recommend using C(1h) and C(4h) as surrogate markers of area under the concentration-time curve from time 0 h to 12 h in our heart transplant patients. Because C(1h) and C(4h) represent timepoints within the zone of highest variability for Neoral's absorption phase, a model incorporating these timepoints would be able to explain a greater degree of variability associated with the Neoral absorption profile.     

How many lymph nodes are enough? Assessing the adequacy of lymph node yield for staging in favorable histology wilms tumor

PurposeCurrent investigational priorities in the treatment of favorable histology Wilms tumor (FHWT) center on accurate staging and risk-stratification. The extent of lymph node (LN) sampling has not been clearly defined; its importance cannot be overstated as it guides adjuvant therapy. The identification of a minimum LN yield to minimize the risk of harboring occult metastatic disease could help development of surgical guidelines. This study focuses on using the beta-binomial distribution to estimate the risk of occult metastatic disease in patients with FHWT.Materials & methodsThe National Cancer Database was queried for patients with unilateral FHWT from 2004 to 2013. Data were used to characterize nodal positivity for patients who underwent surgery and had ≥ 1 positive LN and ≥ 2 LNs examined. The probability of missing a positive LN (i.e., false negative) for a given LN yield was calculated using an empirical estimation and the beta-binomial model. Patients were then stratified by tumor size.Results422 patients met study criteria. To limit the chance of missing a positive LN to ≤ 10%, the empirical estimation and beta-binomial model estimated that 6 and 10 LNs needed to be sampled, respectively. Tumor size did not influence the result. Internal validation showed little variation to maintain a false negative rate ≤ 10%.ConclusionsUsing mathematical modeling, it appears that the desired LN yield in FHWT to reduce the risk of false-negative LN sampling to ≤ 10% is between 6 and 10. The current analysis represents an objective attempt to determine the desired surgical approach to LN sampling to accurately stage patients with FHWT.Level of evidenceII     

Clinical evaluation of the albumin/creatinine ratio in outpatients with diabetes

For the early diagnosis of diabetic nephropathy, it is best to use the albumin excretion rate (AER). However, it is a complicated test to perform in the outpatient setting, and it is sometimes affected by inaccurate urine collection. Therefore, we have used the albumin/creatinine ratio, which is measured simply with randomly collected urine, for evaluation of microalbuminuria and found it to be of equal diagnostic value to the AER. The AER, albumin/creatinine ratio, and creatinine excretion rate were measured in 86 patients with NIDDN who were negative for proteinuria. Urine was obtained after bed rest and in the outpatients department (without rest). 1) The reproducibility of time-restricted urine sampling was investigated using the rate of creatinine excretion. The mean coefficient of variation was found to be 42%, and inaccurate urine sampling appeared to cause variation in the AER. 2) The AER and albumin/creatinine ratio obtained in the outpatient setting were higher than those after bed rest, and urine collection at the time of outpatient examination was considered to be more useful than that after bed rest. To check variations in urine collection at the time of outpatient examination, the albumin/creatinine ratio in random urine samples was superior on the basis of the correlation coefficients to urine obtained after bed rest. 3) The urinary creatinine excretion rate showed a significant sex difference (males: 0.823 +/- 0.152 mg/g. creat., females: 0.577 +/- 0.194 mg/g. creat) (p less than 0.001), but there was no significant difference for BMI and age. The relationship between each level of microalbuminuria and the creatinine excretion rate did not change significantly. 4) The following formula was used to calculate the albumin/creatinine ratio corresponding to the AER. Albumin/creatinine ratio formula; (see text) An AER of 30 micrograms/min thus corresponds to an albumin/creatinine ratio of 36 mg/g. creat. for males and 51 mg/g. creat. for females. 5) The percentage of positive results for microalbuminuria in patients with NIDDM showed that the albumin/creatinine ratio and the AER were equal as diagnostic criteria, when the sex difference was taken into consideration. Thus, the albumin/creatinine ratio is equal to the AER for evaluation of microalbuminuria, and it is a simple and convenient test to use in daily clinical practice.     

Natural history of chronic renal failure: a reappraisal.

In this retrospective study we have analysed the rate of progression of renal insufficiency, ascertained from the slopes of the plot of inverse serum creatinine against time, of 102 patients with moderate to severe chronic renal failure (CRF). We have applied 'breakpoint' analysis of the slopes to identify changes in the rate of progression and attempted to determine the factors associated with these changes. Seventy-one patients were found to have progressive CRF, while the remaining 31 had stable or improving renal function. Of the parameters studied, using weighted least-squares analysis, proteinuria was the most significant predictor of progression (regression coefficient: -0.1775, P = 0.0075, adjusted r2 = 0.1059). A positive correlation was observed between proteinuria and diastolic blood pressure (DBP) (r = 0.336, P = 0.0054). Once the predictive value of proteinuria was taken into account, there was no difference in the progression rate between diagnostic groups, other than those patients with polycystic kidney disease who had a significantly faster rate of progression (P = 0.0037). In 49 patients, there was at least one change in the rate of progression with time. There was an inverse correlation between change in slope and a change in DBP (r = -0.352, P = 0.003). We conclude that changes in DBP are often associated with the frequent changes in the rate of progression of CRF. However, a causal link could not be established as in a large number of cases the two changes appeared to occur simultaneously in the absence of changes in antihypertensive therapy.     

Factors related to the development of myelopathy in patients with cervical ossification of the posterior longitudinal ligament

This study evaluates factors related to myelopathic symptoms in patients with ossification of the posterior longitudinal ligament (OPLL). A total of 87 patients with OPLL were included. Of these, 53 (Group I) had no symptoms or presented with neck pain and radiculopathy and 34 (Group II) had myelopathic symptoms. Gender, age, and history of trauma were evaluated in the two groups. The range of movement of the cervical spine was measured using plain radiographs. The number of involved segments, type of OPLL, and maximal compression ratio were analysed using CT and signal change in the spinal cord was evaluated using MRI. The patients' age was found to be significant (p = 0.001). No difference was found between gender and the range of movement in the two groups. The maximum compression of the spinal canal showed a difference (p = 0.03). The signal change of the spinal cord was different between the two groups. In patients with OPLL of the cervical spine, myelopathic symptoms are not related to the range of movement or the number of involved segments.     

Deep brain stimulation for Parkinson's disease: association between stimulation parameters and cognitive performance

Chronic subthalamic nucleus stimulation produces inconsistent patterns of cognitive change in Parkinson's disease patients. Individually tailored stimulation parameters may contribute to this variable pattern of change. Systematic variation of amplitude, pulse width, and rate of stimulation has been reported to produce unique changes in motor and limbic response. To evaluate the association between stimulation parameters and cognitive/behavioral response, neuropsychological performance and stimulation parameter data of 8 Parkinson's disease patients were submitted to Pearson r correlation analysis. Results indicate that each stimulation parameter was significantly associated with a subset of measures. The current findings raise the possibility that adverse cognitive/behavioral responses may be treated through parameter modification while maintaining motor symptom efficacy.     

Variation in the use of laparoscopic cholecystectomy for acute cholecystitis: a population-based study

HYPOTHESIS: There is wide variation in the use of laparoscopic cholecystectomy (LC) for acute cholecystitis among all public hospitals in Hong Kong. The objective of this study was to determine the factors responsible for the use of LC for acute cholecystitis in a stable population. DESIGN: A retrospective survey on 2353 patients with pathologically proven acute cholecystitis treated with cholecystectomy in Hong Kong from 1998 to 2002. SETTING: All public hospitals in Hong Kong. RESULTS: The rate of using LC for acute cholecystitis increased by 30.4% from 1998 to 2002. We observed a wide variation in the use of LC for acute cholecystitis ranging from 3.7% to 92.9% (P<.001). There was no correlation between the number of cholecystectomies performed and the percentage of LCs performed in each hospital (P = .39). Logistic regression analysis showed that the hospital, year of operation, and age of the patients were independent variables for LC. CONCLUSIONS: A wide variation in the use of LC for acute cholecystitis was observed among the public hospitals in Hong Kong. Young female patients from selected hospitals recently are more likely to be treated with LC.     

Serum CrossLaps for monitoring the response in individuals undergoing antiresorptive therapy

The Serum CrossLaps (CTx) enzyme-linked immunosorbent assay (ELISA) is specific for a cross-linked, beta-aspartate-isomerized form of the epitope EKAHDGGR derived from the carboxyterminal telopeptide region of type I collagen alpha(1) chain. Collagen type I fragments reactive in the CTx assay are released during osteoclastic bone resorption and can be used as a measure of bone resorption activity. Our objectives were to assess the intraindividual variation of serum CTx concentration as well as the clinical value of the serum CTx assay for monitoring antiresorptive therapy in individual patients. The influence of the sampling time and fasting on the serum CTx measurements was studied with the aim of determining an optimal sampling protocol. Studies of circadian variation in serum CTx concentration in 15 postmenopausal women showed that fasting significantly reduced the average circadian variation of the marker from 36% to 8.7%. This was further supported by assessing short-term (2 weeks) intraindividual variation in ten postmenopausal women who were sampled in the morning, either fasting or nonfasting. The average short-term intraindividual coefficient of variation (CV) was 7.9% in the samples obtained from fasting women, and 14.3% in the samples obtained from nonfasting women. The long-term intraindividual biological variation was 13.4% in 44 postmenopausal women sampled every 6 months (fasting morning samples) over a 1 year period. The ability of the serum CTx assay to monitor individual responses to antiresorptive therapy was assessed in studies of the effects of hormone replacement therapy (HRT) and bisphosphonate (alendronate). Serum samples (morning fasting) were obtained from postmenopausal women treated with either bisphosphonate or HRT at baseline and then after various timepoints of therapy. Spine bone mineral density (BMD) measurements were carried out and the annual percentage change in spine BMD (alphaBMD) was calculated. Sixteen of 17 (94%) of the HRT-treated and 12 of 13 (92%) of the bisphosphonate-treated women showed a decrease in serum CTx after 6 months that was greater than the calculated least significant change (LSC) of the marker (LSC(CTx)). In contrast, only 59% of the HRT-treated and 64% of the bisphosphonate-treated women showed a response in spine BMD greater than the LSC(BMD) 0%) from women with a loss in spine BMD (alphaBMD < 0%). In conclusion, the serum CTx showed high specificity and sensitivity for monitoring individual responses to antiresorptive therapy. More than 92% of the treated women showed significant responses in serum CTx measurements after 6 months.     

Refracture after Ilizarov osteosynthesis in atrophic-type congenital pseudarthrosis of the tibia

We investigated patterns of refracture and their risk factors in patients with congenital pseudarthrosis of the tibia after Ilizarov osteosynthesis. We studied 43 cases in 23 patients. Temporal and spatial patterns of refracture and refracture-free survival were analysed in each case. The refracture-free rate of cumulative survival was 47% at five years and did not change thereafter. Refracture occurred at the previous pseudarthrosis in 16 of 19 cases of refracture. The risk of refracture was significantly higher when osteosynthesis was performed below the age of four years, when the tibial cross-sectional area was narrow, and when associated with persistent fibular pseudarthrosis. Refracture occurs frequently after successful osteosynthesis in these patients. Delaying osteosynthesis, maximising the tibial cross-sectional area and stabilising the fibula may reduce the risk of refracture.     

Kappa statistics in the assessment of observer variation: the significance of multiple observers classifying ankle fractures

Studies using kappa statistics have been conducted with a varied but limited number of observers. The aim of this study was to evaluate the significance of multiple observers on kappa as a measure of observer variation. One hundred orthopedic specialists were asked to assess a random sample of ten sets of standard radiographs of 94 consecutive patients with ankle fractures. The observers were randomly allocated into four groups, which again were divided into subgroups with an increasing number of observers. Random subgroups of three observers revealed kappa values from 0.20 to 0.64 in the Lauge-Hansen and 0.27 to 0.90 in the Weber classification system. With an increasing number of observers in the subgroups, kappa stabilizes around a mean value, indicating that the sampling variation and standard error decrease. The standard error found in this study makes kappa questionable as a measure for agreement among a small number of observers. Thus, kappa values obtained for a given diagnostic tool at one department are not directly comparable with results from other departments. We conclude that kappa cannot stand alone as a simple measure of observer variation. Received: February 2, 2001 / Accepted: November 22, 2001