Do androgens enhance the response to antithymocyte globulin in patients with aplastic anemia? A prospective randomized trial

We analyzed the effect of antithymocyte globulin (ATG) with or without androgens in 121 patients with aplastic anemia. Fifty-three patients with moderate to severe aplastic anemia were prospectively randomized to receive ATG with or without oral androgens. Eleven of 26 patients (42%) receiving ATG plus androgen responded, including three complete and eight partial responses. Twelve of 27 patients (44%) receiving ATG plus placebo responded, including five complete and seven partial responses. The difference in response rates was not significant (P greater than .9). Survival was also comparable in the two groups; for patients with severe aplastic anemia, actuarial survival at two years was 55% +/- 24% (95% confidence interval) in patients receiving ATG plus androgen compared with 50% +/- 24% in the ATG plus placebo group (P = .65). Furthermore, results in both groups were indistinguishable from those obtained in 68 historical controls receiving ATG without androgens. These data indicate that androgens are not required in order to respond to antithymocyte globulin and the addition of androgens, as used in this trial, did not significantly improve response rates to ATG treatment.     

ST段抬高心肌梗死（STEMI）的治疗：美国及欧洲更新指南的比较（2）

7抗凝剂——再灌注疗法的辅助疗法 更新的指南根据许多新的临床试验的结果，对4种新的抗凝剂提出了新的临床应用建议，见表2，有3项重要的临床试验：EXTRACT—TIMI25，OASIS-6以及CREATE证实，进行纤溶疗法的患者应用新的抗凝剂可以降低死亡率或MI的发生率。     

Stent-assisted coiling of intracranial aneurysms aided by virtual parent artery reconstruction

The availability of stents designed specifically for use in the intracranial vasculature has increased the use of stent-assisted coiling for treatment of wide-necked and complex intracranial aneurysms. We present a technique for pretreatment planning and visualization of a virtual stent within the parent artery by using a virtual reconstruction of the parent artery across the aneurysm neck. As illustrated by 2 clinical examples, this method provides information not otherwise available regarding the location of portions of the stent that are not visible on fluoroscopy. During treatment, this information enhances the ability to determine the location of coils in relation to the stent boundaries and should thereby improve the ability to avoid parent artery compromise.     

SIDS, illness, and acute medical care. New Zealand Cot Death Study Group

One component of the Back to Sleep campaign to reduce the risk of sudden infant death syndrome (SIDS) is the recommendation that parents seek medical attention if their infant is unwell. The aim of this study was to investigate of SIDS could in part be explained by sick infants not getting appropriate medical care. Data on symptoms of illness and on acute medical contacts made for infants dying from SIDS (n = 390) within two weeks of their death were compared with those from a randomly selected group of control infants (n = 1592). SIDS cases had more severe illness than controls (odds ratio (OR) = 3.43; 95% confidence interval (CI) = 1.69 to 5.38), and were more likely to have seen a general practitioner (OR = 1.37; 95% CI = 1.09 to 1.73) or attended hospital (OR = 3.43, 95% CI = 1.09 to 1.73). Only 1.3% of all SIDS cases had symptoms suggesting severe illness and had not seen a general practitioner. A lack of medical contacts in the two weeks before death does not contribute to the risk of SIDS.     

Temporal relationship between cancers of the lung and upper aerodigestive tract

We retrospectively reviewed the chart records at the Veterans General Hospital-Taipei for the period between January 1985 and December 1994 to examine the temporal relationship between cancers of the lung and upper aerodigestive tract. A total of 56 patients (54 males, 2 females) with histocytologically proven double primary cancers, with either lung cancer or upper aerodigestive tract cancers appearing first, were found. Squamous cell carcinoma was the most frequent histologic type of lung cancer (squamous 57%, adenocarcinoma 27%, poorly differentiated carcinoma 9%, small cell lung cancer 7%). The incidence of lung cancer patients with upper aerodigestive tract cancer was 0.9% (56/6412). There was no significant difference in the occurrence of upper aerodigestive tract cancer between non-small cell and small cell lung cancer (P > 0.05). However, the incidence of squamous cell lung cancer with upper aerodigestive tract cancer was higher than that of non-squamous cell lung cancer (P < 0.05). With regard to the location of lung cancer, the right lung was more commonly affected than the left (P < 0.001). The locations of upper aerodigestive tract cancers in these lung cancer patients were as follows: larynx 24, nasopharynx 11, esophagus 10, hypopharynx 4, pharyngeal tonsils 2, oral cavity 5. Most upper aerodigestive tract cancers were diagnosed before lung cancer (36/56, 64%), and lung cancer was diagnosed within 3 years in more than half of cases after the diagnosis of upper aerodigestive tract cancer (58.3%). Most lung cancers that preceded upper aerodigestive tract cancer were at an early stage at diagnosis (stage I 4, stage Illa 1), whereas the others, appearing either synchronously or after the diagnosis of upper aerodigestive tract cancer, were mostly at the late stage. There was no difference in survival between lung cancer patients with upper aerodigestive tract cancer and those without (P > 0.05).      

The failed thoracocentesis

How often do we consider a differential diagnosis of diaphragmatic hernia in cases of failed thoracocentesis? How many of us remember that omental fat in the chest can behave in a fluid manner, layering along the chest wall, resulting in the misinterpretation of a decubitus view. A case is presented of a diaphragmatic hernia that was missed on conventional chest radiographs resulting in CT having to be performed. A high degree of suspicion is mandatory to reach the final diagnosis. Radiographs could be used more effectively and CT avoided.     

Use of routine computed tomography brain scanning of psychiatry patients*

The aim of this study was to evaluate the usefulness of CT of the brain in patients presenting with a psychiatric condition without focal neurological signs. The reports of 397 consecutive CT brain scans of patients presenting to two acute tertiary hospital psychiatric services over a 2‐year period were assessed retrospectively. Of the 397 patients, 241 had psychosis, 87 had depression, 44 had bipolar affective disorder, seven had alcohol dependence, five had dementia, and the remaining 13 had a variety of diagnoses including personality disorder and transient ischaemic attack. Findings on 377 (95%) of the CT scans showed no abnormality. Specific abnormalities were described in 20 (5%) of the CT scans. Three scans showed non‐specific minor abnormalities, which, when followed up by MRI, showed no relevant abnormality. All the abnormalities shown on CT were considered to be clinically unrelated to the patient's psychiatric condition. In conclusion, the pretest probability of finding a space‐occupying lesion or other pertinent abnormality in patients presenting with psychiatric illnesses in this retrospective study appears not to be greater than that of the general population. The outcome of this study could be implemented to develop a clinical pathway for limiting assessment by CT for possible organic pathology in acute psychiatric illness.     

The natural history of anterior cruciate ligament reconstruction using patellar tendon autograft

The purpose of this study was to review the results of ACL reconstruction using a patellar tendon graft placed ‘over the top’ plus a Macintosh lateral tenodesis, examining changes in knee laxity and functional status with increasing time. There were 74 patients operated on over an 11 year period, and divided into four groups for analysis according to postoperative time. There was a significant and progressive increase in side-to-side laxity difference with time, although functional status did not change significantly, indicating a lack of correlation between objective clinical tests and subjective findings. The highest Lysholm, Tegner and IKDC scores were at 4–5 years after operation, when 60% of patients were at their pre-injury level of sports activity. However, there was always a very significant difference between actual and desired Tegner activity levels for the group as a whole. While there was a significant correlation between degenerative changes and the time between injury and reconstruction, there was no correlation with postoperative time: this provides evidence that ACL reconstruction can protect the knee from later degeneration.