The U.K. skin cancer 'two-week rule' proforma: assessment of potential modifications to improve referral accuracy

Background In England and Wales, patients with suspected skin cancer are referred to specialists within 2 weeks (‘two‐week rule’, TWR) by tick‐box proforma. Objectives To evaluate proforma details that might be amended to improve sensitivity and specificity. Methods Five hundred and six TWR referrals were evaluated. Potential proforma changes were criteria for melanoma, and guidance that most squamous cell carcinomas (SCCs) measure ≥ 1 cm. We compared melanomas vs. benign pigmented lesions using seven‐point, and amended (10‐point), checklist scores. We examined sizes of 82 SCCs and investigated influence of size on TWR referral. Results Of 506 TWR referrals, 381 (75%) were suspected melanoma [30 (7·8%) correct], and 125 (25%) were suspected SCC [22 (17·6%) correct]. Fifty per cent of melanomas were referred by TWR, but only 8% of SCC. No combination of seven‐point checklist criteria had discriminatory value for melanoma; total scores (seven‐ or 10‐point) were not significantly different between melanomas and nonmelanomas. No total score, using either system, had acceptable sensitivity and specificity. Measured size of SCCs varied from 4 to 30 mm; 88% were ≥ 1 cm. Reducing the ‘cut‐off’ to 7 mm identified only another 3·5%. Even at 2·5–3 cm, only 50% of SCCs were referred by TWR. Conclusions The seven‐point checklist for melanoma, when used in TWR format, does not have discriminatory value for melanoma. Altering the suggested cut‐off size for SCC is unlikely to alter referrals. Education may be a more important factor in refining use of the TWR.     

Ocular disorders in children with learning disabilities in special education schools of Pune, India

Aim:

The aim was to study and treat ocular disorders in children with learning disabilities (cLDs) and explore associations with their perinatal history.

Materials and Methods:

cLDs attending 11 special schools were examined by a team consisting of an ophthalmologist, optometrist, and a social worker in 2007 and followed up in 2008. The students‘ intelligence quotient (IQ) and their medical histories were noted. Distant visual acuities were measured using Kay pictures or Snellen''s tumbling E chart and complete ocular examination was performed. Students were assessed at the pediatric ophthalmology unit and low vision center, if needed. Statistical analysis was done with SPSS and the Chi-square test for ordinal data.

Results:

A total of 664 students were examined, 526 of whom were <16 years of age; 323 (61.4%) were male. A total of 326 (60%) had moderate-to-severe learning disabilities (IQs <50), and the mean IQ was 45.4. Two hundred and thirty-eight (45.3%) had ocular disorder; 143 (27.3%) had an uncorrected refractive error, followed by strabismus in 83 (15.8%), nystagmus in 36 (6.8%), optic atrophy in 34 (6.5%), and congenital anomalies in 13 (2.5%), 103 children had more than one abnormality. Only 12 of the 143 students with refractive errors were using spectacles. A total of 132 (48.7%) children with a history of perinatal insult had ocular problems. Ocular disorders were also common in those with a history of epilepsy, Down''s syndrome, and cerebral palsy.

Conclusion:

Nearly half the cLDs in this study had ocular disorders and one-fourth had their vision improved.     

Cavitary lung lesion 6 years after renal transplantation

The differential diagnoses of a cavitary lung lesion in renal transplant recipients would include infection, malignancy and less commonly inflammatory diseases. Bacterial infection, Tuberculosis, Nocardiosis, fungal infections like Aspergillosis and Cryptococcosis need to be considered in these patients. Pulmonary cryptococcosis usually presents 16-21 mo after transplantation, more frequently in patients who have a high level of cumulative immunosuppression. Here we discuss an interesting patient who never received any induction/anti-rejection therapy but developed both BK virus nephropathy as well as severe pulmonary Cryptococcal infection after remaining stable for 6 years after transplantation. This case highlights the risk of serious opportunistic infections even in apparently low immunologic risk transplant recipients many years after transplantation.     

Papillary fibroelastoma of the aortic valve: An unusual cause of angina

Papillary fibroelastoma of the aortic valve is an uncommon benign tumor of the heart that can present with embolic events. We report a case of 54-year-old lady with exertional chest pain and prior history of ST segment elevation myocardial infarction who was subsequently found to have a fibroelastoma of the aortic valve. The absence of angiographically significant coronary artery disease and resolution of anginal symptoms post-surgery in our patient points to the possibility of fibroelastoma causing these anginal symptoms. Although uncommon, fibroelastoma are being recognized more frequently with the help of transesophageal echocardiography. Hence, in the absence of significant coronary artery disease, we emphasize the importance of consideration of papillary fibroelastoma of the aortic valve as a cause of angina. We also discuss the key aspects of the fibroelastoma including presentation, diagnostic modalities and treatment options.     

Calibrating models in economic evaluation: a seven-step approach

In economic evaluation, mathematical models have a central role as a way of integrating all the relevant information about a disease and health interventions, in order to estimate costs and consequences over an extended time horizon. Models are based on scientific knowledge of disease (which is likely to change over time), simplifying assumptions and input parameters with different levels of uncertainty; therefore, it is sensible to explore the consistency of model predictions with observational data. Calibration is a useful tool for estimating uncertain parameters, as well as more accurately defining model uncertainty (particularly with respect to the representation of correlations between parameters). Calibration involves the comparison of model outputs (e.g. disease prevalence rates) with empirical data, leading to the identification of model parameter values that achieve a good fit. This article provides guidance on the theoretical underpinnings of different calibration methods. The calibration process is divided into seven steps and different potential methods at each step are discussed, focusing on the particular features of disease models in economic evaluation. The seven steps are (i) Which parameters should be varied in the calibration process? (ii) Which calibration targets should be used? (iii) What measure of goodness of fit should be used? (iv) What parameter search strategy should be used? (v) What determines acceptable goodness-of-fit parameter sets (convergence criteria)? (vi) What determines the termination of the calibration process (stopping rule)? (vii) How should the model calibration results and economic parameters be integrated? The lack of standards in calibrating disease models in economic evaluation can undermine the credibility of calibration methods. In order to avoid the scepticism regarding calibration, we ought to unify the way we approach the problems and report the methods used, and continue to investigate different methods.     

Carbohydrate modified ultrafine ceramic nanoparticles for allergen immunotherapy

The uses of drug-delivery systems in allergen specific immunotherapy appear to be a promising approach due to their ability to act as adjuvants, transport the allergens to immune-competent cells and tissues and reduce the number of administrations. The aim of this work was to evaluate the carbohydrate modified ultrafine ceramic core based nanoparticles (aquasomes) as adjuvant/delivery vehicle in specific immunotherapy using ovalbumin (OVA) as an allergen model. Prepared nanoparticles were characterized for size, shape, zeta potential, antigen integrity, surface adsorption efficiency and in vitro release. The humoral and cellular-induced immune responses generated by OVA adsorbed aquasomes were studied by two intradermal immunizations in BALB/c mice. OVA sensitized mice were treated with OVA adsorbed aquasomes and OVA adsorbed aluminum hydroxide following established protocol. Fifteen days after therapy, animals were challenged with OVA and different signs of anaphylactic shock were evaluated. Developed aquasomes possessed a negative zeta potential (-11.3 mV) and an average size of 47 nm with OVA adsorption efficiency of ~60.2 μg mg(-1) of hydroxyapatite core. In vivo immune response after two intradermal injections with OVA adsorbed aquasomes resulted in a mixed Th1/Th2-type immune response. OVA-sensitized mice model, treatment with OVA adsorbed aquasomes elicited lower levels of IgE (p<0.05), serum histamine and higher survival rate in comparison with alum adsorbed OVA. Symptoms of anaphylactic shock in OVA aquasome-treated mice were weaker than the one induced in the alum adsorbed OVA group. Results from this study demonstrate the valuable use of aquasomes in allergen immunotherapy.     

Preoperative Exchange Transfusion for Sickle Cell Disease Patients Undergoing Open‐Heart Surgery: An Exception to the Rule

Abstract Preoperative exchange transfusion is a routine practice in patients with sickle cell disease having elevated sickle cell hemoglobin levels (>40%) undergoing open‐heart surgery on cardiopulmonary bypass. A new approach toward acceptance and management of sickle cell disease patients with high sickle cell hemoglobin levels for open‐heart surgery without preoperative exchange transfusion of blood is presented. (J Card Surg 2010;25:691‐693)     

Endoscopic and imaging appearance after injection of an ano-rectal bulking agent

The use of hyaluronic acid and dextranomer (Solesta, Salix) injection in the anal canal is an emerging modal-ity in the treatment of fecal incontinence. However, little is known regarding the endoscopic and radiological appearance following injection of this ano-rectal bulking agent. We report computed tomography and endoscopic findings after hyaluronic acid/dextranomer injection in the ano-rectal area.