Comparison of the Diamond-Forrester method and Duke Clinical Score to predict obstructive coronary artery disease by computed tomographic angiography

We sought to evaluate the ability of the Diamond and Forrester method (DFM) and the Duke Clinical Score (DCS) to predict obstructive coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA) and the effect of these different risk scores on the appropriateness level using the 2010 Appropriate Use Criteria. Consecutive symptomatic patients who underwent CCTA for evaluation of CAD (n = 114) were classified as having a low, intermediate, or high pretest probability using the DFM and DCS. Using the Appropriate Use Criteria, the indications for CCTA were classified according to the pretest probability and previous testing. The CCTA results were classified as revealing obstructive (≥70% stenosis), nonobstructive (<70%), or no CAD. When the patients' risk was classified using the DFM, 18% were low, 65% intermediate, and 17% high risk. When using the DCS, 53% of patients had a reclassification of their risk, most of whom changed from intermediate to either low or high risk (50% low, 19% intermediate, 35% high risk). The net reclassification improvement for the prediction of obstructive CAD was 51% (p = 0.01). Of the 37 patients who were reclassified as low risk, 36 (97%) lacked obstructive CAD. Appropriateness for CCTA was reclassified for 13% of patients when using the DCS instead of the DFM, and the number of appropriate examinations was significantly fewer (68% vs 55%, p <0.001). In conclusion, reclassification of risk using the DCS instead of the DFM resulted in improved prediction of obstructive CAD on CCTA, especially in low-risk patients. More patients were categorized as having a high pretest probability of CAD, resulting in reclassification of their examination indications as uncertain or inappropriate. These results identify the need for improved pretest risk scores for noninvasive tests such as CCTA and suggest that the method of risk assessment could have important implications for patient selection and quality assurance programs.     

Impaired diffusion capacity predicts for decreased treatment tolerance and survival in limited stage small cell lung cancer patients treated with concurrent chemoradiation

PURPOSE: To determine if stratification of limited stage small cell lung cancer (LSCLC) patients by pre-treatment pulmonary function test (PFT) prognostic indicators predicts for treatment-related toxicity risks and survival following concurrent chemoradiation. MATERIALS AND METHODS: From 1989 to 1999, 215 LSCLC patients received six cycles of alternating cyclophosphamide/doxorubicin/vincristine and etoposide/cisplatin (EP). Thoracic radiation (RT) was initiated only with EP and at cycle 2 or 3. RT dose was: 40 Gy/15 fractions/3 weeks or 50 Gy/25 fractions/5 weeks. RT fields encompassed gross and suspected microscopic disease with a 2 cm margin. Pre-treatment PFT values analyzed included forced expiratory volume in 1s (FEV1) (in liter and as % predicted) and diffusion capacity for carbon monoxide (DLCO) (as % predicted). The "marker" for toxicity during concurrent chemoradiation was the duration of any RT breaks initiated for severe hematologic or locoregional symptomatology. Patient outcomes were analyzed for associations between recognized PFT cut-offs (FEV1 <2l, > or =2l; FEV1 <60%, > or =60% predicted; DLCO <60%, > or =60% predicted), toxicity rates, and survival. RESULTS: For the whole study cohort, median, 2- and 5-year overall survivals were: 14.7 months, 22.7 and 7.2%, respectively. Fifty-six patients (26%) required treatment breaks due to toxicity. FEV1 and DLCO results were available for 96 (45%) and 86 (40%) patients, respectively. Two thirds of FEV1s measured were <2l. On statistical analysis, the incidence of toxicity-related interruptions was significant for DLCO<60% (P=0.043), suggestive for FEV1<2l (P=0.1) and non-significant for FEV1<60%. Patients with simultaneous DLCO<60% and FEV1<2l showed a trend toward increase toxicity risk (P=0.1). For selected PFT measures, median overall survivals were: 12.7 months versus 14.8 months for DLCO<60% versus > or =60%; 13.4 months versus 17.7 months for FEV1<2l versus > or =2l; 15.4 months versus 19.9 months for DLCO<60% + FEV1<2l versus DLCO> or =60% + FEV1> or =2l. Although absolute differences favored all patients with PFT values above the prognostic cut-offs, differences were not statistically significant on this analysis. Patients with both a treatment break and a DLCO<60% had the poorest median survival of all patient subsets, at 11.4 months (P=0.09). CONCLUSIONS: Impaired DLCO (i.e. <60%) is a novel predictor of increased treatment-related toxicity leading to interruptions. The present study suggests a probable role for DLCO and FEV1 (in l) as prognostic factors for predicting survival but larger patient samples are required for confirmation. Patients with impaired DLCOs experiencing treatment interruptions have the poorest survival. Assessment of pre-treatment PFTs contributes to determining optimal management strategies for LSCLC patients receiving definitive chemoradiation.     

Adjuvant radiation therapy after breast-conserving surgery in elderly women with early-stage breast cancer: controversy or consensus?

Breast-conservation therapy (BCT), which consists of breast-conserving surgery (BCS) and postoperative radiation therapy (RT), provides similar levels of local control and survival compared with mastectomy. Although the incidence of breast cancer increases with age and the proportion of elderly women in the population continues to increase, clinical trials of BCT have included few women aged > or = 65 years, limiting the ability to establish clear consensus regarding optimal therapy in this population. This article examines the literature on BCT in elderly women with early-stage breast cancer. A systematic search of the Medline and CancerLit databases was conducted to identify articles specifically addressing BCT in elderly women. The outcomes evaluated were local control, disease-free survival, overall survival, and treatment-related toxicities. The lack of consensus in breast-conservation management in elderly patients is highlighted by a paucity of prospective data and numerous retrospective series reporting diverse treatment approaches with conflicting results. The available evidence from BCT trials with and without age subgroup analyses support BCS with postoperative RT as the standard approach associated with the most favorable local control outcomes. A low-risk subset of patients in whom RT may be omitted without compromising local control remains to be defined. Despite these findings, the use of standard therapy significantly decreases with advancing patient age. Although data specifically addressing BCT in elderly patients are limited, age should not preclude consideration of standard treatment strategies to optimize local disease control. Modern clinical trials with representative samples of elderly patients evaluating cancer recurrence and survival as well as functional and quality-of-life outcomes are needed to define optimal breast-conservation management for this important patient population.     

A positive margin is not always an indication for radiotherapy after mastectomy in early breast cancer

OBJECTIVE: Postoperative radiotherapy is frequently employed among breast cancer patients with positive surgical margins after mastectomy but there is little evidence to support this practice. This study examined relapse and survival among women with node-negative breast cancer and positive surgical margins after mastectomy. METHODS: Among 2570 women diagnosed between 1989 and 1998 and referred to the British Columbia Cancer Agency with pathologic (p)T1-2, pN0 invasive breast cancer treated with mastectomy, 94 had positive surgical margins and formed the study cohort. Women with more established indications for postmastectomy radiotherapy (PMRT) including T3-4 tumors or node-positive disease were excluded. Demographic, tumor, and treatment factors; relapse patterns; and Kaplan-Meier 8-year locoregional relapse-free, breast cancer-specific, and overall survival rates were compared between women who were treated with (n = 41) and without (n = 53) PMRT. RESULTS: Median follow-up time was 7.7 years. The distributions of age, histologic grade, lymphovascular invasion (LVI), estrogen receptor status, and number of axillary nodes removed were similar between the two treatment groups. Six local chest wall recurrences (6.4%), 4 regional recurrences (4.3%), and 11 distant recurrences (11.7%) were identified. Local relapse rates were 2.4% vs. 9.4% (p = 0.23), and regional relapse rates were 2.4% vs. 5.7% (p = 0.63), with and without PMRT, respectively. Trends for higher cumulative locoregional relapse (LRR) rates without PMRT were identified in the presence of age <==50 years (LRR 20% without vs. 0% with PMRT), T2 tumor size (19.2% vs. 6.9%), grade III disease (23.1% vs. 6.7%), and LVI (16.7% vs. 9.1%). Statistical significance was not demonstrated in these differences (p > 0.10), possibly because of the small number of events. In patients with age >50 years, T1 tumors, grade I/II disease, and absence of LVI, no locoregional relapse occurred even with positive margins. PMRT did not improve distant relapse, 8-year breast cancer-specific and overall survival rates. CONCLUSION: This study suggests that not all patients with node-negative breast cancer with positive margins after mastectomy require radiotherapy. Locoregional failure rates approximating 20% were observed in women with positive margins plus at least one of the following factors: age <==50 years, T2 tumor size, grade III histology, or LVI. The absolute and relative improvements in locoregional control with radiotherapy in these situations support the judicious, but not routine, use of PMRT for positive margins after mastectomy in patients with node-negative breast cancer.     

Characterization of the interstitial cellular infiltrate in experimental chronic cyclosporine nephropathy

In a recently described rodent model of chronic cyclosporine nephropathy (CCN) (consisting of irregularly distributed areas of interstitial inflammation, interstitial fibrosis, and tubular atrophy) we have characterized the interstitial inflammatory cells. Using a modified avidin-biotin peroxidase technique, kidney tissue was examined with monoclonal antibodies directed against leukocyte-common antigen (LCA), T lymphocytes, T helper and T nonhelper lymphocytes, Ia (B cell marker), and macrophages. Injured cortex from cyclosporine-treated animals demonstrated increased numbers of T helper and B lymphocytes, macrophages, and cells bearing LCA. Cytotoxic (T nonhelper) cells were scant. Non-injured areas of cortex from CsA-treated animals demonstrated only a modest increase in macrophages when compared with vehicle controls and normal rats. We conclude that CCN in rodents is characterized by an interstitial inflammatory infiltrate of T helper cells, B cells, and macrophages. The role of these cells in the pathogenesis of CCN, however, remains speculative.     

Periodontal disease among the middle-aged Vietnamese population

Information about periodontal disease patterns among the populations of developing countries is limited. These populations may illustrate the natural history of the disease owing to low or virtually no access to dental care, contributing to a more complete understanding of the disease process. The present study aimed to describe the patterns of periodontal loss of attachment (LOA) among representative middle-aged Vietnamese adults. A multi-stage, stratified random sampling technique was employed in two randomly selected provinces. The US NIDR protocol with two sites per tooth for the whole mouth, excluding third molars, was used to assess LOA. A total of 575 subjects aged 35-44 years were interviewed and periodontally examined (response 84.6%). Data were re-weighted to reflect the population of the two provinces. Oral hygiene status was poor with high accumulation of plaque and calculus. The prevalence, extent of sites with pockets (PD), recession (GR) and LOA exceeding various thresholds and the severity of LOA were calculated. Almost all subjects presented with at least one site with LOA > or = 2 mm but the higher levels of the disease were skewed. The extent of sites with GR, PD and LOA > or = 4mm was 1.35, 5.04 and 11.81 per cent respectively. More buccal sites had GR, while more mesial sites had PD and LOA. Severity score of LOA was 2.5 (SD: 0.7). LOA of 4+mm were observed more at maxillary molar buccal sites, followed by mandibular incisor mesial sites. LOA was prevalent among middle-aged Vietnamese adults. The loss of periodontal support was positively skewed and varied between teeth and sites.     

Prevalence of surgical-site infections and patterns of antimicrobial use in a large tertiary-care hospital in Ho Chi Minh City, Vietnam.

BACKGROUND: Few studies have been conducted in Vietnam on the epidemiology of healthcare-associated infections or antimicrobial use. Thus, we sought to determine the prevalence of and risk factors for surgical-site infections (SSIs) and to document antimicrobial use in surgical patients in a large healthcare facility in Vietnam. METHODS: We conducted a point-prevalence survey of SSIs and antimicrobial use at Cho Ray Hospital, Ho Chi Minh City, a 1,250-bed inpatient facility. All patients on the 11 surgical wards and 2 intensive care units who had surgery within 30 days before the survey date were included. RESULTS: Of 391 surgical patients, 56 (14.3%) had an SSI. When we compared patients with and without SSIs, factors associated with infection included trauma (relative risk [RR], 2.65; 95% confidence interval [CI95], 1.60 to 4.37; P < .001), emergency surgery (RR, 2.74; CI95, 1.65 to 4.55; P < .001), and dirty wounds (RR, 3.77; CI95, 2.39 to 5.96; P < .001). Overall, 198 (51%) of the patients received antimicrobials more than 8 hours before surgery and 390 (99.7%) received them after surgery. Commonly used antimicrobials included third-generation cephalosporins and aminoglycosides. Thirty isolates were identified from 26 SSI patient cultures; of the 25 isolates undergoing antimicrobial susceptibility testing, 22 (88%) were resistant to ceftriaxone and 24 (92%) to gentamicin. CONCLUSIONS: Our data show that (1) SSIs are prevalent at Cho Ray Hospital; (2) antimicrobial use among surgical patients is widespread and inconsistent with published guidelines; and (3) pathogens often are resistant to commonly used antimicrobials. SSI prevention interventions, including appropriate use of antimicrobials, are needed in this population.     

Endoskopische therapie benigner anastomosenstenosen im kolon- und rektumbereich durch elektroinzision und ballondilatation

Zusammenfassung 21 Patienten mit postoperativ aufgetretenen Anastomosenstenosen wurden mittels Elektroinzision in Kombination mit einem Ballondilatator behandelt. Der Schweregrad des Beschwerdebilds korrelierte direkt mit dem Ausmaß der Lumeneinengung (Grad I: Durchmesser 13 mm, n = 12; Grad II: Durchmesser 7 mm, n = 6; Grad III: Durchmesser 4 mm, n = 3). Nach einer endoskopischen Therapie waren alle Patienten mit einer erst- und zweitgradigen Anastomosenstenose beschwerdefrei. Drittgradige Stenosen konnten in 2 Fällen klinisch weitgehend mit verbleibenden gelegentlichen abdominalen Krämpfen und Meteorismus gebessert werden. Ein Patient mit Stenosegrad III profitierte von der Therapie nicht. Die durchschnittliche Dilatationsfrequenz betrug 1,5mal, Komplikationen wie Blutung und Perforation traten nicht auf. Tierexperimentell erhobene Befunde erklären Anastomosenstenosen Durch eine vermehrte, submuköse Kollagenfasereinlagerung mit nachfolgender Narbenbildung im Anastomosenbereich. Die Effektivität der Therapiekombination Elektroinzision und Ballondilatation begründet sich in einer Aufweitung des Narbenrings, ohne eine erneute Kollagenfaserbildung zu induzieren.

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Endoscopic therapy of benign anastomotic stenosis of the colorectal region by electroincision and balloon dilatation

21 patients with a severe anastomotic stenosis in the colorectal region were treated with hydraulic balloon dilatation and endoscopic electroincision. The severity of symptoms directly correlates with the extent of stenosis (degree I Ø 13 mm, n = 12; degree II Ø 7 mm, n = 6; degree III Ø 4 mm, n = 3). All patients with a stenosis of degree I and II were symptom-free after the endoscopic therapy. In 2 of 3 cases the symptoms of stenosis of degree III could clinically be improved after the treatment. The average frequence of dilatation was 1.5 ×, complications such as bleeding or perforation were not registered. Animal studies explain anastomotic stenosis through an increased submucosal formation of collagen fibers followed by formation of scars in the anastomosis. The efficiency of electroincision and balloon dilatation is based on an increased diameter in the anastomotic region without increased formation of new collagen fibers.