Structuring a safer donor-replacement program

BACKGROUND: Replacement donors are more likely than volunteer donors to have positive or abnormal tests for transfusion-transmissible disease. In an effort to increase the donor pool, workers sought to identify a safer replacement-donor subgroup that may be acceptable for routine donations. STUDY DESIGN AND METHODS: In a retrospective review and cohort study, the replacement-donor effect was separated from the new- donor effect. The relative effect the replacement donor has on the risk of transfusion-transmissible diseases, donor retention, and frequency of returning donations was then quantified by comparison against the effect of repeat volunteer donors. RESULTS: The replacement donor had 3.1 times the risk and 0.72 times the donor retention rate and made 0.81 times as many returning donations as the repeat volunteer donor. The figures for the new-donor effect were similar. The two risks were additive, making a new replacement donor particularly hazardous. If replacement donations only from repeat replacement donors were considered, the donor risk and the number of donations per returning donor were made comparable to those for the general (combined) volunteer donor. CONCLUSION: The negative effect of the replacement donor is similar in magnitude to that of the new volunteer donor. A replacement-donation program targeting repeat replacement donors has an acceptable risk profile and may be a valuable adjunct to the collection of blood from general volunteer donors.     

Challenges of Efficacy Assessments in Pseudomyxoma Peritonea

Several critical issues need to be considered in interpreting the results of the single-center observational study of the FOLFOX regimen in appendiceal pseudomyxoma peritonei reported by Pietrantonio et al.Several critical issues need to be considered in interpreting the results of the single-center observational study of the FOLFOX regimen in appendiceal pseudomyxoma peritonei (PMP) reported by Pietrantonio et al. [1].Clinical behavior of mucinous appendiceal neoplasms is variable and highly dependent on histological grade [2]. Currently, multiple histopathological grading systems exist [3–5]. Although the authors’ eligibility criteria describe inclusion of borderline mucinous tumors and well-differentiated appendiceal adenocarcinomas, the grading is reported as either low (n = 12) or high (n = 8). Because no reference grading system is provided, the meaning of high and low grade is unclear. According to the American Joint Committee on Cancer’s AJCC Cancer Staging Manual, 7th edition, high-grade mucinous appendiceal adenocarcinomas are defined as moderate to poorly differentiated tumors [6], and that is inconsistent with the inclusion criteria.Eligible patients were either unresectable (n = 6) or had relapsed following initial cytoreductive surgery (CRS; n = 14). It was reported that 2 of the 6 initially unresectable cases underwent cytoreductive surgery, but the rate of repeat CRS in the 14 patients who had initially relapsed following a complete CRS was not reported. Because repeated CRS in appendiceal PMP represents a proven approach [7, 8] the rate of a second CRS should be reported. Because both PFS and overall survival times are not censored at the time of a second CRS, the reported time-to-event analyses may best reflect an anticancer approach of chemotherapy followed by repeated CRS [9].Low-grade mucinous appendiceal neoplasms are known to have an indolent disease course; therefore, the presence of 7 cases with >20% growth at 3 months (progressive disease) is highly unusual for this disease type. Furthermore, the >30% shrinkage seen in 4 of these patients is unusual in the context of a median of 8 cycles (∼4 months) and a maximum of 12 (∼6 months). As a center that has conducted extensive research in appendiceal neoplasms, we disagree with the statement that a “decrease in the amount of mucus was invariably observed” and feel that the magnitude of radiographic change reported over a 3- to 6-month period for low-grade mucinous appendiceal neoplasms is not an accurate reflection of the disease biology under study. Prior reports documenting radiographic responses have all included more aggressive and higher grade appendiceal neoplasms and are not reflective of the population in this report [10, 11]. In part, we believe that the findings reported reflect the intrinsic challenges of both separating mucinous from more serous peritoneal accumulations and measuring geographically shaped mucinous implants that shift between scans. This latter point is amplified by the limitation of measuring only two peritoneal areas, as per Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1.Prospective controlled studies are needed to clarify the role of chemotherapy in PMP. A clinical trial ({"type":"clinical-trial","attrs":{"text":"NCT01946854","term_id":"NCT01946854"}}NCT01946854) for unresectable low-grade mucinous appendiceal adenocarcinomas with PMP is ongoing at MD Anderson. In that trial, patients are randomized to either 6 months of chemotherapy followed by 6 months of observation or 6 months of observation followed by 6 months of chemotherapy. Within this study, a modified peritoneal RECIST measurement in which five locations are measured is being investigated. Because each patient serves as his or her own control, we hope this study will better clarify the true rate of radiographic change for this biologically unique tumor type.     

Improved outcome for children with disseminated adenoviral infection following allogeneic stem cell transplantation

Adenovirus (AdV) infections are a frequent cause of morbidity and mortality following allogeneic stem cell transplantation (SCT), and disseminated infection is associated with high mortality, particularly in paediatric SCT. Here, we describe an approach to reduce mortality from adenoviraemia by combining prospective monitoring for the occurrence of adenoviraemia using a sensitive polymerase chain reaction method, early antiviral therapy and prompt withdrawal of immunosuppression. A total of 155 consecutive paediatric SCT procedures were prospectively monitored, of which 113 (73%) transplants involved donors other than matched siblings and 126 (83%) employed T-cell depletion. Adenoviraemia was detected in 26/155 (17%) transplants and developed exclusively in patients who had received T-cell-depleted grafts. Withdrawal of immunosuppression coupled with early antiviral therapy led to resolution of adenoviraemia in 19/26 (81%) patients with only five patients succumbing to disseminate AdV infection. Survival from adenoviraemia was associated with lymphocyte recovery to above 0.3x10(9)/l. Mortality was closely linked with the absence of lymphocyte recovery because of profound T-cell depletion of the graft with CD34+ magnetic-activated cell sorting. Mortality from disseminated AdV infection was 5/26 (19%) in this study, which is significantly lower than previously reported.     

The urodynamic evaluation of lower urinary tract symptoms in men

Urodynamic investigation is recommended when it influences the management of patients and is used before invasive therapies for lower urinary tract dysfunction. Urodynamics has been shown to improve symptomatic and objective outcomes after surgical treatment of bladder outlet obstruction (BOO) of which benign prostatic obstruction (BPO) is the principal cause. The diagnosis of BOO is made from pressure-flow studies (PFS) of micturition using the International Continence Society nomogram, which places patients in three categories: obstructed (BOO index [BOOI] ≥ 40); equivocal (no definite obstruction; BOOI 20–40); and no obstruction (BOOI ≤ 20). PFS are reliable and reproducible; however, they are invasive tests, and efforts to find sensitive and specific methods of diagnosing BPO without catheterization are under way. Promising noninvasive techniques include the penile compression release index, the condom catheter method, and the penile cuff technique. Uroflowmetry and the ultrasound estimation of residual urine remain useful screening tests. Due to its diagnostic and prognostic value, urodynamics is recommended to assess lower urinary tract symptoms before surgery to relieve BOO.     

Outcomes of trauma patients: direct transport versus transfer after stabilisation at another hospital

BackgroundIn this study, we attempted to identify differences in the outcomes of patients with severe trauma who were directly transported to our hospital, and those who were stabilised initially at other hospitals in south-central Taiwan.MethodsWe performed a prospective observational study to review the records of 231 patients with major trauma (Injury Severity Scores (ISS) >15) who visited our hospital's emergency department from January 2010 to December 2010. Among these patients, 75 were referred from other hospitals. Logistic regression was performed to assess the effects of transfer on mortality.ResultsPatients in the transfer group had a shorter interval between trauma and admission to the first hospital (25.3 min vs. 28.1 min), and the average interval between the two hospital arrivals was 138.3 min. Transfer from another hospital was not significantly correlated with mortality in this study (odds ratio: 1.124, 95% confidence interval: 0.276–4.578).ConclusionIn trauma patients with ISS > 15, there is no difference in mortality between those transferred from another hospital after initial stabilisation and those who visited our emergency department directly.     

Geographic factors are associated with increased risk for out-of hospital cardiac arrests and provision of bystander cardio-pulmonary resuscitation in Singapore

Background

Bystander Cardio-Pulmonary Resuscitation (BCPR) can improve survival for Out-of-Hospital Cardiac Arrest (OHCA). This study aimed to investigate the geographic variation of BCPR provision and survival to discharge outcomes among residential OHCA cases, evaluate this variation with individual and population characteristics and identify high-risk residential areas with low relative risk (RR) of BCPR and high RR of OHCA at the development guide plan (DGP) census tract levels in Singapore.

Methods

This was a retrospective, secondary analysis of two prospectively-collected registries in Singapore from 2001 to 2011. We used Bayesian conditional autoregressive spatial models to examine predictors at the DGP level and calculate smoothed RR to identify high-risk areas. We used multi-level mixed-effects logistic regression models to examine the independent effects of individual and neighborhood factors.

Results

We found a total of 3942 OHCA with a BCPR rate of 20.3% and a survival to discharge rate of 1.9% and 3578 cases eligible for BCPR. After adjusting for age, witnessed status, presumed cardiac etiology and longer response time, the risk of BCPR provision significantly increased by 0.02% for every 1% increase in the proportion of household size 5 and above in the DGP area (odds ratio1.02, 95%CI = 1.002–1.038, p < 0.026). We identified 10 high-risk residential areas with low RR of BCPR and high RR of OHCA.

Conclusion

This study informed that neighborhood household size could have played a significant role in the provision of BCPR and occurrence of high-risk areas. It demonstrates the public health potential of combining geospatial and epidemiological analysis for improving health.     

美国教学医院教师专业发展的全国性调查

在当前医学教育持续变革的背景中,医学教师的专业发展成为广泛关注的焦点.为了解目前美国以提高教师的教学技能为目标的教师专业发展(faculty development,FD)活动的参与率、课程设计、教学方法和评估策略等情况,美国约翰·霍普金斯大学预防、流行病学和临床研究中心采取邮件调查的方式,对美国277家教学医院进行了调查.     

Complications in tunneled CVL versus PICC lines in very low birth weight infants.

OBJECTIVE:Comparison of complications associated with tunneled central venous lines (TCVLs) versus peripherally inserted central catheters (PICCs) in infants <1500 g. STUDY DESIGN:A retrospective cohort study at a university medical center. A total of 96 catheters were placed in 60 infants between 4/94 and 3/99. A retrospective review of these infants' medical record was done to review associated complications of catheter placement. RESULTS:Both groups had similar weights and gestational ages. The duration of catheterization was 28 days in TCVLs and 11 days in PICCs (p<0.05). Total, infectious, and mechanical complications between the two groups were similar. Survival function estimates showed no difference between the two groups up to the 15th day of catheterization. CONCLUSION:There is no difference in efficacy or associated complications between the two groups. If one could anticipate needing a catheter longer than 15 days, then a TCVL might be the better choice.     

Benign prostatic hyperplasia--video image analysis and its relationship to androgen and epidermal growth factor receptor expression.

Androgens are essential for the development and maintenance of the prostate. However, prostatic growth may be mediated by epidermal growth factor (EGF) and the expression of the EGF receptor (EGFR) may be influenced by the androgenic milieu. We have characterized the expression of cytosolic androgen receptor (ARc), nuclear salt extractable androgen receptor (ARn) and EGFR in 89 consecutive cases of benign prostatic hyperplasia, 84 of which were treated by transurethral prostatic resections. Image analysis morphometry was performed on the histological sections to determine the epithelial content of the gland. Our results indicate that there is a vast heterogeneity of receptor expression in benign prostatic hyperplasia. Expression of ARc ranged from zero to 1312 fmol/gm. tissue (mean +/- SD 265 +/- 290), ARn ranged from zero to 531 fmol/gm. tissue (mean +/- SD 145 +/- 98) and EGFR ranged from zero to 316 fmol/gm. tissue (mean +/- SD 121 +/- 76). A statistically significant association was found between expression of ARn and EGFR, and these were both significantly correlated with the epithelial content of the gland.