Small cell lung cancer in Norway. Should more patients have been offered surgical therapy?

OBJECTIVE: The final outcome of patients with small cell lung cancer (SCLC) is poor with an overall 5-year survival rate of less than 10%. Therefore, the question of surgery in patients with a technically-operable solitary tumor has been raised. The purpose of this study was to identify the proportion of patients with operable SCLC and to assess the prognosis of different treatment strategies. For patients who were operated, we compared the resection specimens from patients with more than 5-year survival with those with shorter survival to see whether the specimens belonged to different subclasses of SCLC. METHODS: In Norway all clinical and pathologic departments submit reports on cancer patients to the Cancer Registry. The Registry also has a law-regulated authority to collect supplemental information regarding diagnosis, treatment and outcome for all cancer patients from the hospitals in charge. All reports on patients diagnosed as having SCLC in limited disease or unknown stage during the time interval 1993-1999 were reviewed. Patients with a T2-tumor, in whom a pneumonectomy would have to be performed, were classified as potentially operable. Five-year relative survival was calculated for patients diagnosed in 1993-1997. RESULTS: During the actual period 2442 individuals with SCLC were identified. The majority was treated with conventional chemotherapy or concurrent chemoradiotherapy while 38 underwent surgical therapy. Following reclassification of 697 patients reported to have limited disease or unknown stage 180 were judged to be in stage I. In addition to the 38 resected patients 14 were considered fit for surgery technically and medically while 97 were found to be potentially operable treatment modalities apart from surgery yielded a 5-year survival rate <7%. For stage I (N=96) the rate was 11.3% in conventionally treated patients compared to 44.9% for those who underwent surgical resection. By pathological review of surgical specimens a diagnosis of SCLC was confirmed in all patients treated by surgery in the groups with long and short survival. CONCLUSION: This investigation demonstrates that patients with SCLC having a peripherally located tumor should be referred to surgery, as long time survival is far better than for conventionally treated patients.     

Fractures of the neuro-cranium: sensitivity and specificity of post-mortem computed tomography compared with autopsy

Post–mortem computed tomography (PMCT) is a routine tool in many forensic pathology departments as it is fast and non-destructive and allows less gruesome visualization than photographs, and the images are indefinitely storable. Several studies investigated congruence between PMCT and autopsy for skull fracture but registered only the presence or absence of fracture systems. The objective of this study was to determine location-specific sensitivity and specificity of PMCT for individual fracture lines in blunt force head trauma. Accurate 3D models based on PMCT data with all fracture lines visible are important for future studies on fractures, applying finite element analysis (FEA). We retrospectively sampled adult cases from 2013 to 2019 with skull fracture mentioned in the autopsy report. PMCT was on a Siemens 64-slice scanner and autopsy according to international guidelines. The location and direction of all fracture lines at autopsy and at de novo interpretation of scans were registered and compared. Ninety-nine cases with 4809 individual findings were included. Age ranged from 18 to 100 years. The overall sensitivity was 0.58, and specificity was 0.91. For individual locations, sensitivity ranged from 0.24 to 0.85, and specificity ranged from 0.73 to 1.00. Intra-observer agreement was 0.74, and inter-observer agreement ranged from 0.43 to 0.58. In conclusion, PMCT is suited for detection of fracture systems, but not for detection of all individual fracture lines. Our results differed from the existing literature due to the methodological choices of registering individual fracture lines. Future studies utilising FEA must supplement PMCT with autopsy data.

     

Prevalence of conditions potentially associated with lower urinary tract symptoms in men

OBJECTIVE: To estimate the frequency of conditions associated with lower urinary tract symptoms (LUTS, typically included when assessing benign prostatic hyperplasia, BPH), as other causes of LUTS should be excluded when diagnosing BPH, using data from the Olmsted County Study of Urinary Symptoms and Health Status among Men. SUBJECTS AND METHODS: During 1989-91, Caucasian men aged 40-79 years were randomly selected from the Olmsted County population. Before contact, eligibility was determined by reviewing the community medical records. Baseline exclusion criteria included comorbid pre-existing conditions or treatments, e.g. prostate, bladder or lower back surgery, bladder neck contracture or cancer, diabetes with lower extremity amputation, and neurological diseases, including Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, tabes dorsalis and stroke. Men with these conditions were excluded from the Olmsted County Study at baseline, because these conditions are potentially associated with LUTS. RESULTS: Of the 5100 randomly sampled men, 13.4% met at least one of the pre-existing exclusion criteria. Individually, the frequency of exclusions was 7.8% for prostate cancer or surgery, 4.8% for back surgery, 1.3% for bladder surgery and 1.4% for neurological conditions. All other conditions represented <1.0% of the study exclusions. Older men were more likely to meet at least one of the exclusion criteria, with men in their fifth to eighth decade having a total exclusion frequency of 1.4%, 5.4%, 8.5% and 32.8%, respectively. The most common reason for men in their fifth decade to be excluded was lower back surgery (0.9%), whereas the most common reason in the eighth was prostate surgery (21.8%). CONCLUSIONS: In men, conditions that may contribute to LUTS, other than BPH, are prevalent in the community and increase in frequency with age. It is important that other conditions associated with LUTS be excluded before a definitive diagnosis of BPH. Any oversight in this initial evaluation can potentially result in misclassification bias, misdiagnosis and incorrect treatment of patients.     

Bile reflux in benign and malignant barrett’s esophagus: Effect of medical acid suppression and nissen fundoplication

Bile reflux has been implicated in the pathogenesis and malignant degeneration of Barrett’s esophagus, but clinical studies in patients with adenocareinoma arising in Barrett’s esophagus are lacking. Ambulatory esophageal measurement of acid and bile reflux was performed with the previously validated fiberoptic bilirubin monitoring system (Bilitec) combined with a pH probe in 20 asymptomatie volunteers, 19 patients with gastroesophageal reflux disease (GERD) but no mucosal injury, 45 patients with GERD and erosive esophagitis, 33 patients with GERD and Barrett’s esophagus, and 14 patients with early adenocarcinoma arising in Barrett’s esophagus. Repeat studies were done in 15 patients under medical acid suppression and 16 patients after laparoscopie Nissen fundoplication. The mean esophageal bile exposure time showed an exponential increase from GERD patients without esophagitis to those with erosive esophagitis and benign Barrett’s esophagus and was highest in patients with early carcinoma in Barrett’s esophagus (P <0.01). Pathologic esophageal bile exposure was documented in 18 (54.5%) of 33 patients with benign Barrett’s esophagus and 11 (78.6%) of 14 patients with early adenoearcinoma in Barrett’s esophagus. Nissen fundoplieation but not medical acid suppression resulted in complete suppression of bile reflux. Bile reflux into the esophagus is particularly prevalent in patients with Barrett’s esophagus and early cancer. Bile reflux into the esophagus can be completely suppressed by Nissen fundoplication but not medical acid suppression alone. (J GASTROINTEST SURG 1998;2:333-341.) Presented at the Thirty-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997     

Presumed circle area ratio of the prostate in a community‐based group of men

OBJECTIVE

To determine the normal values for the presumed circle area ratio (PCAR) in a group of community‐based men, and to determine whether PCAR is associated with specific urological outcomes.

PATIENTS AND METHODS

The study was a cross‐sectional analysis among 328 Caucasian men (94% participation) residing in Olmsted County, Minnesota, USA. The PCAR was measured during prostatic ultrasonography. Lower urinary tract symptoms (LUTS) were measured using the American Urologic Association Symptom Index. The peak urinary flow rate was measured by a uroflowmeter, and the postvoid residual volume (PVR) was assessed using the BladderScan^TM BVM 6500 (Verathon, Bothell, WA, USA). Correlations between PCAR and presence of LUTS, peak urinary flow rate, and PVR were determined using Spearman correlation coefficients. Unadjusted and adjusted odds ratios (ORs) were calculated using logistic regression to determine the associations between PCAR thresholds and categorical urological outcomes.

RESULTS

The median (interquartile range) PCAR was 0.85 (0.81–0.88). After adjusting for age and total prostate volume, men who had PCARs of >0.90 were more likely to have elevated overall and obstructive symptom scores (OR 2.95, 95% confidence interval 1.39–6.25, and 3.47, 1.63–7.39, respectively).

CONCLUSION

PCAR might add further information beyond total prostate volume when predicting the development of obstructive LUTS.     

Good performance of a titanium femoral component in cementless hip arthroplasty in younger patients

We performed 97 uncemented primary total hip arthroplasties in 80 patients having an average age of 50 years. The femoral implant was a titanium stem with a proximal circumferential plasma spray-coating. Three different acetabular components were used: a threaded and partly porous-coated design in 70% of the cases. The average follow-up period was 8 years. 1 stem was revised 9 years after insertion due to a comminuted fracture of the proximal femur, 1 stem was revised 9 years after insertion due to a deep infection. No stem revisions were due to aseptic loosening. 1 femora had areas of distal osteolysis associated with a deep infection, but no signs of proximal loosening. 3 femora had areas of minor proximal osteolysis. 16 acetabular components (14 threaded) had been revised in 13 patients. The average Harris hip score was 91 points at the latest follow-up We conclude that the uncemented titanium femoral component with a circumferential porous coating performed well in these patients, most of whom were young. As reported previously, aseptic loosening of threaded acetabular components was common.     

Unusually extensive head trauma in a hydraulic elevator accident: post-mortem MSCT findings, autopsy results and scene reconstruction

Accidental or intentional falls from a height are a form of blunt trauma and occur frequently in forensic medicine. Reports describing elevator accidents as a small subcategory of falls from heights are rare in the medical literature and no report on injury patterns or scene reconstruction of such an accident was found. A case of an accident in a hydraulic elevator with a man falling 3m was examined using post-mortem multi-slice computed tomography (MSCT) and autopsy. The man suffered an unusually extensive trauma and died at the scene. Post-mortem MSCT examination showed a comminute fracture of the skull, the right femur and the first lumbar vertebra. Severe lacerations of the brain with epidural, subdural and subarachnoidal haemorrhages over both hemispheres were diagnosed. Autopsy confirmed these findings. To reconstruct the accident we used radiological and autopsy results as well as findings at the scene.     

Dual blockade of the renin-angiotensin system in type 1 patients with diabetic nephropathy.

BACKGROUND: Albuminuria and hypertension are predictors of poor renal and cardiovascular outcome in patients with diabetes. Approximately 30% of type 1 patients with diabetic nephropathy (DN) have albuminuria >1 g/day, and blood pressure >135 and/or >85 mmHg despite antihypertensive therapy with recommended doses of ACE inhibitor (ACEI) and diuretics. We tested the effect of dual blockade of the renin-angiotensin system (RAS) in these patients. METHODS: We performed a randomised double blind crossover trial with 2 months treatment with Irbesartan 300 mg o.d. and placebo added on top of previous antihypertensive treatment. We included 21 type 1 patients with DN responding insufficiently to ACEI and diuretics, as defined above. At the end of each treatment period, albuminuria, 24-h blood pressure and glomerular filtration rate (GFR) were measured. RESULTS: Addition of 300 mg Irbesartan to the patients' usual antihypertensive therapy induced a mean reduction in albuminuria of 37% (95% CI 20-49, P<0.001); from 1574 mg/24 h (95% CI 1162-2132) to 996 mg/24 h (95% CI 699-1419), a reduction in 24-h blood pressure of 8 mmHg systolic (95% CI -2 to 18) and 5 mmHg diastolic (95% CI 1-9) (P=0.11 and 0.01, respectively) (from placebo, mean (SE) 146 (4)/80 (2) mmHg). GFR remained unchanged. Serum potassium increased (mean 4.3 to 4.6 mmol/l, P=0.02). Intervention to reduce serum potassium was needed in two patients with GFR <35 ml/min/1.73 m(2). Otherwise the dual blockade with Irbesartan was safe and well tolerated. CONCLUSIONS: Dual blockade of the RAS may offer additional renal and cardiovascular protection in type 1 patients with DN responding insufficiently to conventional antihypertensive therapy, including recommended doses of ACEI and diuretics.