Mammographic screening: case-control studies.

BACKGROUND: The case-control design can be used to evaluate the benefit of cancer screening programmes. MATERIALS AND METHODS: This paper outlines the main methodological features of the case-control design in this context, and indicates some potential biases. It also reviews the existing case-control literature on mammographic screening. RESULTS: Case-control studies consistently indicate a reduction of approximately 50% in breast cancer mortality associated with mammography. This result indicates greater benefit than shown in randomised trials; however, one should recognise that trials indicate effectiveness whereas case-control studies indicate efficacy. The two types of evidence are broadly compatible when one allows for screening non-compliance and contamination in the randomised trials. CONCLUSIONS: The case-control evidence supports and is consistent with the findings of randomised trials of mammography. Effectiveness estimates from trials indicate the benefit of screening to the population as a whole, and are pertinent to the public policy debate as to the value of offering screening. In contrast, case-control studies indicate benefit to actual screening participants. As such, case-control estimates of efficacy are appropriate for individual decision-making by women about their use of mammography when it is potentially available to them.     

Adaptive group sequential design for phase II clinical trials: A Bayesian decision theoretic approach

Bayesian decision theoretic approaches (BDTAs) have been widely studied in the literature as tools for designing and conducting phase II clinical trials. However, full Bayesian approaches that consider multiple endpoints are lacking. Since the monitoring of toxicity is a major goal of phase II trials, we propose an adaptive group sequential design using a BDTA, which characterizes efficacy and toxicity as correlated bivariate binary endpoints. We allow trade‐off between the two endpoints. Interim evaluations are conducted group sequentially, but the number of interim looks and the size of each group are chosen adaptively based on current observations. We utilize a loss function consisting of two components: the loss associated with accruing, treating, and monitoring patients, and the loss associated with making incorrect decisions. The performance of our Bayesian modeling, and the operating characteristics of decision rules under a wide range of loss function parameters are evaluated using seven scenarios in a simulation study. Our method is illustrated in the context of a single‐arm phase II trial of bevacizumab, gemcitabine, and oxaliplatin in patients with metastatic pancreatic adenocarcinoma. Copyright © 2009 John Wiley & Sons, Ltd.     

Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial.

BACKGROUND: We tested whether transcranial magnetic stimulation (TMS) over the left dorsolateral prefrontal cortex (DLPFC) is effective and safe in the acute treatment of major depression. METHODS: In a double-blind, multisite study, 301 medication-free patients with major depression who had not benefited from prior treatment were randomized to active (n = 155) or sham TMS (n = 146) conditions. Sessions were conducted five times per week with TMS at 10 pulses/sec, 120% of motor threshold, 3000 pulses/session, for 4-6 weeks. Primary outcome was the symptom score change as assessed at week 4 with the Montgomery-Asberg Depression Rating Scale (MADRS). Secondary outcomes included changes on the 17- and 24-item Hamilton Depression Rating Scale (HAMD) and response and remission rates with the MADRS and HAMD. RESULTS: Active TMS was significantly superior to sham TMS on the MADRS at week 4 (with a post hoc correction for inequality in symptom severity between groups at baseline), as well as on the HAMD17 and HAMD24 scales at weeks 4 and 6. Response rates were significantly higher with active TMS on all three scales at weeks 4 and 6. Remission rates were approximately twofold higher with active TMS at week 6 and significant on the MADRS and HAMD24 scales (but not the HAMD17 scale). Active TMS was well tolerated with a low dropout rate for adverse events (4.5%) that were generally mild and limited to transient scalp discomfort or pain. CONCLUSIONS: Transcranial magnetic stimulation was effective in treating major depression with minimal side effects reported. It offers clinicians a novel alternative for the treatment of this disorder.     

弹拨手法治疗腰椎间盘突出症臀后部肌痉挛患者的疗效观察

患者,男,22岁。主因双手近端指间关节对称性肿胀1年于2006年10月20日至我科门诊就诊。患者1年前开始出现双手多个近端指间关节肿胀,无关节痛,无关节活动受限。曾至我院骨科门诊,怀疑为“类风湿性关节炎”,口服滑膜炎冲剂、非甾体类消炎止痛药物,症状持续不缓解。现仍有双手食、中、无名指近端指间关节扁梭形肿胀,中指、无名指明显。肿胀局部无压痛,各关节活动度正常。患者无晨僵,无发热及咽痛。既往患者有下意识掰动手指弄出声响的习惯。查体:一般情况良好。双手食、中、无名指近端指间关节梭形肿胀,关节两侧皮肤增厚,未见苔藓样变(图1 a)。…     

骨巨细胞瘤继发动脉瘤样骨囊肿的影像诊断

目的提高骨巨细胞瘤（GCT）继发动脉瘤样骨囊肿（ABC）的认识和影像诊断水平。方法搜集经手术病理证实的12例GCT继发ABC的X线、CT、MRI和病理学资料，分析和总结其影像征象。结果12例中6例病变发生于长管状骨，6例发生于盆骨。12例病变X线均表现为囊状膨胀性溶骨性骨破坏，10例呈偏心性破坏，2例为中心性破坏；4例病灶内出现骨性分隔，6例骨皮质中断，4例出现软组织肿块，有明显硬化边者2例。10例行MR平扫和增强检查，均呈多囊的囊实性膨胀性肿块，8例为边缘性实性结节，2例为实性基础上的广泛囊变，全部患者均可见多个液一液平面，7例出现软组织肿块；1例肿块内可见局灶性含铁血黄素沉着。8例行螺旋cT平扫、增强、CT血管成像（CTA）和三维（3D）多平面重组（MPR），病变显示为囊实性肿块，骨皮质破裂并形成软组织肿块5例，6例肿块内出现液．液平面，全部肿块实质性部分和囊壁明显强化，囊性部分不强化，3例肿块内可见增粗迂曲的供血动脉，未发现动静脉畸形。12例手术所见和术后病理显示肿块均由多发含血的囊腔和实性部分组成，病理诊断结果均为GCT伴发ABC，其中Ⅱ级GCTl0例，Ⅲ级2例。结论GCT伴发ABC并不少见，充分理解其病理组织学基础，并选择恰当的影像检查方法（X线＋MRI或X线＋CT）对其正确诊断非常重要。     

提高中医临床疗效的科学学检讨(连载三)

中医学的生命力在于临床疗效 ,社会对于中医学的需要也在于临床疗效。提高中医临床疗效的科学学研究 ,要以中医基础理论为依据 ,以理、法、方、药一脉相承的辨证论治为前提。造成中医临床疗效下降的问题在于“三个脱节” ,即中医学与自身文化基础脱节 ,中医临床与辨证论治脱节 ,中药与中医临床脱节。中医学正处于行将消亡的边缘 ,也处在新的突破的前夜。实事求是地进行科学、历史的反思 ,中医学完全有可能走出百年困惑 ,得到振兴和发展。     

高危人群微量乙肝疫苗免疫效果动态观察

采用微量乙肝疫苗（总剂量为６μｇ）对ＨＢＶ高流行区居民进行随机对照研究，免疫Ⅰ组（疫苗＜８℃保存）Ｔ１２抗体阳转率和保护率分别为９０．８％和８７．０％，和对照组相比，差异显著（Ｐ均＜０．００１）；和常规剂量（总剂量９０μｇ）比，其抗体阳转率和保护率基本相同。提示ＨＢＶ高流行区可用微量乙肝苗代替常量乙肝苗进行预防接种。免疫Ⅰ组和免疫Ⅱ组（乙肝疫苗室温保藏２８℃±）免疫效果和保护率基本相同，认为室温条件下乙肝疫苗６个月内效价不变。     

Assessment of MRI criteria for abnormal brain MRI in acute monosymptomatic optic neuritis. Comparison to findings in healthy persons

To evaluate various MRI criteria we studied a representative group of 149 consecutive patients below 50 years with acute monosymptomatic optic neuritis (AMON), a frequent first manifestation of multiple sclerosis (MS). The presence, number, size, and localization of areas of increased signal (AIS) on T₂-weighted brain MRIs obtained at 1.5 T were described and compared with findings in 71 healthy persons aged 21–50 years without diabetes, cerebrovascular or neurologic diseases. MRI was performed within 2–145 days, median 16 days from onset of AMON and showed from 0 to 26 AIS, sized 2–30 mm, in 79 of 149 (53%) patients compared to 0–18 AIS, sized 2–12 mm, in 31 of 71 (44%) healthy persons. In patients, AIS were significantly more frequent in women than in men (χ² = 4.67, p > 0.05). Periventricular AIS were revealed in 70 (47%) patients and in 14 (20%) healthy persons. Subcortical AIS were present in 5 (3%) patients and in 18 (25%) healthy persons. Infratentorial AIS were present in only 3 (2%) patients. The sensitivity and specificity of previously proposed diagnostic MRI criteria for MS were unsatisfactory in our group of patients and have previously only been validated in definite MS. We therefore constructed and tested four new sets of criteria. The set with the best relation between sensitivity (e.g. 41%) and specificity (e.g. 93%) was the following: presence of two or more AIS, of which at least one is periventricular or infratentorial, combined with the absence of subcortical AIS. These criteria are recommended for patients with AMON and might be used in other patients with possible or probable MS.