Effects of FRAX Model Calibration on Intervention Rates: A Simulation Study

The WHO fracture risk assessment tool (FRAX^®) estimates an individual’s 10-yr major osteoporotic and hip fracture probabilities using a tool customized to the fracture epidemiology of a specific population. Incorrect model calibration could therefore affect performance of the model in clinical practice. The current analysis was undertaken to explore how simulated miscalibration in the FRAX^® tool would affect the numbers of individuals meeting specific intervention criteria (10-yr major osteoporotic fracture probability ≥20%, 10-yr hip fracture probability ≥3%). The study cohort included 36,730 women and 2873 men aged 50 yr and older with FRAX^® probability estimates using femoral neck bone mineral density. We simulated relative miscalibration error in 10% increments from −50% to +50% relative to a correctly calibrated FRAX^® model. We found that small changes in model calibration (even on the order of 10%) had large effects on the number of individuals qualifying for treatment. There was a steep gradient in the relationship between relative change in calibration and relative change in intervention rates: for every 1% change in calibration, there was a 2.5% change in intervention rates for women and 4.1% for men. For hip fracture probability, the gradient of the relationship was closer to unity. These results highlight the importance of FRAX^® model calibration, and speak to the importance of using high-quality fracture epidemiology in constructing FRAX^® tools.     

Survival in familial and non-familial breast cancer by age and stage at diagnosis

We aimed to compare the survival in familial and sporadic breast cancer (BC) patients who were diagnosed at an identical age and TNM stage. The Nationwide Swedish Family-Cancer Database including all Swedes born after 1931 and their biological parents, totalling >14.7 million individuals, was used. Hazard ratios (HRs) were calculated for women with BC in a first-degree relative (FDR) versus BC patients without positive family history. There was no difference in survival of familial BC patients who were diagnosed at higher TNM status or older age (>40) compared to sporadic BC cases diagnosed at the same late TNM stage. Young BC patients (age <40) in early stages had the worst survival when their FDR was diagnosed with single (HR: 2.0–3.7) or multiple (HR: 2.4–7.1) BC at any age. We concluded that there is no difference in survival of familial and non-familial BC patients who are diagnosed at higher TNM status or older ages (>40). Young familial BC patients (age <40), diagnosed at early stage, have the poorer survival compared to sporadic cases. Our results urge the need for identifying the underling genetic component for such a difference in survival of familial BC.     

子宫颈上皮内瘤变患者CD4＋、CD8＋T细胞表达与高危型HPV感染的关系

目的探讨不同级别宫颈上皮内瘤变（CIN）组织中CD4＋、CD8＋T细胞表达及与高危型人乳头瘤病毒（HR-HPV）的关系。方法对2005年1月至2008年8月在珠海市人民医院阴道镜下宫颈活检诊断为CIN并行宫颈锥切治疗的72例患者的资料进行分析,采用杂交捕获第二代方法（HC-Ⅱ）检测高危型HPVDNA含量;采用免疫组化检测30例CIN1、43例CIN2/3及10例正常宫颈组织中CD4＋、CD8＋T细胞的表达。结果 CIN2/3组的HR-HPV感染率显著高于CIN1组（P〈0.05）,CIN组HR-HPV感染率高于慢性宫颈炎组（P〈0.01）。慢性宫颈炎组、CIN1组和CIN2/3组CD4＋T细胞表达率分别为60.0%、43.3%和33.3%,CD8＋T细胞的表达率分别为70.0%、46.7%和31.0%;CD4＋、CD8＋T细胞在CIN1组及CIN2/3组的表达显著低于慢性宫颈炎组（P〈0.05）。结论 CD4＋、CD8＋T细胞表达下调可能促进宫颈HR-HPV感染的发生,并对宫颈癌前病变的发生、发展起一定的作用。     

Vol vasculaire secondaire à la création d’un shunt artérioveineux pour hémodialyse,information du patient et responsabilité du néphrologue

Although responsibility is a fundamental determinant in medical practice, physicians are generally unfamiliar with its principles. The same is true for disclosure requirements and requests for compensation in the event of physical injury. We report on a representative survey of iatrogenic complications that may arise after the implementation of vascular access for haemodialysis and that illustrate's the physician's responsibility and obligation to inform the patient. Vascular access steal syndrome is a serious complication of arteriovenous fistulas, and physicians may not be sufficiently aware of the likelihood of its occurrence. Diabetes (via medial calcific sclerosis) and placement in the brachial artery (with excessively high flow rates) are the main risk factors. The precariousness of vascular status in dialysis patients threatens to increase the incidence of this complication. The therapeutic challenge is to resolve ischemic events while maintaining vascular access. The presence of gangrene of the fingers is a formal indication for surgery. The borderline between therapeutic risk (the risk inherent in a medical procedure and which cannot be controlled) and liability for injury is blurred. The French Patient's Rights Act (voted on March 4th, 2002) emphasizes the physician's duty to inform the patient of treatment-associated risks and the fact that the physician now bears the burden of proof. We suggest that a patient information sheet on the benefits and risks of vascular access should be published on the French Society of Nephrology, Dialysis and Transplantation's website.     

Perineal approach to vascular anatomy during transobturator cystocele repair

Objective  To evaluate the risk of vascular injury during transobturator approach of cystocele repair.
Design  Dissection of the obturator area by perineal approach was performed after placement of mesh needles used for cystocele mesh repair.
Setting  Surgery school of Paris.
Population or sample  Twenty obturator regions in ten fresh female cadavers.
Methods  Transperineal dissection of the obturator area was conducted in ten fresh female anatomic subjects after inserting anterior Prolift^® needles.
Main outcome measures  The vascular anatomy of the obturator region was mapped. Distances between needles and vascular structures of the obturator area were measured three times and averaged for each side.
Results  The anterior cannula-equipped needle perforated the gracilis and the adductor brevis muscles. The mean (SD) distance to the anterior obturator vessels was 21.2 (1.6) mm on the right side and 20.4 (1.5) mm on the left. The posterior needle perforated the adductor magnus. Its distance to the posterior division of the obturator vessels was 1.8 (1.0) mm on the right side and 1.1 (0.9) mm on the left.
Conclusions  During mesh cystocele repair by transobturator approach, the posterior obturator vessels division seems at risk of injury during the posterior needle insertion.