Does a high Mandard score really define a poor response to chemotherapy in oesophageal adenocarcinoma?

Background A high Mandard score implies a non-response to chemotherapy in oesophageal adenocarcinoma. However, some patients exhibit tumour volume reduction and a nodal response despite a high score. This study examines survival and recurrence patterns in these patients.Methods Clinicopathological factors were analysed using multivariable Cox regression assessing time to death and recurrence. Computed tomography-estimated tumour volume change was examined in a subgroup of consecutive patients.Results Five hundred and fifty-five patients were included. Median survival was 55 months (Mandard 1–3) and 21 months (Mandard 4 and 5). In the Mandard 4 and 5 group (332 patients), comparison between complete nodal responders and persistent nodal disease showed improved survival (90 vs 18 months), recurrence rates (locoregional 14.75 vs 28.74%, systemic 24.59 vs 48.42%) and circumferential resection margin positivity (22.95 vs 68.11%). Complete nodal response independently predicted improved survival (hazard ratio 0.34 (0.16–0.74). Post-chemotherapy tumour volume reduction was greater in patients with a complete nodal response (−16.3 vs −7.7 cm³, p = 0.033) with no significant difference between Mandard groups.Conclusion Patients with a complete nodal response to chemotherapy have significantly improved outcomes despite a poor Mandard score. High Mandard score does not correspond with a non-response to chemotherapy in all cases and patients with nodal downstaging may still benefit from adjuvant chemotherapy.Subject terms: Oesophageal cancer, Surgical oncology     

The use of cadaver models to diagnose rib fractures: A pilot study

Background

In the emergency department, rib fractures are a common finding in patients who sustain chest trauma. Rib fractures may be a sign of significant, underlying pathology, especially in the elderly patients where rib fractures are associated with significant morbidity and mortality. To date, no studies have evaluated the ability of ultrasound to detect rib fractures using cadaver models and subsequently use this model as a teaching tool.

The probability of treatment success,failure and duration—what can be learned from empirical data to support decision making in clinical practice?

Empirical methods have been found to be superior to clinical judgment for the purpose of correctly identifying patients at risk for treatment failure and, hence, to enhance psychotherapy outcomes. The development and evaluation of an empirical approach aimed at supporting clinical decisions during the course of psychotherapy is described. The tool provides predictions based on a patient‐specific sampling strategy called the nearest neighbors method and on growth curve approaches to model an expected treatment course for each patient. Using session‐by‐session data from an outpatient center in the US (N = 4365), this new empirically derived decision model was evaluated and compared with a clinically based approach loosely based on an adaptation of clinically significant change concepts. The empirically derived decision system was found to be superior to the rational clinically based one in almost all measures of prediction accuracy, indicating its potential to identify patients at risk for treatment failure. Copyright © 2006 John Wiley & Sons, Ltd.     

Venous valves in subclavian and internal jugular veins. Frequency, position, and structure in 100 autopsy cases

Valves in the subclavian and internal jugular veins were studied in 100 autopsy cases (52 men and 48 women; range, 18 to 91 years old; mean, 67 years). In 87 cases, valves were present in all 4 veins, and in 13 cases, valves anatomically were absent from 16 veins, 9 of which were the left internal jugular vein. The average distance from the valve to the junction with the innominate vein was 1.7 cm for the subclavian vein and 0.3 cm for the internal jugular vein. Cuspid height averaged 0.9 cm. Valves were bicuspid in 347 (90%) and unicuspid in 39 (10%); unicuspid valves were more common in the internal jugular vein than in the subclavian vein. Catheter-induced trauma was observed in 4 cases and implied in 4 more. These findings may have important implications concerning the failure, in some cases, of closed-chest cardiac resuscitation to maintain forward blood flow at adequate pressure.     

Decreased Risk of Renal Allograft Thrombosis Associated With Interleukin-2 Receptor Antagonists: A Report of the NAPRTCS

Graft thrombosis is the most common cause of first year graft failure in pediatric renal transplantation. The North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) database was analyzed for cases of graft failure due to thrombosis among patients transplanted from 1998 to 2004. The impact of interleukin-2 (IL-2) receptor antagonists as induction therapy was determined. There were a total of 51 graft failures due to thrombosis among the 2750 reported renal transplants (1.85%) (95% CI (1.39%, 2.41%)). This represents the most common cause of graft loss during the first year post-transplant accounting for 35% of first year losses and 18% of all graft losses. The incidence of thrombosis among patients who received IL-2 receptor antibodies was 1.07% (12/1126) compared to 2.40% (39/1624) among patients who did not (OR 0.44, 95% CI 0.23, 0.84, p = 0.014). Use of IL-2 receptor blockade was the only significant prognostic factor in a multivariate model with previously identified risk factors. Analysis of NAPRTCS data found that the use of IL-2 receptor antibodies as induction therapy is associated with a significantly decreased risk of graft failure due to thrombosis. This provocative finding requires further investigation to determine whether thrombotic failure can be decreased by this therapeutic strategy.