Short-term prognosis of pulmonary embolism

Risk stratification tools that accurately quantify the prognosis of patients with pulmonary embolism (PE) may be useful in guiding medical decision making. Prospective studies demonstrated that clinical factors, echocardiographic right ventricular dysfunction, and cardiac biomarkers (troponins, brain natriuretic peptides) are independent predictors of short-term mortality in patients with PE. The presence of systemic hypotension or shock carries the highest risk of death, and thrombolysis is usually indicated. Among hemodynamically stable patients, clinical prognostic models, echocardiography, and biomarkers accurately identify low-risk patients with PE who are potential candidates for less costly outpatient care. However, the practical use of these prognostic measures is currently limited by the lack of studies demonstrating a positive impact on patient care. The benefit of risk stratification strategies based on clinical prognostic models, echocardiography, and cardiac biomarkers should be demonstrated in prospective studies before their implementation as decision aid to guide initial treatment can be recommended.

Solar urticaria successfully treated with intravenous immunoglobulin

Idiopathic solar urticaria (SU) is a rare, debilitating photodermatosis, which may be difficult to treat. First-line treatment with antihistamines is effective in mild cases, but remission after phototherapeutic induction of tolerance is often short-lived. Other treatment options include plasma exchange, photopheresis and cyclosporin. We present two cases of severe, idiopathic SU, which were resistant to conventional treatment. Both patients achieved remission after administration of intravenous immunoglobulin (IVIg) and have remained in remission at 13 months and 4 years, respectively. There are only two case reports of successful treatment of solar urticaria with IVIg. In our experience IVIg given at a total dose of 2 g/kg over several 5-day courses about a month apart is an effective treatment option for severe idiopathic SU. It is also generally safe, even if certainly subject to significant theoretical risks, such as induction of viral infection or anaphylaxis.

Mechanisms of glucose intolerance in cystic fibrosis

AIMS

Although cystic fibrosis-related diabetes (CFRD), a poor prognostic factor in cystic fibrosis (CF), is characterized by insulinopenia, the role of insulin resistance is unclear. Using a prospective study design, we measured insulin resistance, pancreatic beta-cell function and correlated glycaemic status with clinical parameters.

METHODS

Oral glucose tolerance test was performed in 60 stable adult CF patients. Insulin sensitivity and beta-cell function were measured using the homeostatic model assessment (HOMA2), Stumvoll and oral glucose insulin sensitivity (OGIS) indices.

RESULTS

Forty-two (70%) had normal glucose tolerance (NGT), 10 (17%) impaired glucose tolerance (IGT) and eight (13%) CFRD. There was no difference in insulin sensitivity among the three groups (HOMA2: NGT 280, IGT 250, CFRD 339, P = 0.42; Stumvoll: NGT 0.128, IGT 0.126, CFRD 0.129, P = 0.76; and OGIS: NGT 515, IGT 472, CFRD 472, P = 0.12). Pancreatic beta-cell function (CFRD 50% vs. NGT 67%; P < 0.05) and first-phase insulin secretion were reduced in CFRD (250 vs. NGT 509; P = 0.004). First-phase insulin secretion was inversely correlated with 1-h (r = -0.74; P < 0.0001) and 2-h glucose levels (r = -0.34; P < 0.05). There was no difference in body mass index or poor lung function (forced expiratory volume in 1 s: CFRD 54% vs. NGT 65%; P = 0.43). However, there were more hospital admissions in the CFRD group (three vs. NGT one per patient per year; P < 0.05).

CONCLUSIONS

CFRD is characterized by qualitative and quantitative defects in insulin secretion, but not insulin resistance, and is associated with increased hospital admissions for pulmonary exacerbations.

A single-center study of the utility of squamous cell carcinoma antigen (SCCAg) levels in epidermoid carcinoma of the anal canal and margin (ECACM) treated with chemoradiation (CRT)

4117

Background: SCCAg is a tumour marker expressed by ECACM, measured by microparticle enzyme immunoassay; normal range 0–150ng/dl. Methods: This retrospective study examined the role of SCCAg in staging and prediction of recurrence in 195 patients (pts); 76 m:119 f with ECACM treated 1997–2007. All 195 were treated with CRT- (50.4Gy in 28 fractions of 1.8 Gy with 5-fluorouracil (5-FU) + mitomycin (MMC). Radiotherapy comprised the schedule of the UK Anal cancer Trial (ACT II). Variations included 5FU and cisplat, and capecitabine. 30 had neo-adjuvant chemotherapy followed by CRT and 3 pts had planned surgery followed by CRT. Median follow up was 36 months (range 1 - 168). Median age was 61 years (range 30 -91). In 149 pts with SCCAg samples taken prior to CRT, 107 had one or more samples taken at follow up at 3 - 6 monthly intervals. Clinical stage at diagnosis- Tx (6) T1 (28), T2 (80), T3 (65), T4 (16), N0 (126), N+ (66) Nx (3). Results: Mean baseline SCCAg by cT and cN stage were: T1 93 (ng/dl), T2 300, T3 607, T4 882, N0 376, N+ 529 (correlation coeff: T: 0.47, N: 0.33, both p< 0.001). 135 patients had baseline SCCAg with a documented response on completion of CRT. The mean baseline SCCAg for pts achieving CR was 408 and non CR was 513 (p = 0.13). Sensitivity of baseline SCCAg to predict relapse was 0.56 (specificity 0.4). Sensitivity of two consecutive elevated SCC levels during the follow up period in patients who achieved a CR to predict for relapse was 0.56 and specificity 0.83. The positive likelihood ratio was 3.3 (1.8 - 6.1) and the negative was 0.53 (0.3 - 0.9). Conclusions: There is a correlation between T and N stage and baseline SCC. In follow-up, a sustained rise in SCCAg increases the odds of relapse three-fold. We recommend SCCAg measurement in the first year after CRT.

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Studies on replacement and suppressive dosages of 1-thyroxine

Serum thyrotropin (TSH) levels were studied in 55 hypothyroid patients in order to determine adequate replacement and suppression dosages of 1-thyroxine (T4). In accordance with previous reports it was found that most patients had normal TSH levels and were clinically euthyroid at daily doses of 0.10-0.15 mg T4. None of the patients required a dose exceeding 0.20 mg. When the TSH levels normalized, serum thyroxine and serum triiodothyronine also fell to levels within their normal ranges. The effectiveness of various doses of T4 in suppressing the temporary rise in serum TSH concentration normally induced by thyrotropin-releasing hormone was examined in 57 patients treated with T4 for atoxic goitre or after subtotal surgical removal of such a goitre. The rise in TSH was not usually inhibited by a T4 dose of less than 0.20 mg, a finding which at least theoretically has implications for the adequate suppressive dose of T4.

Development of a nasal cast model to test medicinal nasal devices

Bespak, a division of Consort Medical plc, and Queen's University Belfast have developed a viable and unique in-vitro testing capability for nasal drug delivery devices. The aim was to evaluate and optimize current and conceptual drug delivery devices by quantifying the deposition of drug in the various distinct regions of the nasal cavity. The development of this test apparatus employed computed tomography (CT) scan data of the human nasal cavity to construct an accurate representation of the human nasal airways. An investigation of suitable materials and manufacturing technologies was required, together with extensive analytical method development. It is possible for this technique to be further developed in an attempt to create a standardized apparatus based on nasal geometry that can be used to compare accurately deposition from drug delivery devices. This paper presents the issues encountered in the development of this test apparatus, including manufacturing and material limitations, investigation and choice of suitable materials, laboratory testing considerations, and the steps required to validate the analytical process.

Further experience of using azathioprine in the treatment of severe atopic dermatitis

Atopic dermatitis (AD) is a common disease. Severe AD has a significant effect on quality of life and is difficult to treat. We have previously reported 10 patients treated with azathioprine over a 7-year period, to good effect. We have now treated 37 patients over 18 years, and report our findings. The aim of the study was to review the efficacy and safety of azathioprine as a long-term treatment for severe atopic eczema. Patients who began treatment between 1987 and 2005 were identified. The dose and number of courses of azathioprine, duration of treatment, treatment response, and adverse events were recorded up to June 2006. In total, 37 patients were treated with azathioprine. Of these, 15 (40.5%) achieved remission in a median period of 5 months (range 4-29). Nine patients had an initial good response but either did not have sufficient clearance to be able to stop azathioprine, or deteriorated while on treatment over a period of 4-27 months; these were considered late failures. One patient showed no response, and five experienced reactions leading to withdrawal of the drug. Our experience with azathioprine for the treatment of severe atopic eczema, is very encouraging.

Early life growth and hemostatic factors: the Barry Caerphilly Growth study

Associations between early life growth trajectories and a range of adult (aged approximately 25 years) hemostatic factors were assessed in the Barry Caerphilly Growth study (N = 517) in South Wales, 1974-1999. Associations of birth weight, birth length, and weight and height velocities during three periods ("immediate": 0-<5 months, "infant": 5 months-<1 year 9 months, and "childhood": 1 year 9 months-5 years) with adult levels of hemostatic factors were assessed. Birth weight was inversely associated with fibrinogen (beta per 1-unit change in z score = -0.08, 95% confidence interval (CI): -0.15, -0.02). Immediate weight velocity was inversely associated with factor VII (beta = -1.88, 95% CI: -3.84, 0.09), factor VIII (beta = -2.58, 95% CI: -4.07, -0.45), and von Willebrand factor antigen (beta = -4.07, 95% CI: -7.25, -0.89). Birth length was inversely associated with fibrinogen (beta = -0.07, 95% CI: -0.14, -0.01). Evidence was weaker for an inverse association of immediate height velocity with factor VIII (beta = -2.16, 95% CI: -4.62, 0.29) and von Willebrand factor antigen (beta = -2.85, 95% CI: -6.52, 0.81). Childhood height velocity was positively associated with D-dimer (ratio of geometric means = 1.11, 95% CI: 1.01, 1.23). Results support the view that the immediate postnatal period may be particularly important, possibly through impaired liver development and/or infection in early life, in determining cardiovascular disease risk.

Immune responses to myelin proteins in Guillain-Barré syndrome

BACKGROUND

Potential target autoantigens in the demyelinating form of Guillain-Barré syndrome (GBS) include the myelin proteins PMP22, P0 and P2.

METHODS

We investigated immunoreactivity to P0, P2 and PMP22 proteins in 37 patients with GBS and 32 healthy controls.

RESULTS

Antibodies to PMP22 or P0 peptides were detected at presentation in only 5 out of 37 patients. In ELISPOT assays, blood mononuclear cells from 15 out of 24 patients with GBS, but none of the control subjects, produced interleukin-10 (IL-10) in response to peptides from proteins P0, P2 or PMP22 (p = 0.0003). The cells from only two patients produced interferon-gamma (IFN gamma). The cells from 11 patients with GBS had increased IL-10 responses to peptides representing sequences from the extracellular domains of PMP22 before intravenous immunoglobulin (IVIg) treatment (p = 0.006). The cells from 11 patients with GBS, including 7 who responded to the extracellular domains of PMP22, had increased IL-10 responses to the intracellular domain of P0 before (p = 0.005) and those from 9 patients after they had been treated with IVIg (p = 0.01).

CONCLUSIONS

Antibodies to P0 and PMP22 protein peptides do occur in GBS but are uncommon. Circulating mononuclear cell IFN gamma responses to P0, P2 and PMP22 myelin protein peptides are rare, but IL-10 responses occur significantly more often than in normal subjects. They might be part of a harmful pathogenetic process or represent a regulatory response.

An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial

BACKGROUND

Schools in many countries undertake programmes for smoking prevention, but systematic reviews have shown mixed evidence of their effectiveness. Most peer-led approaches have been classroom-based, and rigorous assessments are scarce. We assessed the effectiveness of a peer-led intervention that aimed to prevent smoking uptake in secondary schools.

METHODS

We undertook a cluster randomised controlled trial of 10 730 students aged 12-13 years in 59 schools in England and Wales. 29 schools (5372 students) were randomly assigned by stratified block randomisation to the control group to continue their usual smoking education and 30 (5358 students) to the intervention group. The intervention (ASSIST [A Stop Smoking In Schools Trial] programme) consisted of training influential students to act as peer supporters during informal interactions outside the classroom to encourage their peers not to smoke. Follow-up was immediately after the intervention and at 1 and 2 years. Primary outcomes were smoking in the past week in both the school year group and in a group at high risk of regular smoking uptake, which was identified at baseline as occasional, experimental, or ex-smokers. Analysis was by intention to treat. This study is registered, number ISRCTN55572965.

FINDINGS

The odds ratio of being a smoker in intervention compared with control schools was 0.75 (95% CI 0.55-1.01) immediately after the intervention (n=9349 students), 0.77 (0.59-0.99) at 1-year follow-up (n=9147), and 0.85 (0.72-1.01) at 2-year follow-up (n=8756). The corresponding odds ratios for the high-risk group were 0.79 (0.55-1.13 [n=3561]), 0.75 (0.56-0.99 [n=3483]), and 0.85 (0.70-1.02 [n=3294]), respectively. In a three-tier multilevel model with data from all three follow-ups, the odds of being a smoker in intervention compared with control schools was 0.78 (0.64-0.96).

INTERPRETATION

The results suggest that, if implemented on a population basis, the ASSIST intervention could lead to a reduction in adolescent smoking prevalence of public-health importance.

Neuropathic pain: redefinition and a grading system for clinical and research purposes

Pain usually results from activation of nociceptive afferents by actually or potentially tissue-damaging stimuli. Pain may also arise by activity generated within the nervous system without adequate stimulation of its peripheral sensory endings. For this type of pain, the International Association for the Study of Pain introduced the term neuropathic pain, defined as "pain initiated or caused by a primary lesion or dysfunction in the nervous system." While this definition has been useful in distinguishing some characteristics of neuropathic and nociceptive types of pain, it lacks defined boundaries. Since the sensitivity of the nociceptive system is modulated by its adequate activation (e.g., by central sensitization), it has been difficult to distinguish neuropathic dysfunction from physiologic neuroplasticity. We present a more precise definition developed by a group of experts from the neurologic and pain community: pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. This revised definition fits into the nosology of neurologic disorders. The reference to the somatosensory system was derived from a wide range of neuropathic pain conditions ranging from painful neuropathy to central poststroke pain. Because of the lack of a specific diagnostic tool for neuropathic pain, a grading system of definite, probable, and possible neuropathic pain is proposed. The grade possible can only be regarded as a working hypothesis, which does not exclude but does not diagnose neuropathic pain. The grades probable and definite require confirmatory evidence from a neurologic examination. This grading system is proposed for clinical and research purposes.

Vena caval filters for the prevention of pulmonary embolism

BACKGROUND

Pulmonary emboli can have potentially fatal consequences. Inferior vena caval filters are metal alloy devices that mechanically trap fragmented thromboemboli from the deep leg veins en route to the pulmonary circulation. Filters in current clinical use are designed to be introduced (and in the case of retrievable filters, removed) percutaneously. Although their deployment seems of theoretical benefit, their clinical efficacy and adverse event profile is unclear.

OBJECTIVES

To examine evidence for the effectiveness of vena caval filters in preventing pulmonary embolism (PE). Secondary outcomes were mortality, distal (to filter) thrombosis, and filter-related complications.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases Group Specialised Register (last searched August 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2007, Issue 3, MEDLINE (1966 to August 2007), and EMBASE (1966 to August 2007). Filter manufacturers and clinicians interested in filters were contacted for information.

SELECTION CRITERIA

Controlled clinical trials (CCTs) and randomised controlled trials (RCTs) that examined the efficacy of filters in preventing PE were selected.

DATA COLLECTION AND ANALYSIS

Three authors extracted information independently. Incidence figures were extracted from survival tables. Dichotomous outcomes were analysed as hazard ratio estimates.

MAIN RESULTS

One RCT was included. The PREPIC (Prévention du Risque d'Embolie Pulmonaire par Interruption Cave) trial was an open RCT of 400 participants with documented proximal deep vein thrombosis (DVT) or PE and who received concurrent anticoagulation. Permanent caval filters prevented PE at eight years (HR 0.37, 95% CI 0.17 to 0.79, in favour of the filter). No reduction in mortality was seen, but this reflected an older study population (mean age 73 years); the majority of deaths were due to cancer or cardiovascular causes. There was an increased incidence of DVT in the filter group (HR 1.52, 95% CI 1.02 to 2.27). No details were recorded of adverse events of filters.

AUTHORS' CONCLUSIONS

Limited generalisability prevents any conclusions to be drawn from the PREPIC trial in that permanent filters were used and the study lacked statistical power to detect a reduction in PE over shorter and more clinically significant time periods. However, the PREPIC trial demonstrated that permanent caval filters were associated with an increased risk of long term lower limb DVT. There is a marked paucity of caval filter outcomes evidence when used within their currently approved indications. There is also a lack of retrievable filter trials. Further trials are needed to assess vena caval filter safety and effectiveness.

Health-related quality of life among patients with adenocarcinoma of the gastro-oesophageal junction treated by gastrectomy or oesophagectomy

Background

Tumours of the gastro-oesophageal junction may be resected by total gastrectomy (TG) or transthoracic oesophagectomy (TTO). This study compared health-related quality of life (HRQL) following these procedures.

Methods

Prospective clinical and HRQL data (European Organization for Research and Treatment of Cancer QLQ-C30) were collected from 63 consecutive patients (20 TG and 43 TTO) before and 6 months after surgery for Siewert type I–III gastro-oesophageal tumours.

Results

Questionnaire response rates exceeded 90 per cent. Patients were similar with respect to disease stage, treatment-related mortality and survival, but those selected for TTO were younger with less co-morbidity than those undergoing TG. These differences were reflected in baseline HRQL scores, which were better in patients selected for TTO. Six months after surgery, however, HRQL showed a greater deterioration after TTO than after TG in terms of role and social function, global quality of life and fatigue. Symptom scores for pain and diarrhoea increased in both groups.

Conclusion

TTO had a greater negative impact on HRQL than TG for tumours of the gastro-oesophageal junction.

Vena caval filters for the prevention of pulmonary embolism

BACKGROUND

Pulmonary emboli can have potentially fatal consequences. Inferior vena caval filters are metal alloy devices that mechanically trap fragmented thromboemboli from the deep leg veins en route to the pulmonary circulation. Filters in current clinical use are designed to be introduced (and in the case of retrievable filters, removed) percutaneously. Although their deployment seems of theoretical benefit, their clinical efficacy and adverse event profile is unclear.

OBJECTIVES

To examine evidence for the effectiveness of vena caval filters in preventing pulmonary embolism (PE). Secondary outcomes were mortality, distal (to filter) thrombosis, and filter-related complications.

SEARCH STRATEGY

Searches were conducted in the Cochrane Peripheral Vascular Diseases Group Specialised Register (last searched May 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2007), MEDLINE (1966 to May 2007), and EMBASE (1966 to May 2007). Filter manufacturers and clinicians interested in filters were contacted for information.

SELECTION CRITERIA

Controlled clinical trials (CCTs) and randomised controlled trials (RCTs) that examined the efficacy of filters in preventing PE were selected.

DATA COLLECTION AND ANALYSIS

Three authors extracted information independently. Incidence figures were extracted from survival tables. Dichotomous outcomes were analysed as hazard ratio estimates.

MAIN RESULTS

One RCT met the inclusion criteria. The PREPIC trial was an open RCT of 400 participants with documented proximal deep vein thrombosis (DVT) or pulmonary embolism and who received concurrent anticoagulation.PREPIC demonstrated the efficacy of permanent caval filters in preventing PE at eight years (HR 0.37, 95% CI 0.17 to 0.79, in favour of the filter). No reduction in mortality was seen, but this reflected an older study population (mean age 73 years); the majority of deaths were due to cancer or cardiovascular causes. There was an increased incidence of DVT in the filter group (HR 1.52, 95% CI 1.02 to 2.27). No details were recorded of adverse events of filters. No CCTs suitable for inclusion were found.

AUTHORS' CONCLUSIONS

Limited generalisability prevents any conclusions to be drawn from PREPIC. PREPIC employed permanent filters and lacked statistical power to detect a reduction in PE over shorter and more clinically significant time periods. However, PREPIC demonstrated that permanent caval filters are associated with an increased risk of long term lower limb DVT. There is a marked paucity of evidence regarding caval filter outcomes when used within their currently approved indications. There is also a lack of retrievable filter trials. Further trials are needed to assess vena caval filter safety and effectiveness.

The use of alternative medicine in pediatric patients with atopic dermatitis

Alternative medicine has been defined as forms of therapy or examination that have no scientific basis and for which no effective or diagnostic reliability has been demonstrated by scientific methods. The use of complementary or alternative medicine is increasing and controlled clinical trials on the subject are few. We performed a questionnaire-based study of 80 pediatric patients with atopic dermatitis. This questionnaire assessed the duration of treatment, the reason(s) for trying alternative therapy, the approximate cost and the success of the treatment, the duration of the childhood eczema, and whether the child had ever required hospital admission for eczema. Of the total, 34 (42.5%) patients had used alternative medicine. Herbal remedies and homeopathy were used most often. Most treatments were reported to show no benefit and in three instances deterioration was reported. This study has prompted us to enquire routinely regarding alternative medicine use. Alternative therapies are subject to minimal regulation and have been associated with serious side effects. We would recommend enquiries regarding alternative medicine use in all pediatric dermatology patients.