Results of screening for intracranial aneurysms in patients with coarctation of the aorta

BACKGROUND AND PURPOSE

IAs are found in 2.3% of adults; the mean age at detection is 52 years. Prevalence is <0.5% in young adults. Early studies suggest that 10%-50% of patients with aortic coarctation have IAs. Screening recommendations are variable. We sought to examine the prevalence of IAs through screening with MRA.

MATERIALS AND METHODS

Consecutive patients older than 16 years of age with coarctation undergoing brain MRA between May 1999 and October 2007 were included. MRA was performed by using a 1.5T scanner with a 3D time-of-flight protocol; simultaneous MR imaging was performed of the heart and aorta. Cerebral MRAs were double-reported by a neuroradiologist. Statistics are described as mean ± SD and median ± range. Continuous variables were compared by using Student t tests and Mann-Whitney U tests (categoric variables, by using the Fisher exact test).

RESULTS

One hundred seventeen MRAs were double-reported. The median age was 29 ± 11 years (range, 16-59 years). IAs were found in 12 patients (10.3%). The mean diameter of IAs was 3.9 mm (range, 2.0-8.0 mm). Patients with aneurysms were older (median, 37 years; range, 16-50 years) than those without (median, 23 years; range, 16-59 years; Z = -2.01, P = .04). Hypertension was more common in those with IAs (IA 83% versus no IA 43%, P = .01). There was no association between ascending aortopathy, bicuspid aortic valves, and IAs.

CONCLUSIONS

Patients with coarctation have a higher prevalence of IAs, occurring at an earlier age than in population studies. Whether routine screening is appropriate for this group of patients is unclear. Hypertension is likely to be an important pathophysiologic factor.

Transafe

An earlier version of this paper was presented at the 2011 IEEE International Symposium on Technology and Society (ISTAS) at Saint Xavier University in Chicago, Illinois (and printed in the 2011 ISTAS proceedings).

This paper describes a proposed mobile platform, Transafe , that captures and analyses public perceptions of safety to deliver 'crowdsourced' collective intelligence about places in the City of Melbourne, Australia, and their affective states at various times of the day. Public perceptions of crime on public transport in Melbourne are often mismatched with actual crime statistics and such perceptions thus can act as social barriers to visitors and locals traversing within and through the city. Using interactive mobile applications and social media, the visualization of this crowdsourced safety perception information will increase the commuter's awareness of various situations in the City of Melbourne. In addition, through social behavioral analysis and ethnographic research, the collective public intelligence will also help inform the stakeholders of the city for future policy-making and policing strategies for safety perception management. At the centre of the proposed platform is the design and development of a mobile phone application that can contribute to people feeling safer by supporting users to report crimes and misdemeanors that they witness, and provide information about transportation and emergency services around where the users are located. The proposed application can also act as a crime deterrent with one feature that enables user tracking by up to three nominated friends if the user opts to activate tracking when feeling unsafe while roaming the city.

Erlotinib 'dosing-to-rash': a phase II intrapatient dose escalation and pharmacologic study of erlotinib in previously treated advanced non-small cell lung cancer

BACKGROUND

To evaluate the anticancer activity of erlotinib in patients with previously treated, advanced non-small cell lung cancer (NSCLC) whose dose is increased to that associated with a maximal level of tolerable skin toxicity (i.e., target rash (TR)); to characterise the pharmacokinetics (PK) and pharmacodynamics (PD) of higher doses of erlotinib.

METHODS

Patients initially received erlotinib 150 mg per day. The dose was successively increased in each patient to that associated with a TR. Anticancer activity was evaluated. Plasma, skin, and hair were sampled for PK and PD studies.

RESULTS

Erlotinib dose escalation to 200-475 mg per day was feasible in 38 (90%) of 42 patients. Twenty-four (57%) patients developed a TR, but 19 (79%) did so at 150 mg per day. Five (12%) patients, all of whom developed a TR, had a partial response. Median progression-free survival (PFS) was 2.3 months (95% CI: 1.61, 4.14); median PFS was 3.5 months and 1.9 months, respectively, for patients who did and did not experience a TR (hazard ratio, 0.51; P=0.051). Neither rash severity nor response correlated with erlotinib exposure.

CONCLUSION

Intrapatient dose escalation of erlotinib does not appreciably increase the propensity to experience a maximal level of tolerable skin toxicity, or appear to increase the anticancer activity of erlotinib in NSCLC.

Outcomes of critically ill patients with cirrhosis admitted to intensive care: an important perspective from the non-transplant setting

BACKGROUND

Hospital admissions for cirrhosis have been increasing in the United Kingdom, leading to increased pressure on intensive care (ICU) services. Outcome data for patients admitted to ICU are currently limited to transplant centre reports, with mortality rates exceeding 70%. These tertiary reports could fuel a negative bias when patients with cirrhosis are reviewed for ICU admission in secondary care.

AIMS

To determine whether disease severity and mortality rates in non-transplant general ICU are less severe than those reported by tertiary datasets.

METHODS

A prospective dual-centre non-transplant ICU study. Admissions were screened for cirrhosis and physiological and biochemical data were collected. Disease-specific and critical illness scoring systems were evaluated.

RESULTS

Cirrhosis was present in 137/4198 (3.3%) of ICU admissions. ICU and hospital mortality were 38% and 47%, respectively; median age 50 [43-59] years, 68% men, 72% alcoholic cirrhosis, median Child Pugh Score (CPS) 10 [8-11], Model for End-Stage Liver Disease (MELD) 18 [12-24], Acute Physiology and Chronic Health Evaluation II score (APACHE II) 16 [13-22].

CONCLUSIONS

Mortality rates and disease staging were notably lower than in the published literature, suggesting that patients have a more favourable outlook than previously considered. Transplant centre data should therefore be interpreted with caution when evaluating the merits of intensive care admission for patients in general secondary care ICUs.

Should non-mosaic Klinefelter syndrome men be labelled as infertile in 2009?

BACKGROUND

Klinefelter syndrome is a common genetic condition. Affected non-mosaic men are azoospermic and have been labelled as infertile. Despite reports that these men can have children using assisted reproduction techniques, it is not common practice in the UK to offer sperm retrieval to these men.

METHODS

Medline and EMBASE (1980-2009) were searched independently by two authors and all studies involving surgical sperm retrieval in non-mosaic Klinefelter syndrome were included. The primary outcome was success of surgical sperm retrieval and the secondary outcome was live birth rate.

RESULTS

The overall success rate for sperm retrieval was 44%, with a higher rate of success using micro-dissection testicular sperm aspiration (micro-TESE) (55%). This, along with ICSI, has led to the birth of 101 children. However, there are no known predictors for successful sperm retrieval. Although there are concerns about genetic risk to the offspring of non-mosaic Klinefelter patients, this risk has not been found to be greater than that of patients with non-obstructive azoospermia with normal karyotype.

CONCLUSIONS

It is possible for a man with non-mosaic Klinefelter to father a child. However, before these techniques are offered, some ethical issues need to be explored.

The epidemiology of infertility in the North East of Scotland

BACKGROUND

There is a perception that the prevalence of infertility is on the rise. This study aimed to determine the current prevalence of infertility in a defined geographical population, ascertain changes in self-reported infertility over time and identify risk factors associated with infertility.

METHODS

A postal questionnaire survey of a random population-based sample of women aged 31-50 years was performed in the Grampian region of Scotland. Questions addressed the following areas: pregnancy history, length of time taken to become pregnant each time, whether medical advice had been sought and self-reported exposure to factors associated with infertility.

RESULTS

Among 4466 women who responded, 400 (9.0%) [95% CI 8.1, 9.8] had chosen not to have children. Of the remaining 4066 women, 3283 (80.7%) [95% CI 79.5, 82.0] reported no difficulties in having children and the remaining 783 (19.3%) [95% CI 18.1, 20.5] had experienced infertility, defined as having difficulty in becoming pregnant for more than 12 months and/or seeking medical advice. In total 398 (9.8%) [95% CI 8.9, 10.7] women had primary infertility, 285 (7.0%) [95% CI 6.2, 7.8] had secondary infertility, 100 (2.5%) [95% CI 2.0, 2.9] had primary as well as secondary infertility. A total of 342 (68.7%) and 208 (73.0%) women with primary and secondary infertility, respectively, sought medical advice and 202 (59.1%) and 118 (56.7%) women in each group subsequently conceived. History of pelvic surgery, Chlamydial infection, endometriosis, chemotherapy, long-term health problems and obesity were associated with infertility. In comparison with a similar survey of women aged 46-50 from the same geographical area, the prevalence of both primary infertility (>24 months) [70/1081, (6.5%) versus 68/710 (9.6%) P = 0.02] and secondary infertility [29/1081 (2.7%) versus 40/710 (5.6%) P = 0.002] were significantly lower.

CONCLUSIONS

Nearly one in five women attempting conception sampled in this study experienced infertility, although over half of them eventually conceived. Fertility problems were associated with endometriosis, Chlamydia trachomatis infection and pelvic surgery, as well as obesity, chemotherapy and some long-term chronic medical conditions. There is no evidence of an increase in the prevalence of infertility in this population over the past 20 years.

Implementation of the NICE guideline – Recommendations from the British Fertility Society for national criteria for NHS funding of assisted conception

Assisted conception providers in England were surveyed to establish the uptake of NICE guideline for infertility particularly in respect of assisted conception and the criteria used to accept patients for NHS funded treatment. Detailed information on selection criteria was obtained from a group of commissioning consortia at an advanced stage in their arrangements. While there was an overall increase in the number of NHS IVF cycles purchased in England, implementation is stalled at one fresh cycle in the vast majority of Primary Care Trusts (PCTs). There is little consensus about the criteria used for acceptance into an NHS programme. This is particularly so in respect of social criteria which are often arbitrary and used as a rationing tool. This information complements that provided by the survey of Primary Care Trusts performed in March 2005 by the All Party Parliamentary Group on Infertility (APPGI) in partnership with the National Infertility Awareness Campaign (NIAC) which together provide a basis for recommendations for NHS funding. The recommendations presented should be applied across England and Wales to ensure consistency, fairness and equity of access.

A potential model of pediatric posttraumatic epilepsy

Preclinical models of pediatric posttraumatic epilepsy (PTE) are lacking. We hypothesized that traumatic brain injury (TBI), induced by controlled cortical impact, in immature rats would cause electroencephalographic (EEG) epileptiform activity and behavioral seizures. TBI or sham craniotomy was performed on postnatal day 17. Using video-EEG monitoring 4-11 months post-TBI, most TBI rats (87.5%) showed EEG spiking and one had spontaneous, recurrent seizures. Controls showed neither EEG spikes nor electrographic/behavioral seizures. Late seizures were rare after TBI, but EEG spiking was common and may represent a surrogate for PTE.

"Allow natural death" versus "do not resuscitate": three words that can change a life

Physician-written "do not resuscitate" DNR orders elicit negative reactions from stakeholders that may decrease appropriate end-of-life care. The semantic significance of the phrase has led to a proposed replacement of DNR with "allow natural death" (AND). Prior to this investigation, no scientific papers address the impact of such a change. Our results support this proposition due to increased likelihood of endorsement with the term AND.

Initial management of infertility: an audit of pre-referral investigations and exploration of couples' views at the interface of primary and secondary care

This study aimed to audit pre-referral investigations in primary care, and survey patients' views on the referral process from primary to secondary care. Referral letters and case notes of 250 consecutive couples referred to the Aberdeen Fertility Centre were audited in order to establish whether mid-luteal serum progesterone, rubella status and semen analysis had been performed. Couples attending a specialist hospital clinic for the first time completed a questionnaire on their experience of the referral process and consultation. Mid-luteal progesterone was performed in 105 (51%) cases, rubella status checked in 42 (20%) cases and semen analysis arranged in 70 (34%) cases. Overall, 274 (93%) patients were satisfied or very satisfied with the hospital consultation compared to 216 (84%) who utilised the general practitioner (GP) consultation (p < or = 0.001); 79 (59%) women and 91 (68%) men wanted the current system of GP referral to continue (p < 0.001); and 74 (56%) women and 69 (52%) men (p < 0.001) favoured the option of direct self-referral.

CONCLUSIONS

Despite high levels of satisfaction among couples, there is scope for further improvement in terms of pre-referral fertility investigations. Further evaluation of the referral process is needed, and potential changes to the existing system should be considered.

Phase II clinical trial of mutant Ras peptide vaccine in combination with GM-CSF and IL-2 in advanced cancer patients

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Background: Mutant ras oncogenes produce novel proteins that are processed and displayed through HLA molecules on tumor cells. Therefore, mutant ras is an attractive target for vaccine therapy. We have shown in a previous phase I trial that vaccination with mutant ras peptides produced specific immune responses (IR). Here we tested in a phase II trial the use of specific mutant ras peptides in combination with GM-CSF and IL-2 in advanced cancer patients carrying the ras mutation in their tumors. Methods: We treated 17 patients with advanced cancers (14 CRC, 1 NSCLC and 2 pancreatic) with 5000μg of the corresponding mutant ras peptide given SQ along with GM-CSF and IL-2. GM-CSF was given SQ on days -1,0,1,2 followed by ten days of low dose SQ IL-2. Vaccines were repeated every 5 weeks for a maximum of 15 cycles or until disease progression. Results: 11 patients who received 3 or more vaccinations were tested for immune response by measuring IFN-γ mRNA copies in PBMCs pre and post vaccination. 6/11 patients generated specific IR to the corresponding mutant ras vaccine. The median overall survival and the median progression-free survival for all patients were 25.8 and 13.1 months respectively. However, in the 6 patients with positive IR, it was 39.9 and 17.9 months compared to 18.5 and 15.6 months in the 5 patients who showed no IR. No grade IV toxicity occurred. Most adverse events were Grade I-II toxicities and resolved spontaneously. Grade III toxicities led to IL-2 dose reduction in 3/17 patients (18%). Conclusions: The study showed that vaccination of advanced cancer patients with mutant ras peptides in combination with GM-CSF and IL-2 is safe and can induce specific immune responses. Furthermore, those patients who generated IR showed better clinical outcome, as reflected by PFS and OS. So we believe that this vaccine may form a potentially promising approach in combination with other therapeutic modalities in advanced solid tumors.

No significant financial relationships to disclose.

Opportunistic screening for Chlamydia trachomatis in men attending three different secondary healthcare settings

OBJECTIVES

To assess the feasibility and acceptability of opportunistic Chlamydia trachomatis (CT) screening of asymptomatic men attending three different secondary healthcare settings and to investigate CT positivity in these settings.

METHODS

Men attending fracture, fertility and family planning (FP) clinics were invited to be screened by first-void urine and complete a questionnaire which collected demographic, sexual and behavioural characteristics, and their opinion about the screening process.

RESULTS

1290 men were approached, with 80% participating. The number of men approached, number providing a satisfactory urine specimen and CT positivity rate (95% CI) were, respectively, n = 401, n = 206, 14.6% (10.4 to 20.1) for the FP clinic, n = 505, n = 328, 1.2% (0.5 to 3.2) for the fracture clinic and n = 384, n = 319, 0.3% (0.1 to 1.8) for the fertility clinic. The highest rates of CT infection were found in men attending the FP clinics, aged between 20-24 years. Most of the men from all three clinics felt that the setting (87.9%) and specimen (97.7%) were acceptable.

CONCLUSION

Opportunistic chlamydial screening of asymptomatic men in three secondary healthcare settings found high positivity rates, but low uptake rates in a FP setting compared with fertility and fracture clinics. Innovative and targeted intervention strategies are required to engage this high-risk group of men in screening.

Liver haemorrhage in haemophilia--a case report and review of the literature

We present two patients with severe haemophilia A, who presented with haemorrhagic shock, secondary to a liver haematoma in the neonatal period. Both required emergency treatment and diagnosis of the hereditary coagulation defect. Major organ bleeding in severe haemophilia A in the newborn period is rare, and this unusual complication is not well recognized. Failure to recognize that the bleeding is due to a bleeding disorder, particularly in the absence of a family history, may lead to delay in appropriate management.