Management and outcome of sight-threatening diabetic retinopathy in pregnancy

AIMS

To report the management and outcomes of sight-threatening diabetic retinopathy in pregnancy.

METHODS

A retrospective review of 8 diabetic females who developed pregnancy related sight-threatening diabetic retinopathy requiring treatment over a 12-year period.

RESULTS

In total, 16 eyes of eight patients were included in this series. The mean age of the patients at presentation was 30.75 years +/-3.8 SD and the mean duration of diabetes was 21.0 years +/-5.1 SD. The mean follow-up period was 46.75 months +/-47.2 SD. A total of 87.5% of patients showed progression of diabetic retinopathy during pregnancy, 71% of which were in the sight-threatening proliferative category. In the postpartum period, 81% of patients continued to progress to proliferative diabetic retinopathy, requiring panretinal photocoagulation and multiple other surgical procedures. In all, 69% of eyes retained visual acuity equal to or better than 0.3 logMAR units (6/12).

CONCLUSION

Sight-threatening diabetic retinopathy in pregnancy is a rare disease, but it can have devastating consequences for mother and child. Laser photocoagulation should be considered for pregnant women with severe preproliferative diabetic retinopathy. Proliferative diabetic retinopathy may not regress postpartum. Close followup should be extended in the postpartum period in this group of patients until the retinopathy is stabilised. The presence of combined rhegmatogenous and tractional retinal detachment and neovascular glaucoma were associated with the worst outcome.

Cancer mortality trends in the EU and acceding countries up to 2015

BACKGROUND

Examination of trends in cancer mortality in Europe over the past 30 years has shown that, after long-term rises, age-standardised mortality from most common cancer sites has fallen in the EU since the late 1980s. This study aimed to examine trends in the age-specific and age-standardised cancer mortality rates and numbers of cancer deaths up to 2020 for all cancers and various specific sites for all 15 EU countries, the 10 acceding countries, Bulgaria and Romania (currently applicant countries, along with Turkey), and Iceland, Norway and Switzerland of the four EEA countries.

PATIENTS AND METHODS

Mortality rates were modelled as a function of age, calendar period and birth cohort. Birth cohort was calculated as age subtracted from calendar period.

RESULTS

As a consequence of the generally decreasing trends in the age-standardised rates, the best estimate is that there will be approximately 1.25 million cancer deaths in 2015, which is almost 130,000 (11%) more deaths than in 2000, but 155,000 (11%) fewer deaths than the 1.4 million projected in 2015 on the basis of demographic changes alone. The increases in the forecast numbers of cancer deaths in 2015 are proportionally larger in males than in females (13% and 10%, respectively) and proportionally larger in the acceding countries than in the current EU member countries (14% and 11%, respectively).

CONCLUSIONS

Our forecasts are conservative best estimates of future cancer mortality. There is clearly scope for large improvements in survival, and hence reductions in cancer mortality, in some countries, through eliminating these differences using existing knowledge and treatment regimes.

Trends in oesophageal and gastric cancer incidence, mortality and survival in England and Wales 1971-1998/1999

BACKGROUND

In England and Wales, 7% of cancers diagnosed in 1997 were oesophageal or gastric cancer.

AIM

To review the epidemiology of these cancers in England and Wales using cancer registration data from 1971 to 1998 and mortality data from 1971 to 1999.

METHODS

We calculated age-specific and age-standardised incidence and mortality rates; crude and relative survival by age group; age-standardised relative survival; and relative survival by socio-economic status.

RESULTS

The age-standardised incidence of oesophageal cancer increased from 7.6 to 12.8 per 100,000 men and from 4.2 to 5.7 per 100,000 women. The incidence of gastric cancer decreased from 31.8 to 18.9 per 100,000 men and from 15.1 to 7.3 per 100,000 women. For both cancers, the 1- and 5-year age-standardised relative survival improved for men and women from 1971-1975 to 1992-1994; the 5-year age-standardised relative survival was significantly higher in women than in men diagnosed in 1992-1994; for some periods from 1971-1975 to 1986-1990, the 1-year relative survival was significantly higher in the least deprived men than in the most deprived men.

CONCLUSIONS

Survival improved for both cancers over the study period, but there were unexplained differences related to sex and deprivation.

Trends in the subsite and morphology of oesophageal and gastric cancer in England and Wales 1971-1998

BACKGROUND

The incidence of adenocarcinoma of the oesophagus and gastric cardia has increased in many countries.

AIM

To describe the trends in the subsite and morphology of oesophageal and gastric cancer using cancer registry data from 1971 to 1998.

METHODS

We calculated the overall age-standardised incidence in each year; the age-standardised incidence by subsite, by morphology and by subsite and morphology; and the ratio of the rates in men and women in 1971 and 1998.

RESULTS

The incidence of oesophageal adenocarcinoma increased from 1.5 to 7.0 per 100,000 men and from 0.4 to 1.5 per 100,000 women. The incidence of cancer at the cardia also increased, from 2.0 to 5.4 per 100,000 men and from 0.6 to 1.4 per 100,000 women, but the incidence of gastric cancer without a specified subsite decreased markedly from 21.3 to 9.3 per 100,000 men and from 10.7 to 4.2 per 100,000 women.

CONCLUSIONS

Although some of the increase in the incidence of adenocarcinoma of the gastric cardia is probably real, this interpretation is limited by the proportion of cancers without specified subsites or morphologies.

Classification and incidence of cancers in adolescents and young adults in England 1979-1997

Cancer patients aged 15-24 years have distinct special needs. High quality cancer statistics are required for service planning. Data presented by primary site are inappropriate for this age group. We have developed a morphology-based classification and applied it to national cancer registration data for England 1979-1997. The study included 25,000 cancers and 134 million person-years at risk. Rates for each diagnostic group by age, sex and time period (1979-83, 1984-87, 1988-92, 1993-1997) were calculated. Overall rates in 15-19 and 20-24-year-olds were 144 and 226 per million person-years respectively. Lymphomas showed the highest rates in both age groups. Rates for leukaemias and bone tumours were lower in 20-24 year olds. Higher rates for carcinomas, central nervous system tumours, germ-cell tumours, soft tissue sarcomas and melanoma were seen in the older group. Poisson regression showed incidence increased over the study period by an average of 1.5% per annum (P<0.0001). Significant increases were seen in non-Hodgkins lymphoma (2.3%), astrocytoma (2.3%), germ-cell tumours (2.3%), melanoma (5.1%) and carcinoma of the thyroid (3.5%) and ovary (3.0%). Cancers common in the elderly are uncommon in adolescents and young adults. The incidence of certain cancers in the latter is increasing. Future studies should be directed towards aetiology.

Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes

Antagonists of the platelet fibrinogen receptor glycoprotein IIb/IIIa are potent inhibitors of platelet function and provide marked protection from ischemic events in patients undergoing PCI. These agents are also of benefit in patients with unstable angina or non-ST segment elevation myocardial infarction (MI) and provide a 9% reduction in the combined endpoint of 30-day death or MI. This benefit is most marked in patients undergoing early PCI or those at increased risk due to history of diabetes or elevation of the cardiac marker troponin. Based on these findings, the combined American Heart Association and American College of Cardiology guidelines on the management of unstable angina and non-ST segment elevation MI recommend intravenous GPIIb/IIIa in patients in whom PCI is planned particularly those with elevated troponin or diabetes. The use of these agents is associated with a slight increase in major bleeding and in rare instances thrombocytopenia that usually resolves quickly after therapy is discontinued.

Current trends in colorectal cancer: site, incidence, mortality and survival in England and Wales

The objective was to examine trends in colorectal cancer (CRC) incidence and mortality in England and Wales over the last 30 years. Age-standardized incidence, mortality and survival rates for CRC, based on data from the National Cancer Intelligence Centre at the Office for National Statistics, were calculated and trends assessed. Between 1971 and 1997 the total number of cases of CRC increased by 42%, from 20,400 to 28,900. The site distribution of CRC between 1971 and 1994 was: rectum 38%, sigmoid 29%, caecum 15%, transverse colon and flexures 10%, ascending colon 5%, and descending colon 3%. Between 1971 and 1997 the direct age-standardized incidence increased by 20% in males and by 5% in females. The direct age-standardized mortality fell by 24% in males and by 37% in females. Age-standardized relative 5-year survival in adults improved from 22%-27% for patients diagnosed during 1971-1975 to over 40% for those diagnosed during the period 1991-1993. In conclusion, the incidence of CRC in England and Wales has been steadily rising. It is more common in males and has increased more rapidly in males than in females. The reasons for these trends remain unclear. Five-year survival has improved substantially, but rates are still below those in comparable countries elsewhere in Europe and in the USA.

Cancer prevalence in European registry areas

BACKGROUND

Information on cancer prevalence is of major importance for health planning and resource allocation. However, systematic information on cancer prevalence is largely unavailable.

MATERIALS AND METHODS

Thirty-eight population-based cancer registries from 17 European countries, participating in EUROPREVAL, provided data on almost 3 million cancer patients diagnosed from 1970 to 1992. Standardised data collection and validation procedures were used and the whole data set was analysed using proven methodology. The prevalence of stomach, colon, rectum, lung, breast, cervix uteri, corpus uteri and prostate cancer, as well as of melanoma of skin, Hodgkin's disease, leukaemia and all malignant neoplasms combined, were estimated for the end of 1992.

RESULTS

There were large differences between countries in the prevalence of all cancers combined; estimates ranged from 1170 per 100000 in the Polish cancer registration areas to 3050 per 100000 in southern Sweden. For most cancers, the Swedish, Swiss, German and Italian areas had high prevalence, and the Polish, Estonian, Slovakian and Slovenian areas had low prevalence. Of the total prevalent cases, 61% were women and 57% were 65 years of age or older. Cases diagnosed within 2 years of the reference date formed 22% of all prevalent cases. Breast cancer accounted for 34% of all prevalent cancers in females and colorectal cancer for 15% in males. Prevalence tended to be high where cancer incidence was high, but the prevalence was highest in countries where survival was also high. Prevalence was low where general mortality was high (correlation between general mortality and the prevalence of all cancers = -0.64) and high where gross domestic product was high (correlation = +0.79). Thus, the richer areas of Europe had higher prevalence, suggesting that prevalence will increase with economic development.

CONCLUSIONS

EUROPREVAL is the largest project on prevalence conducted to date. It has provided complete and accurate estimates of cancer prevalence in Europe, constituting essential information for cancer management. The expected increases in prevalence with economic development will require more resources; allocation to primary prevention should therefore be prioritised.

Clinical performance indicators at hysterectomy

The short-term complications of hysterectomy in 184 women have been documented over 12 months against a panel of clinical performance indicators in a district general hospital. One hundred and fifty-nine operations (159/184, 86.4%) were performed by the abdominal route; 25/184 (13.6%) by the vaginal route. Clinical indications for hysterectomy varied from menorrhagia (75/184, 40.7%) to Stage III/IV endometriosis (10/184, 5.4%). Clinical performance indicators (cPI) were triggered in 32/184 (17.4%) cases; 19/ 184 (10.3%) triggered a single performance indicator, 9/184 (4.9%) triggered two performance indicators and 4/184 (2.2%) triggered three performance indicators. Combining the number of hysterectomies performed per annum (HYST 1), with the proportion of cases triggering three or more clinical performance indicators (HYST 2) and the rate of hysterectomy for histologically normal uteri weighing less than 120 g excluding genital prolapse (HYST 3) provides a profile of the operation for comparison with other clinical services.

Common variations in platelet glycoproteins: pharmacogenomic implications

Atherosclerosis and its complications are the result of complex interactions between the environment and genetic factors. Platelets play an important role in this disease process and antiplatelet agents are an essential part of its treatment. However, individual response to antiplatelet therapy is variable and agents that are safe and effective in one individual may be ineffective or harmful in another. It is likely that genetic factors are involved in this variance as platelet, and platelet-associated proteins are highly polymorphic. Up to 30% of natural variation in platelet reactivity is related to genetic inheritance. Rare inherited defects of platelet function due to the absence or reduced surface expression of platelet adhesion receptors have long been recognised. These cause minor bleeding defects and are usually clinically apparent. Antiplatelet agents should be avoided in these situations. The importance of the more common genetic variations or polymorphisms, which result in minor changes in the expressed protein and are often clinically silent, is unknown. Investigations are ongoing into the role of this variation in platelet physiology. A number of polymorphisms in platelet surface glycoproteins have received particular attention; the (A1/2) polymorphism resulting in conformational change at the amino terminus of the beta-3 chain of the platelet fibrinogen receptor glycoprotein (GP) IIb/IIIa and polymorphisms in the platelet collagen (GPIa/IIa and GPVI) and von Willebrand receptors (GPIb-IX). The (A2) allele has been associated with resistance to the antiplatelet agent aspirin and increased platelet responsiveness. The GPIa polymorphism has been associated with increased surface expression of GPIa and increased platelet adhesion to collagen. Recently, conflicting reports of the association of these polymorphisms with coronary artery disease (CAD) and its complications have been described. Mutations have also been identified in other platelet surface receptors including the recently identified G(i)-linked platelet adenosine diphosphate (ADP) receptor (P2Y(12)), targeted by the antiplatelet agents ticlopidine and clopidogrel. These discoveries have stimulated interest in the role of genetic factors in platelet physiology. In this article, the current knowledge of the influence of genetic make-up on antiplatelet therapy is discussed.

Do nodal metastases from cutaneous melanoma of the head and neck follow a clinically predictable pattern?

BACKGROUND

Potential lymphatic drainage patterns from cutaneous melanomas of the head and neck are said to be variable and frequently unpredictable. The aim of this article is to correlate the anatomic distribution of pathologically involved lymph nodes with primary melanoma sites and to compare these findings with clinically predicted patterns of metastatic spread.

METHODS

A prospectively documented series of 169 patients with pathologically proven metastatic melanoma was reviewed by analyzing the clinical, operative, and pathologic records. Clinically, it was predicted that melanomas of the anterior scalp, forehead, and face could metastasize to the parotid and neck levels I-III; the coronal scalp, ear, and neck to the parotid and levels I-V; the posterior scalp to occipital nodes and levels II-V; and the lower neck to levels III-V. Minimum follow up was 2 years.

RESULTS

There were 141 therapeutic (97 comprehensive, 44 selective) and 28 elective lymphadenectomies (4 comprehensive dissections, 21 selective neck dissections, and 3 cases in which parotidectomy alone was performed). Overall, there were 112 parotidectomies, 44 of which were therapeutic and 68 elective. Pathologically positive nodes involved clinically predicted nodal groups in 156 of 169 cases (92.3%). The incidence of postauricular node involvement was only 1.5% (3 cases). No patient was initially seen with contralateral metastatic disease; however, 5 patients (2.9%) failed in the contralateral neck after therapeutic dissection. In 68% of patients, metastatic disease involved the nearest nodal group, and in 59% only a single node was involved.

CONCLUSIONS

Cutaneous malignant melanomas of the head and neck metastasized to clinically predicted nodal groups in 92% of patients in this series. Postauricular and contralateral metastatic node involvement was uncommon.

Temporalis muscle transfer for facial paralysis: a further refinement

Facial nerve paralysis can occur due to failure of the central driving mechanism (nuclear or supranuclear pathology), failure of the conduit between the brainstem and the peripheral musculature (the facial nerve), or failure of the peripheral end organ (the neuromuscular system). Where the peripheral neuromuscular system fails, the options for dynamic reanimation include a regional muscle transfer driven by another ipsilateral cranial nerve, or a free muscle transfer driven by the contralateral facial nerve. Temporalis muscle transfer is an example of regional muscle transfer and has been used since early in the twentieth century. A further refinement, involving mobilization of the coronoid process of the mandible in continuity with the insertion of the temporalis muscle via a nasolabial fold approach, using fascial strips to re-create movement around the mouth, is presented.

Occupancy of the internal and external pools of glycoprotein IIb/IIIa following abciximab bolus and infusion

The internal pool of GPIIb/IIIa, which is expressed upon platelet activation, may be inaccessible to inhibition by GPIIb/IIIa antagonists. To determine the occupancy of the internal and external pools of GPIIb/IIIa and platelet function following an abciximab bolus and infusion, 15 patients undergoing elective percutaneous transluminal coronary angioplasty were administered abciximab as a bolus and 36-h infusion. GPIIb/IIIa receptor number and occupancy in resting and TRAP-6 (20 microM)-activated samples (to expose the internal pool of GPIIb/IIIa) was quantified using a monoclonal antibody-based assay. Antibody binding was quantified by flow cytometry and platelet inhibition by light transmittance aggregation and by the rapid platelet function analyser (Accumetrics, San Diego, CA). The target of >80% receptor occupancy (range 82--99% occupancy) of the external pool of GPIIb/IIIa was achieved in all patients at 3 min. Receptor occupancy of the combined internal and external pools of GPIIb/IIIa was less, ranging from 75 to 93% and again was maximal at 3 min. Platelet aggregation was markedly inhibited to 20 microM ADP (maximal, 11 +/- 2% of baseline), but less so to 5 microM TRAP-6 (maximal, 36 +/- 25% of baseline). Following discontinuation of the drug, there was a gradual fall in receptor occupancy over 15 days coinciding with the disappearance of abciximab from the platelet surface. Maximum inhibition of platelet function and receptor occupancy of the external pool of GPIIb/IIIa occurs within 3 min of an abciximab bolus and infusion. However, some internal receptors that are expressed by potent agonists are not occupied, which may explain the incomplete inhibition of platelet aggregation.

Subcutaneously tunnelled peritoneal dialysis catheters with delayed externalization: long-term follow-up

We performed a retrospective analysis of our institution's experience with the technique of delayed externalization of subcutaneously tunnelled peritoneal dialysis catheters. From 1993 to 1999, 49 catheters were implanted in 37 patients. Median age of the patients was 43.6 years; 70% were female; 32% had diabetes. Most of the catheters were midline, single-cuff, curled Quinton catheters without a swan neck. One patient underwent transplantation prior to catheter externalization. One catheter leaked prior to externalization and was removed. The remaining catheters were externalized a median of 40 days (range: 18-319 days) post implantation. At externalization, two leaks and one omental obstruction occurred, causing primary catheter failure. Total days of catheter follow-up were 17,895. One-year and two-year catheter survival rates were 70% and 40% respectively. Catheter failure occurred owing to infection in 7 cases and to mechanical complications in 10 cases. The rate of exit-site infection was 1 per 9.9 patient-months, and of peritonitis, 1 per 16.2 patient-months. Including primary failures, mechanical complications were 12 hernias, 6 leaks, and 4 instances of malposition. We conclude that delayed externalization of single-cuff catheters without a swan neck is associated with increased mechanical and infectious complications. These findings may warrant a change to a double-cuff catheter with a swan neck.

Glycoprotein IIb/IIIa receptor number and occupancy during chronic administration of an oral antagonist

Long-term treatment with oral glycoprotein (GP)IIb/IIIa antagonists has failed to produce significant clinical benefit. We have examined the pharmacology of xemilofiban in the evaluation of oral xemilofiban in controlling thrombotic events (EXCITE) trial. The EXCITE trial was a multicenter study of xemilofiban in 7232 patients undergoing percutaneous coronary intervention. Thirty-two patients randomized to xemilofiban (10 or 20 mg three times daily) or placebo were followed for up to 6 months. GPIIb/IIIa receptor number and occupancy were quantified using two monoclonal antibodies mAb1 and mAb2. mAb1 was used to quantify receptor number. mAb2 recognizes an epitope that is lost due to a ligand-induced conformational change in GPIIb/IIIa and is a marker of receptor occupancy. Platelet aggregation was performed by light transmission. In vitro, the active metabolite of xemilofiban (SC-54701) inhibited mAb2 binding (IC(50) of 0.5 +/- 0.1 x 10(-8) M) but not mAb1. In vivo, long-term therapy with xemilofiban did not alter GPIIb/IIIa receptor number. mAb2 binding was inhibited throughout the treatment period and recovered slowly after drug withdrawal. Maximum inhibition of ADP-induced aggregation occurred at 4 to 7 h after the first dose of study medication. However, inhibition of platelet aggregation was low (between 24 and 45%) before dosing on days 60 and 180. There was no significant rebound increase in platelet aggregation after drug withdrawal. Long-term xemilofiban therapy does not alter platelet GPIIb/IIIa receptor number. Inhibition of platelet aggregation was poor at the end of each dosing interval and this may explain the failure of xemilofiban to alter clinical events.