Vitamin K supplementation for the primary prevention of osteoporotic fractures: is it cost-effective and is future research warranted?

Lifetime supplementation with vitamin K, vitamin D(3), and calcium is likely to reduce fractures and increase survival in postmenopausal women. It would be a cost-effective intervention at commonly used thresholds, but high uncertainty around the cost-effectiveness estimates persists. Further research on the effect of vitamin K on fractures is warranted.

INTRODUCTION

Vitamin K might have a role in the primary prevention of fractures, but uncertainties about its effectiveness and cost-effectiveness persist.

METHODS

We developed a state-transition probabilistic microsimulation model to quantify the cost-effectiveness of various interventions to prevent fractures in 50-year-old postmenopausal women without osteoporosis. We compared no supplementation, vitamin D(3) (800 IU/day) with calcium (1,200 mg/day), and vitamin K(2) (45 mg/day) with vitamin D(3) and calcium (at the same doses). An additional analysis explored replacing vitamin K(2) with vitamin K(1) (5 mg/day).

RESULTS

Adding vitamin K(2) to vitamin D(3) with calcium reduced the lifetime probability of at least one fracture by 25%, increased discounted survival by 0.7 quality-adjusted life-years (QALYs) (95% credible interval (CrI) 0.2; 1.3) and discounted costs by $8,956, yielding an incremental cost-effectiveness ratio (ICER) of $12,268/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 95% and the population expected value of perfect information (EVPI) was $28.9 billion. Adding vitamin K(1) to vitamin D and calcium reduced the lifetime probability of at least one fracture by 20%, increased discounted survival by 0.4 QALYs (95% CrI -1.9; 1.4) and discounted costs by $4,014, yielding an ICER of $9,557/QALY. At a $50,000/QALY threshold, the probability of cost-effectiveness was 80% while the EVPI was $414.9 billion. The efficacy of vitamin K was the most important parameter in sensitivity analyses.

CONCLUSIONS

Lifetime supplementation with vitamin K, vitamin D(3), and calcium is likely to reduce fractures and increase survival in postmenopausal women. Given high uncertainty around the cost-effectiveness estimates, further research on the efficacy of vitamin K on fractures is warranted.

Malaria burden in human population of Quetta, Pakistan

Malaria is a serious global health challenge, which is responsible for more than one million deaths a year. Malarial infection is more prevalent in developing countries including Pakistan. Significant efforts have been made to control malaria; however, due to socio-environmental factors, it remains a frequent problem in Quetta. The present study was undertaken to determine the malarial incidence, species prevalence, and its demographic evaluation in human population of Quetta, Pakistan. A total of 1831 subjects, comprising 1072 male and 759 female presenting symptoms of malaria, were included in this study. Blood samples from clinically suspected individuals were subjected to the standard immunochromatographic and malaria parasite smear analysis for malaria diagnosis. Out of 1831 subjects, 338 (18.45%) patients were positive for malarial parasite while the species prevalence was found as 276 (81.66%) and 62 (18.34%) for Plasmodium vivax, and Plasmodium falciparum, respectively. Furthermore, seasonal variations gradual increase in the prevalence rate. The age group of 21-30 years (30.47%) was found more prone to malaria. The suspected malaria cases were found more frequent in rural (72.1%) as compared to urban (27.9%). In addition, the malaria burden was high in urban area (22.89%) population as compared to the rural area (16.74%) population. It was observed that the highest disease occurrence was caused by P. vivax, which reflects a serious threat for public health. The current findings will be helpful to plan effective strategies to prevent and control malaria in this area.

Are all patients diagnosed with tuberculosis in Indian medical colleges referred to the RNTCP?

To assess the proportion of tuberculosis (TB) patients diagnosed in three medical colleges in the states of West Bengal and Meghalaya who benefited from the services provided under the Revised National Tuberculosis Control Programme (RNTCP), a line list of patients with reports of investigations suggesting probable or confirmed TB was prepared from the records of the pathology, radiology and microbiology departments. This was compared with another line list prepared using RNTCP records. Only 150 (36%) of 420 probable or confirmed TB patients were referred to the RNTCP services. This suggests a need for more intensive supervision and training of medical college faculty.

Nutritional evaluation of distillery sludge and its effect as a substitute of canola meal on performance of broiler chickens

The study was conducted to investigate the chemical composition of distillery yeast sludge and its inclusion in broiler diets to replace canola meal. Raw distillery yeast sludge was washed with water using water and sludge in the ratio 6:1, respectively. Proximate analysis of raw distillery yeast sludge and washed distillery sludge was carried out for crude protein (CP), true protein (TP), ether extract (EE), ash, acid insoluble ash and nitrogen free extract (NFE) determination. Mineral contents and amino acid profile of raw distillery yeast sludge and washed distillery sludge were also determined. After chemical evaluation, four iso-caloric and iso-nitrogenous broiler starter and finisher diets were prepared in mash form using 0 (control), 4, 8 and 12% levels of washed distillery sludge replacing canola meal. One hundred and twenty day-old broiler chicks were randomly distributed into 12 experimental units in such a way that each diet was offered to three experimental units, each comprising of 10 chicks. It was observed that washing affected the nutrients either by decreasing or increasing their concentration. It decreased the total mineral contents whereas CP, TP, EE and NFE contents increased. Washing also increased amino acid profile. Average feed intake and weight gain were higher in birds fed diet containing 8% washed distillery sludge and lower in birds fed diet containing 0% washed distillery sludge. Feed cost per kg live weight gain decreased significantly as the level of washed distillery sludge was increased in the diet. Average heart, liver and pancreas weights decreased with increased level of washed distillery sludge in the diet. The study revealed that after washing, distillery yeast sludge can be used successfully in broiler diets up to the level of 8% without any adverse effect on broiler’s performance.

Topical vasoconstrictor use for nasal intubation during pregnancy complicated by cardiomyopathy and preeclampsia

Ankylosing spondylitis presents challenges for the obstetric anesthesiologist in administering neuraxial anesthesia or managing the airway. A pregnant patient with ankylosing spondylitis, cardiomyopathy and preeclampsia requiring cesarean delivery was managed with an awake nasotracheal fiberoptic intubation. The use of topical cocaine, epinephrine, phenylephrine, and oxymetazoline to produce nasal vasoconstriction is discussed. Selective alpha-2 agonists that can potentially provide nasal mucosa vasoconstriction and placental vasculature vasodilation are also discussed.

Molecular disruption of NBS1 with targeted gene delivery enhances chemosensitisation in head and neck cancer

BACKGROUND

a fibroblast growth factor 2 (FGF2)-targeted adenoviral system can alter viral tropism and allow for improved transduction and reduced systemic toxicity. This study is to investigate if the FGF2-targeted adenoviral mutant Nijmegen breakage syndrome 1 (FGF2-Ad-NBS1) gene transfer can enhance cisplatin chemosensitisation not only by targeting DNA repair, but also through the induction of antiangiogenesis, whereas at the same time reducing toxicities in treating head and neck squamous cell carcinoma (HNSCC).

METHODS

the human HNSCC cell line was treated in vitro and in a nude mouse xenograft model. We conducted verification of binding ability of mutant NBS1 and downregulation of MRN complex, evaluation of transduction efficiency and combined antitumour activities. The antiangiogenesis mechanism was also investigated. Finally, we estimated the distribution of adenoviral vector in the liver.

RESULTS

the mutant NBS1 protein retains the binding ability and effectively suppresses the expression level of the MRN in infected cells. Transduction efficiency in vitro and cisplatin chemosensitisation were upregulated. The FGF2-Ad-NBS1 also showed detargeting the viral vectors away from the liver. The downregulation of NF-κB expression was supposed to correlate with increased antiangiogenesis.

CONCLUSIONS

FGF2-targeted adenoviral system enhances the cisplatin chemosensitisation of mutant NBS1 and may avoid viral-associated liver toxicities.

Assessment of radiological hazards of clay bricks fabricated in the Punjab province of Pakistan

The Punjab is the most populous among the four provinces of Pakistan, which has around 72 million of people and 205 344 km(2) of land. The majority of the population of this province lives in houses made of clay bricks that contain variable amounts of naturally occurring radioactive material (NORM). The concentration level of NORM in clay bricks used to construct dwellings may pose health hazards to inhabitants if it exceeds the permissible limits. For radiological surveillance, activity concentrations of the primordial radionuclides (40)K, (226)Ra and (232)Th were measured in 140 brick samples collected from 35 districts of the Punjab province. A high-purity germanium gamma-ray detector coupled with a personal computer-based multichannel analyzer was employed for the measurement of activity concentrations of primordial radionuclides in the brick samples. The province-wide average activity concentrations and the range (given in parenthesis) of (40)K, (226)Ra and (232)Th were found to be 624 ± 133 (299-918), 35 ± 7 (21-47) and 42 ± 8 (22-58) Bq kg(-1), respectively. The values lie within the range of activity concentration values for clay bricks of some countries of Asia. Potential radiological constraint was checked in the form of hazard indices calculated from the measured activity concentrations; the indices were found to be less than their limiting values. Indoor external dose was calculated for a standard size room made of clay bricks, and the dose rate was 159 ± 30 (83-219) nGy h(-1). The average value of the dose rate is comparable to that of Asian countries and is about twice the worldwide average value. Annual effective dose E(ff) in the bricks-made room was calculated and the average value of the dose was 0.80 mSv y(-1), which is about twice the worldwide background value of 0.41 mSv y(-1).

Neovascular AMD: an overlooked risk factor for injurious falls

While those with neovascular age-related macular degeneration (NV-AMD) may be at increased risk of injurious falls risk due to poor central vision and suboptimal responses when falling, preserved peripheral vision and decreased activity levels may actually be protective. Compared with control participants, patients with NV-AMD had a significantly greater number of falls and almost twice the risk of injurious falls.

INTRODUCTION

Impaired vision, particularly peripheral visual function, is a key risk factor for injurious falls. NV-AMD is a leading cause of severely impaired vision among older adults but is associated with a profound central, rather than peripheral, deficit. The objective was to determine whether older women with NV-AMD are at an increased risk of falls or injurious falls.

METHODS

We conducted a 12-month prospective cohort study of community-dwelling older (>or=70 years) women, enrolling 114 with NV-AMD and 132 without from a retinal clinic in Vancouver, Canada. Fall incidence was determined through monthly telephone follow-up, with fall severity classified by a blinded reviewer. We compared mean injurious falls per person-year between groups using negative binomial regression.

RESULTS

A mean of 0.37 injurious falls per person-year were experienced among NV-AMD participants, compared to 0.16 injurious falls per person-year among non-NV-AMD participants (p = 0.006). The age-adjusted incidence rate ratio for injurious falls, for an individual with NV-AMD compared to without, was 1.77 (1.07-3.02).

CONCLUSIONS

Older women with NV-AMD are at almost twice the risk of injurious falls compared to those without. Clinicians caring for older adults should recognise NV-AMD as an important risk factor for injurious falls.

Introduction of Portable Computed Tomography Scanners, in the Treatment of Acute Stroke Patients via Telemedicine in Remote Communities

Background

Thrombolysis is an established treatment in selected patients who present early to hospital after symptoms of acute ischaemic stroke. Treatment can only be offered after the patient has been assessed by highly trained physicians and imaging studies have ruled out a brain haemorrhage. This limits the wider availability of thrombolysis to patients in remote communities, especially in countries with limited resources. There has been considerable success with the use of TeleStroke to overcome such barriers. TeleStroke is feasible in remote hospitals provided there is an available computed tomography scanner, a fundamental prerequisite in the assessment of acute stroke and thrombolysis. This is a luxury not widely available, especially in remote sites. Recently, Neurologica introduced a portable computed tomography scanner that can be operated after minimal training.

Methods

We report our preliminary experience with the portable computed tomography scanner in a remote community where Telemedicine was successfully used to evaluate and treat patients presenting with symptoms suggestive of an acute ischaemic stroke. The University of Alberta Hospital in Edmonton, Canada was the ‘hub’ site and Wainwright Community Hospital was the ‘spoke’ site.

Results

Over a 3-month period, 18 patients were evaluated in the emergency department of the remote hospital where the referring physician felt that symptoms indicated potential for thrombolysis. All patients were evaluated remotely by a stroke neurologist in a TeleStroke service situated 207 km from the rural site. After clinical examination, cranial computed tomography scans were obtained with the portable scanner and evaluated by the stroke neurologist. In three patients, thrombolysis was not offered because the computed tomography showed evidence of brain haemorrhage: two intracerebral haemorrhage and one subarachnoid haemorrhage. Three patients meeting the standard criteria received thrombolysis within 4·5 h from onset of symptoms. There was a significant improvement in two patients. One patient did not make a good recovery. Repeat computed tomography scans showed a small haemorrhagic transformation in one patient. In the remaining 12 subjects, symptoms improved rapidly, were outside the window for thrombolysis, or were not consistent with an acute ischaemic stroke.

Interpretations

Our preliminary study shows that the portable scanner can be used successfully in the evaluation of patients in remote regions that are not within timely reach of stroke experts or do not have available conventional imaging with computed tomography scans. Telemedicine, in combination with the use of portable scanners, offers hope to a large remote population base that would otherwise not have access to appropriate acute stroke treatment.

Radon monitoring in water sources of Balakot and Mansehra cities lying on a geological fault line

This paper relates to a series of systematic studies regarding measurement of radon concentration in the earthquake-affected areas of northern Pakistan. Radon is a radioactive alpha-particle-emitting gas originating from the decay series of uranium and thorium and is found anywhere in soil, air and water. The nature of water does not matter with regard to the presence of radon, however, the level of radon concentration varies in different types of water. The present survey is carried out in water samples from the fault zone of Balakot and Mansehra regions, North West Frontier Province, Pakistan, which is important for geological consideration and protection from radiation hazards. The measurements were made on a Pylon system that is based on the radon gas measurement with a Lucas cell. In 72 water samples in the equilibrium state between radon and its progeny, the concentration level of radon is measured. The results show that the radon concentrations are in the range of 4.99-24.52 kBq/m(3), with an average value of 15.52 kBq/m(3) for all types of water taken in this survey.

Hip protectors: recommendations for conducting clinical trials--an international consensus statement (part II)

INTRODUCTION

While hip protectors are effective in some clinical trials, many, including all in community settings, have been unable to demonstrate effectiveness. This is due partly to differences in the design and analysis. The aim of this report is to develop recommendations for subsequent clinical research.

METHODS

In November of 2007, the International Hip Protector Research Group met to address barriers to the clinical effectiveness of hip protectors. This paper represents a consensus statement from the group on recommended methods for conducting future clinical trials of hip protectors.

RESULTS AND CONCLUSIONS

Consensus recommendations include the following: the use of a hip protector that has undergone adequate biomechanical testing, the use of sham hip protectors, the conduct of clinical trials in populations with annual hip fracture incidence of at least 3%, a run-in period with demonstration of adequate adherence, surveillance of falls and adherence, and the inclusion of economic analyses. Larger and more costly clinical trials are required to definitively investigate effectiveness of hip protectors.

Hip protectors: recommendations for biomechanical testing--an international consensus statement (part I)

INTRODUCTION

Hip protectors represent a promising strategy for preventing fall-related hip fractures. However, clinical trials have yielded conflicting results due, in part, to lack of agreement on techniques for measuring and optimizing the biomechanical performance of hip protectors as a prerequisite to clinical trials.

METHODS

In November 2007, the International Hip Protector Research Group met in Copenhagen to address barriers to the clinical effectiveness of hip protectors. This paper represents an evidence-based consensus statement from the group on recommended methods for evaluating the biomechanical performance of hip protectors.

RESULTS AND CONCLUSIONS

The primary outcome of testing should be the percent reduction (compared with the unpadded condition) in peak value of the axial compressive force applied to the femoral neck during a simulated fall on the greater trochanter. To provide reasonable results, the test system should accurately simulate the pelvic anatomy, and the impact velocity (3.4 m/s), pelvic stiffness (acceptable range: 39-55 kN/m), and effective mass of the body (acceptable range: 22-33 kg) during impact. Given the current lack of clear evidence regarding the clinical efficacy of specific hip protectors, the primary value of biomechanical testing at present is to compare the protective value of different products, as opposed to rejecting or accepting specific devices for market use.

Prognosis in isolated gastroschisis with bowel dilatation: a systematic review

OBJECTIVES

To investigate prognosis of the fetus with isolated gastroschisis and bowel dilatation from a systematic review of the literature. We aimed to compare the incidence of (a) intrauterine death, (b) death within 4 weeks of delivery, (c) bowel resection, (d) length of time to oral feeds and (e) time as inpatient in fetuses with gastroschisis with and without evidence of bowel dilatation.

METHODS

Literature was identified by searching two bibliographical databases between 1980 and 2007. Studies were assessed for quality and stratified according to the definition of bowel dilatation. The data extracted were inspected for clinical and methodological heterogeneity.

RESULTS

The search strategy yielded 1335 potentially relevant citations. Full manuscripts were retrieved for 92 citations. 10 studies (273 patients) were finally included in the systematic review. No difference was found between groups for death within 4 weeks of delivery (OR = 0.62 (95% CI 0.11 to 3.32); heterogeneity p = 0.39) or bowel resection (OR = 3.35 (95% CI 0.82 to 13.74); heterogeneity p = 0.39). There were insufficient data to compare the risk of intrauterine death and length of time to oral feeds. The mean inpatient stay was not significantly different between groups (OR = 16.63 (95% CI 0.98 to 32.28); heterogeneity p = 0.23).

CONCLUSION

Current available evidence suggests that fetuses with isolated gastroschisis and bowel dilatation are not at increased risk of adverse perinatal outcome compared to those without bowel dilatation. However, there is a paucity of studies, and a randomised controlled trial is urgently needed.

Factors affecting the stability of L-glutamine in solution

The degradation rate of L-glutamine in water, various buffers, and intravenous solutions was assessed over a period of 2 weeks. Measurements were made at various temperatures (22-24 degrees C, and 4 degrees C and -80 degrees C) and pH, and also in the presence and absence of light and oxygen (intravenous solutions only). At 22-24 degrees C, the degradation rate of glutamine was variable depending on the type of solution used (0.23% in water pH 6.5; 0.22% in dextrose/water [15% w/v]; 0.8% in mixed total parenteral nutrition (TPN) solution), and on the pH, molarity and type of buffer used. The degradation rate was essentially unaffected by light and O(2). The degradation rate of L-glutamine in the intravenous solutions was less than 0.15%/day at 4 degrees C, minimal at -20 degrees C (<0.03%/day), and undetectable at -80 degrees C. Glutamine degradation resulted in the equimolar formation of ammonia and no associated formation of glutamate. It is concluded that (a) glutamine degradation in solution is variable due to the effect of physico-chemical factors, and (b) glutamine degradation in TPN solutions is sufficiently slow, especially during storage at 4 degrees C or below, to consider its inclusion in such solutions, for clinical use.

Expression of somatostatin and dopamine 2 receptors in neuroendocrine tumours and the potential role for new biotherapies

INTRODUCTION

Somatostatin and dopamine receptors are both G-protein-coupled receptors. Somatostatin receptor (SSTR) expression in neuroendocrine tumours has been well characterised, and there is evidence of dopamine receptor expression in neuroendocrine tumours. In this study, we examined expression of D2R, SSTR-2 and SSTR-5 using immunohistochemistry in patients with neuroendocrine tumours.

METHODS

Consecutive samples of formalin-fixed paraffin-embedded tumour tissue were available from 56 patients with a histologically confirmed diagnosis of neuroendocrine tumour (NET). The study population was divided into low-grade (n = 29), intermediate-grade (n = 18) and high-grade NET (n = 9). Immunohistochemical evaluation was performed for the expression of SSTR-2a, SSTR-5 and D2 receptors (D2R).

RESULTS

Both SSTR-2 and SSTR-5 were expressed in 100% of low-grade, 94.4% of intermediate-grade and 66.7% of high-grade NET. D2R was expressed in 93.1% of low-grade, 77.8% of intermediate-grade and 44.4% of high-grade tumours. Co-expression of all 3 receptors was present in 93.1% of low-grade tumours. There was an inverse correlation of SSTR-2 (r = -0.380, p < 0.005) and SSTR-5 (r = -0.472, p < 0.0001) with tumour grade. D2R was positively correlated with SSTR-2 (r = 0.269, p = 0.041) and SSTR-5 (r = 0.267, p = 0.045). Also, D2R expression was inversely correlated with grade of tumour (r = 0.395, p = 0.006). Octreoscan correlated with SSTR-2, SSTR-5 and D2R expression.

CONCLUSION

D2R is expressed in the majority of low and intermediate grade tumours. It is co-expressed with SSTR-2 and SSTR-5 in the majority of cases. The advent of new chimeric molecules that bind both somatostatin and dopamine receptors may provide a new therapeutic option in the management of neuroendocrine patients.

Environmental gamma radiation measurement in district Swat, Pakistan

External exposure to environmental gamma ray sources is an important component of exposure to the public. A survey was carried out to determine activity concentration levels and associated doses from (226)Ra, (232)Th, (40)K and (137)Cs by means of high-resolution gamma ray spectrometry in the Swat district, famous for tourism. The mean concentrations for (226)Ra, (232)Th and (40)K were found to be 50.4 +/- 0.7, 34.8 +/- 0.7 and 434.5 +/- 7.4 Bq kg(-1), respectively, in soil samples, which are slightly more than the world average values. However, (137)Cs was only found in the soil sample of Barikot with an activity concentration of 34 +/- 1.2 Bq kg(-1). Only (40)K was determined in vegetation samples with an average activity of 172.2 +/- 1.7 Bq kg(-1), whereas in water samples, all radionuclides were found below lower limits of detection. The radium equivalent activity in all soil samples is lower than the limit set in the Organisation for Economic Cooperation and Development report (370 Bq kg(-1)). The value of the external exposure dose has been determined from the content of these radionuclides in soil. The average terrestrial gamma air absorbed dose rate was observed to be 62.4 nGy h(-1), which yields an annual effective dose of 0.08 mSv. The average value of the annual effective dose lies close to the global range of outdoor radiation exposure given in United Nations Scientific Committee on the Effects of Atomic Radiation. However, the main component of the radiation dose to the population residing in the study area arises from cosmic ray due to high altitude.

An open-label pilot study of infliximab therapy in diffuse cutaneous systemic sclerosis

AIM

The safety and potential efficacy of a chimaeric anti-tumour necrosis factor alpha monoclonal antibody (infliximab) were examined in diffuse cutaneous systemic sclerosis (dcSSc).

METHODS

A 26-week open-label pilot study in which 16 cases of dcSSc received five infusions of infliximab (5 mg/kg). Clinical assessment included skin sclerosis score, scleroderma health assessment questionnaire, self-reported functional score and physician global visual analogue scale. Collagen turnover, skin biopsy analysis and full safety evaluation were performed.

RESULTS

There was no significant change in skin score at 26 weeks but a trend for lower modified Rodnan skin score at 22 weeks (OR 17, 95% CI 6 to 46) compared with peak value (OR 29, 95% CI 11 to 44; p = 0.10). Serum aminoterminal propeptide of type III collagen level was significantly lower at week 26 compared with baseline (p = 0.03). Secretion of type I collagen by dermal fibroblasts was reduced at 26 weeks compared with baseline (p = 0.02). There were no deaths during the study and no suspected unexpected serious adverse reactions. 21 serious adverse events (AE) occurred in seven subjects, mostly attributable to dcSSc. 127 distinct AE occurred in 16 subjects. Of these, 19 AE (15%) were probably or definitely related to infliximab treatment. Eight (50%) patients prematurely discontinued infliximab. Anti-infliximab antibodies developed during the study in five subjects and were significantly associated with suspected infusion reactions (p = 0.025).

CONCLUSION

In dcSSc infliximab did not show clear benefit at 26 weeks but was associated with clinical stabilisation and a fall in two laboratory markers of collagen synthesis. The frequency of suspected infusion reactions may warrant additional immunosuppression in any future studies in systemic sclerosis.

Mortality estimates in the elderly burn patients: the Northern Ireland experience

There is a relative paucity of mortality data in the medical literature from UK burn units. The objective of this study was to audit our mortality in the elderly during a 10-year period and compare it with the most robust data available in the UK from Birmingham. Data were collected on all patients 65 years of age and older between 1st January 1996 and 31st December 2005. Data included age, burn size, cause of thermal injury, outcome (survival/death) and the expected mortality derived from the revised Bull mortality grid. Notes on 143 patients were available for review. The mean age was 76.7 years and the maximum burn size treated was 65%. Ten patients were diagnosed with smoke inhalation. All but 22 patients had a pre-morbid condition, predominantly cardiovascular disease. Surgical procedures were performed on 113 patients. We performed excision and grafting of burned tissue, in 50% of patients, within 72 h of sustaining thermal injury. There were 18 deaths in the group while the expected number of deaths was estimated to be 33. This difference was found to be statistically significant (x(2)=8.92, d.f.=1, p<0.005). In conclusion, our experience has shown better survival in the elderly than was expected. This we mainly attribute to an aggressive therapy approach including admission to the intensive care unit and early surgery.

Clinical role of flow cytometry in redefining bone marrow involvement in diffuse large B-cell lymphoma (DLBCL) - a new perspective

AIMS

The clinical role of flow cytometry in staging bone marrow in diffuse large B-cell lymphoma (DLBCL), especially its impact on outcome, remains uncertain. The aim was to determine the contribution of flow cytometry to conventional staging, and to study the impact of this revised staging on survival.

METHODS AND RESULTS

One hundred and thirteen cases of DLBCL diagnosed at The Canberra Hospital from 1996 to 2005 were identified. Blinded analysis of bone marrow (BM) morphology and flow cytometric data showed involvement on morphology (M) in 25 (22.1%) cases, on flow cytometry (F) in 21 (18.6%) cases and overall (M + F) in 32 cases (28.3%); discordance was noted in 16 cases (16.1%). Cases with and without marrow involvement on conventional staging alone (M) had no significant difference in survival (P = NS). However, when BM involvement was defined as positivity on morphology and/or flow cytometry (M + F), the median survival of patients with involvement was significantly worse than patients without involvement (P = 0.026).

CONCLUSIONS

Flow cytometry-positive cases should be included with those positive on morphology in a summative model to define BM involvement in DLBCL, as it may have a potential impact on predicting outcome.

Ergebnisse nach Verwendung der BI-RADS®-Kategorien an 1777 klinischen Mammographien

PURPOSE

The purpose of our study was to evaluate the results after using the BI-RADS categories in clinical mammography, especially in the BI-RADS 0 and BI-RADS 3 categories.

MATERIAL AND METHODS

During 1 year clinical mammograms were performed in 1,777 patients. The assessment reported by radiologists was based on the American College of Radiology using BI-RADS categories. In BI-RADS 0 and BI-RADS 3 categories additional examinations, histopathological results, und follow-up results were reported.

RESULTS

Of 1,777 mammograms, 135 (4.1%) were classified into the BI-RADS 0 category. In 60 of 67 (90%) findings categorized as BI-RADS 0, MR mammography was performed and the results of the mammograms were ultimately classified into the BI-RADS 2 category. In 18 of 135 (13.3%) patients with BI-RADS 0 no further examinations were done. In 113 of 1,777 (3.4%) mammograms were classified into the BI-RADS 3 category. In 11 of 113 (9.7%) patients with BI-RADS 3 histopathology was done. A follow-up mammogram after 6 months was done only in 24 of 102 (23%) patients. In 21 of 102 (18.5%) patients with BI-RADS 3 follow-up mammograms were not performed.

CONCLUSIONS

Not all patients with mammographic lesions in the BI-RADS 0 category avail themselves of further diagnostic work-up. Therefore in BI-RADS 0 category lesions, additional work-up should be performed directly after mammography during the same consultation. In some cases of BI-RADS 0 category, MR mammography is able to resolve the problem. Therefore the indication for MR mammography should be more commonly used.

Optical coherence tomographic pattern may predict visual outcome after intravitreal triamcinolone for diabetic macular edema

OBJECTIVE

To identify an optical coherence tomography (OCT) pattern predictive of visual outcome in patients with diabetic macular edema (DME) who underwent a single dose of intravitreal triamcinolone.

DESIGN

Retrospective case analysis with prospective data collection for controls.

PARTICIPANTS

Ninety-three cases and 25 controls.

METHODS

Two independent masked observers retrospectively examined preoperative macular OCTs of 93 eyes of 93 patients who were given a single dose (4 mg in 0.1 ml) of intravitreal triamcinolone for DME and categorized them as belonging to 2 groups: 1, comprised of eyes with high reflectivity (bright colors) from inner retinal layers, and 2, comprised of eyes that had low reflectivity (darker colors) from inner retinal layers. Logarithm of the minimum angle of resolution visual acuity (VA) and macular thickness measured by OCT were assessed preoperatively and postoperatively at 1 and 3 months.

MAIN OUTCOME MEASURES

Optical coherence tomographic appearance of inner retinal layers.

RESULTS

All patients completed 3 months of follow-up. In group 1, 45 of 51 eyes (88%) experienced visual improvement of > or =2 lines on an Early Treatment Diabetic Retinopathy Study (ETDRS) chart at 1 month of follow-up. Forty-four of 51 patients (86%) experienced visual improvement of > or =2 lines on an ETDRS chart at 3 months of follow-up. In group 2, 18 of 42 patients (43%) experienced visual improvement of > or =1 lines on an ETDRS chart at 1 and 3 months of follow-up. For the remaining patients, VA remained unchanged during the postoperative course of 3 months.

CONCLUSIONS

Patients in whom OCT demonstrated the high reflectivity of inner retinal layers achieved greater VA though macular thickness decreased significantly after intravitreal triamcinolone in both groups. It may be hypothesized that a lower optical reflectivity of inner retinal layers is related to the atrophy of the inner retinal layers, thus resulting in a failure of VA recovery in these patients. The level of reflectivity from inner retinal layers on OCT may provide objective criteria in predicting the response of DME to intravitreal triamcinolone and help in preoperative counseling of patients with DME.