Long-term clinical outcome following lower limb arterial angioplasty

INTRODUCTION

The aim of this study was to determine the clinical outcome of lower limb arterial angioplasty in a busy district general hospital practice.

PATIENTS AND METHODS

All angioplasties performed from January 1999 to December 2004 were identified and data collected included cardiovascular risk factors, indications for and complications of angioplasty, limb salvage and patient survival rates, and clinically significant re-stenoses.

RESULTS

471 interventions were performed in 385 patients (231 men, 154 women). The median age was 67.9 years (range: 39-93 years). Indications for angioplasty were critical ischaemia (n=247, 52%) and lifestyle-limiting intermittent claudication (n=224, 48%). Stenotic lesions accounted for 378 (80%) cases and occlusion for 93 (20%). Radiological success was obtained in 417 (88.5%), improving to 93.6% if only those in whom access was achieved were included. Post-angioplasty complications were observed in 42/471 (9.1%) of interventions. The actual patient survival at 1, 2, and 3 years was 87.4%, 85.1% and 83.2% respectively. Indication for angioplasty and the number of lesions present were identified as risk factors for outcome on multivariate analysis. The cumulative post-angioplasty patency rates at 1, 2 and 3 years were 86.0%, 83.1% and 81.6% respectively. The only factor associated with patency was the mode of presentation.

CONCLUSIONS

Angioplasty for lower limb peripheral vascular disease can be performed safely and efficaciously with a high technical success rate and a low complication rate. The patient survival and post-angioplasty patency data reflect the progressive and multi-site nature of the underlying disease process.

Severe orthostatic hypotension in a diabetic patient may not be due to diabetic autonomic neuropathy

This lesson describes an unusual case of a man who was recently diagnosed with type 1 diabetes and who presented with severe orthostatic hypotension. As his diabetes was recent in onset, well controlled, and he had no other signs of microvascular disease, other causes of orthostatic hypotension were sought. His serum and cerebrospinal fluid were strongly positive for Borrelia burgdorferi IgG, suggesting a diagnosis of Lyme neuroborreliosis. Autonomic instability in Lyme, while rare, has been previously reported.

Q fever: the neglected biothreat agent

Coxiella burnetii is the causative agent of Q fever, a disease with a spectrum of presentations from the mild to fatal, including chronic sequelae. Since its discovery in 1935, it has been shown to infect a wide range of hosts, including humans. A recent outbreak in Europe reminds us that this is still a significant pathogen of concern, very transmissible and with a very low infectious dose. For these reasons it has also featured regularly on various threat lists, as it may be considered by the unscrupulous for use as a bioweapon. As an intracellular pathogen, it has remained an enigmatic organism due to the inability to culture it on laboratory media. As a result, interactions with the host have been difficult to elucidate and we still have a very limited understanding of the molecular mechanisms of virulence. However, two recent developments will open up our understanding of C. burnetii: the first axenic growth medium capable of supporting cell-free growth, and the production of the first isogenic mutant. We are approaching an exciting time for expanding our knowledge of this organism in the next few years.

MUC1 as a discriminator between endometrium from fertile and infertile patients with PCOS and endometriosis

CONTEXT

Endometrium of fertile women expresses progesterone-regulated Mucin 1 (MUC1) that carries selectin ligands recognized by the human blastocyst. Altered MUC1 expression at the time of implantation may contribute to endometrial infertility.

OBJECTIVE

The aim was to assess the expression of MUC1 in the endometrium from polycystic ovary syndrome (PCOS), endometriosis, and fertile women in comparison with other hormone-regulated proteins [hydroxysteroid dehydrogenase (HSD) 1, HSD2, estrogen receptor (ER) and progesterone receptor (PR)].

DESIGN AND PATIENTS

Endometrial samples were obtained from 33 fertile patients, 26 ovulatory PCOS patients, 15 anovulatory PCOS patients, and 25 endometriosis patients.

MAIN OUTCOME MEASURE

Immunohistochemistry assessed the expression of MUC1 subunits ER, PR, HSD1, and HSD2 in endometrial epithelium. Endometrial MUC1 expression was quantified by immunoblots and RT-PCR. HSD1 and HSD2 expression was assayed by RT-PCR.

RESULTS

MUC1ND expression was significantly higher in ovulatory PCOS than in fertile and anovulatory PCOS patients, even after progesterone stimulation. MUC1ND and -CD expression was lower in anovulatory PCOS than in fertile patients. Only MUC1CD expression was lower in endometriosis patients. Endometrial ER expression was significantly higher in PCOS and endometriosis patients, whereas PR expression was significantly higher in PCOS than in fertile patients. The expression of HSD1 was significantly higher in anovulatory PCOS than in fertile patients. Expression of HSD2 was significantly higher in PCOS patients and lower in endometriosis patients.

CONCLUSION

Expression of MUC1 subunits in the infertile endometrium is significantly different from fertile and appears to be a component of altered gene expression that potentially contributes to endometrial insufficiency.

Structure of lipid tubules formed from a polymerizable lecithin

We have studied tubules formed from a polymerizable lipid in aqueous dispersion using freeze-fracture replication and transmission electron microscopy. The polymerizable diacetylenic lecithin 1,2-bis(10,12-tricosadiynoyl)-sn-glycero-3-phosphocholine converts from liposomes to hollow cylinders, which we call tubules, on cooling through its chain melting phase transition temperature. These tubules differ substantially from cochleate cylinders formed by phosphatidylserines on binding of calcium. The tubules have diameters that range from 0.3 to 1 mum and lengths of up to hundreds of micrometers depending on conditions of formation. The thickness of the walls varies from as few as two bilayers to tens of bilayers in some longer tubules. Their surfaces may be either smooth, gently rippled, or with spiral steps depending on sample preparation conditions, including whether the lipids have been polymerized. The spiral steps may reflect the growth of the tubules by rolling up of flattened liposomes.

Comparative study of kala-azar vector control measures in eastern Nepal

This study was conducted to explore the most effective vector control tool among indoor residual spraying (IRS), long lasting insecticidal nets (LLINs) and ecological vector management (EVM) as a part of the regional visceral leishmaniasis elimination initiative. Alpha-cypermethrin as IRS, PermaNet as LLINs and plastering the inner walls of houses with lime as EVM were the interventions. One baseline and three follow-up entomological surveys were carried out in all arms using CDC miniature light traps (LT) and mouth aspirators. Comparisons were made between intervention arms and control arms with pre-intervention and post-intervention vector densities. Light traps were found more efficient in the collection of Phlebotomus argentipes in comparison with aspiration. Vector densities were significantly low in both IRS arm (p=0.009 in LT and p<0.001 in aspirator collections) and LLIN arm (p=0.019 in LT and p=0.023 in aspirator collections) in comparison with control arm. However, in EVM arm, there was no significant difference in P. argentipes sand fly density in comparison with control arm (p=0.785) in LT collections in follow-up surveys. Hence, IRS was found most effective control measure to decrease vector density. LLINs were also found effective and can be considered as a promising alternative vector control tool in VL elimination initiative.

Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast

Individual patient data were available for all four of the randomized trials that began before 1995, and that compared adjuvant radiotherapy vs no radiotherapy following breast-conserving surgery for ductal carcinoma in situ (DCIS). A total of 3729 women were eligible for analysis. Radiotherapy reduced the absolute 10-year risk of any ipsilateral breast event (ie, either recurrent DCIS or invasive cancer) by 15.2% (SE 1.6%, 12.9% vs 28.1% 2 P <.00001), and it was effective regardless of the age at diagnosis, extent of breast-conserving surgery, use of tamoxifen, method of DCIS detection, margin status, focality, grade, comedonecrosis, architecture, or tumor size. The proportional reduction in ipsilateral breast events was greater in older than in younger women (2P < .0004 for difference between proportional reductions; 10-year absolute risks: 18.5% vs 29.1% at ages <50 years, 10.8% vs 27.8% at ages ≥ 50 years) but did not differ significantly according to any other available factor. Even for women with negative margins and small low-grade tumors, the absolute reduction in the 10-year risk of ipsilateral breast events was 18.0% (SE 5.5, 12.1% vs 30.1%, 2P = .002). After 10 years of follow-up, there was, however, no significant effect on breast cancer mortality, mortality from causes other than breast cancer, or all-cause mortality.

042. THE EFFECT OF THE INSECTICIDE PYRIPROXYFEN ON OVARY SYNTHESIS IN THE CHRISTMAS ISLAND RED CRAB, GECARCOIDEA NATALIS; A POSSIBLE CASE OF ENDOCRINE DISRUPTION?

The yellow crazy ant, Anopholepis gracilipes is an invasive species on Christmas Island, Indian Ocean whose population needs to be controlled before there is irrevocable environmental damage. The insecticide, pyriproxyfen, a compound which mimics juvenile hormone of insects, has been proposed to do this. Before it can be used in the field, its effects on non target species such as the endemic red crab, Gecarcoidea natalis, need to be investigated. Land crabs, like all decapods, may utilise a similar hormone called methyl farnesoate which is thought to be involved in controlling early ovary development. Pyriproxyfen may also mimic methyl farnesoate and thus disrupt this process. The effect of pyriproxyfen on early ovary synthesis in G. natalis was investigated by feeding crabs a mixture of leaf litter and bait containing 0.5% pyriproxyfen (experimental groups) or a mixture of leaf litter and bait containing no pyriproxyfen (control groups) at simulated baiting doses (2 kg ha–1 and 4 kg ha–1). Two additional groups of crabs were fed ad libitum, either bait containing 0.5% pyriproxyfen or the control bait. Experiments were conducted from July to September of 2007. Red crabs synthesise their ovaries annually over two months (July to September) in the dry season. This situation of high nitrogen demand is funded from small excesses of nitrogen assimilated from a mainly leaf litter diet. Pyriproxyfen affected early ovary development. Ovaries from crabs in the experimental groups at all baiting levels had a higher total nitrogen content and dry mass than that of the control animals. The ovaries from the experimental animals were also more mature; they contained more previtellogenic and early vitellogenic oocytes, of a larger diameter, than ovaries of the control animals. Significant amounts of pyriproxyfen were accumulated in the target tissues, the midgut gland and ovary. Minor amounts of pyriproxyfen were accumulated in muscle, a non-target tissue. By mimicking methyl farnesoate, pyriproxyfen may have caused endocrine disruption in G. natalis. In particular it may have stimulated early ovary development and synthesis of yolk protein.

Buttock cellulitis as a presentation of psoas abscess: a clinical reminder

Cellulitis is a common condition that is frequently managed by the general physicians on an acute medical take. This case report describes buttock cellulitis as a presentation of an iliopsoas abscess and illustrates the importance of considering a deep abscess when there are atypical features, when the cellulitis is in an unusual location or when the patient fails to improve with standard anti-microbial therapy.

Grade 3 Status Dominates Prognosis in Breast Cancer

Background: Histological grading (HG) is probably the most important clinico-pathological parameter that will provide information about tumour intrinsic characteristics and aggressiveness. HG is included in prognostic guidelines for treatment decision making such as St Gallen, Nottingham Prognostic Index and Adjuvant!Online. Grade 3 (G3) Breast cancer (BC) is associated with poor prognosis in terms of survival and recurrence. G3 BC reflects independent biological entities rather than being the end of the spectrum of cancer progression. Our aim is to establish the clinical relevance of HG as prognostic factor in a specific cohort of BC patients and define its relation with survival and recurrence endpoints.Method: This is a retrospective cohort analysis from 1489 operable Breast Cancer patients attending the Oncology Service at Singleton Hospital, Wales, UK between 1996 and 2002.HG was recorded for 1339 cases and outcome data were available on 1213 cases. Correlation of clinical variables with Overall Survival (OS), Distant Disease Free Survival (DDFS) and Disease Free Survival (DFS) was performed using Cox regression model.Results:The median follow-up for the cohort was 5.43 years (range 0.09 to 10.14 years) Patients were characterised according to age, HG, tumour size (TNM-T), nodal status, ER status and systemic treatment received (polychemotherapy/tamoxifen). Independent Cox regression models for each endpoint were developed based on univariate analyses. Multivariate analysis results are presented in Figure 1.Subgroup analysis of G3 cases showed a younger population: median age G3 59.4y vs G1/G2 62.9 y p:&lt; 0.001); 47.5% of G3 cases were ER positive against 94.5% of Grade 1/2 (p &lt; 0.001). Patients with G3 tumours died more rapidly from all causes (median time to death 2.22 vs 3.42 y, p &lt;0.001) and from BC (median time to death from BC 2.22 y vs 3.82 y in G1/G2, p &lt;0.001) than other HG. Similarly, G3 also relapsed quicker both distantly, (median time 1.64 vs 2.54 y G1/G2 (p&lt;0.04) and locally, median time to relapse 1.6 vs 2.35 y for G1/G2 (p&lt;0.036). There was also a significant association between grade and tumour size (median G1/G2 1.7cm vs G3 2.2cm(p&lt; 0.001); and nodal involvement and tumour size, median 1.5cm N-ve, 2.2 cm N+ve (p&lt; 0.001).Conclusion: Patients with G3 tumours tended to be younger, had a more advanced TNM staging at diagnosis and relapsed and died more rapidly than other histological grades. In our cohort, G3 tumours were adversely associated with OS, DDFS and DFS with a stronger association with these endpoints than node positivity. It is perhaps time to reconsider the HG as a prognostic factor as important as nodal status for the selection of adjuvant chemotherapy regimens.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6005.

Molecular Heterogeneity of Grade 3 Breast Cancer

Background: Histological grade (HG) is one the main prognostic factors used in clinical practice, along with nodal status and tumour size, for the classification of patients into different prognostic groups that support the clinical decision making process and to tailor adjuvant treatment according to specific risk of death or relapse. The aim of this study was to examine the effect of Grade in prognosis in an unselected series of breast cancers, and to examine copy number alteration (CNA) specifically in Grade 3 (G3) breast cancer and its relationship to nodal status (N-ve/N+ve) and clinical outcome, to seek genetically determined markers of prognosis for treatment tailoring in this poor prognosis group.Method: We established a clinical database of 1489 operable Breast Cancer patients attending the Oncology Service at Singleton Hospital, Wales, UK between 1996 and 2002. HG was known for 1339 of these cases, and outcome in 1213, with a median of 5.32 years (range 0.09 - 10.14 years) follow-up. From the 466 G3 cases of primary breast cancer, we analysed 81 cases using 1Mb BAC array CGH for genomic copy number alterations. Spatial normalisation, circular binary segmentation and the CGHcall algorithm was used to generate CGH profiles. Unsupervised hierarchical clustering, supervised, correlation and survival analyses were carried out using packages and tests within the R statistical platform.Results: Patients were characterised according to grade, ER and nodal status. Kaplan Meier analysis for overall survival (OS) and disease specific survival (DFS) confirmed the poor prognosis of G3 (Cox proportional hazards regression, Wald-test p-value &lt;&lt; 0.05). The majority of G1 (98%) and G2 (93%) cases were ER +ve, whereas 52.5% G3 cases were ER-ve. ER status was known for 316 of the 466 G3 cases, and ER negativity was significantly associated with a decreased OS (p-value 0.02), but not DFS (p-value: 0.13). Similarly N+vity also showed significant correlation with both OS and DFS (p-values &lt; 0.05). BAC aCGH analysis showed significant copy number gains on chromosomes 1,4,5,7,11 and 21 in N+ve and losses on chromosomes 1,6 and 10 in N-ve G3. One region of chromosome 1 (1p36 – 1p35) in particular was lost in N0 but gained in N+ve, and this was significantly associated with ER-ve/N+ve cases (FDR p-value &lt; 0.05). BAC aCGH profiles did not significantly associate with ER status in G3 disease. Two clusters, delineated on unsupervised hierarchical cluster analysis, correlated with OS. Neither correlated with nodal or ER status, indicating that further analysis may discover genes of prognostic potential within these profiles.Conclusion HG was significantly associated with clinical outcome and ER status. Genomic copy number analysis (CNA) in G3 breast cancer revealed significant associations between DNA alterations and nodal status and OS. The study is currently being extended to investigate the relationship between specific CNA and clinical outcome in G3 disease.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5167.

Determinants of bednet ownership and use in visceral leishmaniasis-endemic areas of the Indian subcontinent

OBJECTIVE

To document ownership and use of bednets with its determinants in the visceral leishmaniasis (VL)-endemic region where mainly non-insecticide impregnated nets are available through commercial channels, and bednets are being considered as a leishmaniasis vector control measure.

METHODS

In August-September 2006, semi-structured household (HH) questionnaires and observation guides were used in a random sample of 1330 HHs in VL-endemic districts of India and Nepal to collect data on VL knowledge, HH socio-economic status, bednet ownership and use patterns. An asset index was constructed to allow wealth ranking of the HH. A binary logistic response General Estimating Equations model was fitted to evaluate the determinants of bednet ownership and use.

RESULTS

The proportion of HHs with at least one bednet purchased on the commercial market was 81.5% in India and 70.2% in Nepal. The bednets were used in all seasons by 50.6% and 54.1% of the Indian and Nepalese HH owning a bed net. There was striking inequity in bednet ownership: only 38.3% of the poorest quintile in Nepal owned at least one net, compared to 89.7% of the wealthiest quintile. In India, the same trend was observed though somewhat less pronounced (73.6%vs. 93.7%). Multivariate analysis showed that poverty was an important independent predictor for not having a bednet in the HH [OR 5.39 (2.90-10.03)].

CONCLUSION

Given the inequity in commercial bednet ownership, free distribution of insecticide-treated bednets to the general population seems imperative to achieve a mass effect on vector density.

Varenicline and suicidal behaviour: a cohort study based on data from the General Practice Research Database

OBJECTIVE

To determine whether varenicline, a recently licensed smoking cessation product, is associated with an increased risk of suicide and suicidal behaviour compared with alternative treatments bupropion and nicotine replacement therapy.

DESIGN

Cohort study nested within the General Practice Research Database.

SETTING

Primary care in the United Kingdom.

PARTICIPANTS

80,660 men and women aged 18-95 years were prescribed a new course of a smoking cessation product between 1 September 2006 and 31 May 2008; the initial drugs prescribed during follow-up were nicotine replacement products (n=63 265), varenicline (n=10 973), and bupropion (n=6422).

MAIN OUTCOME MEASURES

Primary outcomes were fatal and non-fatal self harm, secondary outcomes were suicidal thoughts and depression, all investigated with Cox's proportional hazards models.

RESULTS

There was no clear evidence that varenicline was associated with an increased risk of fatal (n=2) or non-fatal (n=166) self harm, although a twofold increased risk cannot be ruled out on the basis of the upper limit of the 95% confidence interval. Compared with nicotine replacement products, the hazard ratio for self harm among people prescribed varenicline was 1.12 (95% CI 0.67 to 1.88), and it was 1.17 (0.59 to 2.32) for people prescribed bupropion. There was no evidence that varenicline was associated with an increased risk of depression (n=2244) (hazard ratio 0.88 (0.77 to1.00)) or suicidal thoughts (n=37) (1.43 (0.53 to 3.85)).

CONCLUSION

Although a twofold increased risk of self harm with varenicline cannot be ruled out, these findings provide some reassurance concerning its association with suicidal behaviour.

Cost analysis of an integrated care model in the management of acute exacerbations of chronic obstructive pulmonary disease

Home treatment models for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) proved to be a safe alternative to hospitalization. These models have the potential to free up resources; however, in the United Kingdom, it remains unclear to whether they provide cost savings compared with hospital treatment. Over a 12-month period from August 2003, 130 patients were selected for the integrated care group (total admissions with AECOPD = 546). These patients were compared with 95 retrospective controls in the hospital treatment group. Controls were selected from admissions during the previous 12 months (total of 662 admissions) to match the integrated care group in age, sex, and postal code. Resource use data were collected for both groups and compared using National Health Service (NHS) perspective for cost minimization analysis. In the integrated care group (130 patients), 107 (82%) patients received home support with average length of stay 3.3 (SD 3.9) days compared with 10.4 (SD 7.7) in the hospital group (95 patients). Average number of visits per patients in the integrated care group was 3.08 (SD = 0.95; 95% CI = 2.9—3.2). Cost per patient in the integrated care group was £1653 (95% CI, £1521—1802) compared with £2256 (95% CI, £2126— 2407) in the hospital group. The integrated care group resulted in cost saving of approximately £600 (P < 0.001) per patient. This integrated care model for the management of patients with AECOPD offered cost savings of £600 per patient over the conventional hospital treatment model using the new NHS tariff from an acute trust provider perspective.