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The Decision-Making Value of Magnetic Resonance Cholangiopancreatography in Patients Seen in a Referral Center for Suspected Biliary and Pancreatic Disease. Anand V. Sahai, David Devonshire, Khay G. Yeoh, et al. Am J Gastroenterol 2001; 96:2074–2080. (A.V.S., Départment de Gastroentérologie, CHUM, Campus St Luc, 1058 Rue Saint Denis, Montréal, Québec H2X 3J4, Canada)
Objective: To assess the ability of MRCP to alter the differential diagnosis and to prevent diagnostic and/or therapeutic ERCP. The diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) for biliary and pancreatic disease is well documented. Some believe MRCP may prevent diagnostic ERCP or add useful information, however there are no reports of its impact on clinical management. Methods: Consecutive patients referred for ERCP underwent clinic evaluation, then MRCP, and then ERCP. In Phase 1, the number of differential diagnoses and the perceived need for diagnostic ERCP were evaluated after each step by the endoscopist who performed the ERCP. In Phase 2, the process was repeated after presenting clinical information and MRCP results to different individual physicians: another endoscopist, a hepatologist, a radiologist, and a surgeon (all were blinded to ERCP results). Results: Forty patients were enrolled. Clinical contexts were jaundice (19.7%), abnormal liver enzymes (42.6%), abdominal pain (11.5%), recurrent acute pancreatitis (11.5%), and suspected complications of chronic pancreatitis (14.7%). In Phase 1, adding MRCP information to diagnostic ERCP information did not change the mean number of differential diagnoses significantly and prevented no therapeutic ERCP. In Phase 2, adding MRCP to clinical information only (without ERCP) reduced the differential diagnosis significantly for the radiologist and the surgeon only and would have prevented 
3% of diagnostic and therapeutic ERCP for all physicians. Conclusion: The value of MRCP information may be limited if patient selection is inappropriate and may differ in physicians depending on their speciality.
Authors’ Abstract
Reasons for selecting abstract:
• Comparison of MRCP and ERCP
Selected by Philip Goodman, MD
University of Kentucky Medical Center, Lexington
Value of Magnetic Resonance Cholangiography in the Preoperative Diagnosis of Common Bile Duct Stones. Aklesso Laokpessi, Philippe Bouillet, Denis Sautereau, et al. Am J Gastroenterol 2001; 96:2354–2359. (A.L., Service Hépato-Gastroentérologie, CHU Dupuytren, 2 Avenue Martin Luther King, 87042 Limoges, France)
Objective: The aim of this study was to assess the performance of magnetic resonance cholangiography (MRC) in the preoperative diagnosis of choledocholithiasis. Methods: A total of 147 consecutive patients underwent MRC for clinical and biological signs of common bile duct stones. ERCP was then carried out in 101 patients in whom there was a past history of cholecystectomy. The remaining 46 patients without a past history of biliary surgery underwent cholecystectomy and intraoperative cholangiography (IOC). The diagnosis obtained by MRC was compared with the final diagnosis established after endoscopic or surgical removal of calculi. Results: A total of 113 patients had choledocholithiasis (single or multiple, including 15 cases of microlithiasis). There were no false-positive results with MRC. The falsenegative results were caused mainly by small stones <3 mm in diameter, and to a lesser extent, cholangitis. Overall, the sensitivity was 93% and the specificity 100% for MRC in detecting common bile duct stones. The sensitivity and specificity of ERCP were respectively 94% and 100%, versus 93.5% and 93.3% for IOC. There was no statistically significant difference, however, between MRC and the other techniques. Conclusion: MRC is a key technique in the preoperative diagnosis of choledocholithiasis. Its diagnostic value is comparable to ERCP, but it appears to be more specific than IOC. Nevertheless, its diagnostic capability remains limited in cases of microlithiasis and cholangitis.
Authors’ Abstract
Reasons for selecting abstract:
• Comparison of MRCP and ERCP
Selected by Philip Goodman, MD
University of Kentucky Medical Center, Lexington
Malignant Melanoma: Patterns of Metastasis to the Small Bowel, Reliability of Imaging Studies, and Clinical Relevance. Greg N. Bender, Dean D. T. Maglinte, John H. McLarney, et al. Am J Gastroenterol 2001; 96:2392–2400. (D.D.T.M., Department of Radiology, Indiana University Hospital, 550 N University Blvd, Indianapolis, IN 46202-5253)
Objectives: The aims of this study were to determine the frequency of different patterns of melanoma metastases to small bowel on radiological examination, and to assess the reliability of the most commonly used radiological methods for detecting these lesions. Methods: The records of cases archived as melanoma metastatic to the small bowel of the Armed Forces Institute of Pathology were reviewed. The clinical information, type of imaging procedure performed, and radiological features were analyzed and compared to the findings at surgery and at autopsy. Results: A total of 32 patients had clinical and surgical data with pathological confirmation. Seven patients had metastasis involving the duodenum, 22 had jejunal involvement, and 11 had ileal involvement. Metastases were categorized as polypoid, cavitary, infiltrating, or exoenteric. The polypoid pattern was seen in 20 patients (63%), six of whom showed multiple polypoid lesions (>10), referred to as polyposis. The "target lesion," a discrete polypoid mass with a central ulceration, was observed in only three (9%) of the 32 patients. Eight patients (25%) demonstrated a cavitary pattern, a circumferential mass with inner marginal necrosis, and five (16%) showed an infiltrating pattern. One patient (3%) had an exoenteric lesion with a fistulous tract. The small bowel follow-through demonstrated 32 of 55 metastases (sensitivity 58%). Contrast-enhanced CT demonstrated 32 of 48 masses (sensitivity 66%). Of the six cases of malignant polyposis, none were identified using CT, and only two were diagnosed by small bowel follow-through. Conclusions: The polypoid pattern, equally distributed between the jejunum and ileum, is the most common manifestation of metastatic melanoma to the small bowel. The target lesion was infrequently seen in this series. Small bowel follow-through and conventional CT seem to be unreliable in demonstrating melanoma metastases to the small bowel.
Authors’ Abstract
Reasons for selecting abstract:
• Review of Armed Forces Institute of Pathology cases
Selected by Philip Goodman, MD
University of Kentucky Medical Center, Lexington
Chemoradiotherapy after Surgery Compared with Surgery Alone for Adenocarcinoma of the Stomach or Gastroesophageal Junction. John S. Macdonald, Stephen R. Smalley, Jacqueline Benedetti, et al. N Engl J Med 2001; 345:725–730. (Publications Office, Southwest Oncology Group [SWOG-9008], Operations Office, 14980 Omicron Dr, San Antonio, TX 78245-3217)
Background: Surgical resection of adenocarcinoma of the stomach is curative in less than 40 percent of cases. We investigated the effect of surgery plus postoperative (adjuvant) chemoradiotherapy on the survival of patients with resectable adenocarcinoma of the stomach or gastroesophageal junction. Methods: A total of 556 patients with resected adenocarcinoma of the stomach or gastroesophageal junction were randomly assigned to surgery plus postoperative chemoradiotherapy or surgery alone. The adjuvant treatment consisted of 425 mg of fluorouracil per square meter of body-surface area per day, plus 20 mg of leucovorin per square meter per day, for five days, followed by 4500 cGy of radiation at 180 cGy per day, given five days per week for five weeks, with modified doses of fluorouracil and leucovorin on the first four and the last three days of radiotherapy. One month after the completion of radiotherapy, two five-day cycles of fluorouracil (425 mg per square meter per day) plus leucovorin (20 mg per square meter per day) were given one month apart. Results: The median overall survival in the surgery-only group was 27 months, as compared with 36 months in the chemoradiotherapy group; the hazard ratio for death was 1.35 (95 percent confidence interval, 1.09 to 1.66; P = 0.005). The hazard ratio for relapse was 1.52 (95 percent confidence interval, 1.23 to 1.86; P<0.001). Three patients (1 percent) died from toxic effects of the chemoradiotherapy; grade 3 toxic effects occurred in 41 percent of the patients in the chemoradiotherapy group, and grade 4 toxic effects occurred in 32 percent. Conclusions: Postoperative chemoradiotherapy should be considered for all patients at high risk for recurrence of adenocarcinoma of the stomach or gastroesophageal junction who have undergone curative resection.
Authors’ Abstract
Reasons for selecting abstract:
• Benefit of chemoradiotherapy
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Has Misdiagnosis of Appendicitis Decreased Over Time? A Population-Based Analysis. David R. Flum, Arden Morris, Thomas Koepsell, E. Patchen Dellinger. JAMA 2001; 286:1748– 1753. (D.R.F., Department of Surgery, Robert Wood Johnson Clinical Scholars Program, Box 357183, H-220 Health Sciences Center, University of Washington, Seattle, WA 98195-7183; e-mail: daveflum@u.washington.edu)
Context: Misdiagnosis of presumed appendicitis is an adverse outcome that leads to unnecessary surgery. Computed tomography, ultrasonography, and laparoscopy have been suggested for use in patients with equivocal signs of appendicitis to decrease unnecessary surgery. Objective: To determine if frequency of misdiagnosis preceding appendectomy has decreased with increased availability of computed tomography, ultrasonography, and laparoscopy. Design, Setting, and Patients: Retrospective, population-based cohort study of data from a Washington State hospital discharge database for 85 790 residents assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy, and United States Census Bureau data for 1987-1998. Main Outcome Measure: Population-based age- and sex-standardized incidence of appendectomy with acute appendicitis (perforated or not) or with a normal appendix. Results: Among 63 707 nonincidental appendectomy patients, 84.5% had appendicitis (25.8% with perforation) and 15.5% had no associated diagnosis of appendicitis. After adjusting for age and sex, the population-based incidence of unnecessary appendectomy and of appendicitis with perforation did not change significantly over time. Among women of reproductive age, the population-based incidence of misdiagnosis increased 1% per year (P = .005). The incidence of misdiagnosis increased 8% yearly in patients older than 65 years (P<.001) but did not change significantly in children younger than 5 years (P = .17). The proportion of patients undergoing laparoscopic appendectomy who were misdiagnosed was significantly higher than that of open appendectomy patients (19.6% vs 15.5%; P<.001). Conclusion: Contrary to expectation, the frequency of misdiagnosis leading to unnecessary appendectomy has not changed with the introduction of computed tomography, ultrasonography, and laparoscopy, nor has the frequency of perforation decreased. These data suggest that on a population level, diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing.
Authors’ Abstract
Reasons for selecting abstract:
• Misdiagnosis unchanged
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Patient Satisfaction After MRCP and ERCP. Krishna Menon, Alan N. Barkun, Joseph Romagnuolo, et al. Am J Gastroenterol 2001; 96:2646–2650. (A.N.B., Division of Gastroenterology, Room D7-148, Montreal General Hospital, 1650 Cedar Ave, Montreal, Quebec, Canada H3G 1A4)
OBJECTIVE: Magnetic resonance cholangiopancreatography (MRCP) is an accurate diagnostic test for detecting abnormalities of the pancreaticobiliary system. Because it is noninvasive, MRCP appears to be more tolerable than ERCP, although this has not been studied. The purpose of this study is to compare patient satisfaction after MRCP and ERCP performed sequentially. METHODS: We prospectively recruited 34 patients undergoing ERCP, for whom an MRCP was able to be performed before ERCP. Patient satisfaction was assessed by validated questionnaires using seven-point Likhert scales (individual ratings and direct comparisons). The following dimensions were explored: anxiety, pain, discomfort, tolerability (relative to expectations), willingness to repeat the procedure, and overall preference. 
2 and Student’s t tests (paired and unpaired) were performed, and 95% CIs were provided. RESULTS: Two patients (5.9%) were unable to undergo MRCP because of claustrophobia. The remaining 32 completed both tests (94% same day) and all questionnaires. Average age was 56 ± 18 yr, and 66% were women. In 23 patients, some degree of biliary obstruction was suspected; nine patients had pancreatitis. Patients reported a lower degree of pain (p < 0.001) and discomfort (p = 0.047) with MRCP, but MRCP was more difficult than they expected (p = 0.012). Patients were marginally more willing to repeat MRCP (ns, p = 0.09). On direct comparisons, patients were more satisfied with MRCP regarding anxiety (p = 0.04) and pain (p = 0.001). Patients displayed a higher overall preference for MRCP compared with ERCP (p = 0.01); however, only 59% clearly preferred MRCP over ERCP. The most common problem with MRCP was claustrophobia or noise (n = 15), and the differences were more striking in the subgroup without this problem. The subgroup undergoing purely diagnostic ERCPs showed clear preferences for MRCP. CONCLUSIONS: In many respects, MRCP is well tolerated, and certain subgroups, especially those undergoing diagnostic ERCPs, prefer MRCP over ERCP. As an endoscopist, one needs to be aware of the limitations of MRCP and relay these to the patient, as it seems that patients find MRCP more difficult than anticipated, and a significant number still prefer ERCP over MRCP. Patient satisfaction may be further improved by reducing noise and claustrophobia with selective premeditation, earplugs, and the use of the new quieter fenestrated magnetic resonance imaging scanners.
Authors’ Abstract
Reasons for selecting abstract:
• Comparison of MRCP and ERCP
Selected by Philip Goodman, MD
University of Kentucky Medical Center, Lexington
Thorax
Diagnostic Accuracy of a Bedside D-dimer Assay and Alveolar Dead-Space Measurement for Rapid Exclusion of Pulmonary Embolism: A Multicenter Study. Jeffrey A. Kline, Elizabeth G. Israel, Edward A. Michelson, et al. JAMA 2001; 285:761–768. (J.A.K., Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC 28232-2816; e-mail: jkline@carolinas.org)
Context: A previous study suggested that the combination of a normal D-dimer assay and normal alveolar dead-space fraction is a highly sensitive screening test for pulmonary embolism (PE). Objective: To determine if the combination of a normal alveolar dead-space fraction (volume of alveolar dead space/tidal volume 20%) and a normal whole-blood agglutination D-dimer assay can exclude PE in emergency department (ED) patients. Design: Prospective, noninterventional study conducted in 1998-1999. Study data were obtained prior to standard testing for PE, consisting of radionuclide lung scanning or contrast-enhanced computed tomography and 6-month follow-up plus selective use of venous ultrasonography and pulmonary angiography. Imaging studies were interpreted by blinded observers. Setting: Six urban teaching hospitals in the United States. Patients: A total of 380 hemodynamically stable ED patients aged 18 years or older with suspected acute PE. Main Outcome Measures: Sensitivity and specificity for PE with a positive test defined as having either alveolar dead-space fraction or D-dimer assay results abnormal. Alveolar dead-space fraction was determined by subtracting airway dead space from physiological dead space (determined using the modified Bohr equation) and D-dimer assay, assayed at bedside using 20 µL of arterial blood. Results: Pulmonary embolism was diagnosed in 64 patients (16.8%), of those 20 had an abnormal D-dimer assay result, 3 had an abnormal alveolar dead-space fraction, 40 had abnormal results in both, and 1 had normal results for both tests. The sensitivity for diagnosis of PE was 98.4% (95% confidence interval [CI], 91.6%–100.0%). Among the 316 patients without PE, both D-dimer and dead-space results were normal in 163, for a specificity of 51.6% (95% CI, 46.1 %–57.1%). Posterior probability of PE with normal results on both tests was 0.75% (95% CI, 0%–3.4%). Conclusion: In this multicenter study of ED patients, a normal D-dimer assay result plus a normal alveolar dead-space fraction was associated with a low prevalence of PE.
Authors’ Abstract
Reasons for selecting abstract:
• Use of D-dimer assay
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Accuracy of Positron Emission Tomography for Diagnosis of Pulmonary Nodules and Mass Lesions: A Meta-analysis. Michael K. Gould, Courtney C. Maclean, Ware G. Kuschner, et al. JAMA 2001; 285:914–924. (M.K.G., Pulmonary Section [111P], VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304; e-mail: gould@stanford.edu)
Context: Focal pulmonary lesions are commonly encountered in clinical practice, and positron emission tomography (PET) with the glucose analog 18-fluorodeoxyglucose (FDG) may be an accurate test for identifying malignant lesions. Objective: To estimate the diagnostic accuracy of FDG-PET for malignant focal pulmonary lesions. Data Sources: Studies published between January 1966 and September 2000 in the MEDLINE and CANCERLIT databases; reference lists of identified studies; abstracts from recent conference proceedings; and direct contact with investigators. Study Selection: Studies that examined FDG-PET or FDG with a modified gamma camera in coincidence mode for diagnosis of focal pulmonary lesions; enrolled at least 10 participants with pulmonary nodules or masses, including at least 5 participants with malignant lesions; and presented sufficient data to permit calculation of sensitivity and specificity were included in the anaylsis. Data Extraction: Two reviewers independently assessed study quality and abstracted data regarding prevalence of malignancy and sensitivity and specificity of the imaging test. Disagreements were resolved by discussion. Data Synthesis: We used a meta-analytic method to construct summary receiver operating characteristic curves. Forty studies met inclusion criteria. Study methodological quality was fair. Sample sizes were small and blinding was often incomplete. For 1474 focal pulmonary lesions of any size, the maximum joint sensitivity and specificity (the upper left point on the receiver operating characteristic curve at which sensitivity and specificity are equal) of FDG-PET was 91.2% (95% confidence interval, 89.1%–92.9%). In current practice, FDG-PET operates at a point on the summary receiver operating characteristic curve that corresponds approximately to a sensitivity and specificity of 96.8% and 77.8%, respectively. There was no difference in diagnostic accuracy for pulmonary nodules compared with lesions of any size (P = .43), for semiquantitative methods of image interpretation compared with qualitative methods (P = .52), or for FDG-PET compared with FDG imaging with a modified gamma camera in coincidence mode (P = .19). Conclusions: Positron emission tomography with 18-fluorodeoxyglucose is an accurate noninvasive imaging test for diagnosis of pulmonary nodules and larger mass lesions, although few data exist for nodules smaller than 1 cm in diameter. In current practice, FDG-PET has high sensitivity and intermediate specificity for malignancy.
Authors’ Abstract
Reasons for selecting abstract:
• Meta-analysis
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Diagnostic Value of CYFRA 21-1 Tumor Marker and CEA in Pleural Effusion Due to Mesothelioma. Michela Paganuzzi, Marina Onetto, Paola Marroni, et al. Chest 2001; 119:1138–1142. (M.P., Clinical Pathology Laboratory, National Institute for Cancer Research, Largo R. Benzi 10, 16132 Genoa, Italy; e-mail: patclin@hp380.ist.unige.it)
Study objective: The aim of our study was to assess the clinical value of CYFRA 21-1 tumor marker and carcinoembryonic antigen (CEA) as diagnostic tools that are complementary to cytology in the diagnosis of malignant mesotheliomas. Patients: We measured CEA and CYFRA 21-1 in the pleural effusions (PEs) and serum of 106 patients (benign lung disease, 34 patients; bronchogenic and metastatic carcinoma, 40 patients; mesothelioma, 32 patients). Methods: CEA and CYFRA 21-1 levels were determined by means of two commercial enzyme immunoassays. Results: The cutoff levels of CYFRA 21-1 and CEA in malignant PEs, selected on the basis of the best diagnostic efficacy, were 41.9 ng/mL and 5.0 ng/mL, respectively. In all neoplastic PEs, CYFRA 21-1 and CEA sensitivity was 78% and 30.6%, respectively, with a specificity of 80% and 91%, respectively. The sensitivity of CYFRA 21-1 and CEA in patients with mesothelioma was 87.5% and 3.1%, respectively. The results of the CYFRA 21-1 assay were positive in 17 of 19 cases of mesothelioma (89.5%) with a negative or uncertain cytology. The association of the tumor marker assay and the cytology allowed a correct diagnosis in 30 of 32 cases of mesothelioma (93.7%). Conclusion: This study suggests that CYFRA 21-1 would provide a useful parameter for the differential diagnosis between benign and malignant PE from mesothelioma when the result of cytology is negative or uncertain and the clinical context does not allow a more aggressive approach. Moreover, the association of CYFRA 21-1 with CEA could provide details for a differential diagnosis between mesotheliomas and carcinomas. In fact, an elevated CYFRA 21-1 level with a low CEA level is highly suggestive of mesothelioma, whereas high levels of CEA alone or high levels of both the markers suggest a diagnosis of malignant PE, excluding mesothelioma.
Authors’ Abstract
Reasons for selecting abstract:
• Markers for diagnosis
Selected by Robert M. Steiner, MD
New York Methodist Hospital–Weill Medical College of Cornell University, New York, NY
Typical and Atypical Pulmonary Carcinoids: Outcome in Patients Presenting With Regional Lymph Node Involvement. Charles F. Thomas Jr, Henry D. Tazelaar, James R. Jett. Chest 2001; 119:1143–1150. (C.F.T., Thoracic Diseases Research Unit, Guggenheim Bldg 696, Mayo Clinic and Foundation, Rochester, MN 55905; e-mail: thomas.charles@mayo.edu)
Study objective: Typical pulmonary careinoid tumors are well-differentiated neuroendocrine tumors that are associated with good patient survival rates, while atypical careinoid tumors are more aggressive and have worse patient survival rates. Because these tumors rarely involve the thoracic lymph nodes at presentation, it is currently unknown to what extent the presence of thoracic lymph node metastases at the time of diagnosis influences patient survival. Methods: A computerized search of the medical records for pulmonary careinoid tumor at the Mayo Clinic from 1976 to 1997 revealed 517 patients, from which we identified 36 patients with pulmonary carcinoid tumors involving regional thoracic lymph nodes but without distant disease. For each patient, we reviewed the tumor histology, stage, and outcome. In addition, because the histologic criteria for the diagnosis of carcinoid tumors had changed significantly during the time of the study, we reexamined all of the histologic specimens using the current World Health Organization (WHO) criteria for classifying pulmonary neuroendocrine tumors. Results: After reclassification with the WHO criteria for neuroendocrine tumors, 23 patients had typical carcinoid tumors with thoracic lymph node involvement. At the last follow-up, 19 patients had no evidence of disease (NED), 2 patients had developed systemic metastases (SM) and are still alive, and 2 patients had died. Eleven patients had atypical carcinoid tumors with thoracic lymph node involvement. At the last follow-up, four patients had NED, seven patients had developed SM within a median time of 17 months, and six patients with SM died shortly thereafter (median survival time, 25.5 months), while one is still alive. Two patients had been reclassified with large cell neuroendocrine carcinoma at the time of this review; both of these patients had developed SM (at 4 months and 21 months after diagnosis) and had died (at 15 months and 21 months after diagnosis, respectively). Conclusions: These data suggest that patients with atypical pulmonary carcinoid tumors with regional lymph node metastases have a high likelihood of developing recurrent disease if treated with surgical resection alone and have significantly worse outcome (p < 0.001) compared to those patients with typical carcinoid tumors with thoracic lymph node involvement.
Authors’ Abstract
Reasons for selecting abstract:
• Often poorly understood tumor family
• Importance of regional lymph nodes for prognosis
Selected by Robert M. Steiner, MD
New York Methodist Hospital–Weill Medical College of Cornell University, New York, NY
Pneumonia in Patients With Severe Burns: A Classification According to the Concept of the Carrier State. Miguel A. de la Cal, Enrique Cerdá, Paloma García-Hierro, et al. Chest 2001; 119:1160–1165. (M.A.C., Servicio de Cuidados Intensivos, Hospital Universitario de Getafe, Carretera de Toledo, km. 12.5, Madrid 28905, Spain; e-mail: mcal@hug.es)
Objective: To establish baseline values of pneumonia incidence and mortality and to distinguish primary endogenous from secondary endogenous and exogenous pneumonias in a homogeneous patient population with severe burns. Design: Cohort study. Setting: A six-bed burn ICU. Patients: All patients of 
14 years admitted to the ICU between January 1995 and June 1996 with a total body surface area burn of 20%. Intervention: Collection of data on surveillance samples from throat and rectum on admission and twice weekly afterward, and pneumonias during the ICU stay. Measurements and results: Fifty-six patients fulfilled the criteria of the study. Mean age was 43 ± 19.8 years; total body surface area burn, 41 ± 18.2%; the area of full-thickness burn was 24 ± 17.7%. Forty-one patients required mechanical ventilation. Twenty-seven patients (48%) experienced 37 episodes of pneumonia. Twenty-one pneumonias were of primary endogenous development, ie, caused by potential pathogens carried in the admission flora. There were 14 secondary endogenous and 2 exogenous infections caused by microorganisms acquired on the burn unit. Inhalation injury was identified in 26 patients. The pneumonia rate was two times higher in the subset of patients with inhalation injury compared with the group of patients without inhalation injury (p < 0.001). Overall mortality was 25%. Conclusions: This study shows that pneumonia in burn patients is mainly an endogenous problem. Interventions that prevent the development of endogenous infections deserve prospective evaluation in patients with severe burns.
Authors’ Abstract
Reasons for selecting abstract:
• Pneumonia incidence and source in patients with severe body burns
Selected by Robert M. Steiner, MD
New York Methodist Hospital–Weill Medical College of Cornell University, New York, NY
Risk Factors for ARDS in the United States: Analysis of the 1993 National Mortality Followback Study. Terri TenHoor, David M. Mannino, Marc Moss. Chest 2001; 119:1179–1184. (M.M., Crawford Long Hospital of Emory University, Ste 5310, 550 Peachtree St NE, Atlanta, GA 30365-2225; e-mail: marc_moss@emory.org)
Objective: To identify specific comorbid factors that are present in US decedents with ARDS. Design: We searched the 1993 National Mortality Followback Study for all decedents who had a code for ARDS mentioned on their death certificate. We also searched for comorbid conditions both on the death certificates (sepsis, medical or surgical misadventures, cirrhosis) and in the study database (current or former smoking, use of alcohol at least 3 d/wk, race, gender, and age). We calculated proportional mortality ratios (PMRs) for these risk factors. Results: Of the 19,003 decedents for whom data were available, 252 decedents, representing an estimated 19,460 US decedents, had ARDS listed on their death certificate. PMRs among decedents with ARDS were significantly increased for medical or surgical misadventures (PMR, 11.8; 95% confidence interval [CI], 3.8 to 36.7), sepsis (PMR, 5.6; 95% CI, 2.0 to 16.0), nonwhite race (PMR, 2.6; 95% CI, 1.4 to 5.0), and cirrhosis (PMR, 2.2; 95% CI, 1.1 to 4.6). PMRs were increased but not statistically significant for current smokers (PMR, 1.2; 95% CI, 0.5 to 3.0) or former smokers (PMR, 1.8; 95% CI, 0.7 to 4.3) compared to never smokers, and drinking alcohol on 3 d/wk in the year prior to death, when compared to drinking alcohol less than < 3 d/wk (PMR, 1.8; 95% CI, 0.6 to 4.9). Conclusions: The results of this study confirm the positive associations between ARDS mortality and the presence of sepsis and cirrhosis, and suggest possible new relationships between ARDS mortality and nonwhite individuals and patients with medical or surgical misadventures.
Authors’ Abstract
Reasons for selecting abstract:
• Multifactoral causes of ARDS
Selected by Robert M. Steiner, MD
New York Methodist Hospital–Weill Medical College of Cornell University, New York, NY
Cardiovascular System
Usefulness of Intravascular Ultrasound in Preventing Stenting of Hazy Areas Adjacent to Coronary Stents and Its Support of Support Spot-Stenting. Jasmine Grewal, Peter Ganz, Andrew Selwyn, Scott Kinlay. Am J Cardiol 2001; 87:1246–1249. (S.K., Division of Cardiovascular Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115; e-mail: skinlay@massmed.org)
The uncertain significance of hazy areas at the margins of coronary stents may lead to further, at times unnecessary, stenting. However, the risk of restenosis increases substantially when additional stents are deployed. We used intravascular ultrasound (IVUS) to identify the causes of hazy segments adjacent to stents. We identified 13 cases with hazy regions adjacent to coronary stents and 20 controls without hazy regions matched by age, gender, and vessel stented. Hazy regions were defined from the angiogram as reduced contrast density without a clearly defined intimal tear, dissection, thrombus, or stenosis (>50%). IVUS images were obtained from the reference, stent, and hazy and control regions adjacent to the stent. Computerized planimetery was used to measure the vessel, lumen, and plaque cross-sectional areas (CSAs), the maximum arc of calcium, and the eccentricity ratio (minimum:maximum lumen diameter). There were no significant differences between hazy and control segments in the vessel, lumen, and plaque CSAs. All lumen CSAs were >4.0 mm2. Compared with control regions, the hazy regions had calcified plaque more often (69% vs 25%; odds ratio [OR] 6.75, 95% confidence intervals [CI] 1.82 to 25.0]) and more frequent intimal tears (23% vs 0%, OR 6.67, 95% CI 1.98 to 35.0). Haziness was particularly associated with calcified plaque and eccentric lumen (p = 0.037). Thus, haziness at the margins of coronary stents is often caused by calcified plaque. IVUS can differentiate calcified plaques from intimal tears and thereby obviate unnecessary stenting.
Authors’ Abstract
Reasons for selecting abstract:
• Application for ultrasonography
Selected by Patricia A. Randall, MD
SUNY Health Science Center at Syracuse, NY
Management of Suspected Deep Venous Thrombosis in Outpatients by Using Clinical Assessment and D-Dimer Testing. Clive Kearon, Jeffrey S. Ginsberg, James Douketis, et al. Ann Intern Med 2001; 135:108–111. (C.K., McMaster University Clinic, Rm 401, Henderson General Hospital, 711 Concession St, Hamilton, Ontario L8V 1C3, Canada)
Background: When deep venous thrombosis is suspected, objective testing is required to confirm or refute the diagnosis. Objective: To determine whether the combination of a low clinical suspicion and a normal D-dimer result rules out deep venous thrombosis. Design: Prospective cohort study. Setting: Three tertiary care hospitals in Canada. Patients: 445 outpatients with a suspected first episode of deep venous thrombosis. Interventions: Patients were categorized as having low, moderate, or high pretest probability of thrombosis and underwent whole-blood D-dimer testing. Patients with a low pretest probability and a negative result on the D-dimer test had no further diagnostic testing and received no anticoagulant therapy. Additional diagnostic testing was done in all other patients. Measurements: Venous thromboembolic events during 3-month follow-up. Results: 177 (40%) patients had both a low pretest probability and a negative D-dimer result. One of these patients had deep venous thrombosis during follow-up (negative predictive value, 99.4% [95% CI, 96.9% to 100%]). Conclusion: The combination of a low pretest probability of deep venous thrombosis and a negative result on a whole-blood D-dimer test rules out deep venous thrombosis in a large proportion of symptomatic outpatients.
Authors’ Abstract
Reasons for selecting abstract:
• Use of D-dimer test
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Three Months versus One Year of Oral Anticoagulant Therapy for Idiopathic Deep Venous Thrombosis. Giancarlo Agnelli, Paolo Prandoni, Maria Gabriella Santamaria, et al. N Engl J Med 2001; 345:165–169. (G.A., Sezione di Medicina Interna e Cardiovascolare, Dipartimento di Medicina Interna, Università di Perugia, Via Enrico dal Pozzo, 06123 Perugia, Italy; e-mail: agnellig@unipg.it)
Background: In patients with idiopathic deep venous thrombosis, continuing anticoagulant therapy beyond three months is associated with a reduced incidence of recurrent thrombosis during the period of therapy. Whether this benefit persists after anticoagulant therapy is discontinued is controversial. Methods: Patients with a first episode of idiopathic proximal deep venous thrombosis who had completed three months of oral anticoagulant therapy were randomly assigned to the discontinuation of oral anticoagulants or to their continuation for nine additional months. The primary study outcome was recurrence of symptomatic, objectively confirmed venous thromboembolism during at least two years of follow-up. Results: The primary intention-to-treat analysis showed that of 134 patients assigned to continued oral anticoagulant therapy, 21 had a recurrence of venous thromboembolism (15.7 percent; average follow-up, 37.8 months), as compared with 21 of 133 patients assigned to the discontinuation of oral anticoagulant therapy (15.8 percent, average follow-up, 37.2 months), resulting in a relative risk of 0.99 (95 percent confidence interval, 0.57 to 1.73). During the initial nine months after randomization (after all patients received three months of therapy), 1 patient had a recurrence while receiving oral anticoagulant therapy (0.7 percent), as compared with 11 of the patients assigned to the discontinuation of oral anticoagulant therapy (8.3 percent, P = 0.003). The incidence of recurrence after the discontinuation of treatment was 5.1 percent per patient-year in patients in whom oral anticoagulant therapy was discontinued after 3 months and 5.0 percent per patient-year in patients who received an additional 9 months of oral anticoagulant therapy. None of the recurrences were fatal. Four patients had nonfatal major bleeding during the extended period of anticoagulant therapy (3.0 percent). Conclusions: In patients with idiopathic deep venous thrombosis, the clinical benefit associated with extending the duration of anticoagulant therapy to one year is not maintained after the therapy is discontinued.
Authors’ Abstract
Reasons for selecting abstract:
• Clinical benefit not maintained
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Acute Effects of Passive Smoking on the Coronary Circulation in Healthy Young Adults. Ryo Otsuka, Hiroyuki Watanabe, Kumiko Hirata, et al. JAMA 2001; 286:436–441. (H.W., Department of Internal Medicine and Cardiology, Osaka City University Medical School, 1-4-3 Asahimachi Abeno-ku, Osaka City, Japan 545-8585; e-mail: watanabe@med.osaka-cu.ac.jp)
Context: Recent studies have shown that passive smoking is a risk factor for ischemic heart disease and may be associated with vascular endothelial dysfunction. The acute effects of passive smoking on coronary circulation in nonsmokers are not known. Objective: To determine the acute effects of passive smoking on coronary circulation using coronary flow velocity reserve (CFVR), assessed by noninvasive transthoracic Doppler echocardiography. Design, Setting, and Participants: Cross-sectional study conducted from September 2000 to November 2000 among 30 Japanese men (mean age, 27 years; 15 healthy nonsmokers and 15 asymptomatic active smokers) without history of hypertension, diabetes mellitus, or hyperlipidemia. Main Outcome Measures: Coronary flow velocity reserve, calculated as the ratio of hyperemic to basal coronary flow velocity induced by intravenous infusion of adenosine triphosphate and measured in each participant before and after a 30-minute exposure to environmental tobacco smoke. Results: Heart rate and blood pressure responses to adenosine triphosphate infusion were not affected by passive smoking exposure in either group. Passive smoking exposure had no effect on basal coronary flow velocity in either group. Mean (SD) CFVR in nonsmokers was significantly higher than that in active smokers before passive smoking exposure (4.4 [0.91] vs 3.6 [0.88], respectively; P = .02), while CFVR after passive smoking exposure did not differ between groups (P = .83). Passive smoking exposure significantly reduced mean (SD) CFVR in nonsmokers (4.4 [0.91] vs 3.4 [0.73], respectively; P<.001). Conclusions: Passive smoking substantially reduced CFVR in healthy nonsmokers. This finding provides direct evidence that passive smoking may cause endothelial dysfunction of the coronary circulation in nonsmokers.
Authors’ Abstract
Reasons for selecting abstract:
• Evidence for passive smoking effects
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Mutation in the Gene for Bone Morphogenetic Protein Receptor II as a Cause of Primary Pulmonary Hypertension in a Large Kindred. John H. Newman, Lisa Wheeler, Kirk B. Lane, et al. N Engl J Med 2001; 345:319–324. (J.H.N., Allergy, Pulmonary, and Critical Care Division, T-1218, Vanderbilt University Medical Center N, Nashville, TN 37232-2650; e-mail: john.newman@med.va.gov)
Background: Most patients with primary pulmonary hypertension are thought to have sporadic, not inherited, disease. Because clinical disease develops in only 10 to 20 percent of persons carrying the gene for familial primary pulmonary hypertension, we hypothesized that many patients with apparently sporadic primary pulmonary hypertension may actually have familial primary pulmonary hypertension. Methods: In a study conducted over 20 years, we developed a registry of 67 families affected by familial primary pulmonary hypertension. Through patient referrals, extensive family histories, and correlation of family pedigrees, we discovered shared ancestry among five subfamilies. We assessed some family members for mutations in the gene encoding bone morphogenetic protein receptor II (BMPR2), which has recently been found to cause familial primary pulmonary hypertension. Results: We linked five separately identified subfamilies that included 394 known members spanning seven generations, which were traced back to a founding couple in the mid-1800s. Familial primary pulmonary hypertension has been diagnosed in 18 family members, 12 of whom were first thought to have sporadic disease. The conditions of 7 of the 18 were initially misdiagnosed as other cardiopulmonary diseases. Six members affected with familial primary pulmonary hypertension and 6 of 10 at risk for carriage have undergone genotype analysis, and they have the same mutation in BMPR2, a transversion of thymine to guanine at position 354 in exon 3. Conclusions: Many cases of apparently sporadic primary pulmonary hypertension may be familial. The recent discovery of mutations in BMPR2 should make it possible to identify those with susceptibility to the disease.
Authors’ Abstract
Reasons for selecting abstract:
• Gene and primary pulmonary hypertension
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Clinical and Molecular Genetic Features of Pulmonary Hypertension in Patients with Hereditary Hemorrhagic Telangiectasia. Richard C. Trembath, Jennifer R. Thomson, Rajiv D. Machado, et al. N Engl J Med 2001; 345:325–334. (R.C.T., Division of Medical Genetics, Departments of Medicine and Genetics, Adrian Bldg, University of Leicester, Leicester LE1 7RH, England; e-mail: rtrembat@hgmp.mrc.ac.uk)
Background: Most patients with familial primary pulmonary hypertension have defects in the gene for bone morphogenetic protein receptor II (BMPR2), a member of the transforming growth factor ß (TGF-ß) superfamily of receptors. Because patients with hereditary hemorrhagic telangiectasia may have lung disease that is indistinguishable from primary pulmonary hypertension, we investigated the genetic basis of lung disease in these patients. Methods: We evaluated members of five kindreds plus one individual patient with hereditary hemorrhagic telangiectasia and identified 10 cases of pulmonary hypertension. In the two largest families, we used microsatellite markers to test for linkage to genes encoding TGF-ß-receptor proteins, including endoglin and activin-receptor–like kinase 1 (ALK1), and BMPR2. In subjects with hereditary hemorrhagic telangiectasia and pulmonary hypertension, we also scanned ALK1 and BMPR2 for mutations. Results: We identified suggestive linkage of pulmonary hypertension with hereditary hemorrhagic telangiectasia on chromosome 12q13, a region that includes ALK1. We identified amino acid changes in activin-receptor–like kinase 1 that were inherited in subjects who had a disorder with clinical and histologic features indistinguishable from those of primary pulmonary hypertension. Immunohistochemical analysis in four subjects and one control showed pulmonary vascular endothelial expression of activin-receptor–like kinase 1 in normal and diseased pulmonary arteries. Conclusions: Pulmonary hypertension in association with hereditary hemorrhagic telangiectasia can involve mutations in ALK1. These mutations are associated with diverse effects, including the vascular dilatation characteristic of hereditary hemorrhagic telangiectasia and the occlusion of small pulmonary arteries that is typical of primary pulmonary hypertension.
Authors’ Abstract
Reasons for selecting abstract:
• Gene mutation and pulmonary hypertension
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Age and Gender Distributions of Coronary Artery Calcium Detected by Electron Beam Tomography in 35,246 Adults. Julie Anne Hoff, Eva V. Chomka, Andrew J. Krainik, et al. Am J Cardiol 2001; 87:1335–1339. (George T. Kondos, Department of Medicine, Section of Cardiology, 840 S Wood St (m/c 787), Chicago, IL 60612; e-mail: gtkondos@uic.edu)
Electron beam tomography (EBT) is a noninvasive method used to detect coronary artery calcium (CAC). Due to the age-associated increase in incidence and magnitude of CAC, interpretation of results can be difficult. The purpose of this study was to develop a set of age- and gender-stratified CAC distributions to serve as standards for the clinical interpretation of EBT scans. Between 1993 and 1999, 35,246 asymptomatic subjects, 30 to 90 years of age, were self-referred for CAC screening using an Imatron EBT scanner. CAC score was calculated based on the number, areas, and peak computed tomographic density for each detected calcific lesion. CAC score in each coronary artery was equal to the sum of all lesions for that artery and the total CAC score was equal to the sum of the score of each artery. Total CAC scores were assigned to a percentile according to age and gender. CAC scores were reported at the 10th, 25th, 50th, 75th, and 90th percentiles for 16 age and/or gender groups. The prevalence of CAC increased with age for men and women. The extent of CAC differed significantly between men and women in the same age group. In summary, this study reports the distribution of CAC score by age and gender. Knowledge of the distribution of CAC, the effect of age on the total CAC score as well as the differences in total CAC scores that exist between men and women of similar age will assist the clinician in interpreting EBT CAC results.
Authors’ Abstract
Reasons for selecting abstract:
• Helpful information
Selected by Patricia A. Randall, MD
SUNY Health Science Center at Syracuse, NY
False Lumen Patency as a Predictor of Late Outcome in Aortic Dissection. Yvette Bernard, Hugues Zimmermann, Sidney Chocron, et al. Am J Cardiol 2001; 87:1378–1382. (Y.B., Service de Cardiologie, Pôle Coeur-Poumons, Hôpital Universitaire Jean Minjoz, Boulevard Fleming, 25030 Besançon Cedex, France; e-mail: yvette_bernard@yahoo.com)
Aortic dissection (AD) is a disease with a high-risk of mortality. Late deaths are often related to complications in nonoperated aortic segments. Between 1984 and 1996, we retrospectively analyzed the data of 109 patients with acute AD (81 men and 28 women; average age 61 ± 14 years). All imaging examinations were reviewed, and a magnetic resonance imaging examination was performed at the time of the study. Aortic diameters were measured on each aortic segment. Predictive factors of mortality were determined by Cox’s proportional hazard model, in univariate and multivariate analyses, using BMDP statistical software. Follow-up was an average of 44 ± 46 months (range 24 to 164). Actuarial survival rates were 52%, 46%, and 37% at 1, 5, and 10 years, respectively, for type A AD versus 76%, 72%, and 46% for type B AD. Predictors of late mortality were age >70 years and postoperative false lumen potency of the thoracic descending aorta (RR 3.4, 95% confidence intervals 1.20 to 9.8). Descending aorta diameter was larger when false lumen was patent (31 vs 44 mm; p = 0.02) in type A AD. Furthermore, potency was less frequent in operated type A AD when surgery had been extended to the aortic arch. Thus, potency of descending aorta false lumen is responsible for progressive aortic dilation. In type A AD, open distal repair makes it possible to check the aortic arch and replace it when necessary, decreases the false lumen potency rate, and improves late survival.
Authors’ Abstract
Reasons for selecting abstract:
• More than 2 years of follow-up
Selected by Patricia A. Randall, MD
SUNY Health Science Center at Syracuse, NY
Design of the Therapeutic Angiogenesis With Recombinant Fibroblast Growth Factor-2 for Intermittent Claudication (TRAFFIC) Trial. Robert J. Lederman, Alan N. Tenaglia, R. David Anderson, et al. Am J Cardiol 2001; 88:192–195. (Brian H. Annex, Durham Veterans Affairs Medical Center, 508 Fulton St (111A), Durham, NC 27705; e-mail: annex001@mc.duke.edu)
Therapeutic angiogenesis seeks to treat disorders of inadequate tissue perfusion by promoting the growth and proliferation of blood vessels from existing vascular structures. Basic fibroblast growth factor (also known as b-FGF or FGF-2) is a potent mitogen for endothelial cells. FGF-2 has been shown to promote angiogenesis and improve perfusion in animal models of hindlimb and myocardial ischemia.
Authors’ Abstract
Reasons for selecting abstract:
• Important study
Selected by Patricia A. Randall, MD
SUNY Health Science Center at Syracuse, NY
Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients: A Randomized Controlled Trial. Jacques Merrer, Bernard De Jonghe, Franck Golliot, et al. JAMA 2001; 286:700–707. (J.M., Service de Réanimation Médicale, Hôpital de Poissy/St Germain-en-Laye, 10 Rue du Champ-Gaillard, 78303 Poissy, France; e-mail: jmerrer@chi-poissy-st-germain-fr)
Context: Whether venous catheterization at the femoral site is associated with an increased risk of complications compared with that at the subclavian site is debated. Objective: To compare mechanical, infectious, and thrombotic complications of femoral and subclavian venous catheterization. Design and Setting: Concealed, randomized controlled clinical trial conducted between December 1997 and July 2000 at 8 intensive care units (ICUs) in France. Patients: Two hundred eighty-nine adult patients receiving a first central venous catheter. Interventions: Patients were randomly assigned to undergo central venous catheterization at the femoral site (n = 145) or subclavian site (n = 144). Main Outcome Measures: Rate and severity of mechanical, infectious, and thrombotic complications, compared by catheterization site in 289, 270, and 223 patients, respectively. Results: Femoral catheterization was associated with a higher incidence rate of overall infectious complications (19.8% vs 4.5%; P < .001; incidence density of 20 vs 3.7 per 1000 catheter-days) and of major infectious complications (clinical sepsis with or without bloodstream infection, 4.4% vs 1.5%; P = .07; incidence density of 4.5 vs 1.2 per 1000 catheter-days), as well as of overall thrombotic complications (21.5% vs 1.9%; P < .001) and complete thrombosis of the vessel (6% vs 0%; P = .01); rates of overall and major mechanical complications were similar between the 2 groups (17.3% vs 18.8%; P = .74 and 1.4% vs 2.8%; P = .44, respectively). Risk factors for mechanical complications were duration of insertion (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03–1.08 per additional minute; P < .001); insertion in 2 of the centers (OR, 4.52; 95% CI, 1.81–11.23; P = .001); and insertion during the night (OR, 2.06; 95% CI, 1.04–4.08; P = .03). The only factor associated with infectious complications was femoral catheterization (hazard ratio [HR], 4.83; 95% CI, 1.96–11.93; P < .001); antibiotic administration via the catheter decreased risk of infectious complications (HR, 0.41; 95% CI, 0.18–0.93; P = .03). Femoral catheterization was the only risk factor for thrombotic complications (OR, 14.42; 95% CI,3.33–62.57; P < .001). Conclusion: Femoral venous catheterization is associated with a greater risk of infectious and thrombotic complications than subclavian catheterization in ICU patients.
Authors’ Abstract
Reasons for selecting abstract:
• Risk differences
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Pediatrics
Costs and Effectiveness of Ultrasonography and Limited Computed Tomography for Diagnosing Appendicitis in Children. Barbara M. Garcia Peña, George A. Taylor, Steven J. Fishman, et al. Pediatrics 2000; 106:672–676; http://www.pediatrics.org/cgi/content/full/106/4 /672. (From the Department of Medicine, Division of Emergency Medicine, Children’s Hospital, Harvard Medical School, Boston, Mass)
Background. A protocol of ultrasonography (US) followed by computed tomography with rectal contrast (CTRC) has been shown to be 94% accurate in the diagnosis of acute appendicitis in children. Objective. To evaluate the changes in patient management and costs of a protocol using US and CTRC in the evaluation of appendicitis in children. Design, Setting, and Subjects. Prospective cohort study of 139 children between 3 and 21 years of age who had equivocal clinical findings for acute appendicitis seen in the emergency department of a large, urban pediatric teaching hospital between July 1998 and December 1998. Protocol. Children with equivocal clinical presentations for acute appendicitis were prospectively evaluated with US. Patients with positive findings for acute appendicitis went directly to the operating room. Patients with negative or equivocal findings on US underwent CTRC. Surgical management plans were recorded before imaging, after US, and after CTRC. Main Outcome Measures. Surgical management plans before and after the imaging protocol as well as total hospital direct and indirect costs incurred or saved by each change in management were determined. Costs were obtained through the hospital’s cost database and by ratios of costs to charges. Results. Of the 139 children, the protocol resulted in a beneficial change in management in 86 children (61.9%), no change in management in 50 children (36.0%) and an incorrect change in management in 3 children (2.1%). US alone resulted in a beneficial change in management decision in 12/31 children (38.7%), while US followed by CTRC resulted in a beneficial change in management in 74/108 children (68.5%). The protocol resulted in a total cost savings of $78 503.99 or $565/patient. Conclusion. A protocol of US followed by CTRC in children with negative or equivocal US examinations results in a high rate of beneficial change in management as well as in total cost savings in children with equivocal clinical presentations for suspected appendicitis.
Author’s Abstract
Reasons for selecting abstract:
• Protocol results in time and cost savings
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Elevated Blood Lead Levels and Blood Lead Screening Among US Children Aged One to Five Years: 1988–1994. Rachel B. Kaufmann, Timothy L. Clouse, David R. Olson, et al. Pediatrics 2000; 106:e79. (From the Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Ga)
Objectives. To estimate the proportion of children 1 to 5 years of age who received blood lead testing during 1988–1994 and to assess whether predictors of testing coincided with predictors of elevated blood lead levels. Design. Cross-sectional analysis of data from the Third National Health and Nutrition Examination Survey. Participants. US children 1 to 5 years of age. Outcome Measures. Prevalence of blood lead testing and elevated blood lead levels among children 1 to 5 years of age and odds ratios for factors predicting blood lead testing and elevated blood lead levels. Results. Overall, 6.3% had elevated blood lead levels and 10.2% had undergone previous blood lead tests. Being of minority race/ethnicity, living in an older home, residing in the Northeast or Midwest regions of the United States, being on Medicaid, having a head of household with <12 years of education, and having a history of anemia were significant factors in both models. Additional independent risk factors for an elevated blood lead level included being sampled in phase 1 of the survey, being 1 to 2 years of age, not having a regular doctor, and being sampled during the summer months. Additional independent correlates of a previous blood lead test included having moved less than twice in one’s lifetime, having a female head of household, and having parents whose home language was English. Of an estimated 564 000 children 1 to 5 years of age who had elevated blood lead levels and no previous screening test in 1993, 62% were receiving Medicaid, 40% lived in homes built before 1946, and 34% were black, non-Hispanic. Conclusions. Lead screening was more frequent among children with risk factors for lead exposure. However, among children with elevated blood lead levels, only one third had been tested previously. In 1993 an estimated 564 000 children 1 to 5 years of age had elevated blood lead levels but were never screened. Physicians should screen Medicaid-eligible children and should follow state or local health department recommendations about identifying and screening other at-risk children. In areas where no health department guidelines exist, physicians should screen all children or screen based on known risk factors.
Author’s Abstract
Reasons for selecting abstract:
• Major cause of morbidity in young children
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Decreased Use of Neonatal Extracorporeal Membrane Oxygenation (ECMO): How New Treatment Modalities Have Affected ECMO Utilization. Susan R. Hintz, Denise M. Suttner, Arlene M. Sheehan, et al. Pediatrics 2000; 106:1339–1343. (From the Department of Pediatrics, Division of Neonatal Medicine, Stanford University, Stanford, Calif)
Objective: Over the last decade, several new therapies, including high-frequency oscillatory ventilation (HFOV), exogenous surfactant therapy, and inhaled nitric oxide (iNO), have become available for the treatment of neonatal hypoxemic respiratory failure. The purpose of this retrospective study was to ascertain to what extent these modalities have impacted the use of neonatal extracorporeal membrane oxygenation (ECMO) at our institution. Methods. Patients from 2 time periods were evaluated: May 1, 1993 to November 1, 1994 (group 1) and May 1, 1996 to November 1, 1997 (group 2). During the first time period (group 1), HFOV was not consistently used; beractant (Survanta) use for meconium, aspiration syndrome (MAS), persistent pulmonary hypertension of the newborn (PPBN), and pneumonia was under investigation; and iNO was not yet available. During the second time period (group 2), HFOV and beractant treatment were considered to be standard therapies, and iNO was available to patients with oxygenation index (OI) 25? 2 at least 30 minutes apart, or on compassionate use basis. Patients were included in the data collection if they met the following entry criteria: 1) OI > 15? 1 within the first 72 hours of admission; 2) EGA 35 weeks; 3) diagnosis of MAS, PPHN or sepsis/pneumonia; 4) <5 days of age on admission; and 5) no congenital heart disease, diaphragmatic hernia, or lethal congenital anomaly. Results. Of the 49 patient in group 1, 21 (42.8%) required ECMO therapy. Of these ECMO patients, 14 (66.6%) had received diagnoses of MAS or PPHN. Only 3 of the patients that went onto ECMO received beractant before the initiation of bypass (14.3%). All ECMO patients in group 1 would have met criteria for iNO had it been available. Of all patients in group 1, 18 (36.7%) were treated with HFOV, and 13 (26.5%) received beractant. Of the 47 patients in group 2, only 13 (27.7 %) required ECMO therapy (compared with group 1). Of these ECMO patients, only 5 (38.5%) had diagnoses of MAS or PPHN, with the maj ority of patients (61.5%) requiring ECMO for sepsis/pneumonia, with significant cardiovascular compromise. Only 5 of these ECMO patients, all outborn, did not receive iNO before cannulation because of the severity of their clinical status on admission. Of all patients in group 2, 41 (87.2%) were treated with HFOV (compared with group 1), 42 (89.3%) received beractant (compared with group 1), and 18 (44.7%) received iNO. Conclusions. The results indicate that ECMO was used less frequently when HFOV, beractant and iNO was more commonly used. The differences in treatment modalities used and subsequent use of ECMO were statistically significant. We speculate that, in this patient population, the diagnostic composition of neonatal ECMO patients has changed over time.
Author’s Abstract
Reasons for selecting abstract:
• Outcome of alternative therapy
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Surfactant Treatment of Neonates With Respiratory Failure and Group B Streptococcal Infection. Egbert Herting, Olaf Gefeller, Matthias Land, et al. Pediatrics 2000; 106:957–964. (From the Department of Pediatrics, University of Göttingen, Germany)
Objective. Connatal pneumonia caused by group B streptococcal (GBS) infection maybe associated with surfactant dysfunction. We investigated the effects of surfactant treatment in term and preterm neonates with GBS infection and respiratory failure, in comparison with corresponding data from a control population of noninfected infants treated with surfactant for respiratory distress syndrome (RDS). Design/Methods. The study comprised 118 infants with respiratory failure, clinical and/or laboratory signs of acute inflammatory disease, and GBS infection proven by culture results. They were recruited retrospectively from a database of patients treated with surfactant at 28 neonatology units participating in European multicenter trials (1987–1993) and prospectively from the same units in the following years. A nonrandornized control group of 236 noninfected infants was selected from the same database. The primary parameters evaluated were oxygen requirement, ventilator settings, and incidence of complications. Results. Median birth weight in the GBS study group was 1468 g (25th–75th percentiles: 1015–2170), and median gestational age was 30 (27–33) weeks. Thirty-one percent of the infants weighed >2000 g. Median age at surfactant treatment was 6 hours. The mean initial surfactant dose was 142 mg/kg (standard deviation: 53). Ninety of the infants were treated with Curosurf (Chiesi Farmaceutici, Parma, Italy), 13 with Survanta (Abboth GmbH, Wiesbaden, Germany), 12 with Alveofact (Dr Karl Thomae GmbH, Biberach, Germany), and 3 with Exosurf (Wellcome GmbH, Burgwedel, Germany). Within 1 hour of surfactant treatment, median fraction of inspiratory oxygen was reduced from .84 (25th–75th percentiles: .63–1.0) to .50 (.35–.80). The incidence of complications in the study group (mortality: 30%; pneumothorax: 16%; intracranial hemorrhage: 42%) was high, compared with infants with RDS. Conclusions. Surfactant therapy improves gas exchange in the majority of patients with GBS pneumonia. The response to surfactant is slower than in infants with RDS, and repeated surfactant doses are often needed. The mortality and morbidity are substantial, considering the relatively high mean birth weight of the treated infants.
Author’s Abstract
Reasons for selecting abstract:
• Large multi-institutional study
• New use of surfactant therapy
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Primitive Neuroectodermal Tumors of the Brainstem: Investigation of Seven Cases. David Zagzag, Douglas C. Miller, Edmond Knopp, et al. Pediatrics 2000; 106:1045–1053. (From the Department of Pathology, Kaplan Cancer Center, New York University Medical Center, New York, NY)
Objective. We discuss the clinical aspects, pathology, and molecular genetics of 7 patients with primitive neuroectodermal tumors (PNETs) arising in the brainstem that were treated at our institution from 1986 through 1995. Most neuro-oncologists avoid performing biopsies in children with pontine tumors. This article raises the question as to whether biopsies should be performed, because treatment recommendations might differ if a PNET was diagnosed rather than a pontine glioma. Patients and Methods: We reviewed the clinical neuro-oncology database and the files of the Division of Neuropathology at New York University Medical Center from 1986 through 1995 and identified 7 histologically confirmed PNETs arising in the brainstem among 146 pediatric brainstem tumors. The clinical, neuroradiological, and neuropathological data were reviewed. Postmortem examinations were performed in 2 cases. Formalin-fixed, paraffin-embedded tumor tissues were also available in 6 of 7 patients that were tested for p53 gene mutations using single-strand conformation polymorphism analysis. We also tested 9 cerebellar PNETs, 9 brainstem gliomas, and 3 normal brains for p53 gene mutations as controls. Results. All 7 patients presented with focal cranial nerve deficits, and 2 were also hemiparetic. The median age at diagnosis was 2.7 (1–8 years). Magnetic resonance imaging (MRI) characteristics included a focal intrinsic exophytic nonenhancing brainstern lesion that had low T1-weighted and high T2-weighted signals. Hydrocephalus was present in 5 patients at diagnosis, 3 of whom had leptomeningeal dissemination. Meningeal dissemination occurred later in the course of the disease in 3 other patients. Five children required shunts at diagnosis and another 2 at recurrence. Despite therapy, all 7 PNET patients died within 17 months of diagnosis with a mean survival of 8 (4–17) months. No mutation in the p53 gene was detected. Conclusions. Brainstem PNETs tend to arise at a younger age than brainstem gliomas and medulloblastomas. The MRI pattern suggests a localized rather than a diffuse intrinsic nonenhancing brainstem tumor. Like other PNETs, brainstem PNETs have a high predilection to disseminate within the central nervous system. The absence ofp53 mutations is similar to other PNETs. Despite their origin close to the cerebellum, brainstem PNETs exhibit a more aggressive behavior and result in worse clinical outcomes than do cerebellar PNETs.
Author’s Abstract
Reason for selecting abstract:
• Importance of biopsy
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Necrotizing Enterocolitis in Neonates With Congenital Heart Disease: Risk Factors and Outcomes. Doff B. MeElhinney, Holly L. Hedrick, David M. Bush, et al. Pediatrics 2000; 106:1080–1087. (From the Division of Cardiology, the Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia)
Objective. Necrotizing entercolitis (NEC) is primarily a disease of the premature infant. Among children born at term, however, congenital heart disease maybe an important predisposing factor for this condition. To determine risk factors for NEC in patients with congenital heart disease, we conducted a case-control study of neonates with cardiac disease admitted to the cardiac intensive care unit at our center during the 4-year period from January 1995 to December 1998. Methods. Cardiac diagnosis and age at admission were analyzed for association with NEC among the 643-patient inception cohort. Demographic, preoperative, and operative variables were recorded retrospectively in 21 neonates with congenital heart disease who developed NEC and 70 control neonates matched by diagnosis and age at admission. Using parametric and nonparametric analysis, cases and controls were compared with respect to previously identified risk factors for NEC. Results. Among the entire cohort of643 neonates with heart disease admitted to the cardiac intensive care unit, diagnoses of hypoplastic left heart syndrome (odds ratio [OR] = 3.8 [1.6–9.1]) and truncus arteriosus or aortopulmonary window (OR = 6.3 [1.7–23.6]) were independently associated with development of NEC by multivariable analysis. In the case-control analysis, earlier gestational age at birth (36.7 ± 2.7 weeks vs 38. 1 ± 2.3 weeks), prematurity (OR = 3.9 [1.2–12.5]), highest dose of prostaglandin >0.05 µg/kg/minute (OR = 3.9 [1.2–12.5]), and episodes of low cardiac output (meeting specific laboratory criteria) or clinical shock (OR = 6.5[1.8–23.5]) correlated with the development of NEC. Earlier gestational age and episodes of low output were the only factors that remained significantly associated with NEC by multivariable analysis. Although there was no difference in hospital mortality between patients with and without NEC, mean hospital stay was significantly longer in those who developed NEC (36 ± 22 days vs 19 ± 14 days). Conclusions. The risk of NEC in neonates with congenital heart disease is substantial. Factors associated with an elevated risk of NEC in infants with heart disease include premature birth, hypoplastic left heart syndrome, truncus arteriosus, and episodes of poor systemic perfusion or shock. Heightened suspicion is warranted in newborns with these risk factors.
Author’s Abstract
Reasons for selecting abstract:
• Additional risk factor
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
Daily Physical Activity Program Increases Bone Mineralization and Growth in Preterm Very Low Birth Weight Infants. Laurie J. Moyer-Mileur, Vickie Brunstetter, Teresa P. McNaught, et al. Pediatrics 2000; 106:1088–1092. (From the Department of Pediatrics, University of Utah, Salt Lake City)
Objective. A study of daily physical activity was performed with 32 preterm infants to evaluate changes in body weight and bone mineralization. Study Design. Subjects were matched by birth weight and gestational age and randomly assigned to the physical activity (PA; n = l6) or to the control (C; n = 16) program. PA consisted of range of motion against passive resistance to all extremities for 5 to 10 minutes daily. Peripheral dual energy x-ray of the right forearm (ulna and radius); biomarkers of bone formation (serum type I collagen C-terminal propeptide [PICP]) and resorption (urine pyridinoline cross-links of collagen [Pyd]); serum calcium, phosphate, alkaline phosphatase, parathyroid hormone (PTH), and 1,25-(OH)2 vitamin D; and urine levels of calcium, phosphate, and creatinine were obtained. All measurements were made at study entry and at 2.0 kg of body weight. Results. Despite a similar nutrient intake at advised levels for preterm infants, gains in body weight (g) and forearm bone length (cm), bone area (BA; cm2), bone mineral content (BMC; mg), and fat-free mass (g) were greater in PA infants. Forearm bone mineral density and fat mass gains did not differ between groups. Serum PICP levels remained constant in PA infants but decreased in C infants suggesting a slower rate of bone formation. Urine Pyd or bone resorption activity was similar between groups. A higher level of serum PTH was observed in PA infants at 2.0 kg of body weight; however, the change from study entry to completion did not differ between groups. All other serum and urine values were similar and within normal limits. Conclusion. A daily PA program promotes greater gains in body weight, forearm length, BA, BMC, and fat-free mass in premature infants.
Author’s Abstract
Reasons for selecting abstract:
• Importance of passive exercise
Selected by Beverly P. Wood, MD
University of Southern California School of Medicine, Los Angeles
The Continuing Value of the Apgar Score for the Assessment of Newborn Infants. Brian M. Casey, Donald D. McIntire, Kenneth J. Leveno. N Engl J Med 2001; 344:467–471. (B.M.C., Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; e-mail: brian.casey@utsouthwestern.edu.)
Background: The 10-point Apgar score has been used to assess the condition and prognosis of newborn infants throughout the world for almost 50 years. Some investigators have proposed that measurement of pH in umbilical-artery blood is a more objective method of assessing newborn infants. Methods: We carried out a retrospective cohort analysis of 151,891 live-born singleton infants without malformations who were delivered at 26 weeks of gestation or later at an inner-city public hospital between January 1988 and December 1998. Paired Apgar scores and umbilical-artery blood pH values were determined for 145,627 infants to assess which test best predicted neonatal death during the first 28 days after birth. Results: For 13,399 infants born before term (at 26 to 36 weeks of gestation), the neonatal mortality rate was 315 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 5 per 1000 for infants with five-minute Apgar scores of 7 to 10. For 132,228 infants born at term (37 weeks of gestation or later), the mortality rate was 244 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 0.2 per 1000 for infants with five-minute Apgar scores of 7 to 10. The risk of neonatal death in term infants with five-minute Apgar scores of 0 to 3 (relative risk, 1460; 95 percent confidence interval, 835 to 2555) was eight times the risk in term infants with umbilical-artery blood pH values of 7.0 or less (relative risk, 180; 95 percent confidence interval, 97 to 334). Conclusions: The Apgar scoring system remains as relevant for the prediction of neonatal survival today as it was almost 50 years ago.
Authors’ Abstract
Reasons for selecting abstract:
• Update
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Second-Trimester Ultrasound to Detect Fetuses With Down Syndrome: A Meta-analysis. Rebecca Smith-Bindman, Wylie Hosmer, Vickie A. Feldstein, et al. JAMA 2001; 285:1044–1055. (R.S.B., Department of Radiology, University of California, San Francisco, 1600 Divisadero St, San Francisco, CA 94115; e-mail: Rebecca.Smith-Bindman@radiology.ucsf.edu)
Context: Second-trimester prenatal ultrasound is widely used in an attempt to detect Down syndrome in fetuses, but the accuracy of this method is unknown. Objective: To determine the accuracy of second-trimester ultrasound in detecting Down syndrome in fetuses. Data Sources: English-language articles published between 1980 and February 1999 identified through MEDLINE and manual searches. Study Selection: Studies were included if they recorded second-trimester findings of ultrasonographic markers, chromosomal abnormalities, and clinical outcomes for a well-described sample of women. A total of 56 articles describing 1930 fetuses with Down syndrome and 130365 unaffected fetuses were included. Data Extraction: Articles were independently reviewed, selected, and abstracted by 2 reviewers. Discrepancies in data abstraction were resolved by consensus with a third reviewer. Overall estimates of sensitivity, specificity, and positive and negative likelihood ratios were calculated for the following markers: choroid plexus cyst, thickened nuchal fold, echogenic intracardiac focus, echogenic bowel, renal pyelectasis, and humeral and femoral shortening. Results were stratified by whether markers were identified in isolation or in conjunction with fetal structural malformations. Data Synthesis: When ultrasonographic markers were observed without associated fetal structural malformations, sensitivity for each was low (range, 1%–16%), and most fetuses with such markers had normal outcomes. A thickened nuchal fold was the most accurate marker for discriminating between unaffected and affected fetuses and was associated with an approximately 17-fold increased risk of Down syndrome. If a thickened nuchal fold is used to screen for Down syndrome, 15893 average-risk women or 6818 high-risk women would need to be screened for each case of Down syndrome identified. For each of the other 6 markers, when observed without associated structural malformations, the marker had marginal impact on the risk of Down syndrome. Because the markers were detected in only a small number of affected fetuses, the likelihood of Down syndrome did not decrease substantially after normal examination findings (none of the negative likelihood ratios were significant). Conclusions: A thickened nuchal fold in the second trimester may be useful in distinguishing unaffected fetuses from those with Down syndrome, but the overall sensitivity of this finding is too low for it to be a practical screening test for Down syndrome. When observed without associated structural malformations, the remaining ultrasonographic markers could not discriminate well between unaffected fetuses and those with Down syndrome. Using these markers as a basis for deciding to offer amniocentesis will result in more fetal losses than cases of Down syndrome detected, and will lead to a decrease in the prenatal detection of fetuses with Down syndrome.
Authors’ Abstract
Reasons for selecting abstract:
• Evidence-based practice
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Miscellaneous
Coping With PACS Downtime in Digital Radiology. Mike McBiles, Anna K. Chacko. J Digit Imaging 2000; 13:136–142. (M.M., Department of Radiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234)
As radiology departments become increasingly reliant on picture archiving and communication systems, they become more vulnerable to computer downtime that can paralyze a smoothly running department. The experiences and strategies developed during various types of picture archiving and communication system (PACS) downtime in a large radiology department that has completely converted to soft copy interpretation in all modalities except mammography are presented. Because these failures can be minimized but not eliminated, careful planning is necessary to minimize their impact.
Authors’ Abstract
Reasons for selecting abstract:
• Downtime issues
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Experience With Implementation of a Radiology Speech Recognition System. Jeffrey D. Houston, Frederick William Rupp. J Digit Imaging 2000; 13:124–128. (J.D.H., Department of Radiology [UNMH 1-W], University of New Mexico Health Sciences Center, 915 Camino de Salud NE, Albuquerque, NM 87131-5336)
Recent advances in speech recognition technology have allowed development of computer systems for real-time radiologist-driven generation of reports. The transition to a speech recognition system is a technically complex process with many potential pitfalls that can decrease efficiency and disrupt workflow. In our recent experience with installation of such a system in an academic radiology department, factors that have worked against optimal performance have included environmental logistics, hardware incompatibilities, radiology information system interface problems, lack of suitable training, and inadequate technical support. Communication of our experience is intended to allow radiologists to anticipate complications of these systems and make informed decisions regarding the feasibility of such a system in their practices. With this information, potential buyers should be able to carefully scrutinize specifications for prospective systems and, by avoiding many of the possible pitfalls, make an easier transition to a speech recognition environment.
Authors’ Abstract
Reasons for selecting abstract:
• Implementation issues
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Lack of Effect of Induction of Hypothermia After Acute Brain Injury. Guy L. Clifton, Emmy R. Miller, Sung C. Choi, et al. N Engl J Med 2001; 344:556–563. (G.L.C., Department of Neurosurgery, Vivian L. Smith Center for Neurologic Research, University of Texas-Houston Health Science Center, 6431 Fannin, Ste 7.148, Houston, TX 77030; e-mail: guy.l.clifton@uth.tmc.edu)
Background: Induction of hypothermia in patients with brain injury was shown to improve outcomes in small clinical studies, but the results were not definitive. To study this issue, we conducted a multicenter trial comparing the effects of hypothermia with those of normothermia in patients with acute brain injury. Methods: The study subjects were 392 patients 16 to 65 years of age with coma after sustaining closed head injuries who were randomly assigned to be treated with hypothermia (body temperature, 33°C), which was initiated within 6 hours after injury and maintained for 48 hours by means of surface cooling, or normothermia. All patients otherwise received standard treatment. The primary outcome measure was functional status six months after the injury. Results: The mean age of the patients and the type and severity of injury in the two treatment groups were similar. The mean (±SD) time from injury to randomization was 4.3 ± 1.1 hours in the hypothermia group and 4.1 ± 1.2 hours in the normothermia group, and the mean time from injury to the achievement of the target temperature of 33°C in the hypothermia group was 8.4 ± 3.0 hours. The outcome was poor (defined as severe disability, a vegetative state, or death) in 57 percent of the patients in both groups. Mortality was 28 percent in the hypothermia group and 27 percent in the normothermia group (P = 0.79). The patients in the hypothermia group had more hospital days with complications than the patients in the normothermia group. Fewer patients in the hypothermia group had high intracranial pressure than in the normothermia group. Conclusions: Treatment with hypothermia, with the body temperature reaching 33°C within eight hours after injury, is not effective in improving outcomes in patients with severe brain injury.
Authors’ Abstract
Reasons for selecting abstract:
• Multicenter trial
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Relationship Between Trauma Center Volume and Outcomes. Avery B. Nathens, Gregory J. Jurkovich, Ronald V. Maier, et al. JAMA 2001; 285:1164–1171. (A.B.N., Harborview Medical Center, Box 359796, 325 Ninth Ave, Seattle, WA 98104-2499; e-mail: anathens@u.washington.edu)
Context: The premise underlying regionalization of trauma care is that larger volumes of trauma patients cared for in fewer institutions will lead to improved outcomes. However, whether a relationship exists between institutional volume and trauma outcomes remains unknown. Objective: To evaluate the association between trauma center volume and outcomes of trauma patients. Design: Retrospective cohort study. Setting: Thirty-one academic level I or level II trauma centers across the United States participating in the University Healthsystern Consortium Trauma Benchmarking Study. Patients: Consecutive patients with penetrating abdominal injury (PAI; n = 478) discharged between November 1, 1997, and July 31, 1998, or with multisystem blunt trauma (minimum of head injury and lower-extremity long-bone fractures; n = 541) discharged between June 1 and December 31, 1998. Main Outcome Measures: Inpatient mortality and hospital length of stay (LOS), comparing high-volume (>650 trauma admissions/y) and low-volume (650 admissions/y) centers. Results: After multivariate adjustment for patient characteristics and injury severity, the relative odds of death was 0.02 (95% confidence interval [CI], 0.002–0.25) for patients with PAI admitted with shock to high-volume centers compared with low-volume centers. No benefit was evident in patients without shock (P = .50). The adjusted odds of death in patients with multisystem blunt trauma who presented with coma to a high-volume center was 0.49 (95% CI, 0.26–0.93) vs low-volume centers. No benefit was observed in patients without coma (P = .05). Additionally, a shorter LOS was observed in patients with PAI and New Injury Severity Scores of 16 or higher (difference in adjusted mean LOS, 1.6 days [95% CI, -1.5 to 4.7 days]) and in all patients with multisystem blunt trauma admitted to higher-volume centers (difference in adjusted mean LOS, 3.3 days [95% CI, 0.91–5.70 days]). Conclusions: Our results indicate that a strong association exists between trauma center volume and outcomes, with significant improvements in mortality and LOS when volume exceeds 650 cases per year. These benefits are only evident in patients at high risk for adverse outcomes.
Authors’ Abstract
Reasons for selecting abstract:
• Relationship between experience and outcomes
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Epidemiology of Invasive Streptococcus pneumoniae Infections in the United States, 1995–1998: Opportunities for Prevention in the Conjugate Vaccine Era. Katherine A. Robinson, Wendy Baughman, Gretchen Rothrock, et al. JAMA 2001; 285:1729–1735. (K.A.R., Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, MS D-65, 1600 Clifton Rd NE, Atlanta, GA 30333; e-mail: kad2@cdc.gov)
Context: Pneumococcal polysaccharide vaccine is recommended for elderly persons and adults with certain chronic illnesses. Additionally, a recently licensed pneumococcal 7-valent conjugate vaccine has been recommended for use in young children and could dramatically change the epidemiology of pneumococcal disease. Objectives: To assess pneumococcal disease burden in the United States, estimate the potential impact of new vaccines, and identify gaps in vaccine recommendations. Design and Setting: Analysis of data from the Active Bacterial Core Surveillance (ABCs)/Emerging Infections Program Network, an active, population-based system in 9 states. Patients: A total of 15 860 cases of invasive pneumococcal disease occurring between January 1, 1995, and December 31, 1998. Main Outcome Measures: Age- and race-specific pneumoccocal disease incidence rates per 100 000 persons, case-fatality rates, and vaccine preventability. Results: In 1998, overall incidence was 23.2 cases per 100 000, corresponding to an estimated 62840 cases in the United States. Incidence was highest among children younger than 2 years (166.9) and adults aged 65 years or older (59.7). Incidence among blacks was 2.6 times higher than among whites(95% confidence interval [CI], 2.4–2.8). Overall, 28.6% of case-patients were at least 65 years old and 85.9% of cases in this age group were due to serotypes included in the 23-valent polysaccharide vaccine; 19.3% of case-patients were younger than 2 years and 82.2% of cases in this age group were due to serotypes included in the 7-valent conjugate vaccine. Among patients aged 2 to 64 years, 50.6% had a vaccine indication as defined by the Advisory Committee on Immunization Practices (ACIP). The case-fatality rate among patients aged 18 to 64 years with an ACIP indication was 12.1% compared with 5.4% for those without an indication (relative risk, 2.2; 95% CI, 1.7–2.9). Conclusions: Young children, elderly persons, and black persons of all ages are disproportionately affected by invasive pneumococcal disease. Current ACIP recommendations do not address a subset of persons aged 18 to 64 years but do include those at highest risk for death from invasive pneumococcal disease.
Authors’ Abstract
Reasons for selecting abstract:
• Differences in case-fatality rates
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Association of Cancer With AIDS-Related Immunosuppression in Adults. Morten Frisch, Robert J. Biggar, Eric A. Engels, et al. JAMA 2001; 285:1736–1745. (M.F., Danish Epidemiology Science Center, Statens Serum Institut, 5 Artillerivej, DK-2300 Copenhagen S, Denmark; e-mail: mfr@ssi.dk)
Context: Large-scale studies are needed to determine if cancers other than Kaposi sarcoma, non-Hodgkin lymphoma, and cervical cancer occur in excess in persons with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS). Objectives: To examine the general cancer pattern among adults with HIV/AIDS and to distinguish immunosuppression-associated cancers from other cancers that may occur in excess among persons with HIV/AIDS. Design, Setting, and Subjects: Analysis of linked population-based AIDS and cancer registry data from 11 geographically diverse areas in the United States, including 302 834 adults aged 15 to 69 years with HIV/AIDS. The period of study varied by registry between 1978 and 1996. Main Outcome Measure: Relative risks (RRs) of cancers, calculated by dividing the number of observed cancer cases by the number expected based on contemporaneous population-based incidence rates. We defined cancers potentially influenced by immunosuppression by 3 criteria: (1) elevated overall RR in the period from 60 months before to 27 months after AIDS; (2) elevated RR in the 4- to 27-month post-AIDS period; and (3) increasing trend in RR from before to after AIDS onset. Results: Expected excesses were observed for the AIDS-defining cancers, but non-AIDS-defining cancers also occurred in statistically significant excess (n = 4422; overall RR, 2.7; 95% confidence interval [CI], 2.7–2.8). Of individual cancers, only Hodgkin disease (n = 612; RR, 11.5; 95% CI, 10.6–12.5), particularly of the mixed cellularity (n = 217; RR, 18.3; 95% CI, 15.9–20.9) and lymphocytic depletion (n = 36; RR, 35.3; 95% CI, 24.7–48.8) subtypes; lung cancer (n = 808; RR, 4.5; 95% CI, 4.2–4.8); penile cancer (n = 14; RR, 3.9; 95% CI, 2.1–6.5); soft tissue malignancies (n = 78; RR, 3.3; 95% CI, 2.6–4.1); lip cancer (n = 20; RR, 3.1; 95% CI, 1.9–4.8); and testicular seminoma (n = 115; RR, 2.0; 95% CI, 1.7–2.4) met all 3 criteria for potential association with immunosuppression. Conclusion: Although occurring in overall excess, most non-AIDS-defining cancers do not appear to be influenced by the advancing immunosuppression associated with HIV disease progression. Some cancers that met our criteria for potential association with immunosuppression may have occurred in excess in persons with HIV/AIDS because of heavy smoking (lung cancer), frequent exposure to human papillomavirus (penile cancer), or inaccurately recorded cases of Kaposi sarcoma (soft tissue malignancies) in these persons. However, Hodgkin disease, notably of the mixed cellularity and lymphocytic depletion subtypes, and possibly lip cancer and testicular seminoma may be genuinely influenced by immunosuppression.
Authors’ Abstract
Reasons for selecting abstract:
• Effects of immunosuppression
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
Identification of a Novel Common Genetic Risk Factor for Lumbar Disk Disease. Petteri Paassilta, Jaana Lohiniva, Harald H. H. Göring, et al. JAMA 2001; 285:1843–1849. (Leena Ala-Kokko, Department of Medical Biochemistry, University of Oulu, Aapistie 7, 90220 Oulu, Finland; e-mail: leena.ala-kokko@oulu.fi)
Context: Lumbar disk disease (LDD) is one of the most common musculoskeletal diseases, with a prevalence of about 5%. A tryptophan (Trp) allele (Trp2) was recently discovered in the COL9A2 gene that is associated with dominantly inherited LDD but is only present in about 4% of Finnish patients with LDD. Objective: To determine if other collagen IX gene sequence variations play a role in the pathogenesis of LDD. Design and Setting: Case-control study conducted from February 1997 to May 1998 at university hospitals in Finland. Participants: A total of 171 individuals with LDD (evaluated clinically and by magnetic resonance imaging or computed tomography) and 321 controls without LDD (186 healthy individuals, 83 patients with primary osteoarthritis, 31 with rheumatoid arthritis, and 21 with chondrodysplasias). Main Outcome Measures: Frequencies of sequence variations covering the entire coding sequences and exon boundaries of the collagen IX genes, COL9A1, COL9A2, and COL9A3, which code for the 
1, 2, and 3 chains of the protein, detected by conformation-sensitive gel electrophoresis and confirmed by sequencing, compared between individuals with and without LDD. Results: Mutation analysis of all 3 Collagen IX genes resulted in identification of an Arg103
Trp (argininetryptophan) substitution in the 3 chain (Trp3 allele). The frequency of the Trp3 allele was 12.2% in LDD cases, excluding 7 individuals who were carriers of the previously identified Gln326Trp (glutaminetryptophan) substitution in the 2 chain (Trp2 allele), and was 4.7% among controls. The difference in the frequency was statistically significant (P = .000013). Presence of at least 1 Trp3 allele increases risk of LDD about 3-fold. Conclusion: This study led to the identification of a novel common genetic risk factor for LDD, confirming that genetic risk factors likely play a significant role in LDD.
Authors’ Abstract
Reasons for selecting abstract:
• Information on a common disease
Selected by Anthony V. Proto, MD
School of Medicine, Virginia Commonwealth University, Richmond
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