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Worse Clinical Outcomes (bad + clinical_outcome)
Selected AbstractsPeripheral blood picture following mild head trauma in childrenPEDIATRICS INTERNATIONAL, Issue 3 2008Bulent Alioglu Abstract Background: The aim of the present study was to investigate changes in peripheral white blood cell, and differential counts following mild head trauma in a pediatric population. Methods: Fifty-one patients (mean age, 79 ± 62 months) with mild head trauma (Glasgow Coma Scale [GCS] score 15) who were admitted to the emergency department, were studied. Two blood specimens were collected from each patient, one on arrival and one after 24 h at the emergency department. Complete blood count was performed using a hemocytometer and the absolute cell counts for each sample were calculated after examination of peripheral smear. Results: No patient developed any complication during the hospital stay or after discharge. Significant differences were found for white blood cell, neutrophil, and immature cell counts just after and 24 h after trauma (P = 0.047, 0.039 and 0.009, respectively). Conclusions: Mild head trauma may cause an increase in white blood cell, neutrophil and band counts in children just after trauma. In a child with a mild head trauma, who is asymptomatic, with GCS score of 15 and absence of risk factors, and without clinical deterioration, complete blood cell count may be omitted from laboratory workup. But a prospective randomized study comparing mild head trauma patients with good and bad clinical outcome is needed to draw a definite conclusion. [source] Endpoints of therapy in chronic hepatitis B,HEPATOLOGY, Issue S5 2009Jordan J. Feld Because clearance of hepatitis B virus (HBV) infection is rarely, if ever, achievable, the goals of therapy necessarily focus on prevention of bad clinical outcomes. Ideally, therapies would be shown to prevent tangible clinical endpoints like development of cirrhosis, end-stage liver disease and hepatocellular carcinoma. However, these endpoints typically take years or decades to occur and are therefore impractical targets for clinical trials which last only 1-2 years. As a result, surrogate biomarkers that are believed to correlate with long-term outcome are used to evaluate therapy. Of the clinical, biochemical, serological, virological, and histological endpoints that have been evaluated, none has been shown to be ideal on its own. Symptoms are uncommon and aminotransferase levels fluctuate spontaneously. Loss of hepatitis B e antigen (HBeAg) has been the traditional therapeutic endpoint; however, the indefinite durability off treatment and the emergence of HBeAg-negative disease have made it inadequate as the sole goal of therapy. Loss of hepatitis B surface antigen is associated with improved clinical outcomes, but it is rarely achieved with current therapies. Suppression of viral replication, as measured by serum HBV DNA levels, has become the major goal of therapy, particularly if maintained off therapy. Although useful, the significance of viral levels depends on the stage of disease, degree of liver damage, and the type of therapy. Finally, liver biopsy, often considered the gold standard, is invasive, prone to sampling error, and may take years to change significantly. At present, there is no ideal biomarker for evaluation of therapies for hepatitis B. Future research should be directed at development and validation of surrogate markers that accurately predict or reflect clinically relevant outcomes of chronic hepatitis B. (HEPATOLOGY 2009;49:S96,S102.) [source] Vascular endothelial growth factor (VEGF), VEGF receptors expression and microvascular density in benign and malignant thyroid diseasesINTERNATIONAL JOURNAL OF EXPERIMENTAL PATHOLOGY, Issue 4 2007Ala'eddin Jebreel Summary Angiogenesis is critical for the growth and metastatic spread of tumours. Vascular endothelial growth factor (VEGF) is the most potent inducer of neovasculature, and its increased expression has been related to a worse clinical outcome in many diseases. The purpose of this study was to evaluate the relation between VEGF, its receptors (VEGFR-1 and VEGFR-2) and microvessel density (MVD) in thyroid diseases. Immunostaining for VEGF and VEGF receptors was performed in 66 specimens of thyroid tissue, comprising 17 multinodular goitre (MNG), 14 Graves' disease, 10 follicular adenoma, 8 Hashimoto's thyroiditis, 7 papillary carcinoma and 10 normal thyroid specimens. Thyrocyte positivity for VEGF and VEGF receptors was scored 0,3. Immunohistochemistry for CD31, and CD34 on the same sections was performed to evaluate MVD. Immunohistochemical staining of VEGF in thyrocytes was positive in 92% of all the thyroid tissues studied. Using an immunostaining intensity cut off of 2, increased thyrocyte staining was seen in follicular adenoma specimens, MNG and normal thyroids compared with Hashimoto's thyroiditis and Graves' disease (P < 0.05). Similarly, VEGF thyrocyte expression in Graves' disease was less than other pathologies (P < 0.05). VEGFR-1 expression and the average MVD score did not differ between the different thyroid pathologies. VEGF expression was lower in autoimmune pathologies compared to autonomous growth processes. Conversely, both VEGFR-1 and VEGFR-2 were widely expressed in benign and neoplastic thyroid disease, suggesting that the up-regulation of VEGF and not its receptors occurs as tissue becomes autonomous. There was no clear relationship between MVD measurement and thyroid pathology. [source] High Incidence of Donor-Reactive Delayed-Type Hypersensitivity Reactivity in Transplant PatientsAMERICAN JOURNAL OF TRANSPLANTATION, Issue 10 2002Ronald P. Pelletier Evidence of transplant recipient cellular sensitization towards donor antigens has rarely been directly measured. Rather, sensitization has been generally inferred by the presence of detectable allo-reactive or donor-reactive antibodies. In this study a newly developed delayed-type hypersensitivity assay was used to directly determine the incidence of post-transplant donor-reactive T-cell sensitization in a large cohort of kidney and simultaneous kidney-pancreas recipients. These results were compared with the presence of detectable circulating alloantibodies and with patient clinical outcome. We found an unexpectedly high incidence (52%) of donor-reactive delayed-type hypersensitivity reactivity in our study patients. Donor-reactive delayed-type hypersensitivity reactivity occurred at a much higher frequency than detectable alloantibodies (20%). Further, we found no correlation between the presence of alloantibodies and donor-reactive delayed-type hypersensitivity reactivity. We also found no correlation between the development of donor-reactive delayed-type hypersensitivity reactivity and the degree of donor and recipient HLA matching. Finally, the presence of detectable donor-reactive delayed-type hypersensitivity reactivity did not correlate with a worse clinical outcome at the time of these analyses. We conclude that in transplant recipients, the presence of circulating alloantibodies is a poor indicator of previous T-cell sensitization to donor antigens. We also conclude that our current immunosuppression strategies are relatively ineffective at blocking T-cell allosensitization, but are very effective at blocking the biological consequences of that allosensitization. [source] Anticoagulants in pediatric cerebral sinovenous thrombosis: A safety and outcome studyANNALS OF NEUROLOGY, Issue 5 2010Mahendranath D. Moharir MBBS Objective Clinical trials are lacking in pediatric cerebral sinovenous thrombosis (CSVT). Neonates and children increasingly receive anticoagulant therapy (ACT) based on adult studies. Safety data for ACT in pediatric CSVT are scant and urgently needed. The objective was to assess the safety and outcome of ACT in pediatric CSVT. Methods In a single-center prospective study, neonates and children with CSVT received ACT (standard/low molecular weight heparin, warfarin) by standardized protocol. A study neuroradiologist (M.S.) assessed all initial and follow-up neuroimaging for intracranial hemorrhage (ICH), thrombus propagation, and recanalization. Clinical outcome was assessed with the Pediatric Stroke Outcome Measure. Results Among 162 pediatric patients, 85 received ACT at diagnosis, including 29/83 (35%) neonates and 56/79 (71%) children. Major hemorrhage occurred in 6% (6/99) of treated patients, including 14% (3/21 neonates, 2/15 children) with and 2% (0/17 neonates, 1/46 children) without pretreatment ICH. ACT-associated bleeds were all nonfatal, and clinical outcome was favorable in 50%, similar to the remaining patients (53%). Early follow-up imaging demonstrated thrombus propagation in 11/57 neonates (10/35 [28%] without and 1/22 [4%] with ACT [p = 0.037]) and 10/63 children (7/19 [37%] without and 3/44 [7%] with ACT [p = 0.006]). Propagation was associated with new venous infarcts in 10% neonates and 40% children and worse clinical outcome in children (p = 0.053). Recanalization occurred earlier and more completely in neonates (p = 0.002). Clinical outcome was unfavorable in 47%. Interpretation In pediatric CSVT, ACT appears safe. Nontreatment with ACT is associated with thrombus propagation, observed in ¼ of untreated neonates and over , of children. Anticoagulants merit strong consideration in pediatric CSVT. ANN NEUROL 2010;67:590,599 [source] Racial Disparity in Clinical Outcomes Following Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction: Influence of Process of CareJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2007JOSHUA A. JACOBI M.D. Previous studies have shown that compared with white patients, non-white patients with STelevation myocardial infarction (STEMI) have worse clinical outcomes. Differences in co-morbidities, extent and severity of coronary artery disease, health insurance, and socioeconomic status have been identified as possible reasons for this disparity. However, an alternative explanation for such observed disparities in outcomes could be differences in process of care. For example, in most of these studies, non-white patients were less likely to receive reperfusion therapy, and if treated, were more likely to receive thrombolysis than to undergo primary percutaneous coronary intervention (PCI). We hypothesized that if all patients were treated similarly with primary PCI, there would be no difference in clinical outcomes. We analyzed the demographic, angiographic, in-hospital clinical outcomes, and long-term mortality rates of a racially diverse group of patients presenting to the same hospital with STEMI, all of whom were treated with primary PCI. Our data demonstrate that compared with white patients, non-white patients with STEMI who undergo primary PCI have similar in-hospital clinical outcomes and one-year mortality. This suggests that the previously observed differences in mortality rates may be, at least in part, attributable to differences in the process of care, and not solely to differences in patient factors or differential therapeutic effects. [source] Economic evaluation of erythropoiesis-stimulating agents for anemia related to cancerCANCER, Issue 13 2010Scott Klarenbach MD Abstract BACKGROUND: Erythropoiesis-stimulating agents (ESA) administered to cancer patients with anemia reduce the need for blood transfusions and improve quality-of-life (QOL). Concerns about toxicity have led to more restrictive recommendations for ESA use; however, the incremental costs and benefits of such a strategy are unknown. METHODS: The authors created a decision model to examine the costs and consequences of ESA use in patients with anemia and cancer from the perspective of the Canadian public healthcare system. Model inputs were informed by a recent systematic review. Extensive sensitivity analyses and scenario analysis rigorously assessed QOL benefits and more conservative ESA administration practices (initial hemoglobin [Hb] <10 g/dL, target Hb ,12 g/dL, and chemotherapy induced anemia only). RESULTS: Compared with supportive transfusions only, conventional ESA treatment was associated with an incremental cost per quality-adjusted life year (QALY) gained of $267,000 during a 15-week time frame. During a 1.3-year time horizon, ESA was associated with higher costs and worse clinical outcomes. In scenarios where multiple assumptions regarding QOL all favored ESA, the lowest incremental cost per QALY gained was $126,000. Analyses simulating the use of ESA in accordance with recently issued guidelines resulted in incremental cost per QALY gained of >$100,000 or ESA being dominated (greater costs with lower benefit) in the majority of the scenarios, although greater variability in the cost-utility ratio was present. CONCLUSIONS: Use of ESA for anemia related to cancer is associated with incremental cost-effectiveness ratios that are not economically attractive, even when used in a conservative fashion recommended by current guidelines. Cancer 2010. © 2010 American Cancer Society. [source] Histopathologic grading of medulloblastomasCANCER, Issue 2 2002A Pediatric Oncology Group Study Abstract BACKGROUND Medulloblastomas are small cell embryonal tumors of the cerebellum found predominantly in children, only slightly more than half of whom survive. Predicting favorable outcome has been difficult, and improved stratification clearly is required to avoid both undertreatment and overtreatment. Patients currently are staged clinically, but no pathologic staging system is in use. Two rare subtypes at extreme ends of the histologic spectrum, i.e., medulloblastomas with extensive nodularity and large cell/anaplastic medulloblastomas, are associated with better and worse clinical outcomes, respectively. However, there is little data about correlations between histologic features and clinical outcome for most patients with medulloblastomas that fall between these histologic extremes of nodularity and anaplasia. Therefore, the authors evaluated the clinical effects of increasing anaplasia and nodularity in a large group of children with medulloblastomas, hypothesizing that increasing nodularity would predict better clinical outcomes and that increasing anaplasia would presage less favorable results. METHODS Medulloblastomas from 330 Pediatric Oncology Group patients were evaluated histologically with respect to extent of nodularity, presence of desmoplasia, grade of anaplasia, and extent of anaplasia. Pathologic and clinical data were then compared using Kaplan,Meier and log-rank analyses. RESULTS Increasing grade of anaplasia and extent of anaplasia were associated strongly with progressively worse clinical outcomes (P < 0.0001 for both). Significant anaplasia (moderate or severe) was identified in 24% of medulloblastoma specimens. Neither increasing degrees of nodularity nor desmoplasia were associated significantly with longer survival. CONCLUSIONS Moderate anaplasia and severe anaplasia were associated with aggressive clinical behavior in patients with medulloblastomas and were detected in a significant number of specimens (24%). Pathologic grading of medulloblastomas with respect to anaplasia may be of clinical utility. Cancer 2002;94:552,60. © 2002 American Cancer Society. [source] Clinical Outcomes for Single Stent and Multiple Stents in Contemporary PracticeCLINICAL CARDIOLOGY, Issue 9 2009Qiao Shu Bin MD Background Stents had been demonstrated to be safe and effective in the treatment of severe coronary artery disease (CAD); however, the current knowledge on percutaneous coronary intervention (PCI) in treating patients requiring 2 or more stents placements is still limited. Hypothesis Patients who required 2 or more stents might have worse clinical outcomes. Methods A total of 2371 patients who underwent stenting were divided into a single stenting group (n = 1233) and a multiple stenting group (n = 1138). We assessed the cumulative incidence of major adverse cardiac events (death, acute myocardial infarction, and target-vessel revascularization) and stent thrombosis during 1-year follow-up. Results The 1-year unadjusted cumulative incidence of major adverse cardiac events was 7.7% in the multiple stenting group and 5.4% in the single stenting group (P = 0.02 by log-rank test). After adjustment, there was a trend toward a lower rate of 1-year major adverse cardiac events in the single stenting group than in the multiple stenting group (P = 0.09). A nonsignificant trend was also detected in favor of the single stenting group, as compared with the multiple stenting group, at the rate of acute myocardial infarction (1.3% vs 1.7%, P = 0.89) and at the rate of target-vessel revascularization (4.5% vs 5.4%, P = 0.08). Conclusions Although the use of a single stent in coronary artery disease has less incidence of adverse cardiac events at 1 year as compared with the use of multiple stents, the difference was not statistically significant. Copyright © 2009 Wiley Periodicals, Inc. [source] Magnetic resonance imaging in rectal cancer downstaged using neoadjuvant chemoradiation: accuracy of prediction of tumour stage and circumferential resection margin statusCOLORECTAL DISEASE, Issue 5 2008T. Kulkarni Abstract Objective, The aim was to examine the accuracy of magnetic resonance imaging (MRI) in predicting circumferential resection margin (CRM) involvement, T- and N-stage in patients with locally advanced carcinoma of the rectum, who had undergone long-course downstaging chemoradiation (CRT). Method, Patients with rectal cancer were selected for long-course downstaging CRT if their tumour was considered to threaten (,1 mm) or involve the CRM on MRI. Eighty such patients had a repeat MRI at a median of 6 weeks post-CRT followed by surgical excision soon thereafter. The findings on the post-CRT MRI were compared with histological examination of the surgical specimen. Results, For CRM involvement, post-CRT restaging MRI had an accuracy of 81% (65/80) a sensitivity of 54% (7/13), a specificity of 87% (58/67), a positive predictive value of 44% (7/16) and a negative predictive value of 91% (58/64). Accuracy for T- and N-staging was 43% (34/80) and 78% (62/80), respectively. 38% of T-stages were overstaged and 20% understaged. 4% of N-stages were overstaged and 19% understaged. The 13 patients with histological positive CRM had worse clinical outcomes than the 67 patients with negative CRM in terms of disease-free survival (relative risk of reduced DFS 4.6, P = 0.001) and overall survival (relative risk of death 3.6, P = 0.016). Conclusion, Magnetic resonance imaging has good specificity and negative predictive value for predicting an uninvolved CRM post downstaging CRT in locally advanced rectal cancer although sensitivity and positive predictive value for an involved CRM were unsatisfactory. The shortcomings of MRI stem from poor differentiation of viable tumour from posttreatment changes and inability to identify small nodal and tumour deposits. Clinical correlates in this group of patients have confirmed the importance of achieving a clear CRM at surgery. [source] Prognostic value of c-erbB2 expression in breast cancerJOURNAL OF SURGICAL ONCOLOGY, Issue 4 2002Shinichi Tsutsui MD Abstract Background and Objectives An overexpression of c-erbB2 has been reported to be associated with a poor clinical outcome in breast cancer, however, its prognostic value remains controversial especially in patients with node negative breast cancer, and regarding the estrogen receptor (ER) status. Methods Immunohistochemical staining for c-erbB2 was performed on the primary breast cancer from 698 Japanese patients with a mean follow-up duration of 54 months. Results The c-erbB2 expression was positive in 120 (17.2%) of 698 cases, which inversely correlated with the ER status. Both univariate and multivariate analyses indicated the c-erbB2 expression to be a significant prognostic factor for the disease-free survival (DFS) and overall survival (OS), while the same efffect was also seen in the patient groups with node negative as well as node positive breast cancer. A univariate anlysis also indicated a subgroup with the positive c-erbB2 and negative ER to have both a worse DFS and OS than the other subgroups. The patients with positive c-erbB2 had a significantly worse DFS and OS than the patients with negative c-erbB2 in all patient groups stratified according to the adjuvant therapies, while the prognostic significance of c-erbB2 on DFS was also found in the patients with the node negative breast cancer who received adjuvant tamoxifen alone. Conclusions The c-erbB2 expression is an independent significant factor for breast cancer and the prognostic significance remains in the node negative as well as node positive breast cancer, while the same effect was also found in all subgroups stratified according to the adjuvant therapies. In addition, the combination of c-erbB2 and ER made it possible to identify the subgroup with the worst clinical outcome. J. Surg. Oncol. 2002;79:216,223. © 2002 Wiley-Liss, Inc. [source] Mechanical Ventilation Was Associated with Acidemia in a Case Series of Salicylate-poisoned PatientsACADEMIC EMERGENCY MEDICINE, Issue 9 2008Andrew I. Stolbach MD Abstract Objectives:, Despite little empiric evidence, mechanical ventilation (MV) in the setting of salicylate poisoning is considered by many to be harmful. When salicylate-poisoned patients are ventilated at conventional settings, the respiratory alkalosis is abolished, more salicylate is able to pass into the central nervous system (CNS), and neurotoxicity worsens. The objective of this study was to identify a relationship between MV, acidosis, and outcome in salicylate-poisoned patients. Methods:, The authors electronically searched a poison control center (PCC) database (2001,2007) for patients with salicylate poisoning, defined as a serum concentration >50 mg/dL, who had MV listed as a therapy. For the 7-year study period, a total of 3,144 salicylate-poisoning cases were identified. Eleven patients met the inclusion criteria of having both salicylate concentrations >50 mg/dL and required MV; only 7 of them had post-MV data available. Results:, In all seven patients with post-MV blood gas data, the post-MV pH was <7.4. In five of six patients with recorded PCO2, the post-MV PCO2 was >50 mm Hg. Two of the seven patients in the study group died following intubation (two patients died within 3 hours [serum salicylate concentrations, 85 and 79 mg/dL, respectively]). Another patient sustained severe neurologic injury (serum salicylate concentration, 84 mg/dL). The other four patients were ultimately discharged home. In the three patients with the worst clinical outcome, deterioration was reported within hours of intubation. Conclusions:, Inadequate MV of patients with salicylate poisoning is associated with respiratory acidosis, acidemia, and clinical deterioration in this series of cases. This supports warnings about the danger of improper MV in patients with salicylate poisoning. A prospective study should be performed. [source] | ||||||||||||||||||||||