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Worse Outcome (bad + outcome)
Selected AbstractsPancreas Allograft Biopsies with Positive C4d Staining and Anti-Donor Antibodies Related to Worse Outcome for PatientsAMERICAN JOURNAL OF TRANSPLANTATION, Issue 7 2010H. De Kort C4d+ antibody-mediated rejection following pancreas transplantation has not been well characterized. Therefore, we assessed the outcomes of 27 pancreas transplantation patients (28 biopsies), with both C4d staining and donor-specific antibodies (DSA) determined, from a cohort of 257 patients. The median follow-up was 50 (interquartile range [IQR] 8,118) months. Patients were categorized into 3 groups: group 1, patients with minimal or no C4d staining and no DSA (n = 13); group 2, patients with either DSA present but no C4d, diffuse C4d+ and no DSA or focal C4d+ and DSA (n = 6); group 3, patients with diffuse C4d+ staining and DSA (n = 9). Active septal inflammation, acinar inflammation and acinar cell injury/necrosis were significantly more abundant in group 3 than in group 2 (respective p-values: 0.009; 0.033; 0.025) and in group 1 (respective p-values: 0.034; 0.009; 0.002). The overall uncensored pancreas graft survival rate for groups 1, 2 and 3 were 53.3%, 66.7% and 34.6%, respectively (p = 0.044). In conclusion, recipients of pancreas transplants with no C4d or DSA had excellent long-term graft survival in comparison with patients with both C4d+ and DSA present. Hence, C4d should be used as an additional marker in combination with DSA in the evaluation of pancreas transplant biopsies. [source] Heel ulcers don't heal in diabetes.DIABETIC MEDICINE, Issue 9 2005Or do they? Abstract Aim To obtain information on outcome of heel ulcers in diabetes. Methods Data were recorded prospectively on all patients with heel ulcers who were referred to a specialist multidisciplinary clinic between 1 January 2000 and 30 November 2003. Outcomes were assessed on 31 March 2004. Results There were 157 heel ulcers in the patients referred in the period. Three ulcers were excluded from analysis because of associated osteomyelitis. Of 154 remaining ulcers (121 limbs; 97 patients, 55 male; mean age 68.5 ± 12.8 sd years), 101 (65.6%) healed after a median (range) 200 (24,1225) days. Of 53 non-healed ulcers, 11 (7.1% of 154) were resolved by major amputation, 30 (19.5% of 154) were unhealed at time of patient's death, and 12 (7.8% of 154) remained unhealed. Ulcers healed in 59 of 97 affected patients (60.8%). Twenty-six patients (26.8% of 97) died during the period, of whom 20 died with ulcers unhealed. Worse outcomes were observed in larger ulcers (P = 0.001, Mann,Whitney U -test = 1883.5) and limbs with clinical evidence of peripheral arterial disease (P = 0.001, Mann,Whitney U -test = 1163.00). Backward step-wise logistic regression analysis showed 70.1% of healing could be predicted from these two baseline characteristics. Conclusions The common perception that ,heel ulcers don't heal' is not reflected in clinical practice. Outcome is generally favourable even in a population often affected by serious comorbidity and with limited life expectancy. These data can be used to help define management plans, as well as a basis for counselling of the individual patient. [source] Systematic review of post-treatment psychosocial and behaviour change interventions for men with cancerPSYCHO-ONCOLOGY, Issue 3 2010Hannah L. Dale Abstract Objectives: The psychosocial impacts of a cancer diagnosis include reduced quality of life, poorer inter-personal relationships, hopelessness and mental illness. Worse outcomes, including mortality rates have been found for single men with cancer compared with women and partnered men. The aim of this systematic review was to examine the effectiveness of post-treatment psychosocial and behaviour change interventions for adult men with cancer, in order to inform the development of an intervention. A focus on single men was intended. Methods: Ten databases were searched via Ovid and Web of Science. Papers were systematically extracted by title, abstract and full paper according to the inclusion/exclusion criteria. Full papers were assessed by two authors. Inclusion criteria: participants at any stage of a cancer diagnosis, ,50% male and aged 18+; psychosocial and/or behavioural post-treatment interventions, using any format; a one,three level of evidence. Couple/carer/family interventions were excluded. Results: From 9948 studies initially identified, 11 were finally included in the review. They implemented cognitive behaviour therapy, hypnosis or psychoeducational interventions. All studies had some positive results, however, lack of reporting of intervention content and methodological issues limit the findings. No studies intervened with single men, and none provided comparative outcomes for marital status. Conclusions: Effectiveness of interventions was difficult to assess as, while all had benefits, their generalisability was limited due to methodological and reporting limitations. Improved reporting procedures are required to allow for replication. Copyright © 2009 John Wiley & Sons, Ltd. [source] Relating therapeutic process to outcome: are there predictors for the short-term course in anorexic patients?EUROPEAN EATING DISORDERS REVIEW, Issue 4 2005Almut Zeeck Abstract Objective The aim of the study was to explore if process aspects of the first 12 individual psychotherapy sessions of anorexic patients (6 weeks of treatment) are associated with a good or bad outcome at discharge. Method N,=,38 patients with anorexia nervosa (DSM-IV) were treated in a multimodal setting. Process measures were available from the perspectives of both patients and therapists for N,=,344 sessions. Results 79% of the successful patients (discharge BMI,>,17.5) and 68% of the failures could be correctly identified by process variables measured in the initial treatment phase. Patients' experience of negative emotions re therapy between sessions was associated with a bad outcome, whereas a frequent and intense process of ,recreating the therapeutic dialogue' was found to be associated with a good outcome. Early therapeutic interventions with a focus on symptoms and interpersonal relationships were related to a positive outcome, whereas a focus on self-concept was related to a bad outcome. Copyright © 2005 John Wiley & Sons, Ltd and Eating Disorders Association. [source] Medical malpractice and the thyroid glandHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 6 2003Daniel D. Lydiatt DDS Abstract Background. A medical malpractice litigation "crisis" exists in this country. Analyzing litigation trends through verdict summaries may help understand causes. Methods. Jury verdict reviews from 1987,2000 were obtained from a computerized database. Reviews compile data on defendants, plaintiffs, allegations of wrongdoing, and verdict summaries. Results. Thirty suits from nine states occurred. Plaintiffs were women in 80% of the cases, with a median age of 41. Fifty percent of patients (15 of 30) had a bad outcome, (9 of 30 dead, 4 of 30 with neurologic deficits, 1 blind, and 1 alive with cancer). Thirty percent alleged surgical complications, mostly recurrent laryngeal nerve injury, and 75% of cancer patients alleged a delay, either through falsely negative biopsies or no biopsy taken. Respiratory events occurred in 43% and frequently resulted in large awards. Conclusions. The liberal use of fine-needle aspiration and documentation of surgical risks may help reduce litigation. Complications and bad outcomes do not indicate negligence. Analysis may contribute to risk management strategies or litigation reform. © 2003 Wiley Periodicals, Inc. Head Neck 25: 429,431, 2003 [source] Outcome, timing and adverse events in therapeutic hypothermia after out-of-hospital cardiac arrestACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2009N. NIELSEN Background: Therapeutic hypothermia (TH) after cardiac arrest protects from neurological sequels and death and is recommended in guidelines. The Hypothermia Registry was founded to the monitor outcome, performance and complications of TH. Methods: Data on out-of-hospital cardiac arrest (OHCA) patients admitted to intensive care for TH were registered. Hospital survival and long-term outcome (6,12 months) were documented using the Cerebral Performance Category (CPC) scale, CPC 1,2 representing a good outcome and 3,5 a bad outcome. Results: From October 2004 to October 2008, 986 TH-treated OHCA patients of all causes were included in the registry. Long-term outcome was reported in 975 patients. The median time from arrest to initiation of TH was 90 min (interquartile range, 60,165 min) and time to achieving the target temperature (,34 °C) was 260 min (178,400 min). Half of the patients underwent coronary angiography and one-third underwent percutaneous coronary intervention (PCI). Higher age, longer time to return of spontaneous circulation, lower Glasgow Coma Scale at admission, unwitnessed arrest and initial rhythm asystole were all predictors of bad outcome, whereas time to initiation of TH and time to reach the goal temperature had no significant association. Bleeding requiring transfusion occurred in 4% of patients, with a significantly higher risk if angiography/PCI was performed (2.8% vs. 6.2%P=0.02). Conclusions: Half of the patients survived, with >90% having a good neurological function at long-term follow-up. Factors related to the timing of TH had no apparent association to outcome. The incidence of adverse events was acceptable but the risk of bleeding was increased if angiography/PCI was performed. [source] (217) Selective Nerve Root Injections Can Accurately Predict Level of Nerve Impairment and Outcome for Surgical Decompression: A Retrospective AnalysisPAIN MEDICINE, Issue 3 2001Kevin Macadaeg There remains significant controversy regarding the use of a vertebral selective nerve root injection (SNI) as a diagnostic and therapeutic tool. In addition, the frequency of use of such procedures in patients with radiculopathy has increased dramatically in the last few years. Based on a Medline review there has been no studies combining cervical and lumbar SNI results and comparing preoperative diagnosis to surgical findings and outcome. The purpose of this paper is to retrospectively examine and compare the sensitivity, specificity and predictive value of a good surgical outcome in patients who had an SNI and subsequent surgical intervention. 101 patients from a 1996 thru 1999 database, who were referred to 10 spine surgeons (2 orthopedic and 8 neurosurgeon) for either cervical or lumbar radiculopathy, and had SNI and various imagery studies and subsequent surgery. Patients receive SNIs at our institution if there is a discrepancy between physical exam and radiologic imagery or to confirm a putative pain generator in multilevel pathology. These patients were then retrospectively analyzed with regard to correlation to surgical level and surgical outcome. SNIs were performed by one of three pain specialists in our clinic. Approximation of the appropriate nerve root sleeve was performed using fluoroscopic imagery, a nerve stimulator and contrast. After nerve root stimulation and neurography, 0.5,0.75 cc of lidocaine 2% was injected. Pre- and post-procedural visual analog scale (VAS) pain scores were obtained from the non-sedated patient. A SNI was considered positive or negative if the patient had immediate appendicular pain relief of greater or less then ninety percent respectively. The study was designed to include only those patients that had a SNI, regardless of result, and subsequently had surgical decompression in an attempt to treat the pain that initially prompted the SNI. A statistical analysis was then performed comparing preoperative data to surgical findings and outcome. Overall, 101 patients had SNIs who subsequently underwent surgical decompression. Average duration of symptoms prior to SNI was 1.5,12 months (4 months mean). Fifteen patients presented with cervical and 86 with lumbar radiculopathy. There were a total of 110 procedures performed on these patients. VAS scores of <2 and overall pain reduction openface> 90% with respect to their pre-procedural appendicular were used to determine if a SNI was positive, negative or indeterminate. All of these patients had an MRI or CT with or without a myelogram and all went to surgery. The results yield that SNIs are able to predict surgical findings with 94% and 90% sensitivity and specificity, respectively. A good surgical outcome was determined if the patient would do the surgery again, if they were satisfied or very satisfied and had a VAS of <3 at 6- and 12-month intervals. Our data revealed that a positive SNI was able to predict a good 6-month outcome with 95% and 64% sensitivity and specificity, respectively. At 12-months, similar results were obtained of 95% and 56%. Preoperative MRI results were also evaluated and revealed a 92% sensitivity in predicting surgical findings. We had 24 false positive MRI results and 0 true negatives. Interestingly we had 8 diabetic (IDDM or NIDDM) patients or nearly 8% of our total. The odds ratio of a diabetic having a bad outcome at 12 months was 5.4 to 1. Diabetics had a 50% likelihood of having a bad 12-month outcome versus 16% for non-diabetics with a p value of 0.066. We also looked at gender, smoking history and presence of cardiovascular disease and found no significant relationship with outcomes. Our data indicate that SNIs, when performed under rigorous method, is a highly valuable tool that can accurately determine level of nerve root impairment and outcome in patients being considered for surgical decompression. With a sensitivity of 94% and a specificity of 90%, SNIs offer a major advantage over other diagnostic modalities in patients with difficult-to-diagnose radiculopathies. [source] Determinants of Poor Graft Outcome in Patients with Antibody-Mediated Acute RejectionAMERICAN JOURNAL OF TRANSPLANTATION, Issue 4 2007C. Lefaucheur This study analyzes the incidence and course of antibody-mediated rejection (AMR) in a cohort of 237 renal transplant patients followed for 30 ± 20 months. Among these, 32 patients were considered to be at risk for AMR and received intravenous immunoglobulin (IVIg), either as preconditioning (Group A, n = 18) or at the time of transplant (Group B, n = 14). The prevalence of AMR was 27.8% in Group A, 57.1% in Group B and 3.9% in the remainder of the population. Although graft loss remains greater among AMR than for acute cellular rejection (ACR) or the overall transplant population, we have identified a good outcome group (GFR > 15 mL/min/1.73 m2) (n = 13), whose renal function at the end of follow-up was comparable to that of the general transplant population. The factors associated with bad outcome are: (1) immunologic: presence and/or persistence of donor-specific anti-HLA antibodies post-transplantation and (2) histologic: neutrophilic glomerulitis, peritubular capillary dilatation with neutrophil infiltrates and interstitial edema at the time of first biopsy; and at the time of late biopsy (3,6 months): lesions of vascular rejection, and monocyte/macrophage infiltrates in glomeruli and dilated peritubular capillaries. Persistence of C4d does not predict outcome. This study outlines for the first time the immunologic and histologic profiles of AMR patients with poor prognosis. [source] Medical malpractice and the thyroid glandHEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 6 2003Daniel D. Lydiatt DDS Abstract Background. A medical malpractice litigation "crisis" exists in this country. Analyzing litigation trends through verdict summaries may help understand causes. Methods. Jury verdict reviews from 1987,2000 were obtained from a computerized database. Reviews compile data on defendants, plaintiffs, allegations of wrongdoing, and verdict summaries. Results. Thirty suits from nine states occurred. Plaintiffs were women in 80% of the cases, with a median age of 41. Fifty percent of patients (15 of 30) had a bad outcome, (9 of 30 dead, 4 of 30 with neurologic deficits, 1 blind, and 1 alive with cancer). Thirty percent alleged surgical complications, mostly recurrent laryngeal nerve injury, and 75% of cancer patients alleged a delay, either through falsely negative biopsies or no biopsy taken. Respiratory events occurred in 43% and frequently resulted in large awards. Conclusions. The liberal use of fine-needle aspiration and documentation of surgical risks may help reduce litigation. Complications and bad outcomes do not indicate negligence. Analysis may contribute to risk management strategies or litigation reform. © 2003 Wiley Periodicals, Inc. Head Neck 25: 429,431, 2003 [source] CT32 WHEN TO CALL THE SURGEONANZ JOURNAL OF SURGERY, Issue 2007D. P. Shaw Not infrequently, a patient status has changed and the surgeon is not informed. This not only leads to frustration but potentially bad outcomes. Devising a protocol for when to call the surgeon is fraught with difficulties. Frequently they are so complicated that individuals were unable to remember them thus the protocols are not applied. High turnover of junior staff means that large protocol books are not read. The below three rules are designed to fulfil the role of protocols. They are compulsory flags for when the surgeon is to be called. They are not guides to management nor comments on adequacy of management. Their intent is to flag a change in status of the patient. The compulsory nature of the flags reduces the decision making and stress for the resident staff as to whether or not they should be calling the boss. The surgeon is to be called when 1The patient is to receive blood or blood products 2The inotropes dose is doubled from admission 3A vasoconstrictor is started [source] ,3-Tubulin is induced by estradiol in human breast carcinoma cells through an estrogen-receptor dependent pathwayCYTOSKELETON, Issue 7 2009Jennifer Saussede-Aim Abstract Microtubules are involved in a variety of essential cell functions. Their role during mitosis has made them a target for anti-cancer drugs. However development of resistance has limited their use. It has been established that enhanced ,3-tubulin expression is correlated with reduced response to antimicrotubule agent-based chemotherapy or worse outcome in a variety of tumor settings. However little is known regarding the regulation of ,3-tubulin expression. We investigated the regulatory mechanisms of expression of ,3-tubulin in the MCF-7 cell line, a model of hormone-dependent breast cancer. Exposure of MCF-7 cells to estradiol was found to induce ,3-tubulin mRNA as well as ,3-tubulin protein expression. Conversely, we did not observe induction of ,3-tubulin mRNA by estradiol in MDA-MB-231 cells which are negative for the estrogen receptor (ER). In order to determine whether ,3-tubulin up-regulation is mediated through the ER pathway, MCF-7 cells were exposed to two ER modulators. Exposure to tamoxifen, a selective estrogen receptor modulator, completely abolished the ,3-tubulin mRNA induction due to estradiol in MCF-7 cells. This result was confirmed with fulvestrant, a pure antagonist of ER. These results demonstrate that the effect of estradiol on ,3-tubulin transcription is mediated through an ER dependent pathway. Cell Motil. Cytoskeleton 66:378,388, 2009. © 2009 Wiley-Liss, Inc. [source] A pilot study on systemic thrombolysis followed by low molecular weight heparin in ischemic strokeEUROPEAN JOURNAL OF NEUROLOGY, Issue 10 2006R. Mikulík Low molecular weight heparin (LMWH) administered immediately after intravenous thrombolysis (IT) may reduce the risk of arterial re-occlusion. Its benefit, however, may not outweigh the risk of intracranial hemorrhage (ICH). We sought preliminary data regarding safety of this combined therapy in an open-label, non-randomized study. The patients received either a standard anticoagulation (AC) starting 24 h after IT (the standard AC group) or AC with 2850 IU of nadroparin, given every 12 h immediately after IT (the early AC group). Sixty patients received IT treatment: 25 in the standard AC group [mean age 66, median National Institutes of Health Stroke Scale (NIHSS) 13, 64% men] and 35 in the early AC group (mean age 68, median NIHSS 13, 69% men). Symptomatic ICH occurred in one patient (4%) in the standard AC group and three patients (8.6%) in the early AC group [odds ratio (OR) 1.8; 95%CI 0.2,12.8]. At 3 months, nine patients in the standard AC group (36%) and 16 patients in the early AC group (45.7%) achieved a modified Rankin scale 0 or 1 (OR 1.2; 95%CI 0.5,3.2). Our study suggests that treatment with LMWH could be associated with higher odds of ICH, although it may not necessarily lead to a worse outcome. This justifies larger clinical trials. [source] Sexual dimorphism in the spontaneous recovery from spinal cord injury: a gender gap in beneficial autoimmunity?EUROPEAN JOURNAL OF NEUROSCIENCE, Issue 9 2002Ehud Hauben Abstract Immune cells have been shown to contribute to spontaneous recovery from central nervous system (CNS) injury. Here we show that adult female rats and mice recover significantly better than their male littermates from incomplete spinal cord injury (ISCI). This sexual dimorphism is wiped out and recovery is worse in adult mice deprived of mature T cells. After spinal cord contusion in adult rats, functional recovery (measured by locomotor scores in an open field) was significantly worse in females treated with dihydrotestosterone prior to the injury than in placebo-treated controls, and significantly better in castrated males than in their noncastrated male littermates. Post-traumatic administration of the testosterone receptor antagonist flutamide promoted the functional recovery in adult male rats. These results, in line with the known inhibitory effect of testosterone on cell-mediated immunity, suggest that androgen-mediated immunosuppression plays a role in ISCI-related immune dysfunction and can therefore partly explain the worse outcome of ISCI in males than in female. We suggest that females, which are more prone to develop autoimmune response than males, benefit from this response in cases of CNS insults. [source] Somatic mutations of adenomatous polyposis coli gene and nuclear b-catenin accumulation have prognostic significance in invasive urothelial carcinomas: Evidence for Wnt pathway implicationINTERNATIONAL JOURNAL OF CANCER, Issue 1 2009Efstathios Kastritis Abstract Wnt pathway signaling is crucial in many cancers and data indicate crosstalk with other key cancer pathways, however in urothelial carcinogenesis it has not been extensively studied. We searched for mutations in adenomatous polyposis coli (APC), a key regulator of the pathway, and studied b-catenin expression and interactions with the expression of other markers of apoptosis, angiogenesis, and proliferation in patients with invasive urothelial cancer. The mutation cluster region of APC was directly sequenced in 70 patients with muscle invasive disease who were treated with surgery and adjuvant chemotherapy. COX-2, p53, Ki67, and b-catenin were studied immunohistochemically and micro vessel density was quantified by CD105 expression. Single somatic amino-acid substitutions (missense) were found in 9 (13%) and frameshift deletions in 2 (3%) tumors, all located in regions adjacent to b-catenin binding sites. Patients having either APC missense mutations or b-catenin nuclear accumulation had less frequent COX-2 overexpression (24% vs. 76%, p = 0.043) and more frequent lymph node involvement (75% vs. 38%, p = 0.023). Patients with either APC mutations or b-catenin accumulation had shorter disease-free interval (13.4 vs. 28 months, p = 0.07), whereas in multivariate analysis they had shorter disease-specific survival (60.5 vs. 20.6 months, p = 0.048). Somatic APC missense mutations are not rare in advanced urothelial neoplasms. Either APC mutations and/or aberrant expression of b-catenin are associated with worse outcome. Further study of the role of the Wnt pathway, potential crosstalk with other pathways and potential candidate therapeutic targets in urothelial cancer is needed. © 2008 Wiley-Liss, Inc. [source] Cytochrome c oxidase as the target of the heat shock protective effect in septic liverINTERNATIONAL JOURNAL OF EXPERIMENTAL PATHOLOGY, Issue 5 2004Hsiang-Wen Chen Summary Liver function failure is one of the characteristics of critically ill, septic patients and is associated with worse outcome. Our previous studies have demonstrated that heat-shock response protects cells and tissue from subsequent insults and improves survival during sepsis. In this study, we have shown that mitochondrial cytochrome c oxidase (CCO) is one of the major sources of that protective effect. Experimental sepsis was induced by the cecal ligation and puncture (CLP) method. Heat-shock treatment was induced in rats by hyperthermia 24 h before CLP operation. The results showed that ATP content of the liver declined significantly, and the enzymatic activity of mitochondrial CCO was apparently suppressed during the late stages of sepsis. The mitochondrial ultrastructure of septic liver showed the deformity, mild swelling and inner membrane budding. Heat-shock treatment led to heat-shock protein 72 overexpression and prevented the downregulation of Grp75 during sepsis. On the contrary, the expression of the enzyme complex and its activity were preserved, associated with the minimization of ultrastructural deformities. In conclusion, the maintenance of mitochondrial function, especially the CCO, may be an important strategy in therapeutic interventions of a septic liver. [source] The Poor Outcome of Ischemic Stroke in Very Old People: A Cohort Study of Its DeterminantsJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2010Licia Denti MD OBJECTIVES: To assess how much of the excess risk of poor outcome from stroke in people aged 80 and older aging per se explains, independent of other prognostic determinants. DESIGN: Cohort, observational. SETTING: University hospital. PARTICIPANTS: One thousand five hundred fifty-five patients with first-ever ischemic stroke consecutively referred to an in-hospital Clinical Pathway program were studied. MEASUREMENTS: The relationship between age and 1-month outcome (death, disability (modified Rankin Scale 3,5), and poor outcome (modified Rankin Scale 3,6)) was assessed, with adjustment for several prognostic factors. RESULTS: Six hundred twelve patients aged 80 and older showed worse outcome after 1 month than those who were younger, in terms of mortality (19% vs 5%, hazard ratio (HR)=3.85, 95% confidence interval (CI)=2.8,5.4) and disability (51% vs 33%, odds ratio (OR)=3.16, 95% CI=2.5,4.0), although in multivariate models, the adjusted HR for mortality decreased to 1.47 (95% CI=1.0,2.16) and the ORs for disability and poor outcome decreased to 1.76 (95% CI=1.32,2.3.) and 1.83 (95% CI=137,2.43), respectively. Stroke severity, the occurrence of at least one medical complication, and premorbid disability explained most of the risk excess in the oldest-old. CONCLUSION: Stroke outcome is definitely worse in very old people, and most of the excess risk of death and disability is attributable to the higher occurrences of the most-severe clinical stroke syndromes and of medical complications in the acute phase. These represent potential targets for preventive and therapeutical strategies specifically for elderly people. [source] Prognostic value of serum angiogenic activity in colorectal cancer patientsJOURNAL OF CELLULAR AND MOLECULAR MEDICINE, Issue 1 2007Francisco-Jesus Gonzalez Abstract Angiogenesis, resulting from an imbalance between angiogenic activator factors and inhibitors, is required for tumour growth and metastasis. The determination of the circulating concentration of all angiogenic factors (activators and inhibitors) is not feasible at present. We have evaluated diagnostic and prognostic values of the measurement of serum angiogenic activity in colorectal carcinoma (CRC) patients. Serum proliferative activity (PA) on human umbilical vein endothelial cells (HUVEC) in vitro, and serum vascular endothelial growth factor (VEGF) levels were determined by ELISA in 53 patients with primary CRC, 16 subjects with non-neoplastic gastrointestinal disease (SC) and 34 healthy individuals. Data were compared with clinical outcome of the patients. Although serum from CRC patients significantly increased the PA of HUVEC, compared to culture control (HUVEC in medium + 10% foetal bovine serum (FBS); P < 0.001); our results indicate that serum PA in CRC patients was similar to that of SC or healthy individuals. There was no correlation between serum PA and circulating VEGF concentrations. Surgery produced a decrease of PA at 8 hrs after tumour resection in CRC patients compared to pre-surgery values (186 ± 47 versus 213 ± 41, P < 0.001). However, an increase in serum VEGF values was observed after surgery (280 [176,450] versus 251 [160,357] pg/ml, P = 0.004). Patients with lower PA values after surgery showed a worse outcome that those with higher PA values. Therefore, this study does not support a diagnostic value for serum angiogenic activity measured by proliferative activity on HUVEC but suggests it could have a prognostic value in CRC patients. [source] Mortality association of enhanced CD44v6 expression is not mediated through occult lymphatic spread in stage II colorectal cancerJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 9 2000Gerard Clarke Abstract Background and Aims: In the absence of other metastatic disease, the presence of lymph node metastasis remains the most important determinant of survival in colorectal cancer (CRC). Cluster designation 44 variant 6 (CD44v6) over-expression is associated with worse outcome in all stages of CRC. The CD44v6 is believed to confer metastatic potential through its facilitation of migration, extravasation and proliferation, although the specific means by which it conveys an adverse prognosis in CRC is unknown. The aim of the present study was to determine if CD44v6 over-expression in Stage II CRC subjects was associated with the presence of lymph node micrometastases. Methods: We assessed tumour CD44v6 expression in 43 randomly sampled subjects who had resections for Stage II CRC between 1984 and 1991 by using immunohistochemistry. Micrometastases were sought in corresponding lymph node (LN) sections using keratin immunohistochemistry. Results: There was a statistical trend between tumour CD44v6 over-expression and mortality (P = 0.09) and a significant relationship between LN cytokeratins and mortality (P = 0.01). There was no association between the detection of LN cytokeratins and tumour CD44v6 over-expression. Conclusion: We conclude that the adverse survival effect of CD44v6 over-expression is not mediated though lymphatic spread and postulate that it may therefore facilitate haematogenous metastasis. [source] General psychiatric services for adults with intellectual disability and mental illnessJOURNAL OF INTELLECTUAL DISABILITY RESEARCH, Issue 1 2004R. Chaplin Abstract Background Adults with intellectual disability (ID) and mental illness may use general or specialist psychiatric services. This review aims to assess if there is evidence for a difference in outcome between them. Methods A literature review was conducted using a variety of electronic databases and hand-search strategies to identify all studies evaluating the outcome of people with ID and mental illness using general psychiatric services. Results There is no conclusive evidence to favour the use of general or specialist psychiatric services. People with ID stay less time on general psychiatric than specialist inpatient units. People with severe ID appear not to be well served in general services. Older studies of inpatient samples suggest a worse outcome for people with ID. Novel specialist services generally improve upon pre-existing general services. Assertive outreach in general services may preferentially benefit those with ID. Recent studies suggest similar lengths of stay in general psychiatric beds for people with and without ID. Conclusions Although 27 studies were located, only two were randomized controlled trials. The evidence is poor quality therefore further evaluation of services employing a variety of designs need to be employed to give more robust evidence as to which services are preferred. [source] Survival in patients with papillary thyroid cancer is not affected by the use of radioactive isotopeJOURNAL OF SURGICAL ONCOLOGY, Issue 1 2007Yale D. Podnos MD Abstract Introduction Papillary cancer is the most common neoplasm of the thyroid. The mainstay of treatment is thyroidectomy, but most patients are additionally treated with radioactive iodine (RAI). Its utility is controversial. This study seeks to determine whether RAI use affects patient outcome and to identify specific cohorts of patients that benefit from its use. Methods The Surveillance, Epidemiology, and End Results (SEER) database is a large-scale sample of approximately 14% of the US population. It was used to identify patients with papillary carcinoma of the thyroid. Statistical analyses were used to compare prognostic factors such as lymph node status, age, tumor size, and treatment with RAI. Results A total of 14,545 patients were identified in SEER as having papillary cancer of the thyroid. Multivariate analysis showed significantly worse outcome in patients with age>45 years, tumor size >2 cm, lymph node disease, and distant metastases. Multivariate analysis failed to show RAI significantly affecting mortality. Survival between those not treated with RAI was similar to those whose treatment included it (P,=,0.9176). Subgroup analysis identified patients older than 45 years with primary tumors >2 cm and disease in the lymph nodes with distant metastatic disease as the only group positively affected by RAI. Conclusions Despite its widespread use in the treatment of well-differentiated papillary cancer of the thyroid, RAI only affects a survival advantage in older patients with large primary tumors involving the lymph nodes and with distant spread. Treating other patient groups is costly and offers no improvement in outcome. J. Surg. Oncol. 2007; 96:3,7. © 2007 Wiley-Liss, Inc. [source] Renal failure and abdominal hypertension after liver transplantation: Determination of critical intra-abdominal pressureLIVER TRANSPLANTATION, Issue 12 2002Gianni Biancofiore MD There is growing interest in measuring intra-abdominal pressure (IAP) in postsurgical and critically ill patients because increased pressure can impair various organs and functions. The aim of this study was to evaluate the effect of different IAP levels on the postoperative renal function of subjects undergoing orthotopic liver transplantation. IAP was measured every 8 hours with the urinary bladder pressure method for at least 72 hours after surgery. At the end of the study, the patients were classified on the basis of their IAP values: , 18 mm Hg (group A), 19 to 24 mm Hg (group B), , 25 mm Hg (group C). The three groups were compared in terms of the incidence of acute renal failure (defined as blood creatinine > 1.5 mg/dL or an increase in the same of > 1.1 mg/dL within 72 hours of surgery), hourly diuresis, blood creatinine, the filtration gradient, hemodynamic variations, and outcome. The incidence of renal failure was higher among the subjects in group C (P < .05 versus group A and < .01 versus group B), who also had higher creatinine levels (P < .01), a greater need for diuretics (P < .01) and a worse outcome (P < .05). Receiver Operator Characteristic curve analysis showed that an abdominal pressure of 25 mm Hg had the best sensitivity/specificity ratio for renal failure. An intra-abdominal pressure of , 25 mm Hg is an important risk factor for renal failure in subjects undergoing liver transplant. [source] Hepatitis C: Magnitude of the problemLIVER TRANSPLANTATION, Issue 10B 2002Jorge Rakela MD 1End-stage liver disease associated with hepatitis C virus (HCV) infection has become the leading indication for liver transplantation in the United States. 2Patients with end-stage liver disease caused by HCV may have such associated comorbidities as chronic alcoholism, steatosis, or coinfection with human immunodeficiency virus 1 or other hepatitis viruses. These comorbidities may accelerate disease progression. 3As chronic hepatitis C progresses to cirrhosis, the risk for the development of hepatocellular carcinoma increases; this poses difficult management problems. 4As patients who underwent transplantation for end-stage liver disease caused by HCV infection are followed up long term, it has become clear that patient and graft survival are decreased compared with HCV-negative patients or those with cholestatic liver disorders. 5Risk factors associated with a worse outcome after transplantation include host, viral, donor, and posttransplantation factors. 6Major challenges to be addressed in the future include delineation of the optimal antiviral therapy and how to handle the need to perform retransplantation on patients who develop graft dysfunction as a result of HCV recurrence. [source] Role of gender and race mismatch and graft failure in patients undergoing liver transplantationLIVER TRANSPLANTATION, Issue 6 2002Vinod K. Rustgi MD Previous data have suggested an increased risk of graft failure in male recipients of female livers, and in nonwhite recipients of orthotopic liver transplantation. United Network for Organ Sharing records of liver transplantations from 1992 through 2000 with at least one follow-up visit were reviewed. Analysis of these data was performed with proportional hazards regression, controlling for follow-up time, age, gender, ethnicity, number of comorbidities, functional status at time of transplant, and status 1 designation. Separate analyses comparing transplants among whites and blacks only and matched versus mismatched transplants for male and female recipients were performed. The results revealed that gender-mismatched patients (n = 13,992) had a higher likelihood of graft failure when compared with gender matched transplants (n = 18,522) (12.2% versus 11.3% respectively, P = .013). After controlling for the above potential confounders, gender-mismatched patients were found to have a 6.9% increase in likelihood of graft failure, (P = .042). Female recipients receiving male organs had no significant change in the risk of graft failure (11.5%; P = .368). A worse outcome was found in male recipients receiving female organs (12.9%; P = .0003). Graft failure rate among patients with donors matched by race (white to white or nonwhite to nonwhite; n = 21,818) was 11.6% versus 11.9%, and among unmatched patients (n = 10,697), the difference was not significant (P = .33). Multivariate regression analysis controlling for potential confounders confirmed that this difference was not significant (P = .21). Mismatch between black donors and white recipients was found to increase the risk of liver graft failure (27.4%, P = < .0001), independently of gender, number of comorbidities, and functional status at time of transplant. [source] An abnormal nonhyperdiploid karyotype is a significant adverse prognostic factor for multiple myeloma in the bortezomib era,AMERICAN JOURNAL OF HEMATOLOGY, Issue 10 2010Daryl Tan Multiple myeloma is clinically heterogeneous and risk stratification is vital for prognostication and informing treatment decisions. As bortezomib is able to overcome several high-risk features of myeloma, the validity of conventional risk-stratification and prognostication systems needs to be reevaluated. We study the survival data of 261 previously untreated myeloma patients managed at our institution, where bortezomib became available from 2004 for the treatment of relapse disease. Patient and disease characteristics, and survival data were evaluated overall, and with respect to bortezomib exposure. Overall, the international staging system (ISS), metaphase karyotyping and interphase fluorescence in situ hybridization (FISH) were discerning of survival outcomes, where the median for the entire cohort was 5.2 years. However, when stratified by bortezomib exposure, only metaphase karyotyping was still discriminating of long-term prognosis. The presence of an abnormal nonhyperdiploid karyotype overrides all other clinical and laboratory parameters in predicting for a worse outcome on multivariate analysis (median survival 2.6 years, P = 0.001), suggesting that bortezomib used at relapse is better able to overcome adverse risk related to high tumor burden (as measured by the ISS) than adverse cytogenetics on conventional karyotyping. Metaphase karyotyping provides additional prognostic information on tumor kinetics where the presence of a normal diploid karyotype in the absence of any high-risk FISH markers correlated with superior survival and could act as a surrogate for lower plasma cell proliferation. Am. J. Hematol., 2010. © 2010 Wiley-Liss, Inc. [source] The impact of personality disorders on treatment outcome in bipolar disorder: A reviewPERSONALITY AND MENTAL HEALTH, Issue 1 2007Peter J. Bieling Bipolar disorder (BD) is a chronic psychiatric illness for which there are a number of efficacious and effective treatments. However, for many sufferers recovery is incomplete or tenuous. Factors associated with poor outcomes in the disorder are of special interest, and comorbidity of BD with personality disorder (PD) has been proposed as a possible predictor of poor outcome. We reviewed available studies (n = 12) in the literature that specifically assessed the impact of personality psychopathology on illness outcomes in BD including functioning, response to treatment and suicidality. Quality of methodology, assessment methods and number of participants in studies were highly variable. Despite these variations in study quality, the presence of a PD was robustly associated (usually medium size effects) with a worse outcome in BD. Patients with BD and a diagnosis of PD are more likely to be hospitalized, require more time to achieve symptom stabilization, have more chronic impairments in occupational and social functioning, are less compliant to medication, have greater levels of suicidality and utilize more psychiatric services than patients with BD alone. The implications of these findings for further research and clinical care in BD are discussed. Copyright © 2007 John Wiley & Sons, Ltd. [source] The Impact of C4d Pattern and Donor-Specific Antibody on Graft Survival in Recipients Requiring Indication Renal Allograft BiopsyAMERICAN JOURNAL OF TRANSPLANTATION, Issue 12 2009A. Haririan We examined the pattern of PTC C4d by immunohistochemistry and DSA in 297 kidney recipients with indication biopsies, and evaluated their predictive value for graft survival. Median biopsy time was 5.1 months posttransplant. Patients were followed for 17.9 ± 9.4 months postbiopsy. An 18.5% had focal and 15.2% had diffuse C4d, with comparable graft survival (adjusted graft failure HR: 2.3, p = 0.001; HR:1.9, p < 0.02, respectively). 31.3% were DSA+, 19.5% class I and 22.9% class II DSA. Only those with class II DSA had worse outcome (adjusted HR:2.5, p = 0.001 for class II only; HR:2.7, p < 0.001 for class I/II DSA). Among patients with <10%C4d, 23.9% had DSA, compared to 68.9% with diffuse staining. For patients biopsied in first-year posttransplant presence of DSA, regardless of C4d positivity in biopsy, was a poor prognostic factor (adjusted graft failure HR: 4.2, p < 0.02 for C4d,/DSA+; HR:4.9, p = 0.001 for C4d+/DSA+), unlike those biopsied later. We have shown that focal C4d had similar impact on graft survival as diffuse pattern. During the first-year posttransplant either class I or II DSA, and afterward only class II DSA were associated with worse graft survival. DSA was predictive of worse outcome regardless of C4d for patients biopsied in first year and only with C4d positivity afterward, supporting the importance of assessment of both DSA and C4d pattern in biopsy. [source] D-MELD, a Simple Predictor of Post Liver Transplant Mortality for Optimization of Donor/Recipient MatchingAMERICAN JOURNAL OF TRANSPLANTATION, Issue 2 2009J. B. Halldorson Numerous donor and recipient risk factors interact to influence the probability of survival after liver transplantation. We developed a statistic, D-MELD, the product of donor age and preoperative MELD, calculated from laboratory values. Using the UNOS STAR national transplant data base, we analyzed survival for first liver transplant recipients with chronic liver failure from deceased after brain death donors. Preoperative D-MELD score effectively stratified posttransplant survival. Using a cutoff D-MELD score of 1600, we defined a subgroup of donor,recipient matches with significantly poorer short- and long-term outcomes as measured by survival and length of stay (LOS). Avoidance of D-MELD scores above 1600 improved results for subgroups of high-risk patients with donor age ,60 and those with preoperative MELD ,30. D-MELD ,1600 accurately predicted worse outcome in recipients with and without hepatitis C. There is significant regional variation in average D-MELD scores at transplant, however, regions with larger numbers of high D-MELD matches do not have higher survival rates. D-MELD is a simple, highly predictive tool for estimating outcomes after liver transplantation. This statistic could assist surgeons and their patients in making organ acceptance decisions. Applying D-MELD to liver allocation could eliminate many donor/recipient matches likely to have inferior outcome. [source] A meta-analysis of the utility of C-reactive protein in predicting early, intermediate-term and long term mortality and major adverse cardiac events in vascular surgical patientsANAESTHESIA, Issue 4 2009L. Padayachee Summary We conducted a meta-analysis of the utility of pre-operative C reactive protein (CRP) in predicting early (< 30 days), intermediate (30,180 days) and long term (> 180 days) mortality and major adverse cardiac events (MACE; cardiac mortality and nonfatal myocardial infarction (MI) combined) following vascular surgery. Of 291 studies identified, ten prospective patient cohorts were identified. A pre-operative CRP > 3 mg.l,1 was not associated with 30-day all-cause mortality, cardiac mortality, nonfatal myocardial infarction or MACE. Intermediate-term all-cause mortality, cardiac death and MACE showed a trend to a worse outcome (odds ratio (OR) 9.07, 95% confidence interval (CI) 0.86,96.28, p = 0.07; OR 8.71, 95% CI 0.5,153.1, p = 0.14 and OR 2.81, 95% CI 0.78,5.18, p = 0.15 respectively). Long term all cause mortality (OR 2.40, 95% CI 1.15,5.02, p = 0.02), cardiac death (OR 5.66, 95% CI 1.71,18.73, p = 0.005) and MACE (OR 2.76, 95% CI 1.38,5.55, p = 0.004) were significantly increased. [source] Perfusion computed tomography in the acute phase of mild head injury: Regional dysfunction and prognostic value,ANNALS OF NEUROLOGY, Issue 6 2009Zwany Metting MD Objective Traumatic brain injury is a major cause of disability and death. Most patients sustain a mild head injury with a subgroup that experiences disabling symptoms interfering with return to work. Brain imaging in the acute phase is not predictive of outcome, as 20% of noncontrast computed tomographic (CT) scans on admission is normal in patients with a suboptimal outcome. The aim of this study was to perform perfusion CT imaging in the acute phase of mild head injury in patients without intracranial abnormalities on the noncontrast CT, to assess whether these patients had cerebral perfusion abnormalities. Furthermore, the relation between perfusion CT parameters and severity of head injury and outcome was evaluated. Methods In patients with mild head injury and normal noncontrast CT, perfusion CT was performed directly after admission. The perfusion data were compared with data of 25 healthy control subjects. Outcome was determined 6 months after injury with the extended Glasgow Coma Outcome Scale score and return to work. Results Seventy-six patients were included. In patients with a decreased Glasgow Coma Scale score, a significant decrease of cerebral blood flow and cerebral blood volume was detected in the frontal and occipital gray matter. In logistic regression analyses, decreased cerebral blood flow and cerebral blood volume in the frontal lobes predicted worse outcome according to the extended Glasgow Coma Outcome Scale score. CT perfusion parameters did not predict return to work. Interpretation In the acute phase of mild head injury, disturbed cerebral perfusion is seen in patients with normal noncontrast CT correlating with severity of injury and outcome. Ann Neurol 2009;66:809,816 [source] COST, DEMOGRAPHICS AND INJURY PROFILE OF ADULT PEDESTRIAN TRAUMA IN INNER SYDNEYANZ JOURNAL OF SURGERY, Issue 1-2 2006Timothy J. Small Background: Pedestrian accidents are associated with substantial morbidity, mortality and cost; however, there has been very little published work on this topic in Australasia over recent years. The objective of this study was to examine the demographics, injury profile, outcomes and cost of pedestrian versus motor vehicle accidents in a central city hospital in Sydney. Methods: Consecutive pedestrians injured by motor vehicles and admitted as inpatients during the years 2002,2004 were identified from our prospective trauma registry. A retrospective review included patient profiles (age, sex, time of injury and blood alcohol), injury pattern, cost, morbidity and mortality. Results: A total of 180 patients (64% men and 36% women) with a mean age of 46 and mean injury severity score of 14.1 were identified. Two peak injury periods were observed: one between 17.00 and 18.00 hours (P < 0.01) and the other between 20.00 and 22.00 hours (P < 0.01). Significantly more injuries occurred on Friday (P < 0.01) and during autumn months (P < 0.05). Musculoskeletal (34.3%), head (31.8%) and external (20.2%) injuries predominated. Forty-nine per cent of patients tested positive for consuming alcohol, with an average blood alcohol concentration (BAC) of 0.22%. Alcohol consumption was associated with a worse outcome in terms of hospital and intensive care unit stay, morbidity and mortality. The average length of stay was 13.4 days costing $A16320 per admission. Sixteen patients died (mortality rate of 8.9%), with the highest rate in the elderly group (22.7%) (P < 0.001). Conclusions: Pedestrian accidents in inner Sydney are common with injuries predominating in intoxicated adult males. Mortality was higher in the elderly group. Injuries to the head and lower extremities predominate. Hospital stays are lengthy, resulting in a high cost for each admission. [source] | |||||||||||||||||||||||||||||||||||||||||||||||||