Good outcomes with mycophenolate-cyclosporine-based induction protocol in children with severe proliferative lupus nephritis

The outcomes of children with severe proliferative lupus nephritis (LN) were examined using a new mycophenolate and cyclosporine-based (MMF-CSA) induction protocol. Sixteen children with LN (WHO class III and IV), 31.3% of whom required dialysis at induction, were retrospectively studied. Median MMF dose was 942 mg/m( 2)/day. Thirteen patients (81%) with persistent proteinuria received CSA. Clinical and laboratory parameters were compared at pre-induction, 6 and 12 months. Treatment outcome was defined by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), renal function, haematuria, proteinuria and serological markers (complements C3, C4 and anti-dsDNA). Comparing these parameters at induction, 6 months and 12 months, respectively, SLEDAI (25.4 +/- 8.7 versus 3.2 +/- 2.9 versus 2.9 +/- 2.8), serum C3 (47 +/- 21 versus 107 +/- 27 versus 111 +/- 38 mg/dl), C4 (12 +/- 14 versus 23 +/- 14 versus 22 +/- 11 mg/dl) and urine protein (6.97 +/- 7.09 versus 0.98 +/- 1.56 versus 0.21 +/- 0.13 g/ day/1. 73 m(2)) improved significantly (p < 0.05). Anti-dsDNA titres decreased in 73% by 6 and 12 months (p < 0.05). Complete renal remission was achieved in 7/16 (43.8%) at 6 months and 12/16 (75%) at 12 months, the rest achieving partial remission with no treatment failures. In conclusion, a combination MMF-CSA protocol is an effective therapeutic alternative for induction of children with severe proliferative LN, resulting in significant clinical and serological improvement with minimal adverse effects.

Conflict-of-interest, copyright and other declarations

Declarations of exclusive publication, author contribution, conflict-of-interest and copyright transfer are important formalities required by most biomedical journals. Conflict-of-interest may be personal, commercial, political, academic or financial. It is particularly important for authors to provide a full and complete disclosure of any financial relationship with a commercial organisation that may have an interest in the contents of the submitted manuscript. Editors, editorial board members and reviewers should also declare any possible conflicts-of-interest. The handling of conflict-of-interest during manuscript preparation, peer review and editorial decision making impacts the credibility of published articles and scientific research in general.

Getting to know journal bibliographic databases

A bibliographic database is an organised digital collection of references to published literature. A bibliographic database may be general in scope or may cover a specific academic discipline. There are many types of medical and general bibliographic databases. They cover biomedical and scientific literature, morbidity and mortality statistics, therapeutic regimens, medical records, images and reviews of evidence-based medicine. Getting to know these databases will help researchers and authors to enhance their writing and publishing endeavours.

Writing a book review

A book review is a form of academic writing that provides a succinct yet critical analysis evaluating the content, style, merit and significance of a book. The reader should gain insight into the strengths and weaknesses of the book, aided by input from the reviewer. The four stages of writing a book review are: introducing the book, outlining its contents, highlighting parts of the book by selecting particular chapters or themes, and giving a detailed evaluation.

Squamous odontogenic tumor of the mandible: a case report demonstrating immunoexpression of Notch1, 3, 4, Jagged1 and Delta1

Background

Squamous odontogenic tumor (SOT) is a rare benign odontogenic epithelial neoplasm. A slow-growing painless expansive swelling is the common presenting symptom. Histopathologically, SOT can be easily misdiagnosed as an acanthomatous ameloblastoma. Although Notch receptors and ligands have been shown to play a role in cell fate decisions in ameloblastomas, the role of these cell signaling molecules in SOT is unknown.

Case report

This paper describes a case of SOT affecting the anterior mandible of a 10-year-old Indian female. The patient was treated by local surgical excision and there has been no follow-up clinical record of recurrence 5 years after primary treatment. Histopathological examination revealed a solid, locally-infiltrative neoplasm composed of bland-looking squamatoid islands scattered in a mature fibrous connective tissue stroma and the diagnosis was SOT. Immunohistochemical evaluation showed positive reactivity of varying intensity in the neoplastic epithelial cells for Notch1, Notch3, Notch4, and their ligands Jagged1 and Delta1. Expression patterns showed considerable overlap. No immunoreactivity was detected for Notch2 and Jagged2.

Conclusions

Present findings suggest that Notch receptors and their ligands play differential roles in the cytodifferentiation of SOT.

Usefulness of plasma tissue inhibitors of metalloproteinases as markers of prognosis after acute myocardial infarction

Alterations in the balance of matrix metalloproteinase to tissue inhibitor of metalloproteinase (TIMP) are seen after acute myocardial infarction (AMI) and are associated with adverse left ventricular remodeling and prognosis in this setting. We aimed to investigate the association between TIMP levels and the occurrence of major adverse cardiac events (MACEs) after AMI. We measured plasma TIMP-1, -2, and -4 levels in 1,313 patients presenting with AMI. Subjects were followed over a median period of 520 days for the occurrence of MACEs. Clinical risk was assessed using the Global Registry of Acute Coronary Events (GRACE) score. All TIMP levels correlated with patient age and inversely with estimated glomerular filtration rate (all p values <0.001). Levels were higher in women versus men (p <0.001) and in subjects with a history of diabetes (TIMP-1, p <0.001; TIMP-2, p = 0.002; TIMP-4, p <0.001) or hypertension (TIMP-1, p = 0.031; TIMP-2, p <0.001; TIMP-4, p <0.001). TIMP-1 and TIMP-4 were higher in subjects with previous MI or angina (p <0.001). TIMP levels increased incrementally with quartiles of GRACE score (p <0.001). All TIMPs showed univariate association with the occurrence of MACEs (p <0.001). Areas under the receiver operator characteristic curve for prediction of MACE at 1 year were 0.61 for TIMP-1, 0.57 for TIMP-2, and 0.64 for TIMP-4. Combination of TIMPs with GRACE risk score revealed a greater area under the curve than GRACE score alone (0.72 vs 0.69, p = 0.0015). On multivariable Cox proportional hazards analysis, GRACE score (p <0.001) and plasma TIMPs (log TIMP-1, p = 0.017; log TIMP-2, p <0.001; log TIMP-4, p = 0.011) independently predicted MACEs. Using Kaplan-Meier analysis, the risk of MACEs increased incrementally with the number of TIMPs above their respective median (p <0.001 for all comparisons, log-rank test). In conclusion, higher plasma TIMP-1, -2, and -4 after AMI are associated with MACEs and provide additional prognostic information to that obtained from GRACE clinical risk scores alone.

Writing an editorial

An editorial may be written by the editor or someone invited by the editor. It serves many other purposes, including critiques of original articles published in the same issue of the journal, concise reviews of topics that do not warrant a full-length invited review, and other topics on very recent developments that are deemed by the editor to be important to readers of the journal and the community. As there is typically a limited space in which to deliver its contents, the message contained in the editorial needs to be well thought out and concisely delivered. It should contain the correct sequence of the elements of critical argument, ideally supported by evidence, and end with a clear conclusion.

418 cases of laparoscopic colorectal resections: a single-institution experience and literature review

INTRODUCTION

Evidence from randomised controlled trials has shown that laparoscopic colon and rectal cancer resection not only confers short-term benefits but also does not differ considerably in terms of its long-term oncological outcomes, as compared with open surgery.

METHODS

All laparoscopic colon and rectal resections performed between January 2005 and December 2007 were included. Patient records were reviewed from a prospective database and the relevant clinical data was obtained, with a subgroup analysis of cancer procedures performed.

RESULTS

418 patients (247 male), median age 63 years (range 24 to 88), underwent laparoscopic resection of the colon and rectum. The median Body Mass Index (BMI) was 22.5 (range 13.5 to 39.3). The majority of the procedures were performed for malignant disease (81.3 percent) and the most common procedure was anterior resection (79.4 percent). The median duration of surgery was 135 minutes (range 65 to 330), with conversions to open surgery in 44 patients (10.5 percent). Complications occurred in 78 patients (18.7 percent), including anastomotic leaks in five (1.20 percent). The median length of hospital stay was five days (range 3 to 90) and the median follow-up was 19 months (range 1 to 46). In the 340 patients with malignant disease, the median number of lymph nodes harvested was 13 (range 5 to 48), and at the latest review, 230 patients (67.6 percent) were disease-free, with locoregional recurrence in 2.9 percent and systemic recurrence in 10 percent.

CONCLUSION

To date, this is the largest series of laparoscopic colorectal resections reported locally, and our results show that it is safe, feasible and produces favourable results.

Writing a letter to the Editor

A letter to the Editor is a short communication. It can be written on any subject of interest to the journal reader, and is published at the Editor's discretion. Comments on previously published articles are probably the most common reason for writing a letter. A variety of other types of letters exist, depending on individual journal policy. Letters to the Editor should be objective, constructive and purposeful. They should provide new or useful information that merits publication, or additional or alternative viewpoint or experience to a previously published article. Letters should be short and concise, with clear and specific points.

Single-incision laparoscopic surgery for right hemicolectomy: our initial experience with 10 cases

BACKGROUND

Published data has confirmed the oncological safety and efficacy of laparoscopic colorectal surgery. Continued surgical innovation has seen the recent resurgence of single-port laparoscopic surgery. We present a series of 10 cases of single-incision laparoscopic surgery (SILS) for right hemicolectomy, with the aim of reaffirming the feasibility and favourable short-term results of this technique.

METHODS

Ten patients underwent SILS for right hemicolectomy using the SILS port, between June 2009 and August 2009. A longitudinal periumbilical incision was used as the access point for all cases. Data analysed included age, gender, American Society of Anaesthesiology score, body mass index (BMI), location of disease, duration of surgery, length of incision and duration of hospital stay. Inclusion criteria were no prior abdominal surgery, no intra-abdominal sepsis, no distant metastases and a BMI of <30.

RESULTS

All 10 cases of right hemicolectomy were successfully performed using the SILS port through a single periumbilical incision. The median age of patients was 64 years (range 48-83 years), with a median body mass index of 21.5 kg/m(2) (range 18.9-25.6 kg/m(2)). The median duration of surgery and hospital stay was 83 min (range 60-125 min) and 6 days (range 5-11 days), respectively. No morbidity or mortality was associated with this technique, and all patients recovered uneventfully.

CONCLUSION

This case series illustrates that SILS for right hemicolectomy is feasible and safe. However, the routine use of this innovative technique in malignant disease cannot be recommended without further large-scale prospective trials.

Writing an invited commentary

An invited commentary is a short article that describes an author's personal experience of a specific topic. Unlike a review article, the author gives his own opinions and perspectives. It typically addresses a current, hot and often controversial subject. It may take two formats, namely, provide an expert author's personal views of and insight into a current hot topic, or add balance to another paper being commented upon, with addition of the author's own perspective.

Is utilisation of computed tomography justified in clinical practice? Part IV: applications of paediatric computed tomography

Computed tomography (CT) has been recognised as the most widely used imaging technique in both adults and children, owing to technological developments, especially with the recent innovations in multislice CT. This has resulted in an increase in the use of CT examinations in children younger than 15 years of age in developed countries. The increasing use of paediatric CT in clinical practice has raised concerns regarding the potential risk of radiation-induced malignancy. This is because CT examinations deliver a much higher radiation dose than conventional radiographic techniques. Children are more sensitive to radiation exposure than adults and have a longer time ahead of them to manifest radiation-induced effects and injuries. Therefore, it is of paramount importance to reduce or minimise the radiation dose to children when choosing CT as the major imaging modality for diagnostic purposes. This article reviews the clinical applications of paediatric CT with regard to the adjustment of imaging protocols in routine clinical practice and in the emergency department, the justification of CT use in paediatric imaging, clinical awareness of CT-associated radiation risk and strategies to minimise radiation exposure to children.

Writing a systematic review

Evidence-based medicine (EBM) aims to combine the best available scientific evidence with clinical experience and individual judgment of patient needs. In the hierarchy of scientific evidence, systematic reviews (along with meta-analyses) occupy the highest levels in terms of the quality of evidence. A systematic review is the process of searching, selecting, appraising, synthesising and reporting clinical evidence on a particular question or topic. It is currently considered the best, least biased and most rational way to organise, gather, evaluate and integrate scientific evidence from the rapidly-changing medical and healthcare literature. Systematic reviews could be used to present current concepts or serve as review articles and replace the traditional expert opinion or narrative review. This article explains the structure and content of a systematic review.

Multislice CT angiography in cardiac imaging. Part III: radiation risk and dose reduction

With the introduction of 64- or more-slice computed tomography (CT) technology, multislice CT angiography has been increasingly used as a non-invasive modality for the diagnosis of coronary artery disease. Despite its potential advantages and promising clinical results, multislice CT angiography suffers from high radiation dose which contributes to radiation-induced malignancy in patients undergoing cardiac CT examinations. This has raised serious concerns in clinical practice. A number of strategies have been recommended and implemented to reduce the radiation dose associated with multislice CT angiography in cardiac imaging. The aim of this review is to present an overview of the various approaches used for radiation dose reduction. Future directions of multislice CT angiography with regard to the judicious use of this promising technique and increased awareness of the radiation risk are highlighted.

Multislice CT angiography in cardiac imaging. Part II: clinical applications in coronary artery disease

Multislice computed tomography (CT) angiography represents a technological evolution in cardiac imaging due to improved spatial and temporal resolution. Rapid improvements in multislice CT scanners over the last decade have allowed this technique to become a viable and effective alternative to invasive coronary angiography in selected patients. Multislice CT angiography has demonstrated high sensitivity and specificity, and in particular, a very high negative predictive value, which makes it a valuable imaging modality for screening patients suspected of coronary artery disease. In addition, multislice CT angiography demonstrates accuracy in the detection and characterisation of coronary plaques, and it has been reported to play an important role in predicting disease progression and cardiac events. The aim of this review was to present an overview of the clinical applications of multislice CT angiography in coronary artery disease, with regard to its diagnostic accuracy and predictive value in coronary artery disease. Emerging areas of multislice CT, including dual-energy CT and CT myocardial perfusion, are also discussed. Limitations of multislice CT angiography and future directions of cardiac multislice CT are highlighted.

Writing an invited review

An invited review provides a detailed and comprehensive narrative analysis of recent developments in a specific topic, and highlights important points that have been previously published. It usually consists of a short unstructured abstract, introduction, subheadings to organise the topic, and a summary. The text is usually relatively long compared to other paper categories, typically up to 15 manuscript pages or 4,000 words. The reference list is expected to comprehensively cover all the major published work, with up to 50-75 references being typical. The ideal invited review should be topical, current, balanced, accurate, quotable and easily understood, with clear take-home messages.

An unsuspected ameloblastoma in the subpontic region of the mandible with consideration of pathogenesis from the radiographic course

The purpose of this report is to document a case of unsuspected ameloblastoma involving the right man dibular subpontic region in a 38-year-old Cambodian female patient. This lesion was purportedly preceded by multiple radiolucencies which were diagnosed as radi cular cysts and treated a few times in the past years by enucleation followed by endodontic therapy of the affected teeth. Bridgework restoration of the partially edentulous area was performed. This case report de monstrates radiographic changes that occurred in the periods before and after the diagnosis of amelo blas to ma. The case may represent an example of radicular cysts and ameloblastoma occurring as a collision phenomenon, or the ameloblastoma may have arisen as a result of neoplastic transformation of the lining epi thelium in an inflammatory odontogenic epithelial cyst.

Writing a pictorial essay

A pictorial essay is a type of educational article that aims to provide both textual and visual portrayals of a topical issue. It usually consists of a short unstructured abstract, brief introduction, subheadings to organise the material and a summary. The number of references is limited to a few key articles, typically, eight to 15, or fewer. The text is usually short, often approximately 1,000 to 2,000 words in length, with much of the message contained in the figure legends. This type of article allows for a large number of figures, typically up to 20 figures or 30 figure parts. The main criteria for publication are currency, educational value and high quality of illustrations.

Is utilisation of computed tomography justified in clinical practice? Part I: application in the emergency department

Computed tomography (CT) is currently a widely available imaging technique in clinical practice. Technical developments of CT imaging, especially the emergence of multislice CT, with increased scanning speed and volume as well as higher spatial and temporal resolution, have significantly enhanced the diagnostic value of CT in many clinical applications. CT has become an important diagnostic imaging modality in the emergency department, with high diagnostic accuracy and efficacy in both traumatic and non-traumatic conditions. There is, however, a growing concern about the risk of associated radiation exposure in the population exposed to CT examination. Justification of the application of CT is one of the main principles that physicians need to be aware of when choosing CT as the first-line technique for diagnosis. This article reviews the clinical applications of CT imaging in the emergency department, with a focus on patients presenting with headache, repeat and multiple CT imaging and whole body screening for trauma patients, and explores whether the applications are clinically justified.

Writing a technical note

A technical note is a short article giving a brief description of a specific development, technique or procedure, or it may describe a modification of an existing technique, procedure or device applicable to medicine. The technique, procedure or device described should have practical value and should contribute to clinical diagnosis or management. It could also present a software tool, or an experimental or computational method. Technical notes are variously referred to as technical innovations or technical developments. The main criteria for publication will be the novelty of concepts involved, the validity of the technique and its potential for clinical applications.

Writing a case report

A case report is a description of a single case with unique features. This includes a previously-unreported clinical condition, previously-unreported observation of a recognised disease, unique use of imaging or diagnostic test to reveal a disease, previously-unreported treatment in a recognised disease, or previously-unreported complication of a procedure. Case reports should be short and focused, with a limited number of figures and references. The structure of a case report usually comprises a short unstructured (or no) abstract, brief (or no) introduction, succinct but comprehensive report of the case, and to-the-point discussion.

Dealing with proofs

After submission and acceptance of a scientific paper by a journal, the final stages in the publishing process are copy-editing and proofreading. The primary purpose of this step is to ensure accurate and quality production of scientific papers. Authors are responsible for checking their proofs properly and in detail, ensuring that everything is correct as this is their last chance to make any changes before their work is set in print forever.