Genome-wide analysis of deoxyribonucleic acid in endometrial cancer using comparative genomic hybridization microarrays

The aim of this study was to identify amplified oncogenes in endometrial cancer using array-based comparative genomic hybridization (array CGH). Despite its prevalence, the molecular mechanisms of endometrial carcinogenesis are still poorly understood. The selected array CGH allows the simultaneous examination of 58 oncogenes commonly amplified in human cancers and is capable of achieving increased mapping resolution compared with conventional CGH. A subset of 8 specimens from a bank of 60 malignant and normal specimens was selected for array analysis to identify potential genes of interest. TaqMan polymerase chain reaction was carried out on the 60 specimens to examine if aberrations at the genomic level correlated with gene expression and to compare expression in normal and malignant samples. Oncogenes amplified in the endometrial cancers included AR, PIK3CA, MET, HRAS, NRAS, D17S1670, FGFR1, CTSB, RPS6KB1, LAMC2, MYC, PDGFRA, FGF4/FGF3, PAKI, and FGR. Three genes were examined at the messenger RNA level. AR and PIK3CA were higher in normal specimens, and MET was higher in malignant samples, suggesting a role for MET in endometrial cancer. Newer arrays examining more genes and larger sample numbers are necessary to elucidate the carcinogenic pathway in endometrial cancer.

Managing Breast Cancer in the Renal Transplant Patient: A Unique Dilemma

Improvements in immunosuppression have increased patient and graft survival in transplant recipients. As a result, there is greater risk of neoplastic processes such as breast cancer. Treatment in this population is complicated by the necessary immunosuppression, vascular accesses, and transplant grafts. General surgeons may expect to encounter more of these complex patients in the community setting. We sought to evaluate the surgical treatment of breast cancer in patients with renal transplants. Hospital and private physician records were queried to identify patients who developed breast cancer after a renal or pancreatic/renal transplantation. These charts were reviewed for demographics, type of breast cancer and treatment, location of dialysis access, and complications. From June 1, 1994, to May 31, 2004, 14 patients were identified. Eight patients had functioning transplants. All patients underwent operative interventions. Ten patients underwent adjuvant treatment. Three had functioning transplants and chose not to risk the graft with cessation of immunotherapy. However, no patient with functioning transplants who underwent chemotherapy developed organ failure. Breast cancer after transplantation poses a unique dilemma. The threat of transplanted organ failure is a major concern to these patients and often supersedes adjuvant therapies.

Managing breast cancer in the renal transplant patient: a unique dilemma

Improvements in immunosuppression have increased patient and graft survival in transplant recipients. As a result, there is greater risk of neoplastic processes such as breast cancer. Treatment in this population is complicated by the necessary immunosuppression, vascular accesses, and transplant grafts. General surgeons may expect to encounter more of these complex patients in the community setting. We sought to evaluate the surgical treatment of breast cancer in patients with renal transplants. Hospital and private physician records were queried to identify patients who developed breast cancer after a renal or pancreatic/renal transplantation. These charts were reviewed for demographics, type of breast cancer and treatment, location of dialysis access, and complications. From June 1, 1994, to May 31, 2004, 14 patients were identified. Eight patients had functioning transplants. All patients underwent operative interventions. Ten patients underwent adjuvant treatment. Three had functioning transplants and chose not to risk the graft with cessation of immunotherapy. However, no patient with functioning transplants who underwent chemotherapy developed organ failure. Breast cancer after transplantation poses a unique dilemma. The threat of transplanted organ failure is a major concern to these patients and often supersedes adjuvant therapies.

Abdominal wall abscess formation two years after laparoscopic cholecystectomy

BACKGROUND

Spillage of gallstones within the subcutaneous tissue during laparoscopic cholecystecomy may lead to considerable morbidity.

METHODS

We describe an abdominal wall abscess formation in a 50-year-old female that developed 24 months after a laparoscopic cholecystectomy.

RESULTS

Spilled gallstones at the umbilical port site went undetected. Subsequently, an umbilical port-site abscess formed and was treated 2 years later.

CONCLUSION

Any patient with a foreign body in the subcutaneous tissues after a laparoscopic cholecystectomy should be considered to have a retained stone. Use careful dissection, copious irrigation, and a retrieval device to avoid stone spillage. If spillage does occurs, percutaneous drainage and antibiotics followed by open retrieval of the stones should achieve adequate results during those delayed presentations of abdominal wall abscesses.

Emergency department visits for concern regarding anthrax--New Jersey, 2001

INTRODUCTION

In October of 2001, after letters processed in Trenton, New Jersey, resulted in multiple cases of anthrax, emergency departments (EDs) in New Jersey experienced an increase in visits from patients concerned about possible exposure to agents of biologic terrorism. Information about the effect of an actual biologic terrorism attack on the emergency department population might be useful in the design of biosurveillance systems, particularly with regard to their performance during the mitigation phase that occurs after an attack. In addition, such information might help identify issues that arise regarding the public health response in the ED setting.

OBJECTIVES

The objectives of this report were to identify and characterize ED visits, by patients concerned with exposure to biologic terrorism agents, in selected New Jersey hospitals after the anthrax attack in fall 2001.

METHODS

A retrospective cohort design was used in this study. The setting was 15 New Jersey EDs within a 55-mile radius of Trenton. Participants were consecutive patients evaluated by ED physicians for the following four periods in 2001: 1 month before September 11; 1 month after September 11; 1 month after October 11; and for the second month after October 11. Percentages of visits were calculated with a concern for exposure (CE) visits by using International Classification of Diseases, Ninth Revision (ICD-9) descriptors: Feared Complaint-No Diagnosis (ICD-9 code v65.6) and Screening for Infectious Disease (ICD-9 code v75.9) for all hospitals and for Trenton versus non-Trenton hospitals as a percentage of ED visits. Charts were reviewed by using a structured data form.

RESULTS

A total of 225,403 ED visits occurred during the 4 months, of which 698 were CE visits. The percentages of CE visits for the four periods were 0.06%, 0.06%, 0.92%, and 0.10%, respectively. For the peak third period, the percentage was increased for the two Trenton hospitals, 1.81%, versus 0.82% for the 13 non-Trenton hospitals. This report is a summary of the 508 visits associated with concern for anthrax exposure during the peak third period: 47% reported exposure to powder, 13% were postal workers, 4% received chest radiographs, 65% had a nasal swab for anthrax, 13% had ED decontamination, and 32% received antibiotics.

CONCLUSION

An increase in CE visits occurred during the 1-month period after October 11, 2001. During the peak month, a higher increase occurred in Trenton EDs. Considering the substantial variation in diagnostic evaluation and treatment, readily available guidelines are needed.

The role of laparoscopy in penetrating abdominal trauma

BACKGROUND

Minimally invasive surgery has become increasingly utilized in the trauma setting. When properly applied, it offers several advantages, including reduced morbidity, lower rates of negative laparotomy, and shortened length of hospital stay. The purpose of this study was to evaluate the role of laparoscopy in the management of trauma patients with penetrating abdominal injuries.

METHODS

We conducted a 3-year retrospective chart review of 4541 trauma patients admitted to our urban Level II trauma center. Penetrating abdominal injuries accounted for 209 of these admissions. Patients were divided into 3 treatment groups based on the characteristics of their abdominal injuries. Management was either observation, immediate laparotomy, or screening laparoscopy.

RESULTS

Thirty-three patients were observed in the Emergency Department based on their initial physical examination and radiologic studies. After Emergency Department evaluation, 154 patients underwent immediate laparotomy. In this group, 119 therapeutic laparotomies, 11 nontherapeutic laparotomies, and 24 negative laparotomies were performed. A review of the negative laparotomies revealed that possibly 8 of 10 gun shot wounds and all 14 stab wounds could have been done laparoscopically. Twenty-two patients underwent laparoscopic evaluation, 9 of which were converted to open procedures.

CONCLUSION

Minimally invasive surgical techniques are particularly helpful as a screening tool for anterior abdominal wall wounds and lower chest injuries to rule out peritoneal penetration. Increased use of laparoscopy in select patients with penetrating abdominal trauma will decrease the rate of negative and nontherapeutic laparotomies, thus lowering morbidity and decreasing length of hospitalization. As technology and expertise among surgeons continues to improve, more therapeutic intervention may be done laparoscopically in the future.

The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries

BACKGROUND

The evaluation of multitrauma patients for blunt truncal injuries remains open for debate. We sought to evaluate the role of routine computed tomography (CT) of the chest, abdomen, and pelvis as a screening tool for patients already undergoing cranial CT studies.

METHODS

Charts of blunt trauma patients admitted from June 2000 to June 2001 were reviewed for demographics, Glascow Coma Scale (GCS), physical and radiological findings, and length of stay.

RESULTS

Our study found that 38% of patients undergoing cranial CT scanning had a unexpected finding on body scans. Changes were made in 26% of the study group because results found on the adjuvant CTs.

CONCLUSIONS

Additional body CTs add minimal cost to the care of trauma patients but can significantly change the management. We believe it is beneficial to perform routine body CT examinations when performing cranial imaging for blunt head injury.

CT guided percutaneous fixation of sacroiliac fractures in trauma patients

BACKGROUND

Open reduction and internal fixation of unstable pelvic fractures has been advocated to minimize complications and avoid further injury. We have recently performed CT guided percutaneous fixation of sacroiliac joints as an alternative to open repair.

METHODS

From May 1, 1998 to April 30, 1999, our Level II trauma center admitted 76 patients with pelvic fractures, all due to blunt trauma. Twenty patients with unstable sacroiliac fracture-distractions underwent 22 percutaneous fixation procedures under general anesthesia in the radiology department by the third hospital day. Procedure times averaged 82 minutes. Localization with CT guidance was performed by the radiologist using 3-D images followed by percutaneous screw placement by the orthopaedic surgeon.

RESULTS

There was minimal procedural blood loss and no post-procedural wound complications. There was one operative delay due to respiratory difficulties and one postoperative death unrelated to the pelvic fracture. All patients were mobilized on the first post-procedural day.

CONCLUSION

CT guided fixation of unstable pelvic fractures minimizes blood loss during a short procedure with few subsequent complications and allows early mobilization of the patients.

The prevalence and determinants of health care-seeking behavior for fecal incontinence in multiparous United Arab Emirates females

PURPOSE

This study was designed to determine the prevalence and sociodemographics of fecal incontinence in United Arab Emirates females.

METHODS

A representative sample of multiparous United Arab Emirates females aged 20 years or older (N = 450) were randomly selected from the community (n = 225) and health care centers (n = 225). Patients were interviewed about inappropriate stool loss in the past year using a structured and pretested questionnaire.

RESULTS

Fifty-one participants (11.3 percent) admitted fecal incontinence; 26 (5.8 percent) were incontinent to liquid stool and 25 (5.5 percent) to solid stool. Thirty-eight patients (8.4 percent) had double (urinary and fecal) incontinence. Sixty-five patients (14.4 percent) were incontinent to flatus only but not to stools. The association between having fecal incontinence and chronic constipation was significant (P < 0.0001), but there was no significant association with other known risk factors such as age, parity, and previous instrumental delivery, episiotomy, perineal tears, or anorectal operations. Only 21 incontinent patients (41 percent) had sought medical advice. Patients did not seek medical advice because they were embarrassed to consult their physician (64.7 percent), they preferred to discuss the difficulty with friends, assuming that fecal incontinence would resolve spontaneously (47.1 percent) or was normal (31.3 percent), and they chose self-treatment as a result of low expectations for medical care (23.5 percent). Sufferers were bothered by the inability to pray (92.2 percent) and to have sexual intercourse (43.1 percent). Perceived causes of fecal incontinence were paralysis (90.2 percent), old age (80.4 percent), childbirth (23.5 percent), or menopause (19.6 percent).

CONCLUSIONS

Fecal incontinence is common yet underreported by multiparous United Arab Emirates females because of cultural attitudes and inadequate public knowledge.

Human apolipoprotein E4 accelerates beta-amyloid deposition in APPsw transgenic mouse brain

The human apolipoprotein E4 (ApoE4) isoform is associated with genetic risk for Alzheimer's disease. To assess the effects of different ApoE isoforms on amyloid plaque formation, human ApoE3 and ApoE4 were expressed in the brains of transgenic mice under the control of the human transferrin promoter. Mice were crossed with transgenic mice expressing human amyloid precursor protein containing the Swedish mutation (APPsw), which facilitates amyloid beta peptide (A beta) production. The following progeny were selected for characterization: APPsw+/- x ApoE3+/- and APPsw+/-, APPsw+/- x ApoE4+/- and APPsw+/- littermates. All mice analyzed were wild type for the endogenous mouse APP and ApoE genes. Mice expressing ApoE4 in combination with APPsw have accelerated A beta deposition in the brain as assessed by enzyme immunoassay for A beta40 and A beta42 extractable in 70% formic acid, by assessment of amyloid plaque formation using thioflavin-S staining, and by immunohistochemical staining with antibodies specific for A beta40 or A beta42 and the 4G8 monoclonal or 162 polyclonal antibody. No difference in the rate of A beta deposition in the brain was seen in mice expressing ApoE3 in combination with APPsw. Thus, our data are consistent with the observation in Alzheimer's disease that ApoE4 is associated with increased accumulation of A beta in the brain relative to ApoE3.

Cholecystitis in the octogenarian: is laparoscopic cholecystectomy the best approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.

Diabetes mellitus and its complications in a Hungarian population

The aim of this study was to examine the disease characteristics and complications of diabetes mellitus in patients in a Hungarian rural community. Data relating to age, sex, date of onset of diabetes, fasting blood glucose values and all diseases associated with diabetics were retrieved from the medical records of patients. Almost six percent (5.7%) of the population has diabetes mellitus. The percentage of Type I diabetic patients in this population was 5.8 percent. The prevalence of diabetes was slightly but not significantly higher in females than in males. The mean age of the diabetic population was 52.1 +/- 11.3 for male and 53.47 +/- 15.7 for the female patients. The peak age of onset of diabetes mellitus was in the sixth decade of life. The mean fasting blood sugar value was 10.64 +/- 0.6 and 10.57 +/- 0.5 mmol L(-1), in male and female diabetic patients (n = 103), respectively. Diabetic patients presented with many signs and symptoms in the general practice setting. The findings of this study showed that diabetics present with many disease conditions and signs and symptoms in the general practice setting. Many of these conditions are known to be associated with diabetes while others are not. As a result of the adverse effects of diabetes mellitus on the cardiovascular system and on body metabolism as a whole, the damage and morbidity caused by diabetes mellitus may have been underestimated. The results of this study have shed light on the unrecognised complications of diabetes mellitus.

Cholecystitis in the Octogenarian: Is Laparoscopic Cholecystectomy the Best Approach?

Management of biliary disease in the octogenarian has evolved over the last decade. Laparoscopic cholecystectomy is now more commonly performed in this patient population. Octogenarians with biliary pathology frequently present with complications of acute disease such as biliary pancreatitis, choledocholithiasis, and acute cholecystitis. As a result, laparoscopic management in this patient population can frequently be more challenging than in younger patients. We retrospectively reviewed 70 patients who were 80 years of age and older who underwent cholecystectomy at our institution for biliary tract disease. Seventeen patients presented to the Day Surgery unit for elective management of chronic biliary disease. Sixteen (94%) of these patients were attempted laparoscopically and one (6%) underwent open cholecystectomy. Two patients attempted laparoscopically were converted to open surgery (conversion rate 12.5%). Average length of hospital stay was 3.7 days for those treated laparoscopically and 11 days for patients treated with open cholecystectomy. There were three complications (19%) in this group and no deaths. The remaining 53 patients presented via the emergency room with acute complications of cholelithiasis. Laparoscopic cholecystectomy was attempted in 28 (52%) and open cholecystectomy was performed in 25 (48%) patients. Ten (37%) of the patients attempted laparoscopically were converted to an open procedure. Average length of stay in this group was 11.7 days for those treated laparoscopically and 15.7 days for patients managed with open technique. There were ten (56%) complications in the laparoscopic group and five (14%) complications in the open group. There were four deaths (22%) among those treated laparoscopically and three deaths (8.6%) in the open cholecystectomy group. Comorbid conditions were common in the patients with acute biliary pathology and those presenting for elective cholecystectomy. Laparoscopic cholecystectomy is the procedure of choice in the elective management of biliary tract disease in the octogenarian. Laparoscopic cholecystectomy has no benefit with respect to morbidity and mortality over open cholecystectomy in the management of acute biliary tract disease in this elderly population. When possible, chronic cholecystitis in the elderly should be managed with elective laparoscopic cholecystectomy rather than waiting for complications to develop.

Penetrating esophageal injuries: multicenter study of the American Association for the Surgery of Trauma

OBJECTIVE

The purpose of this study was to define the period of time after which delays in management incurred by investigations cause increased morbidity and mortality. The outcome study is intended to correlate time with death from esophageal causes, overall complications, esophageal related complications, and surgical intensive care unit length of stay.

METHODS

This was a retrospective multicenter study involving 34 trauma centers in the United States, under the auspices of the American Association for the Surgery of Trauma Multi-institutional Trials Committee over a span of 10.5 years. Patients surviving to reach the operating room (OR) were divided into two groups: those that underwent diagnostic studies to identify their injuries (preoperative evaluation group) and those that went immediately to the OR (no preoperative evaluation group). Statistical methods included Fisher's exact test, Student's T test, and logistic regression analysis.

RESULTS

The study involved 405 patients: 355 male patients (86.5%) and 50 female patients (13.5%). The mean Revised Trauma Score was 6.3, the mean Injury Severity Score was 28, and the mean time interval to the OR was 6.5 hours. There were associated injuries in 356 patients (88%), and an overall complication rate of 53.5%. Overall mortality was 78 of 405 (19%). Three hundred forty-six patients survived to reach the OR: 171 in the preoperative evaluation group and 175 in the no preoperative evaluation group. No statistically significant differences were noted in the two groups in the following parameters: number of patients, age, Injury Severity Score, admission blood pressure, anatomic location of injury (cervical or thoracic), surgical management (primary repair, resection and anastomosis, resection and diversion, flaps), number of associated injuries, and mortality. Average length of time to the OR was 13 hours in the preoperative evaluation group versus 1 hour in the no preoperative evaluation group (p < 0.001). Overall complications occurred in 134 in the preoperative evaluation group versus 87 in the no preoperative evaluation group (p < 0.001), and 74 (41%) esophageal related complications occurred in the preoperative evaluation group versus 32 (19%) in the no preoperative evaluation group (p = 0.003). Mean surgical intensive care unit length of stay was 11 days in the preoperative evaluation group versus 7 days in the no preoperative evaluation group (p = 0.012). Logistic regression analysis identified as independent risk factors for the development of esophageal related complications included time delays in preoperative evaluation (odds ratio, 3.13), American Association for the Surgery of Trauma Organ Injury Scale grade >2 (odds ratio, 2.62), and resection and diversion (odds ratio, 4.47).

CONCLUSION

Esophageal injuries carry a high morbidity and mortality. Increased esophageal related morbidity occurs with the diagnostic workup and its inherent delay in operative repair of these injuries. For centers practicing selective management of penetrating neck injuries and transmediastinal gunshot wounds, rapid diagnosis and definitive repair should be made a high priority.

Deep venous thrombosis prophylaxis is not indicated for laparoscopic cholecystectomy

OBJECTIVES

Recent publications have discussed the risk of deep venous thrombosis during laparoscopic cholecystectomy and the need for routine deep venous thrombosis (DVT) prophylaxis. The purpose of this study was to determine the incidence of clinically detectable DVT in patients undergoing laparoscopic cholecystectomy without a standard DVT prophylaxis regimen.

MATERIALS AND METHODS

We performed completed laparoscopic cholecystectomy in 587 patients over a 4-year period. Eighteen of these patients received some form of perioperative DVT prophylaxis, and 569 patients did not. Routine screening with a duplex Doppler was not used. Patients were followed postoperatively for 4 weeks after discharge from the hospital.

RESULTS

In an average of 4 weeks follow-up, 31 complications and 4 deaths were reported. These complications included wound infection (16), postoperative bleeding (3), persistent pain (3), pneumonia (3), retained CBD stones (2), asthma (1), papillary stenosis (1), ileus (1), and intraoperative bowel injury (1). None of the 587 patients in this study had symptoms of DVT or pulmonary embolism.

DISCUSSION

Despite the fact that DVT in this patient population is rare, many reports suggest the use of routine DVT prophylaxis with sequential compression devices (SCDs) or low-molecular-weight heparin (LMWH). Because no clinically detectable evidence was found of DVT in our study group despite the lack of any perioperative DVT prophylaxis, we question whether routine DVT prophylaxis is indicated or cost effective for routine laparoscopic cholecystectomy. A large prospective trial addressing this question is needed.

The role of follow-up radiographic studies in nonoperative management of spleen trauma

The management of splenic injuries has evolved significantly in recent years from an operative to a nonoperative approach in stable patients with blunt abdominal trauma. The management of these patients with serial radiographic studies before hospital discharge remains controversial. We reviewed the management of 90 patients retrospectively who were admitted to our Level II trauma center with splenic injuries secondary to blunt trauma to determine the value of serial radiographic studies. Forty-seven (52%) patients underwent immediate laparotomy. Forty-three (48%) patients were managed conservatively without surgery. All nonoperative patients had an initial CT of the abdomen to evaluate their abdominal injuries. Among the 43 patients managed without surgery 31 had no follow-up radiographic studies. Twelve patients had follow-up studies before discharge. Two of these 12 patients subsequently underwent splenectomy. Both had developed hypotension, tachycardia, and a decreasing hematocrit, which prompted their repeat radiographic studies. Ten patients had no change in their clinical status and showed no significant change in the radiographic injury pattern to the spleen. One patient who was initially managed nonoperatively became hemodynamically unstable with increasing abdominal pain and subsequently underwent splenectomy without follow-up radiographic studies. The remaining 30 patients who had no follow-up studies had no significant change in their clinical abdominal examinations and had no further complications from their splenic injuries. Routine follow-up radiographic evaluations are not necessary in the nonoperative management of stable patients with splenic injuries.

Management of anaemia in United Kingdom renal units: a report from the UK Renal Registry

BACKGROUND

Morbidity and mortality of patients undergoing renal replacement therapy is influenced by the adequacy of correction of renal anaemia. The Renal Association has set standards for attainment of a target haemoglobin of 10 g/dl. This study compared the management of anaemia in dialysis patients in nine renal units in the UK.

METHODS

A cross-sectional analysis was carried out on data submitted electronically to the UK Renal Registry. There were 1449 haemodialysis patients and 741 peritoneal dialysis patients in the nine renal centres analysed. Individual patient data were collected on haemoglobin, ferritin, erythropoietin prescription, and pre- and post-dialysis urea concentrations.

RESULTS

None of the centres achieved the standard of more than 80% of haemodialysis patients with a haemoglobin of greater than 10 g/dl. Three centres achieved this standard for peritoneal dialysis. There was wide variation between centres in the percentage reaching the target. Differences in ferritin, erythropoietin prescription, and dialysis doses between centres could not entirely explain the variations between centres. Females had lower haemoglobin than males despite a greater proportion being treated with erythropoietin. There was a trend of increasing haemoglobin concentration during the study period in haemodialysis but not in peritoneal dialysis patients.

CONCLUSIONS

The Renal Association standards for management of anaemia are not being met. The data allow renal centres to compare their practices with others to identify areas that might be improved. Further analysis may allow a benchmark to be determined of what it is possible to achieve by best practice.

Prediction of probable Alzheimer disease in patients with symptoms suggestive of memory impairment. Value of the Mini-Mental State Examination

BACKGROUND

The Mini-Mental State Examination (MMSE) is a widely used diagnostic tool for dementia. Its use as a predictive indicator of probable Alzheimer disease (AD) has not been established.

OBJECTIVES

To determine the accuracy of the MMSE in predicting emergent AD in a sample of patients who were referred because of symptoms suggestive of memory problems and to determine whether an abbreviated version of the MMSE could be developed that would be as accurate as the full MMSE in predicting emergent AD.

DESIGN

Inception cohort of participants with symptoms suggestive of memory impairment by their family physicians were given baseline assessments, including MMSE. After 2 years, the participants' conditions were diagnosed following the standard criterion for AD. Diagnosticians were blind to baseline scores.

SETTING AND PARTICIPANTS

One hundred eighty-three community-residing participants were referred by their family physicians to a university teaching hospital research investigation. After baseline screening, 165 participants were included in the study who did not have dementia and had no identifiable cause for memory impairment. After 2 years, 29 participants met criteria for AD, 98 did not develop dementia, 18 developed vascular lesions or non-AD dementia, and 20 did not return.

MAIN OUTCOME MEASURE

Diagnostic classification of AD or no evidence of dementia.

RESULTS

Logistic regression model was significant. At a cutoff score of 24 or less, sensitivity was 31%; specificity, 96%; with a likelihood ratio of 7.75. A reduced model of 2 subtests was identified with a sensitivity of 41%; specificity, 98%; with a likelihood ratio of 20.70.

CONCLUSIONS

Results suggest that the full or abbreviated MMSE is useful in predicting emergent AD in patients with positive test results. However, it is not recommended for use as a screening or diagnostic instrument since a negative test result did not rule out emergent AD. It is recommended as a tool to identify those needing closer monitoring.