The Scale of Sexual Aggression in Southeast Asia: A Review

Southeast Asia is one of the most dynamic regions in the world. It is experiencing rapid socioeconomic change that may influence the level of sexual aggression, but data on the scale of sexual aggression in the region remain sparse. The aim of the present article was to systematically review the findings of studies available in English on the prevalence of self-reported sexual aggression and victimization among women and men above the age of 12 years in the 11 countries of Southeast Asia (Brunei, Cambodia, East Timor, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Vietnam). Based on four scientific databases, the search engine Google, Opengrey database, and reference checking, 49 studies were found on sexual victimization. Of those, 32 included only women. Self-reported perpetration was assessed by only three studies and included all-male samples. Prevalence rates varied widely across studies but showed that sexual victimization was widespread among different social groups, irrespective of sex and sexual orientation. Methodological heterogeneity, lack of representativeness of samples, imbalance of information available by country, missing information within studies, and cultural differences hampered the comparability between and within countries. There is a need for operationalizations that specifically address sexual aggression occurring after the age of consent, based on detailed behavioral descriptions of unwanted sexual experiences and allied to a qualitative approach with cultural sensitivity. Data on sexual aggression in conflict settings and in human trafficking are also limited. Recommendations for future research are presented in the discussion.

A prospective study of severity of complications associated with use of misoprostol and other abortion methods in South West Nigeria

OBJECTIVES

To assess the severity of complications following misoprostol used to induce abortion compared with other methods among women admitted for postabortion complications.

METHODS

A cross-sectional study of women who presented with complications of induced abortion at nine secondary and tertiary hospitals in South West Nigeria between April 1, 2013 and May 31, 2014. Face-to-face interviews were conducted and information on the current admission was extracted from patient records. Associations between abortion method used and severity of abortion complications were evaluated using χ² and Fisher exact tests.

RESULTS

Of 522 women included in the study, 177 reported an induced abortion: 41 women (23.2%) had used misoprostol at the first attempt to induce abortion, whereas 79 (44.6%) women had undergone surgical abortion. Occurrence of fever (P=0.06), bleeding (P=0.3), and lower abdominal pain (P=0.32) was not significantly different between the misoprostol and surgical abortion/other methods groups. Severe complications were rare with misoprostol, but more common among women in the surgical abortion/other methods group. Maternal mortality occurred only among women in the surgical abortion/other methods group.

CONCLUSION

Use of misoprostol for induced abortion was associated with fewer complications and no maternal mortality compared with surgical abortion/other methods.

Narratives of women presenting with abortion complications in Southwestern Nigeria: A qualitative study

Unsafe abortion continues to impact negatively on women’s health in countries with restrictive abortion laws. It remains one of the leading causes of maternal mortality and morbidity. Paradoxically, modern contraceptive prevalence remains low and the unmet need for contraception continues to mirror unwanted pregnancy rates in many countries within sub-Saharan Africa. This qualitative study assessed women’s knowledge; their expectation and experiences of the methods employed for abortion; and their health care-seeking decisions following a complicated abortion. Women who presented with abortion complications were purposively sampled from seven health facilities in south-west Nigeria. In-depth interviews were conducted by social scientists with the aid of a semi-structured interview guide. Coding schemes were developed and content analysis was performed with WEFTQDA software. Thirty-one women were interviewed. Misoprostol was used by 16 women; 15 women used other methods. About one-fifth of respondents were aged ≤ 20 years; almost one-third were students. Common reasons for terminating a pregnancy were: “too young/still in school/training”; “has enough number of children”; “last baby too young” and “still breastfeeding”. Women had little knowledge about methods used. Friends, nurses or pharmacists were the commonest sources of information. Awareness about use of misoprostol for abortion among women was high. Women used misoprostol to initiate an abortion and were often disappointed if misoprostol did not complete the abortion process. Given its clandestine manner, women were financially exploited by the abortion providers and only presented to hospitals for post-abortion care as a last resort. Women’s narratives of their abortion experience highlight the difficulties and risks women encounter to safeguard and protect their sexual and reproductive health. To reduce unsafe abortion therefore, urgent and synergized efforts are required to promote prompt access to family planning and post-abortion care services.

Service provider perceptions of the trend in severity of symptoms and complications in women admitted following an incomplete abortion

Background

Sri Lankan abortion law which dates back to the year 1883, and still unchanged, only allows a legal termination when the mother's life is in danger. Many studies undertaken in the country estimates that even in the light of such a backdrop, and with a high contraceptive prevalence rate, many women attempt an abortion when faced with an unwanted pregnancy. This study aims to describe the changes in abortion-related complications in the country over a period of time and explore the reasons for any changes in severity of symptoms among women hospitalized following an abortion based on the perceptions of healthcare service providers.

Method

Using an interviewer guide, in-depth interviews were carried out among 30 service providers of post abortion care with more than 5 years of experience in obstetrics and gynecology in Sri Lanka.

Results

Service providers perceived that the number of women presenting to hospitals after an induced abortion caused by a mechanical method is minimal or not at all at present. Over time, a significant reduction is seen in the number of women presenting with any abortion-related complications and the severity of complications has also reduced significantly. The common method of termination at present identified by the providers was the use of "drugs" or "the drug - Misoprostol."

Conclusion

Over the years, women appear to have switched from surgical and mechanical methods to medical means (drugs) to induce an abortion and this change has contributed to reduce the severity of complications.

Trends in misoprostol use and abortion complications: A cross-sectional study from nine referral hospitals in Nigeria

Objective

The study aimed to assess the use of misoprostol and complications associated with abortions in referral hospitals in Nigeria, a country with restrictive abortion laws.

Methods

A cross-sectional study at nine referral hospitals in South-west Nigeria. Nine years’ data were retrieved from medical records, including 699 induced abortions. Independent variable was the method of abortion; dependent variables were complications, need for treatment and mortality. Statistical significance was tested with Chi-square, Fishers’ exact and chi-square for trend tests (p<0.05).

Results

There were 699 induced abortions amongst 2,463 abortions found in records. Nearly 70% were surgical abortions, but misoprostol use significantly increased over the study period in a linear trend (Χ² trend: 30.96, P <0.001). Patients who used misoprostol were significantly less likely to have infectious morbidity, genital tract injuries or medical complications. There was no difference in incomplete abortion in the groups. Patients were more likely to have in-patient care with surgical abortions (p<0.001), to need prolonged antibiotic regimens (p = 0.003), need further surgeries or additional specialist care (p = 0.009).

Conclusion

Misoprostol abortion has significantly increased over time, and was associated with less morbidity and need for further treatment, in this study. It appears to be the safer option.

The Role of Positron Emission Tomography/Computed Tomography Imaging in Head and Neck Cancer after Radical Chemoradiotherapy: a Single Institution Experience

AIMS

Positron emission tomography/computed tomography (PET/CT) is used to restage head and neck cancer 3 months after chemoradiotherapy. The purpose of this study was to determine the negative predictive value (NPV) of a scan reported as having no abnormal uptake and the positive predictive values (PPV) for different maximum standardised uptake value (SUVmax) thresholds.

MATERIALS AND METHODS

Patients with squamous cell carcinoma of the oro-/hypopharynx/larynx (n = 206) were included. SUVmax and subsequent locoregional recurrence were documented.

RESULTS

The median SUVmax was 11.2 (range 4-33)/4.6 (range 2-30), respectively, in patients with/without definite primary site recurrence (P = 0.004). The median SUVmax was 4.4 (range 2.6-15.6)/3.1 (range 2.1-4.6), respectively, in patients with/without definite nodal recurrence (P = 0.003). The NPV for a scan reported as having no abnormal uptake was 92%. The PPV for the SUVmax thresholds 4, 6 and 8, respectively, were 53, 65 and 92% (primary site) and 93, 100 and 100% (nodes).

CONCLUSIONS

The NPV of PET/CT after chemoradiation is consistent with the literature and underlines the importance of PET/CT in restaging the primary site if salvage neck dissection is considered. The overall PPV of PET/CT remains low but is high for nodal SUVmax > 4. These data could be used to design risk-stratified follow-up schedules.

Evaluating PET-CT in routine surveillance and follow-up after treatment for cervical cancer: a cost-effectiveness analysis

OBJECTIVE

To undertake a cost-effectiveness analysis that compares positron emission tomography - computed tomography (PET-CT) imaging plus standard practice with standard practice alone in the diagnosis of recurrent or persistent cervical cancer during routine surveillance and follow-up of women who have previously been diagnosed and treated.

DESIGN

Model-based economic evaluation using data from a systematic review, supplemented with data from other sources, and taking a UK National Health Service (NHS) perspective.

SETTING

Secondary Care in England.

POPULATION

Women at least 3 months after the completion of treatment, with either recurrent or persistent cervical cancer.

METHODS

A state transition (Markov) model was developed using TreeAge Pro 2011. The structure of the model was informed by the reviews of the trials and clinical input. In the model, two diagnostic strategies were examined. A one-way sensitivity analysis, probabilistic sensitivity analysis, and a value of information analysis were also carried out.

MAIN OUTCOME MEASURES

Cost-effectiveness based on incremental cost per quality-adjusted life year (QALY).

RESULTS

Adding PET-CT to the current treatment strategy of clinical examination and scanning [magnetic resonance imaging (MRI) and/or CT scan] during the routine surveillance and follow-up of women with recurrent or persistent cervical cancer is significantly more costly, with only a minimal increase in effectiveness. The incremental cost-effectiveness ratio (ICER) for the strategy of PET-CT as an adjunct to the standard treatment strategy that included clinical examination, MRI, and/or CT scan, compared with the usual treatment alone, was over £1 million per QALY.

CONCLUSION

The results of the current analysis suggest that use of PET-CT in the diagnosis of recurrent or persistent cervical cancer is not cost-effective. Current guidelines recommending imaging using PET-CT as a diagnostic or surveillance tool need to be reconsidered in light of these results. This study did not specifically investigate the use of PET-CT in women with symptoms and radiological suspicion of recurrence where exenteration was considered. More research in that specific area is required.

Evaluating PET-CT in the detection and management of recurrent cervical cancer: systematic reviews of diagnostic accuracy and subjective elicitation

BACKGROUND

Positron emission tomography-computed tomography (PET-CT) is recommended to triage women for exenterative surgery and surveillance after treatment for advanced cervical cancer.

OBJECTIVE

To evaluate diagnostic accuracy of additional whole body PET-CT compared with CT/magnetic resonance imaging (MRI) alone in women with suspected recurrent/persistent cervical cancer and in asymptomatic women as surveillance.

DESIGN

Systematic reviews. Subjective elicitation to supplement diagnostic information.

SEARCH STRATEGY/SELECTION CRITERIA/DATA COLLECTION AND ANALYSIS

Searches of electronic databases were performed to June 2013. Studies in women with suspected recurrent/persistent cervical cancer and in asymptomatic women undergoing follow up with sufficient numeric data were included. We calculated sensitivity, specificity and corresponding 95% confidence intervals. Meta-analyses employed a bivariate model that included a random-effects term for between-study variations (CT studies) and univariate random effects meta-analyses (PET-CT studies) for sensitivity and specificity separately.

SUBJECTIVE ELICITATION

Prevalence of recurrence and the accuracy of imaging elicited using the allocation of points technique. Coherence of elicited subjective probabilities with estimates in the literature examined.

RESULTS

We identified 15 relevant studies; none directly compared additional PET-CT with MRI or CT separately. Most CT and MRI studies used older protocols and the majority did not distinguish between asymptomatic and symptomatic women. Meta-analysis of nine PET-CT studies in mostly symptomatic women showed sensitivity of 94.8 (95% CI 91.2-96.9), and specificity of 86.9% (95% CI 82.2-90.5). The summary estimate of the sensitivity of CT for detection of recurrence was 89.64% (95% CI 81.59-94.41) and specificity was 76% (95% CI 43.68-92.82). Meta-analysis for MRI test accuracy studies was not possible because of clinical heterogeneity. The sensitivity and specificity of MRI in pelvic recurrence varied between 82 and 100% and between 78 and 100%, respectively. Formal statistical comparisons of the accuracy of index tests were not possible. Subjective elicitation provided estimates comparable to the literature. Subjective estimates of the increase in accuracy from the addition of PET-CT were less than elicited increases required to justify the use in PET-CT for surveillance.

CONCLUSION

Evidence to support additional PET-CT is scarce, of average quality and does not distinguish between application for surveillance and diagnosis. Guidelines recommending PET-CT in recurrent cervical cancer need to be reconsidered in the light of the existing evidence base.

Positron emission tomography/computerised tomography imaging in detecting and managing recurrent cervical cancer: systematic review of evidence, elicitation of subjective probabilities and economic modelling

BACKGROUND

Cancer of the uterine cervix is a common cause of mortality in women. After initial treatment women may be symptom free, but the cancer may recur within a few years. It is uncertain whether it is more clinically effective to survey asymptomatic women for signs of recurrence or to await symptoms or signs before using imaging.

OBJECTIVES

This project compared the diagnostic accuracy of imaging using positron emission tomography/computerised tomography (PET-CT) with that of imaging using CT or magnetic resonance imaging (MRI) alone and evaluated the cost-effectiveness of adding PET-CT as an adjunct to standard practice.

DATA SOURCES

Standard systematic review methods were used to obtain and evaluate relevant test accuracy and effectiveness studies. Databases searched included MEDLINE, EMBASE, Science Citation Index and The Cochrane Library. All databases were searched from inception to May 2010.

REVIEW METHODS

Study quality was assessed using appropriately modified Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. Included were any studies of PET-CT, MRI or CT compared with the reference standard of histopathological findings or clinical follow-up in symptomatic women suspected of having recurrent or persistent cervical cancer and in asymptomatic women a minimum of 3 months after completion of primary treatment. Subjective elicitation of expert opinion was used to supplement diagnostic information needed for the economic evaluation. The effectiveness of treatment with chemotherapy, radiotherapy, chemoradiotherapy, radical hysterectomy and pelvic exenteration was systematically reviewed. Meta-analysis was carried out in RevMan 5.1 (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark) and Stata version 11 (StataCorp LP, College Station, Texas, USA). A Markov model was developed to compare the relative cost-effectiveness using TreeAge Pro software version 2011 (TreeAge Software Inc., Evanston, IL, USA).

RESULTS

For the diagnostic review, a total of 7524 citations were identified, of which 12 test accuracy studies were included in the review: six studies evaluated PET-CT, two evaluated MRI, three evaluated CT and one evaluated both MRI and CT. All studies were small and the majority evaluated imaging in women in whom recurrence was suspected on the basis of symptoms. The PET-CT studies evaluated local and distant recurrence and most used methods similar to current practice, whereas five of the six CT and MRI studies evaluated local recurrence only and not all employed currently used methods. Meta-analysis of PET-CT studies gave a sensitivity of 92.2% [95% confidence interval (CI) 85.1% to 96.0%] and a specificity of 88.1% (95% CI 77.9% to 93.9%). MRI sensitivities and specificities varied between 82% and 100% and between 78% and 100%, respectively, and CT sensitivities and specificities varied between 78% and 93% and between 0% and 95%, respectively. One small study directly compared PET-CT with older imaging methods and showed more true-positives and fewer false-negatives with PET-CT. The subjective elicitation from 21 clinical experts gave test accuracy results for asymptomatic and symptomatic women and the results for symptomatic women were similar to those from the published literature. Their combined opinions also suggested that the mean elicited increase in accuracy from the addition of PET-CT to MRI and/or CT was less than the elicited minimum important difference in accuracy required to justify the routine addition of PET-CT for the investigation of women after completion of primary treatment. For the effectiveness review, a total of 24,943 citations were identified, of which 62 studies were included (chemotherapy, 19 randomised controlled trials; radiotherapy or chemoradiotherapy, 16 case series; radical hysterectomy and pelvic exenteration, 27 case series). None provided the effectiveness of cisplatin monotherapy, the most commonly used chemotherapeutic agent in the NHS, compared with supportive care in a background of other treatment such as radiotherapy in recurrent and persistent cervical cancer. The model results showed that adding PET-CT to the current treatment strategy of clinical examination, MRI and/or CT scan was significantly more costly with only a minimal increase in effectiveness, with incremental cost-effectiveness ratios for all models being > £1M per quality-adjusted life-year (QALY) and the additional cost per additional case of recurrence being in the region of £600,000.

LIMITATIONS

There was considerable uncertainty in many of the parameters used because of a lack of good-quality evidence in recurrent or persistent cervical cancer. The evidence on diagnostic and therapeutic impact incorporated in the economic model was poor and there was little information on surveillance of asymptomatic women.

CONCLUSIONS

Given the current evidence available, the addition of PET-CT to standard practice was not found to be cost-effective in the diagnosis of recurrent or persistent cervical cancer. However, although probabilistic sensitivity analysis showed that the main conclusion about cost-ineffectiveness of PET-CT was firm given the range of assumptions made, should more reliable information become available on accuracy, therapeutic impact and effectiveness, and the cost of PET-CT reduce, this conclusion may need revision. Current guidelines recommending imaging for diagnosis using expensive methods such as PET-CT need to be reconsidered in the light of the above.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Differential effects on T-cell function following exposure to serum from schizophrenia smokers

Cigarette smoking is more prevalent in subjects with schizophrenia compared to those with other psychiatric disorders or the general population and could therefore affect molecular pathways that impact the pathophysiology of this disorder. As smoking is also known to suppress immune responses, we investigated the effects of 'smoking-conditioned' serum obtained from schizophrenia and control subjects on healthy T cell in vitro. We found that T-cell proliferation was significantly increased following exposure to serum from smoking schizophrenia patients whereas no effect was observed when using serum from smoking control subjects or non-smoking patients and controls. We eliminated the possibility that these effects were due to quantitative differences in cigarette consumption as serum levels of the stable nicotine metabolite cotinine were similar in schizophrenic and control smokers. Molecular characterization showed that serum from patient smokers increased expression of T-cell activation markers CD69(high), CD25(high), co-stimulatory molecules CD26+, CD27+ and CD28+, and decreased T-cell receptor complex components TCRalpha/beta and CD3. Moreover, analysis of supernatants collected after T-cell exposure to serum from smoking patients showed a time-dependent decline in interleukin (IL)-2 levels, suggesting that the proliferation effect is promoted by enhanced IL-2 processing. These results suggest that cigarette smoking has selective effects on serum components that, in turn, lead to altered immune function in schizophrenia patients relative to healthy subjects. Further studies aimed at characterizing these components could result in a better understanding of the onset and aetiology of schizophrenia and potentially lead to novel therapeutic strategies.

Rural-urban migration and depression in ageing family members left behind

BACKGROUND

It has been suggested that rural-urban migration will have adverse consequences for older parents left behind.

AIMS

To describe correlates of outmigration and to estimate any association between outmigration of children and depression in rural-dwelling older parents.

METHOD

Population-based survey of 1147 parents aged 60 and over in rural Thailand. We randomly oversampled parents living without children. We defined an outmigrant child as living outside their parent's district, and measured depression as a continuous outcome with a Thai version of the EURO-D.

RESULTS

Outmigration of all children, compared with outmigration of some or no children, was independently associated with less depression in parents. This association remained after taking account of social support, parent characteristics, health and wealth. Parents with all children outmigrated received more economic remittances and they perceived support to be as good as that of those with children close by.

CONCLUSIONS

Outmigration of children was not associated with greater depression in older parents and, after taking account of a range of possible covariables, was actually associated with less parental depression. This could be explained by pre-existing advantages in families sending more migrants and by the economic benefits of migration.

Exposure to secondhand smoke in Kanchanaburi demographic surveillance system, Thailand

Using data from the Kanchanaburi demographic surveillance system in Thailand, this article documents that tobacco smoke affects 60% of the population. The main effect is through exposure to secondhand smoke. More than half of men are smokers compared with only one tenth of women. Most men tend to start smoking during their teenage years, whereas the majority of women start at later ages. The majority of households are exposed to secondhand smoke. The highest level of exposure is in rural areas. Smokers are most likely to be male and older, but those exposed to secondhand smoke tend to be female and younger. Exposure to secondhand smoke is more likely to occur in households with lower socioeconomic status. Logistic regression analysis supports 2 study hypotheses: that children and women are the most affected by secondhand smoke, and household factors are the most important factors affecting the exposure to secondhand smoke.

A Fatal Complication Following Hybrid Total Arch Replacement with Supra-aortic Artery Translocation and Endovascular Stenting

This case highlights the successful management of acute Type B dissection complicated by visceral malperfusion. Even though the procedure of hybrid supra-aortic translocation and endovascular stenting corrected the malperfusion, it is important for vigilant CT scan surveillance for the post operative complications which can occur with this procedure.

Women's status, institutional barriers and reproductive health care: a case study in Yunnan, China

OBJECTIVES

Yunnan is one of the poorest and most remote provinces in China. The reproductive health status of the population is poor. The aim of the study was to identify factors contributing to poor reproductive health and major barriers in accessing reproductive health information and care and to inform interventions to increase access to and the quality of care in service delivery.

METHODS

The study was based on qualitative data collected from structured and unstructured interviews with health program managers, service providers, clients, and community members in three counties. Focus group discussions, field observations, reviews of the records of medical facilities and thematic analysis were used in the study.

RESULTS

Gender inequality and the fragmented health system were some of the barriers in accessing the services. Incorrect diagnosis, over treatment and IUD insertion with un-sterilised tools may have contributed to the persistent high rate of reproductive tract infections (RTI) in the study settings.

CONCLUSIONS

The improvement of reproductive health thus hinges critically upon the elevation of women's status. All health sectors within China's health system need to be better integrated and institutionally induced gender inequality ought to be reduced so that all in the population, particularly the vulnerable, will have equal and adequate access to reproductive health care.

CT colonography: interpretative performance in a non-academic environment

AIM

To investigate interpretative accuracy and reporting time for radiologists performing computed tomography (CT) colonography in day-to-day non-academic clinical practice.

MATERIALS AND METHODS

Thirteen radiologists from seven centres, who were reporting CT colonography in non-academic daily clinical practice, interpreted a dataset of 15 colonoscopically validated cases in a controlled environment. Ten cases had either a cancer or polyp >10mm; one case had a medium polyp and four were normal. Correct case categorization and interpretation times were compared using analysis of variance to aggregated results obtained from both experienced observers and observers recently trained using 50 cases, working in an academic environment. The effect of experience was determined using Spearman's rank correlation.

RESULTS

Individual accuracy was highly variable, range 53% (95% CI 27-79%) to 93% (95% CI 68-100%). Mean accuracy overall was significantly inferior to experienced radiologists (mean 75 versus 88%, p=0.04) but not significantly different from recently trained radiologists (p=0.48). Interpretation time was not significantly different to experienced readers (mean 12.4 min versus 11.7, p=0.74), but shorter than recently trained radiologists (p=0.05). There was a significant, positive, linear correlation between prior experience and accuracy (p<0.001) with no plateau.

CONCLUSION

Accuracy for sub-specialist radiologists working in a non-academic environment is, on average, equivalent to radiologists trained using 50 cases. However, there is wide variability in individual performance, which generally falls short of the average performance suggested by meta-analysis of published data. Experience improves accuracy, but alone is insufficient to determine competence.

An audit of fusion CT-PET in the management of colorectal liver metastases

AIM

To assess the use of positron emission tomography combined with computerized tomography (CT-PET) with fluoro-18-2-deoxy-d-glucose ((18)F-FDG) to identify hyper-metabolic tumours, especially colorectal metastases (CRM).

METHODS

Patient particulars, diagnoses and clinical outcome for each patient were studied. Twenty-three patients underwent CT-PET, 10 males and 13 females, median age 59 (range 34-72). Fourteen patients presented with primary liver CRM and nine had undergone previous liver resections. Indications for CT-PET included; suspected extrahepatic disease in 13/23 patients, possible hepatic recurrence 5/23 and clinical suspicion in 8/23 patients.

RESULTS

Seven patients had a major impact on their management. Unexpected (not seen on CT) findings in the CRM group included, 7/23 (30%) patients with extrahepatic disease, 3/23 with hepatic metastases, 8/23 suspected of having liver or distant metastases on CT had a negative study. A clinical decision, based on the CT-PET report, could be undertaken in 21/23 patients.

CONCLUSION

CT-PET is useful in patients with CRM where conventional imaging presents dilemmas such as: assessment of suspected extrahepatic disease, recurrence in liver, patients with advanced or perforated initial tumours.

Internal migration in Thailand

"Internal migration of the population of Thailand involves a number of distinct forms of movement. Three forms are identified in this research: single-move, seasonal and repeat. The first can be treated as long-term migration while the latter two are more temporary. All forms are characterized by different geographical flows and different selectivity patterns. Long-term migration is highly selective of young adults, females and the more highly educated. It is most likely to occur between urban areas or from rural to urban areas. Temporary migration mainly involves movement back and forth between urban and rural places and is most likely to be engaged in by those with a medium level of education."

Imaging the post-operative thoracic aorta: normal anatomy and pitfalls

Following surgical repair or replacement of the thoracic aorta, interpretation of CT and MRI scans of the thorax can be confusing. It is important to be aware of the variety of appearances that can be encountered. There is usually a surgical explanation and close collaboration with surgical colleagues is required. An appreciation of the normal post-operative appearances allows recognition of the abnormal. Potential pitfalls in interpretation are discussed.

Clinical and patho-anatomical factors affecting expansion of thoracic aortic aneurysms

OBJECTIVE

To examine the expansion of aneurysmal aortic segments (> or = 35 mm) and to assess the impact of clinical and patho-anatomical factors on aneurysm expansion.

DESIGN

87 consecutive patients (mean age 63.6 years, range 22-84 years) were studied using serial (six month intervals) computed tomographic or magnetic resonance imaging to monitor progression of thoracic aortic aneurysms. Aortic diameter was measured at seven predetermined segments and at the site of maximum aortic dilatation (MAX).

RESULTS

780 segment intervals were identified. The median overall aneurysm expansion rate was 1.43 mm/year. This increased exponentially with incremental aortic diameter (p < 0.01) and varied by anatomical segment (p < 0.05). The presence of intraluminal thrombus (p < 0.01) but not dissection or calcification was associated with accelerated growth. Univariate analysis identified thrombus (p < 0.001), previous stroke (p < 0.002), smoking (p < 0. 01), and peripheral vascular disease (p < 0.05) as factors associated with accelerated growth in MAX. Dissection, wall calcification, and history of hypertension did not affect expansion. beta Blocker treatment was not associated with protection. Multivariate analysis confirmed the positive effect of intraluminal thrombus and previous cerebral ischaemia, and the negative effect of previous aortic surgery on aneurysm growth. These findings translated into a mathematical equation describing exponential aneurysm expansion.

CONCLUSIONS

Aneurysmal thoracic aortic segments expand exponentially according to their initial size and their anatomical position within the aorta. The presence of intraluminal thrombus, atherosclerosis, and smoking history is associated with accelerated growth and may identify a high risk patient group for close surveillance.

Percutaneous image-guided biopsy of lung nodules in the assessment of disease activity in Wegener's granulomatosis

OBJECTIVE

In patients with known Wegener's granulomatosis (WG) and persistent chest radiographic abnormalities, assessment for disease activity is often difficult, prompting the need for histological diagnosis to determine appropriate treatment. Here we report the use of automated image-guided core needle biopsy of pulmonary lesions for the assessment of disease activity in WG, rather than for primary diagnosis.

METHODS

Image-guided percutaneous core needle biopsy was performed on five occasions in four patients with thoracic WG and persistent radiographic abnormalities of the chest. Clinical features, indication for biopsy, radiographic abnormalities and pathological findings were recorded.

RESULTS

Adequate pathological specimens were obtained, allowing exclusion of infection and tumour. Active chronic inflammation with or without vasculitis was demonstrated in each case, indicating the need for further immunosuppressive therapy. A small pneumothorax following biopsy in one case required no treatment. Follow-up chest imaging revealed a reduction in the extent of thoracic disease following therapy in all cases.

CONCLUSIONS

The safety and diagnostic accuracy of image-guided core biopsy of thoracic lesions makes it a useful tool in the assessment of disease activity in WG patients with persistent chest radiographic lesions.

Image-guided automated needle biopsy of 106 thoracic lesions: a retrospective review of diagnostic accuracy and complication rates

We reviewed the diagnostic accuracy and complication rates of transthoracic needle biopsy (TNB) with an automated 18-gauge core biopsy needle and gun, using either fluoroscopic or CT guidance. One hundred six lesions were biopsied in 103 patients between 1992 and 1998. Hard-copy images, imaging reports, pathology reports and clinical notes were reviewed. In 3 patients it was not possible to establish the lesion as either malignant or benign from the available follow-up, so these were removed from the analysis of diagnostic accuracy. Adequate samples for histological diagnosis were obtained in 104 of 106 (98%) biopsies. There were 75 of 85 (88%) true-positive core biopsies for malignant lesions and a specific cell type was identified in 70 of 85 (82%) cases. A specific histological diagnosis was obtained in 12 of 18 (66%) biopsies. There was a 19% rate of pneumothorax with only 2.4% requiring drainage. Minor haemoptysis occurred in 3.8% of procedures. The TNB technique with an automated core biopsy needle provides a high level of diagnostic accuracy, effectively distinguishes cell type in malignancy and provides a definite diagnosis in benign disease more frequently than fine needle aspiration (FNA). There is no increased complication rate compared with FNA.

Conversion of multiple solid testicular teratoma metastases to fatty and cystic liver masses following chemotherapy: CT evidence of "maturation"

Testicular germ cell tumour metastases may undergo "retroconversion" to mature differentiated teratoma following chemotherapy or irradiation. We report a patient with testicular germ cell liver metastases in whom computed tomography (CT) scans following chemotherapy demonstrated a reduction in CT attenuation of the liver lesions to that of cystic and fatty density. This is believed to represent CT evidence of liver metastasis "retroconversion", which offers the potential for non-invasive monitoring of histological progression.

Reproducibility of thoracic aortic diameter measurement using computed tomographic scans

OBJECTIVES

Decisions to recommend elective surgical repair of thoracic aortic aneurysms (TAA) may be based on size or expansion rate, which are used as indices of the risk of rupture. Measurement error may thus affect clinical decision-making. In order to evaluate the reproducibility of aortic diameter measurements of TAA, we assessed departmental inter- and intra-observer variability of measurement of pre-selected computed tomographic scan images of aneurysmal segments of the thoracic aorta.

METHODS

We compared measurements of minimum aortic diameter made by four observers in 50 pre-selected scans and at different times by two observers using a calliper method and a measurement tool within the scan. Differences in measured dimension were analysed using Wilcoxon's signed ranks test and the repeatability assessed using the method of Bland and Altman.

RESULTS

There were no significant inter-observer differences among three observers but there were significant differences between another observer and two other observers (P < 0.05). No significant intra-observer differences existed. The best intra-observer repeatability was 2.25 while the worst inter-observer repeatability was 4.37. The mean and maximum difference in measurement were +/-0.88 mm and +/-8.0 mm, respectively. Variability of measurement increased with aortic diameter.

CONCLUSIONS

Calliper measurement of TAA is an acceptable measurement method for surveillance of TAA but appears most accurate with a single observer. Increasing error is seen with increasing diameter which may compound error in estimation of expansion rate. Standardisation of technique is advisable for multiple observers and aortic units should adopt quality assurance protocols to minimise error.

A search for the evidence supporting community paediatric practice

AIM

Controversy exists regarding the evidence base of medicine. Estimates range from 20% to 80% in various specialties, but there have been no studies in paediatrics. The aim of this study was to ascertain the evidence base for community paediatrics.

METHODS

Twelve community paediatricians working in clinics and schools in Yorkshire, Manchester, Teesside, and Cheshire carried out a prospective review of consecutive clinical contacts. Evidence for diagnostic processes, prescribing, referrals, counselling/advice, and child health promotion was found by searching electronic databases. This information was critically appraised and a consensus was obtained regarding quality and whether it supported actions taken.

RESULTS

Two hundred and forty-seven consultations and 1149 clinical actions were performed. Good evidence was found from a randomised controlled trial or other appropriate study for 39.9% of the 629 actions studied; convincing non-experimental evidence for 7%; inconclusive evidence for 25.4%; evidence of ineffectiveness for 0.2%; and no evidence for 27.5%. Prescribing and child health promotion activities had the highest levels of quality evidence, and counselling/advice had the lowest.

CONCLUSIONS

An encouraging amount of evidence was found to support much of community paediatric practice. This study improved on previous research in other specialties because actions other than medications and surgery were included.

Staging of squamous cell carcinoma of the oral cavity and oropharynx: a comparison of MRI and CT in T- and N-staging

PURPOSE

Our purpose was to assess the accuracy of CT and MRI in staging of squamous cell carcinoma (SCC) of the oral cavity and oropharynx.

METHOD

Fifty-one episodes of primary and recurrent SCC were assessed with CT and MRI. The results were compared with pathological staging.

RESULTS

For staging primary tumours, the accuracy of MR was 77% and that of CT was 67%. For detecting recurrent tumour, the accuracy of MR was 89% and that of CT was 100%. For N-staging, nodal sites were divided, according to the site of the primary tumour, into high and low risk. Sensitivity for high risk sites was 60% for clinical assessment, 35% for CT, and 75% for MR. Negative predictive value (NPV) was < or = 50% for all methods. For low risk sites, the NPV was > or = 95% for all methods.

CONCLUSION

For T-staging, MR scanning is overall more accurate than CT. If degraded images and T1 tumours are excluded, the techniques are comparable. MR scanning is oversensitive for recurrent disease. For N-staging, all methods failed to detect small metastatic deposits.

Homograft replacement of thoraco-abdominal aorta for a leaking mycotic aneurysm

We report the case of a 67-year-old, diabetic patient who underwent antibiotic-preserved homograft replacement of a thoraco-abdominal segment of the aorta for leaking mycotic aneurysm. This was successful in eradicating the sepsis and no graft complication had occurred at (18 months). Follow-up with computed tomography (CT) scanning.