Generalizability of predictive models for Clostridioides difficile infection, severity and recurrence at an urban safety-net hospital

INTRODUCTION

Predictive models for Clostridioides difficile infection can identify high-risk patients and aid clinicians in preventing infection. Issues of generalizability regarding current predictive models have been acknowledged but, to the authors' knowledge, have never been quantified.

METHODS

C. difficile infection, severity and recurrence predictive models were created using multi-variate logistic regression through case-control sampling from an urban safety-net hospital. Models were validated using five-fold cross-validation, and inverse probability weights (IPW) based on two different catchment area definitions were used to improve external validity. Akaike Information Criterion (AIC), area under the receiver operating characteristic curve (AUROC), and sensitivity and specificity with bootstrapped confidence intervals (CI) were used to assess and compare model fit and performance.

RESULTS

Changes in performance before and after weighting were small across all models, although differences were more apparent after weighting the recurrence model (AUROC values of 0.78, 0.76 and 0.71 for the unweighted and two weighted models, respectively). Overall, the infection model performed the best (AUROC 0.82, 95% CI 0.78-0.85), followed by the recurrence model (AUROC 0.78, 95% CI 0.69-0.86) and then the severity model (AUROC 0.70, 95% CI 0.63-0.78).

CONCLUSIONS

The performance of the models after weighting did not change drastically, suggesting that the models predicting C. difficile infection, severity and recurrence may not be impacted by patient selection factors. However, other researchers may wish to consider addressing these catchment forces using IPW.

"Time Variable Earth Gravity Field Models From the First Spaceborne Laser Ranging Interferometer"

The Gravity Recovery and Climate Experiment Follow-On (GRACE-FO), launched May 22, 2018 and collecting science data since June 2018, is extending the 15-year data record of Earth mass change established by its predecessor GRACE mission (2002-2017). The GRACE-FO satellites carry onboard a novel technology demonstration instrument for intersatellite ranging, the Laser Ranging Interferometer (LRI), in addition to the microwave interferometer (MWI) carried on GRACE. The LRI has out-performed its in-orbit performance requirements both in terms of accuracy as well as the duration of tracking. Here, we compare and validate LRI-based gravity solutions for January 2019 to September 2020 against the MWI solutions. The comparison between the two sets of gravity solutions shows great similarities in general and nearly perfect consistency at a large hydrologic basin spatial scale (100,000 km² and above), commonly viewed as the spatial resolution established by GRACE. The comparison in the spectral domain shows differences at the higher degrees of the spectrum, with lower error in the zonal and near zonal terms for the LRI solutions. We conclude that the LRI observations can be used to recover time-varying gravity signals to at least the level of accuracy established by the MWI-based solutions. This is a promising finding, especially when considering the benefits of using the LRI over the MWI, such as the great stability of the instrument and the low occurrence of instrument reboot events.

Historical Housing Discrimination, Indicators of Disinvestment, and Breast Cancer Outcomes Nearly a Century Later

Purpose: We investigated associations between 1930's era records of mortgage lending discrimination (i.e., “redlining”), a present-day indicator of disinvestment (i.e., residential physical disorder), and tumor clinicopathologic features (stage, grade, subtype) and survival among women diagnosed with breast cancer in New Jersey. Methods: Historical, Home Owners' Loan Corporation (HOLC) data were recently geocoded from the University of Richmond's Digital Scholarship Lab. Risk grades of ‘A'/‘Best', ‘B'/‘Still Desirable', ‘C'/‘Definitely Declining', and ‘D'/‘Hazardous' – available for six metropolitan areas of New Jersey – were collapsed into C/D (‘redlined') and A/B (‘not redlined') for analyses. Sociodemographics (age, race, ethnicity, geocoded residential address, date of diagnosis), tumor features (stage at diagnosis, grade, subtype), and vital status (cause and date of death) were ascertained from the New Jersey State Cancer Registry for all primary, histologically-confirmed, invasive breast cancer cases diagnosed between 2008 and 2017, among female residents of a HOLC-graded area, who were ≥ 20 years at diagnosis (N = 11,980). Residential physical disorder was estimated based on residential address at diagnosis using spatial prediction models of virtually audited Google Street View scenes of 6,132 locations. Logistic regression models of tumor features and accelerated failure time models of survival time to BrCa-specific death (follow-up through 2019) were built to investigate associations with redlining and physical disorder, while controlling for covariates. Results: There were 1,215 BrCa-specific deaths, a median follow-up time of 5.1 years, and a 5-year survival of 89.6%. Living in a historically redlined neighborhood was associated with higher odds of late-stage and high-grade tumors. Living in a non-redlined neighborhood was associated with a 47.5% (95% CI: 20.1, 79.8) longer survival time in low physical disorder areas. This survival benefit decreased as physical disorder increased. Conclusions: Historical racial housing discrimination might interact with present-day measures of disinvestment to influence BrCa survival. Future studies should collect more comprehensive data including potential confounders and residential history.

Evaluation as Disintegrant, Acetone-dehydrated Pre-Gelatinized Starch of Arthocarpus altilis Fruits in Oral paracetamol Tablets

Introduction: Modifying natural polymers have imparted desirable properties making them suitable as pharmaceutical additives. Aim: This research work was to prepare pre-gelatinized breadfruit starch using acetone to reduce drying time and energy expended. The modified starch was evaluated as a disintegrant in paracetamol oral compacts. Methods: Starch from unripe mature bread fruit was pre-gelatinized, precipitated with acetone to reduce drying time. Native and pre-gelatinized starches were characterized for micromeritics, compatibility studies with test drug using Fourier Transform Infra-Red (FT-IR) and water interaction properties (viscosity, swelling power and hydration capacity). Paracetamol granules formed by wet granulation were compacted incorporating starches as disintegrant intragranularly, extragranularly and combining both methods. Disintegration and dissolution studies done. Results: Pre-gelatinization did not alter the native starch chemically and their pH were within pharmaceutical limits. The disintegration efficiency ratio (DER) for the P2 and P3 (tablet batches with pre-gelatinized starches) compared favourably with that of corn starch. Also, the dissolution kinetics of the breadfruit starches followed the Hixson Crowel’s model while that of reference corn starch was best described by the Higuchi kinetic model. Conclusion: Breadfruit starch is edible and the properties of its pre-gelatinized form as a disintegrant compares favourably with corn starch BP. It could be an good alternative as pharmaceutical excipient.

Health professional mobility and the Global Code of Practice: joint EUROSTAT/OECD/WHO survey data

Background

This study assesses the impact and continuing relevance of the Code of Practice on the International Recruitment of Health Personnel in the WHO Europe region by analysing trends over time in intra- and inter-regional health worker mobility.

Methods

Data from the joint EUROSTAT/OECD/WHO questionnaire are analysed to determine 1) the proportion of foreign-born and foreign-trained doctors and nurses working in WHO Europe Member States, 2) trends in health workforce mobility over time by country of origin and destination, and 3) how the Global Code has impacted mobility patterns.

Results

The size of the foreign-trained health workforce in Europe varies widely, with foreign-trained doctors comprising over a quarter of the workforce in Norway, Switzerland and the UK, but below 2% in Estonia and Serbia. While annual in-flows across the region have been stable since 2009, the share of foreign-trained doctors and nurses have both increased by over 30%. Mobility between The Commonwealth of Independent States has remained steady, but an increase in East-West and South-North migration is observed, driven by European Union expansion in 2004 and the economic crisis. Migration of health workers into Europe from developing countries covered by the Code has fluctuated, with increased numbers seen from some origin countries (e.g. Nigeria, Pakistan). Some Western countries remain reliant on a foreign-trained health workforce. This contributes to a high outward flow of health professionals from other European countries and creates challenges for sustainable workforce development.

Conclusions

The Global Code remains highly relevant, but other factors have more impact on migration flows, such as free movement in the EU. Health workforce mobility data can be improved to support a 'whole of workforce' approach to policy and planning by including more professional groups, and by adding qualitative indicators, e.g. individual perceptions and intention to leave.

Panel: Care4Care: what is it about the migrant care workforce and how to improve inclusion?

A round table comprising three panelists will discuss the topic from different perspectives. Gabrielle Jacob, WHO: The WHO Global Code of Practice on the International Recruitment of Health Personnel. How far have we come, where are we now and what’s next?Natasha Azzopardi-Muscat, EUPHA President: The role of public health in raising awareness on the contribution of migrant workers to health systemsScott L Greer, European Observatory on Health Systems and Policies: Governance4Care of the migrant care workforce: what matters?

Adverse childhood experiences: Basics for the paediatrician

In 1998, the Centers for Disease Control and Prevention Adverse Childhood Experiences study established the profound effects of early childhood adversity on life course health. The burden of cumulative adversities can affect gene expression, immune system development and condition stress response. A scientific framework provides explanation for numerous childhood and adult health problems and high-risk behaviours that originate in early life. In our review, we discuss adverse childhood experiences, toxic stress, the neurobiological basis and multigenerational and epigenetic transmission of trauma and recognized health implications. Further, we outline building resilience, screening in the clinical setting, primary care interventions, applying trauma-informed care and future directions. We foresee that enhancing knowledge of the far-reaching effects of adverse childhood events will facilitate mitigation of toxic stress, promote child and family resilience and optimize life course health trajectories.

Effect of oral administration of meloxicam prior to transport on inflammatory mediators and leukoctye function of cattle at feedlot arrival

OBJECTIVE To investigate the effects of meloxicam administration before long-distance transport on inflammatory mediators and leukocyte function of cattle at feedlot arrival. ANIMALS 60 healthy yearling beef steers. PROCEDURES Single-source steers were assigned to a transported (n = 40) or nontransported (20) group. Then, half of the steers within each group were assigned to receive meloxicam (1 mg/kg, PO) or a lactose placebo (1 bolus/steer, PO). All steers were transported approximately 1,300 km overnight to a feedlot; however, the nontransported group was moved before treatment (meloxicam or placebo) administration and allowed a 17-day acclimation period, whereas the transported group was moved immediately after treatment administration on day -1. Blood samples for measurement of inflammatory mediators and leukocyte function were collected from all steers on days -1, 0, and 3. RESULTS For steers that received meloxicam, mean plasma meloxicam concentration for the transported group was significantly greater than that for the nontransported group on day 0. For steers that received the placebo, mean haptoglobin-matrix metalloproteinase-9 complex for the transported group was significantly greater than that for the nontransported group on day 0. Mean haptoglobin concentration, neutrophil L-selectin intensity, and polymorphonuclear leukocyte count for the transported group were significantly greater than those for the nontransported group. Mean substance P concentration for nontransported steers that received meloxicam was significantly lower than that for the other 3 treatment groups. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated meloxicam administration to healthy steers immediately before long-distance transport did not significantly mitigate the effects of transport-induced stress on leukocyte function or inflammatory markers.

Literacy promotion by health care professionals: A comprehensive biomedical and psychosocial approach

Literacy is the ability to read, write and understand print. Proficiency in literacy is fundamental to social inclusion and strongly linked to health outcomes. Thus, improving literacy is important for lifelong health promotion. Poverty, inadequate hearing, speech and vision and learning disabilities may challenge literacy development. In our review, we explore these topics and suggest recommendations to: Mitigate the Effects of Poverty, Access Comprehensive Medical Assessments, Promote Early Childhood Education and Advocate for Early Intervention and Remediation Programs.

Iron retention in iron-fortified rice and use of iron-fortified rice to treat women with iron deficiency: A pilot study

Objectives

1. Evaluate the effect of washing and cooking iron-fortified rice on iron retention and bioavailability. 2. Evaluate the effect of iron-fortified rice on women with iron deficiency anemia

Methods

1. Iron-fortified rice (18 mg/100 g as FeSO₄) was cooked in Baton Rouge, Louisiana (C), rinsed and cooked (RC), fried and cooked (FC), cooked with extra water (CW), or soaked and cooked with extra water (SCW), and iron retention was determined. 2. Rice samples were cooked in Kampala, Uganda in a lab (C-Uganda) and households using traditional cooking method (TC-Uganda) and iron retention were determined. 3. Seventeen women with iron deficiency (low iron and/or low ferritin) anemia were randomized to 100 g/d of rice (two cooked 0.75 cup servings) for two weeks containing 18 mg/d iron (supplemented) or 0.5 mg/d iron (un-supplemented). Hemoglobin and hematocrit were evaluated at baseline and 2 weeks with other measures of iron metabolism.

Results

1. Iron retention, from highest to lowest, was (C), (RC), (FC), (C-Uganda), (CW), (SCW) and (TC-Uganda). 2. Seventeen women were randomized and 15 completed the study (hemoglobin 10.6 ± 1.6 g, hematocrit 33.7 ± 4.1%), 9 in the iron-fortified rice group and 6 in the un-fortified rice group. The iron-fortified group had a greater increase in hemoglobin (0.82 g, p = 0.0035) and Hematocrit (1.83%, p = 0.0248) with directional differences in other measures of iron metabolism favoring the iron-fortified group.

Conclusions

Iron-fortified rice increased hemoglobin and hematocrit in women with iron-deficient anemia. Iron deficiency and anemia are widespread in Southeast Asia and Africa and undermine development in these regions.

•

Iron deficiency is prevalent engendering poor health and cognitive development.

•

Iron deficiency can be treated effectively with iron fortification.

•

Iron rinses in a rice-based diet have leached reducing fortification.

•

An iron rinse resistant leaching during cooking is described.

•

The leach-resistant iron rinse improved iron deficiency anemia in a clinical trial.

Comparison of innate immune agonists for induction of tracheal antimicrobial peptide gene expression in tracheal epithelial cells of cattle

Bovine respiratory disease is a complex of bacterial and viral infections of economic and welfare importance to the beef industry. Although tracheal antimicrobial peptide (TAP) has microbicidal activity against bacterial pathogens causing bovine respiratory disease, risk factors for bovine respiratory disease including BVDV and stress (glucocorticoids) have been shown to inhibit the induced expression of this gene. Lipopolysaccharide is known to stimulate TAP gene expression, but the maximum effect is only observed after 16 h of stimulation. The present study investigated other agonists of TAP gene expression in primary cultures of bovine tracheal epithelial cells. PCR analysis of unstimulated tracheal epithelial cells, tracheal tissue and lung tissue each showed mRNA expression for Toll-like receptors (TLRs) 1–10. Quantitative RT-PCR analysis showed that Pam3CSK4 (an agonist of TLR1/2) and interleukin (IL)-17A significantly induced TAP gene expression in tracheal epithelial cells after only 4–8 h of stimulation. Flagellin (a TLR5 agonist), lipopolysaccharide and interferon-α also had stimulatory effects, but little or no response was found with class B CpG ODN 2007 (TLR9 agonist) or lipoteichoic acid (TLR2 agonist). The use of combined agonists had little or no enhancing effect above that of single agonists. Thus, Pam3CSK4, IL-17A and lipopolysaccharide rapidly and significantly induce TAP gene expression, suggesting that these stimulatory pathways may be of value for enhancing innate immunity in feedlot cattle at times of susceptibility to disease.

Occurrence of Phyllostomus elongatus (Geoffroy St.-Hilaire, 1810) (Chiroptera, Phyllostomidae) in the Cerrado of Tocantins and a compilation of its Brazilian distribution

The lesser spear-nosed bat, Phyllostomus elongatus, is endemic of South America and in Brazil this species is recorded in Amazon, Atlantic Forest, Cerrado, and Pantanal. Here, we present a new record for P. elongatus in the savanna of central Brazil, known as the Cerrado. In January 2012, five individuals of P. elongatus were captured and recorded in a limestone cave in the Aurora do Tocantins county, Tocantins State. Phyllostomus elongatus has already been registered in 32 locations and 14 Brazilian states, and their records appear to be associated with humid habitats and forested areas.

Precise experimental investigation of eigenmodes in a planar ion crystal

The accurate characterization of eigenmodes and eigenfrequencies of two-dimensional ion crystals provides the foundation for the use of such structures for quantum simulation purposes. We present a combined experimental and theoretical study of two-dimensional ion crystals. We demonstrate that standard pseudopotential theory accurately predicts the positions of the ions and the location of structural transitions between different crystal configurations. However, pseudopotential theory is insufficient to determine eigenfrequencies of the two-dimensional ion crystals accurately but shows significant deviations from the experimental data obtained from resolved sideband spectroscopy. Agreement at the level of 2.5×10(-3) is found with the full time-dependent Coulomb theory using the Floquet-Lyapunov approach and the effect is understood from the dynamics of two-dimensional ion crystals in the Paul trap. The results represent initial steps towards an exploitation of these structures for quantum simulation schemes.

New record of Furipterus horrens (Cuvier, 1828) (Mammalia, Chiroptera) from the Cerrado of Tocantins state with a compilation of the known distribution within Brazil

Furipterus horrens is an insectivorous bat that occurs from Costa Rica to southeastern Bolivia and southern Brazil, with records in the Amazon, Caatinga, Cerrado and Atlantic Forest biomes. Despite this broad distributional range across South America, the species is currently known from few localities, and its habitat preferences are poorly known. We report the first record of Furipterus horrens for the Tocantins state, northern Brazil, based on four individuals collected in two caves surrounded by Neotropical savanna (Cerrado) in the Aurora do Tocantins municipality.

Single-ion heat engine at maximum power

We propose an experimental scheme to realize a nanoheat engine with a single ion. An Otto cycle may be implemented by confining the ion in a linear Paul trap with tapered geometry and coupling it to engineered laser reservoirs. The quantum efficiency at maximum power is analytically determined in various regimes. Moreover, Monte Carlo simulations of the engine are performed that demonstrate its feasibility and its ability to operate at a maximum efficiency of 30% under realistic conditions.

Symptomatic and quality of life response to tolterodine in subgroups of men with overactive bladder symptoms and presumed non-obstructive benign prostatic hyperplasia

OBJECTIVES

To investigate the symptomatic and quality of life (QoL) response to treatment with tolterodine extended release (ER) in subgroups of male patients with Overactive Bladder Syndrome (OAB) and LUTS suggestive of non-obstructive benign prostatic hyperplasia (BPH) according to age, symptom severity, diabetes mellitus status, and concomitant treatment for LUTS.

METHODS

Patients treated with tolterodine ER 4 mg/day for OAB symptoms, alone or added to unsuccessful alpha-blocker treatment of > or =6 weeks duration, and presumed non-obstructive BPH (Q (max) > or = 15 ml/s) were observed for 12 weeks in a non-interventional study. Patients completed the International Prostate Symptom Score (IPSS) and Overactive Bladder Questionnaire (OAB-q) at baseline and after 12 weeks.

RESULTS

52.4% of 741 patients were aged < or =65 years; 4, 64, and 32% had mild, moderate, and severe symptoms, respectively, according to IPSS; 14% had diabetes mellitus, and in 42% tolterodine was added to alpha blockers. In the various subgroups, mean IPSS total scores improved by 2.8-11.1 points, IPSS QoL scores by 1.8-2.4 points, and all OAB-q subscores by more than 14 points. Only IPSS and OAB-q baseline scores had a relevant impact on changes during treatment, benefits were greatest in patients with more severe symptoms and bother.

CONCLUSIONS

In men with symptoms of OAB and LUTS suggestive of non-obstructive BPH of all IPSS severity classes, aged < or =65 years or above, with or without concomitant diabetes or alpha-blockers, symptoms and QoL improved markedly during treatment with tolterodine ER.

Hydration does not prevent orthostatic hypercoagulability

Prolonged standing activates the coagulation cascade by the activation of endothelial cells, and probably the haemoconcentration effect contributes to this "orthostatic hypercoagulability". It was the objective of this study to assess whether rehydration (haemodilution) prevents or attenuates orthostatic induced thrombin formation. Twelve healthy young subjects were studied during two separate visits. Haematocrit (Hct), total plasma protein, coagulation profile tests, including endothelial activation related factors, and protein C global pathway were studied at rest supine, and while standing at 15 and 30 minutes (min). During the second visit the study was repeated after intravenous 1.5 liter 0.9% saline. While in supine posture, intravenous rehydration resulted in Hct reduction of 14.2 +/- 2% (haemodilution), a decrease of 11.5 +/- 1.3% in total protein, as well as a significant dilutional effect on most of the coagulation parameters. Still standing for 30 min, with and without rehydration caused a comparable increase in tissue factor by 49.83 +/- 13.6%, and 35.34 +/- 8.55% (p>0.05), respectively and in von Willebrand factor (vWF) 9.5 +/- 2.4% and 13.59 +/- 2.17% (p>0.05), respectively. At 30 min standing, after intravenous rehydration, factor V and VIII activities, and fibrinogen rose by 22 +/- 1.9%, 31.2 +/- 6.2%, 9.15 +/- 2.64%, (p<0.002 for all), respectively. Prothrombin fragments 1+2 elevated by 84.84 +/- 15.3% (p<0.001). Comparable results were obtained with and without the rehydration. Additionally, protein C assay results decreased by 19.4 +/-1.7% and 17.5 +/- 2.6%, with and without fluids (p<0.05 for both). In healthy subjects, intravenous prophylactic rehydration with normal saline resulted in a haemodilution of all the coagulation parameters, but did neither attenuate nor prevent the orthostatic hypercoagulability.

CA 19-9 to differentiate benign and malignant masses in chronic pancreatitis: is there any benefit?

BACKGROUND

The role of the tumor marker CA 19-9 in differentiating benign from malignant masses in chronic pancreatitis has not been extensively studied.

AIM

This study aims at assessing the accuracy of CA 19-9 in differentiating inflammatory head masses in chronic pancreatitis from superimposed carcinomas on chronic pancreatitis.

METHODS

The data of 84 consecutive patients who had mass lesions in chronic pancreatitis were analyzed to determine the sensitivity, specificity and predictive values at cut-off values of 37, 100, 200 and 300 U/mL. Receiver operating characteristic (ROC) curves were used to assess the sensitivity and specificity.

RESULTS

There were 50 benign masses and 34 malignancies. The overall sensitivity and specificity of CA 19-9 for cancer was 68% and 70%, respectively. There was a higher positivity of CA 19-9 in cancers than in benign masses (23/34; 68% versus 15/50; 30%, P<0.01) with cut-off values of 37 U/mL. Higher positivity rates were obtained in cancers using other cut-off values such as 100, 200 and 300 U/mL. Values over 300 U/mL were 100% specific for malignancy, but occurred in only 5 (of whom had distant metastases) of 34 patients.

CONCLUSION

CA 19-9 level in excess of 300 U/mL in mass lesions in chronic pancreatitis was always indicative of malignancy.

Variations in care for operable breast cancer and outcomes between rural and metropolitan centers in Australia

e11517

Background: The causes of variation in breast cancer survival remain uncertain. Care provided to women with breast cancer may vary in relation to both the care setting and characteristics of the clinicians. Methods: To compare the outcomes of management of breast cancer treated in rural and metropolitan centers, a prospective audit of breast cancer in a region of Australia was undertaken. Over a nine-year observation period 2102 women with invasive breast cancer underwent potentially curative surgery. Treatments received, including systemic adjuvant therapy, were compared to contemporary guideline-based indicators. Breast cancer specific mortality was analyzed using Cox proportional hazards models. Results: Overall agreement of received treatment with the indicators was high. Women treated within rural centers were, however, much less likely to receive post operative radiotherapy after breast conserving surgery (86.4% vs. 97.0%; p<0.001). The overall recurrence rate, including distant metastases, for all women was 11.6%. Local or regional recurrence was more frequent in rural centers compared with metropolitan centers (4.1% versus 2.1%; p=0.05). Breast cancer mortality was increased in women with large tumors, high grade disease, and positive axillary lymph nodes. Non-compliance with treatment guidelines was associated with a trend towards increased breast cancer mortality (HR=1.55; p=0.056). After adjustment for these factors and patient age, undergoing surgery in rural centers was associated with increased breast cancer mortality (HR=1.84; p<0.001). Although women treated in rural centers were older, their cancer stage and tumour characteristics were similar to those of women treated in metropolitan centers. Non-cancer related mortality was elevated in women treated in rural centers compared with women travelling to a city for surgery (HR=2.08; p=0.005). Conclusions: Increased non-cancer related mortality in rural treated women suggests increased medical co-morbidity in this group, which may have influenced treatment choices and outcomes. Low rates of adjuvant radiotherapy were noted for women treated in rural centers. In addition, clinically significant differences in outcome, including breast cancer mortality, were observed.

No significant financial relationships to disclose.

Phase I study results of nanomolecular liposomal annamycin in refractory ALL

7066

Background: There continues to be no effective second-line therapy for refractory AML or ALL and the cure rate with current therapy has not significantly improved in decades. The first-line therapy for adult AML has remained the same 7 + 3 that it was a generation ago. Annamycin was specifically synthesized to overcome MDR and to have little to no cardiac toxicity when given as a nanomolecular liposomal entity. Methods: We performed a phase I multi-center, open-label, MTD study of nanomolecular liposomal annamycin in patients with refractory ALL. The secondary objective was to study the MDR-1 encoded P-1u70 glycoprotein expression in correlation with CD34 expression and MDR-1 MRP mRNA levels in refractory ALL patients before and after receiving liposomal annamycin. Results: Thirty patients were enrolled on the study. The MTD was determined to be 150 mg/m2/day for 3 days. Eight of the patients completed 1 cycle of the 3 days of treatment. Of these 8 subjects, 5 (62%) had an efficacy signal. All 5 completely cleared circulating blasts. Three subjects also cleared bone marrow blasts. Of these 3, 1 went on to a successful bone marrow transplant. The other 2 had tumor lysis syndrome and unfortunately expired. Other than the tumor lysis syndromes, there was only 1 SAE definitely related to the study drug which was a grade 3 mucositis but there were also 3 other SAEs of grade 3 or 4 mucositis probably related to the study drug which comprised the MTD determination. There were no reports of cardiac toxicity. Conclusions: Nanomolecular liposomal annamycin appears to be effective through its innate resistance to MDR even as a single agent in refractory adult ALL. We are now testing it in a phase I study in children and young adults with refractory ALL or AML.

[Table: see text]

The effect of rotational malalignment on X-rays of the wrist

This study evaluates the effect of rotational malposition of the wrist on measured radiographic parameters of the distal radius and carpus. Ten wrists from five healthy volunteers were imaged in varying degrees of rotation. The wrists were placed in a custom, calibrated jig and images were taken in 5 degrees increments to a maximum pronation and supination of 20 degrees . The results demonstrate the following: a steady decrease in the scapholunate and radioscaphoid angles with extremes of supination; an increase in palmar tilt with supination and a decrease in palmar tilt with pronation. The palmar tilt varied from -4 degrees to 15 degrees and the scapholunate angle ranged from 48 degrees to 29 degrees at the extremes of rotation. These results demonstrate how malrotation in X-ray positioning can have a significant effect on the apparent alignment of the distal radius and carpal bones. Measurements taken from poor X-rays typically fall outside the normal range and could adversely effect treatment decisions.

Safety and efficacy of tolterodine extended release in men with overactive bladder symptoms and presumed non-obstructive benign prostatic hyperplasia

Patients with presumed non-obstructive BPH (Q (max )>or= 15 ml/s) treated with tolterodine ER 4 mg/day for OAB symptoms, alone or added to unsuccessful alpha-blocker treatment of >or=6 weeks duration, were observed for 12 weeks in a non-interventional study to generate real-life efficacy and safety data. Patients completed the IPSS, the OAB-q and a 2-day micturition diary at baseline and 12 weeks. PVR was determined sonographically. Seven hundred and forty one patients were analysed. Mean PVR did not increase (25.4 +/- 26.5 vs. 29.3 +/- 30.9 ml at baseline). AUR requiring catheterization occurred in two patients, acute UTI in four patients. Median IPSS total scores decreased from 17 to 10, IPSS QoL scores from 4 to 2, OAB-q symptom bother scores from 50.0 to 22.5 and OAB-q HRQL scores increased from 59.2 to 81.6. In men with OAB symptoms and presumed non-obstructive BPH, tolterodine ER provided considerable symptomatic and QoL improvements with a low risk of AUR, acute UTI, or increased PVR.

Intussusception due to ileal metastases from renal cell carcinoma

Small bowel secondaries from renal cell carcinoma are rare. Patients usually present with features of intestinal obstruction or GI bleeding. Management should be aggressive since metastasectomy can improve the quality of life and survival.

Multidisciplinary approach in the long-term management of intrahepatic stones: Indian experience

BACKGROUND

Intrahepatic stones, though common in East Asia, are uncommon in India. There is paucity of data from India regarding the treatment and long-term outcome of patients with intrahepatic stones.

METHODS

We retrospectively analyzed medical records of 35 patients with intrahepatic stones who had been treated surgically. Endoscopic biliary drainage had been used in patients who presented with acute cholangitis. Intraoperative stone clearance was confirmed by choledochoscopy and intraoperative cholangiography. Outcome of surgery, frequency and subsequent management of recurrent intrahepatic stones, and factors associated with stone recurrence and cholangitis were analyzed.

RESULTS

Twenty-one (60%) patients had bilobar disease. Eight patients underwent hepatectomy and 16 hepatico-jejunostomy with access loop; 12 of these were jejuno-duodenal anastomoses. Postoperative morbidity was observed in 10 patients (29%). Recurrence of stones occurred in 12 patients (34%) and cholangitis in 9 patients (26%). Presence of bilobar disease and associated biliary strictures were associated with recurrent cholangitis (p< 0.05). Two patients (6%) required re-operation for recurrent cholangitis. Complete removal of recurrent stones using conventional endoscope was possible through jejuno-duodenostomy in all 5 cases who had this type of access loop construction.

CONCLUSION

Surgical treatment for intrahepatic stones depends on the site of involvement. Construction of a jejuno-duodenal access loop in patients with bilobar disease and intrahepatic strictures is helpful in facilitating postoperative stone clearance. A multidisciplinary approach is beneficial especially when the disease is bilobar and recurrent in type.

Are some cases of infected pancreatic necrosis treatable without intervention?

BACKGROUND

Infected pancreatic necrosis is considered an absolute indication for interventional management such as percutaneous drainage or surgery. The presence of retroperitoneal air is a sign of anaerobic sepsis.

METHOD

A retrospective review of case records of patients presenting with severe acute pancreatitis and pancreatic necrosis was performed to identify cases in whom conservative treatment was followed by a satisfactory outcome.

RESULTS

Four patients were identified over a 3-year period who had pancreatic necrosis and retroperitoneal air; they were treated with antibiotics and intensive care, and they improved without any interventional treatment.

CONCLUSIONS

Some patients with infected pancreatic necrosis are treatable medically. The clinical status of the patients may well be a more important factor governing the choice of the treatment approach than bacteriological findings of infection alone.

Port-site tuberculosis after laparoscopy: report of eight cases

In light of the explosive increase in laparoscopic surgery, there is concern about the effectiveness of sterilizing reusable laparoscopic instruments by immersion in 2% glutaraldehyde. This article describes the clinical features of eight patients who presented with biopsy-proven tuberculosis at the port-site unassociated with other clinical features of tuberculosis. Three of the eight patients had positive cultures for Mycobacterium tuberculosis. The port-site sinuses healed with antituberculous chemotherapy. There is conflicting information in the literature regarding the effectiveness of a 20-min instrument soak in 2% glutaraldehyde to clear M. tuberculosis. In light of the preceding information, the current practice of glutaraldehyde disinfection for reusable laparoscopes needs to be reexamined.

Case report: gastroduodenal intussusception of a gastrointestinal stromal tumour

Gastrointestinal stromal tumours (GISTs), previously termed leiomyomas and leiomyosarcomas are relatively common tumours of the gastrointestinal tract, most commonly found in the stomach. Most GISTs are asymptomatic but may cause abdominal pain or bleeding from ulceration of the overlying mucosa. A rare case of gastroduodenal intussusception of a large gastric stromal tumour, which presented with intermittent abdominal pain and gastric outlet obstruction, is reported. Pre-operative diagnosis was made on abdominal CT and confirmed at laparotomy. Pre-operative diagnostic difficulties and management are discussed.