Radiological characteristics of invasive micropapillary carcinoma of the breast

AIM

To analyse the various imaging features of invasive micropapillary carcinoma (IMPC), a distinct variant of breast cancer, by mammography, ultrasound, and contrast-enhanced mammography.

MATERIALS AND METHODS

This study included 68 female patients with histopathologically proven invasive micropapillary carcinoma who underwent mammography, ultrasound, and contrast-enhanced mammography examinations. The findings encountered by each imaging tool were analysed using the Breast Imaging Reporting and Data System (BI-RADS) lexicon.

RESULTS

In this retrospective study, 64.7% of cases were of the pure form of IMPC. Most of the cases showed an aggressive clinical course, with lymphovascular invasion noted in 76.5% of cases, while 60.3% of cases showed associated pathological lymphadenopathy. The N3 stage was reported in 25% of cases. On analysing the mammographic and ultrasound imaging findings, a significant association between irregular shape and a non-circumscribed margin with IMPC was found. Associated calcification was noted in 47% of cases. Pathological enhancement of moderate or marked conspicuity was noted in cases that underwent contrast-enhanced mammography, with the most commonly encountered finding being enhancing irregular and non-circumscribed masses.

CONCLUSION

The mammographic and ultrasound imaging features of IMPC are indistinguishable from other aggressive types of breast cancer. At contrast-enhanced mammography examination, pathological enhancement of moderate to marked conspicuity was shown in all cases. The observed strong association of IMPC with lymphovascular invasion and lymph node metastasis with higher nodal stage in this study mandate meticulous sonographic examination of the axilla, as well as the infra, and supraclavicular regions if pathological axillary lymphadenopathy was noted.

The present and future disease burden of hepatitis C virus infections with today's treatment paradigm - volume 3

The total number, morbidity and mortality attributed to viraemic hepatitis C virus (HCV) infections change over time making it difficult to compare reported estimates from different years. Models were developed for 15 countries to quantify and characterize the viraemic population and forecast the changes in the infected population and the corresponding disease burden from 2014 to 2030. With the exception of Iceland, Iran, Latvia and Pakistan, the total number of viraemic HCV infections is expected to decline from 2014 to 2030, but the associated morbidity and mortality are expected to increase in all countries except for Japan and South Korea. In the latter two countries, mortality due to an ageing population will drive down prevalence, morbidity and mortality. On the other hand, both countries have already experienced a rapid increase in HCV-related mortality and morbidity. HCV-related morbidity and mortality are projected to increase between 2014 and 2030 in all other countries as result of an ageing HCV-infected population. Thus, although the total number of HCV countries is expected to decline in most countries studied, the associated disease burden is expected to increase. The current treatment paradigm is inadequate if large reductions in HCV-related morbidity and mortality are to be achieved.

Strategies to manage hepatitis C virus infection disease burden - volume 3

The hepatitis C virus (HCV) epidemic was forecasted through 2030 for 15 countries in Europe, the Middle East and Asia, and the relative impact of two scenarios was considered: increased treatment efficacy while holding the annual number of treated patients constant and increased treatment efficacy and an increased annual number of treated patients. Increasing levels of diagnosis and treatment, in combination with improved treatment efficacy, were critical for achieving substantial reductions in disease burden. A 90% reduction in total HCV infections within 15 years is feasible in most countries studied, but it required a coordinated effort to introduce harm reduction programmes to reduce new infections, screening to identify those already infected and treatment with high cure rate therapies. This suggests that increased capacity for screening and treatment will be critical in many countries. Birth cohort screening is a helpful tool for maximizing resources. Among European countries, the majority of patients were born between 1940 and 1985. A wider range of birth cohorts was seen in the Middle East and Asia (between 1925 and 1995).

Historical epidemiology of hepatitis C virus (HCV) in select countries - volume 3

Detailed, country-specific epidemiological data are needed to characterize the burden of chronic hepatitis C virus (HCV) infection around the world. With new treatment options available, policy makers and public health officials must reconsider national strategies for infection control. In this study of 15 countries, published and unpublished data on HCV prevalence, viraemia, genotype, age and gender distribution, liver transplants and diagnosis and treatment rates were gathered from the literature and validated by expert consensus in each country. Viraemic prevalence in this study ranged from 0.2% in Iran and Lebanon to 4.2% in Pakistan. The largest viraemic populations were in Pakistan (7 001 000 cases) and Indonesia (3 187 000 cases). Injection drug use (IDU) and a historically unsafe blood supply were major risk factors in most countries. Diagnosis, treatment and liver transplant rates varied widely between countries. However, comparison across countries was difficult as the number of cases changes over time. Access to reliable data on measures such as these is critical for the development of future strategies to manage the disease burden.

Aided air conduction threshold as a predictor of cochlear reserve in otosclerosis patients

Otosclerosis classically presents with conductive deafness. However, mainly in older patients or those with a progressive (active) form of this disease, it presents with elevated bone conduction (BC) thresholds. In many cases, an elevation in the BC threshold during otosclerosis is not a true indicator of 'cochlear reserve' and this apparent loss can be corrected by surgery. It is generally accepted that in those patients, elevated BC thresholds are not due to pure sensorineural hearing loss but to the Carhart effect. Speech discrimination tests are routinely done, and the results of these tests determine if a patient is a good candidate for surgery. In most institutions, those with poor speech discrimination scores are considered to be poor candidates due to inadequate cochlear reserve. Using hearing-aid-assisted pure-tone audiometry, we developed an accurate method to identify suitable candidates for surgery among the patients with elevated BC thresholds. This method is meant to complement speech discrimination tests in predicting the success of surgery in those patients. Different variables render speech discrimination tests unreliable in many patients. The rationale behind the current study was the lack of an easy and accurate clinical method to determine if a patient has a good cochlear reserve, and to predict the postoperative hearing threshold outcome.

Carotenoids found in Bacillus

AIMS

To identify the diversity of pigmented aerobic spore formers found in the environment and to characterize the chemical nature of this pigmentation.

MATERIALS AND RESULTS

Sampling of heat-resistant bacterial counts from soil, sea water and the human gastrointestinal tract. Phylogenetic profiling using analysis of 16S rRNA sequences to define species. Pigment profiling using high-performance liquid chromatography-photo diode array analysis.

CONCLUSIONS

The most commonly found pigments were yellow, orange and pink. Isolates were nearly always members of the Bacillus genus and in most cases were related with known species such as Bacillus marisflavi, Bacillus indicus, Bacillus firmus, Bacillus altitudinis and Bacillus safensis. Three types of carotenoids were found with absorption maxima at 455, 467 and 492 nm, corresponding to the visible colours yellow, orange and pink, respectively. Although the presence of other carotenoids cannot be ruled out, these three predominant carotenoids appear to account for the pigments obtained in most pigmented bacilli, and our analysis reveals the existence of a C30 biosynthetic pathway. Interestingly, we report the presence of a water-soluble pigment that may also be a carotenoid. The function of carotenoids is photoprotection, and carotenoid-containing spores exhibited significantly higher levels of resistance to UV radiation than non-carotenoid-containing Bacillus species.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrates that pigmented bacilli are ubiquitous and contain new carotenoid biosynthetic pathways that may have industrial importance.

Windows 99: a source of suburban pediatric trauma

BACKGROUND

Falls from windows in urban areas cause a significant number of pediatric injuries. Window falls have not been well described in the nonurban setting. We describe the epidemiology of window falls from residential homes among pediatric patients at a suburban Level I trauma center.

METHODS

A review of patients admitted from January 1991 through November 1999 to a center serving a rapidly growing suburban area was performed.

RESULTS

A total of 2,322 children, ages 0-14 years, were admitted during the study period. Falls comprised 41% of these admissions, and 11% of falls were from windows, greater than twice the national average. More than 39% of children who fell from windows were admitted directly to the intensive care unit. Overall mortality rate was 4%. Ages 0 to 4 years comprised the largest percentage (83%), and all children who died were in this age group. Children < or = 4 years were more likely to have an Abbreviated Injury Score > or = 2 (head injury) than those ages 10 to 14 years (p = 0.032). More than 31% of all children injured in window falls seen at the study institution between 1991 and 1999 were admitted in the last 2 years.

CONCLUSION

Pediatric falls from windows in this suburban area appear to be increasing, with an incidence greater than the national average. Children at greatest risk are less than 4 years old. Further research in injury prevention at the national level aimed at suburban areas may be warranted.

Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores

The Glasgow Coma Scale (GCS) has been shown to be a valuable tool in assessing the neurologic and physiologic status of critically ill patients. Unfortunately, the GCS requires assessment of the verbal response of the patient and this can be blocked by intubation. The purpose of this study was to assess the ability of a regression model based upon the eye and motor components of the GCS to accurately predict the verbal response of the GCS. The primary hypothesis was that the verbal response could be derived from the motor and eye responses of the GCS.

METHODS

Data were collected prospectively in an intensive care unit computer data base. Patients were divided into training and test data sets. Linear regression was used to derive a model of verbal score from the motor and eye scores of the GCS in the training data set. Correlation between the actual and the predicted verbal scores was calculated.

RESULTS

A total of 2,521 GCS assessments were available for analysis. The second order multiple regression model was an accurate predictor of the verbal score (Pearson's Correlation r = 0.9, R2 = 0.8, p = 0.0001) in 1,463 observations in the training data set. Second Order Multiple Regression Model: Estimated GCS Verbal = (2.3976) + [GCS Motor x (-0.9253)] + [GCS Eye x (-0.9214)] + [(GCS Motor)2 x (0.2208)] + [(GCS Eye)2 x (0.2318)] where r = 0.91, R2 = 0.83, and p = 0.0001. The accuracy of this model was confirmed by comparing the predicted verbal score to the actual verbal score in the test data set (n = 736, r = 0.92, R2 = 0.85, p = 0.0001)

CONCLUSIONS

The GCS is a useful tool in the intensive care unit and a critical part of the APACHE II assessment of patient acuity. GCS has been shown to be a useful tool in its own right as a predictor of outcome in the critically ill. Its use is limited with intubation. (See Segatore M, Way C: Heart Lung 21:548, 1992; and Lieh-Lai MW, Theodorou AA, Sarnaik AP, et al: J Pediatr 120:195, 1992.) The present study demonstrates that a relatively simple regression model can use the eye and motor components of the GCS to predict the expected verbal component of the GCS, thus allowing the calculation of the GCS sum score in intubated patients.

Use of the APACHE II scoring system to determine mortality of gynecologic oncology patients in the intensive care unit

OBJECTIVE

To determine if an elevated score on the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system is associated with mortality of acutely ill gynecologic oncology patients.

METHODS

Gynecologic oncology patients admitted to the surgical intensive care unit (ICU) were identified from the ICU data base. Their admission APACHE II score and type of gynecologic cancer were also extracted from the data base. Charts were reviewed to determine the disease status and reason for admission to the surgical ICU. Patient mortality was correlated with APACHE II scores.

RESULTS

Forty-five gynecologic oncology patients were admitted to the surgical ICU from June 1988 to January 1992. They had a mean age of 62 years and various cancers: ovarian (24), cervical (16), and endometrial (five). The mean APACHE II score was 12 (range 2-26). Eight of 45 (18%) patients died. There was a significant correlation between APACHE II scores and mortality; patients with an APACHE II score of 20 or greater had a 78% risk of death compared to a 3% risk if the score was less than 20 (P < .001, chi 2 test).

CONCLUSION

Elevated APACHE II scores are associated with mortality in acutely ill gynecologic oncology patients.

Injury severity grading in trauma patients: a simplified technique based upon ICD-9 coding

The purpose of this study was to develop a simplified method of stratifying patient risk of death based on ICD-9 codes.

METHODS

Data were obtained from a statewide trauma registry. A mortality risk ratio (MRR) was derived from a "training" subset by calculating a mortality rate for each ICD-9 code of interest. The independent variables of interest included TS, ISS, and MRRs (for the 1st & 2nd Dx, 1st op, & E code).

RESULTS

(n = 37,100). When the 1st Dx and ISS were used as candidate variables in stepwise multivariate modeling, the MRR for the 1st Dx was the first variable to be entered into the model (1st Dx partial R2 = 0.37, ISS partial R2 = 0.02).

CONCLUSION

This study shows that the 1st Dx is a better predictor of outcome than ISS. Since ICD-9 codes are more easily obtained and are better predictors of outcome, this study suggests that they may supersede the use of the ISS in injury severity scoring.

Comparison of APACHE II, Trauma Score, and Injury Severity Score as predictors of outcome in critically injured trauma patients

Trauma Score (TS), APACHE II score, and Injury Severity Score (ISS) have been utilized to quantitate severity of illness in various groups of patients. The purpose of this study was to compare the relationship of the APACHE II score, TS, and "computer-derived" ISS with outcome in critically injured trauma patients. Data were recorded prospectively in a computer database for 428 consecutive trauma admissions. Stepwise discriminate analysis was utilized to determine the best predictor of both intensive care unit (ICU) and hospital outcome. Forty-two patients died in the ICU (10%), and another 18 patients died after leaving the ICU (4%), for a total mortality rate of 14%. The mean p value and partial R2 value obtained from stepwise discriminant analysis of the relationships between APACHE II score, TS, and ISS to ICU and hospital survival are shown. APACHE II score was the best predictor of both ICU and hospital outcome in these critically ill trauma patients. However, when combining all three measures (APACHE II score, TS, and ISS), only a portion of the variance in outcome is explained by the scores (R2 < 0.05). We conclude that scoring systems for outcome prediction should be utilized only as an adjunct to clinical assessment in the evaluation of the severity of illness and mortality risk in critically ill trauma patients.

Prospective comparison of clinical judgment and APACHE II score in predicting the outcome in critically ill surgical patients

Prospective identification of patients who will not survive has been proposed as a means of limiting utilization of medical resources including critical care. This study prospectively compared prediction of outcome for surgical ICU patients by clinical assessment and the APACHE II score. Five hundred seventy-eight patients were assessed within 24 hours of admission by the ICU attending physician and predicted to live or die. An APACHE II score was calculated in that same time period. All data were stored in a data base and compared with actual SICU outcome. There were 40 deaths in 578 patients (6.9%). The clinical assessment had an overall accuracy of 95.2% vs. 90.9% for APACHE II. The Pearson correlation coefficients for the two methods of prediction were 0.59 for clinical assessment and 0.44 for APACHE II. Predictive power was not greatly improved by combining both prediction methods. Over 40% of patients predicted to die by both methods actually survived. This study demonstrates that clinical assessment is superior to APACHE II in predicting outcome in this group of surgical patients, although the difference is small. In addition, this study suggests that neither clinical assessment nor the APACHE II score, when obtained within 24 hours of admission, is very reliable at predicting which surgical ICU patients will die.