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PubMed2006

The incidence of symptomatic lower-extremity lymphedema following treatment of uterine corpus malignancies: a 12-year experience at Memorial Sloan-Kettering Cancer Center.

OBJECTIVES: To describe the incidence of symptomatic postoperative lower-extremity lymphedema in women treated for uterine corpus cancer, and to evaluate its relationship to regional lymph node removal and postoperative therapy. METHODS: A retrospective chart review of all patients with uterine corpus cancer managed over a 12-year period (1/93-12/04). All patients had a hysterectomy as part of their therapy. We identified patients with leg lymphedema - as described by the physician or reported by the patient - through medical records. We excluded cases of leg edema that developed secondary to medical conditions such as cardiovascular and renal disease, venous thrombosis, and end-stage recurrent malignancy. Lymphedema dermal changes and related fibrosis were graded using the common terminology criteria for adverse events. RESULTS: In all, 1,289 patients with uterine corpus malignancy were evaluated. We excluded other chronic lower-extremity edema that was related to a variety of medical conditions in 74 patients (5.7%). With a median follow-up of 3 years (interquartile range, 1.1-5.4 years), new symptomatic post-treatment lower-extremity lymphedema was noted in 16 patients. Patients who had lymph nodes removed at initial surgery had a higher rate of developing lymphedema (16/670, 2.4%) than those who did not (0/619, 0%) (P = 0.0001). Furthermore, symptomatic lymphedema was limited to patients who had 10 or more regional lymph nodes removed 16/469 (3.4%). Lymphedema was noted at a median of 5.3 months after surgery (range, 1-32 months). Lymphedema was unilateral in 11 patients (69%) and bilateral in 5 (31%); moreover, it was considered grade 1 in 12 patients (75%) and grade 2 in 4 (25%). Age, weight, stage, type of hysterectomy, and type of postoperative adjuvant therapy were not associated with lymphedema. CONCLUSIONS: To date, this is the largest series evaluating symptomatic lower-extremity lymphedema in women with uterine corpus cancer. Patients who had 10 or more regional lymph nodes removed at initial surgery appeared to be at higher risk for developing new symptomatic leg lymphedema. Patients undergoing surgery with lymphadenectomy for uterine corpus malignancy should be informed about the possibility of postoperative new symptomatic leg lymphedema. A prospective evaluation of leg lymphedema is needed to accurately determine the incidence, severity, and risk factors of this complication.

Adult↗
PubMed2006

The use of bevacizumab to palliate symptomatic ascites in patients with refractory ovarian carcinoma.

OBJECTIVE: To evaluate our experience with the use of bevacizumab in patients with heavily pretreated recurrent ovarian carcinoma who have symptomatic ascites. METHODS: Four patients were identified who were previously heavily pretreated for recurrent ovarian carcinoma. Each had symptomatic ascites and required frequent therapeutic paracenteses. Each was treated with bevacizumab with the intent to palliate symptomatic ascites. Clinical data including demographic data and clinicopathologic variables was abstracted. RESULTS: The four patients demonstrated symptomatic relief of ascites. Toxicity was manageable in all patients with no grade 3/4 toxicity observed. In addition to symptomatic relief of ascites, no therapeutic paracenteses were required after initiation of therapy with bevacizumab. CONCLUSIONS: Bevacizumab may be a viable palliative option in patients with end stage ovarian carcinoma who have symptomatic ascites.

Angiogenesis Inhibitors↗
PubMed2001

Factors V leiden and II 20210A in patients with symptomatic pulmonary embolism and deep vein thrombosis.

PURPOSE: Factor V Leiden and factor II 20210A are inherited disorders of the clotting system that occur frequently in patients with deep vein thrombosis. We conducted this study to determine whether these factors are also common in patients with pulmonary embolism. SUBJECTS AND METHODS: We determined the prevalence of factor V Leiden and factor II 20210A in 773 consecutive patients with objectively documented symptomatic deep vein thrombosis or symptomatic pulmonary embolism, or with a combination of these disorders. RESULTS: Isolated symptomatic deep vein thrombosis occurred in 345 patients; isolated symptomatic pulmonary embolism occurred in 236; and both anomalies occurred in 192. Factor V Leiden was present in 21 (9%) of the patients with isolated symptomatic pulmonary embolism, in 30 (16%) with both manifestations, and in 63 (18%) with isolated symptomatic deep vein thrombosis (P = 0.007). Factor V Leiden was more common among patients with deep vein thrombosis (odds ratio [OR] = 2.1; 95% confidence interval [CI]: 1.2 to 3.7; P = 0.006) or both pulmonary embolism and deep vein thrombosis (OR = 1.8; 95% CI: 1.0 to 3.3; P = 0.07) than among patients with isolated pulmonary embolism. Factor V Leiden was less common in massive pulmonary embolism (5% [7 of 127]) than in submassive pulmonary embolism (13% [21 of 155], P = 0.03). We found no significant difference in the prevalence of factor II 20210A among the three groups. CONCLUSION: Factors V Leiden and II 20210A vary in prevalence among patients with pulmonary embolism and deep vein thrombosis, suggesting that the risk of pulmonary embolization may vary among patients who have different causes of venous thromboses.

Adult↗
PubMed1998

Postoperative subarachnoid clots and the pattern of cerebral ischemia associated with symptomatic vasospasm.

OBJECTIVE: We retrospectively evaluated the presence of subarachnoid clots and the development of symptomatic vasospasm in 125 patients who had early surgical treatment of a ruptured cerebral aneurysm. SUBJECTS AND METHODS: We studied 16 patients (aged 35-86 years; mean, 58.7 years) who underwent surgery 0 to 6 days (mean, 2.1 days) and then manifested symptomatic vasospasm on day 5-12 (mean, day 7.4), and 57 patients (aged 13-79 years; mean, 52.0 years) who underwent surgery 0-8 (mean, day 2.9) and did not manifest symptomatic vasospasm. The volume and location of subarachnoid clots were evaluated with computed tomographic (CT) scanning. Cerebral ischemia was evaluated clinically and also in eight patients, by measurement of cerebral blood flow (CBF) using xenon-enhanced CT. Angiographic evaluation was performed only on one patient. RESULTS: Of the 16 patients with symptomatic vasospasm, the subarachnoid clots were localized, distributed thickly, or associated with intracerebral hematomas in 15 and thin in 1 at the time of admission. Fifteen patients had CT evidence of a subarachnoid clot during vasospasm. Most of the clots were near the ruptured aneurysms, but in three cases, clots were located in the remote cisterns, which were not accessible operatively. The clinical manifestations of vasospasm in these three patients correlated with the site of the clot. CBF was reduced in the territory of the involved artery in all eight patients in whom it was measured. In two of the eight cases, the reduction occurred in the territory of a contralateral artery. In contrast, in the 57 patients without symptomatic vasospasm, the subarachnoid clots were already gone or disappeared soon after surgery in most patients. CONCLUSIONS: The continued presence of subarachnoid clots is an important risk factor for symptomatic vasospasm after the rupture of a cerebral aneurysm. The clot is not always located near the ruptured aneurysm, and the clinical course may be unpredictable.

Adult↗
PubMed1995

Studies on the relationship between the level of specific IgE antibodies and the clinical expression of allergy: I. Definition of levels distinguishing patients with symptomatic from patients with asymptomatic allergy to common aeroallergens.

BACKGROUND: The detection of specific IgE antibodies to environmental allergens does not always coincide with a diagnosis of clinically evident allergic disease, because some patients with positive skin and/or in vitro test results have no symptoms related to the allergen or allergens that induced the antibodies. OBJECTIVE: In a multicenter study the optimal cutoff values for specific IgE antibody levels and skin test results that could discriminate between patients with symptomatic and those with asymptomatic allergy were determined. METHODS: IgE antibodies specific for a panel of common aeroallergens were assayed with the Pharmacia CAP System (Pharmacia, Uppsala, Sweden) in two groups of patients, a group of 267 patients with symptomatic allergy and a group of 232 with asymptomatic allergy--both with positive skin prick test results--and in a group of 243 healthy, nonallergic control subjects. The cutoff values were established by receiver operating characteristic analysis. RESULTS: A significantly higher mean specific IgE antibody value was found in patients with symptomatic allergy compared with patients with asymptomatic allergy (p < 0.001) and in patients with symptomatic allergy compared with healthy control subjects (p < 0.001). The optimal CAP System cutoff value between patients with symptomatic and those with asymptomatic allergy was 11.7 kU/L, and when seasonal allergens were compared with perennial allergens, the cutoffs were 10.7 kU/L and 8.4 kU/L, respectively. The optimal cutoff value for the skin prick test was a wheel area of 32 mm2 for seasonal allergens and 31 mm2 for perennial allergens. The skin test had a lower diagnostic value (sum of sensitivity and specificity) than the CAP System. CONCLUSIONS: Cutoff values for specific serum IgE antibody levels are likely to be useful in clinical practice to distinguish symptomatic from asymptomatic allergy in patients with positive skin test results.

Adolescent↗
PubMed2003

Prognostic value of extensive coronary calcium quantities in symptomatic males--a 5-year follow-up study.

AIMS: Coronary calcium scores (CSs) have been shown to predict future events in patients presenting for first-time evaluation of CAD. Long-term outcome data on symptomatic subjects with advanced CAD are limited. In this study, we evaluated the prognostic value of very high coronary CSs in symptomatic males undergoing angiography and analyzed the impact of event definitions on identification of risk predictor's. METHODS AND RESULTS: Fifty consecutive symptomatic males with electron beam computed tomography (EBT)-based CSs >1000 were matched 1:2 by age with symptomatic males with scores between 400-1000 and 100-400. All 150 patients underwent coronary angiography. CAD risk factors were ascertained. Events were analyzed after 5 years for: (1) hard coronary events (coronary death and myocardial infarction); (2) overall hard events (adding stroke and non-coronary deaths); and (3) all events (including long-term revascularizations). During follow-up, 17 deaths, two infarctions and three strokes occurred in 21 patients; 38 patients underwent 43 revascularizations. Events occurred earlier and more frequently in patients with scores >1000. Left main disease was the only independent predictor of hard coronary events (hazard ratio, 4.5; 95% confidence interval, 1.1-17.8). Left main disease (4.3; 1.4-13.0) and CSs (1.7; 1.1-2.5) independently predicted overall hard events. Only CSs>90th percentile independently predicted all events (2.5; 1.3-4.8). CONCLUSIONS: Symptomatic males with extensive CSs carry an even higher risk for future events than other symptomatic males with advanced CAD. In these patients, EBT-based calcified plaque burden and angiographic indices of disease severity may have a complementary role in predicting future cardiovascular events.

Calcinosis↗
PubMed1997

Clinical implications of silent versus symptomatic exercise-induced myocardial ischemia in patients with stable coronary disease.

OBJECTIVES: This study was undertaken to better understand the functional and prognostic significance of silent relative to symptomatic ischemia. BACKGROUND: Previous studies have reached conflicting conclusions as to whether painless ischemia identified during noninvasive cardiac testing is related to a lesser extent of myocardial ischemia or a different prognosis than ischemia accompanied by angina, or both. METHODS: Nine hundred thirty-six clinically stable patients 1 to 6 months after an acute coronary event, either myocardial infarction or unstable angina, underwent ambulatory monitoring, exercise treadmill testing and stress thallium-201 scintigraphy. They were then followed up prospectively for a mean of 23 months for recurrent cardiac events (cardiac death, nonfatal myocardial infarction or unstable angina). RESULTS: Compared with patients with symptomatic ischemia during testing (n = 125), those with silent ischemia (n = 378) demonstrated less severe and extensive reversible defects on stress thallium scintigraphy (p = 0.0008), less functional impairment during treadmill testing manifested by longer exercise duration (640 +/- 173 vs. 529 +/- 190 s, p = 0.002) and longer time to ST segment depression (530 +/- 215 vs. 419 +/- 205 s, p = 0.0001) and less frequent ST segment depression during ambulatory monitoring (9% vs. 19%, p = 0.005). Patients with symptomatic ischemia had a significantly (p = 0.004) increased number of subsequent recurrent cardiac events (28.8%) versus those with silent (18.0%) or no (17.3%) ischemia. Adverse outcomes were especially concentrated in the subgroup with symptomatic ischemia and poor exercise tolerance. The difference in cardiac event rates between patients with silent versus symptomatic ischemia persisted after adjustment for baseline clinical characteristics by Cox regression analysis. CONCLUSIONS: Patients with painless ischemia during exercise testing 1 to 6 months after recovery from a coronary event have less jeopardized ischemic myocardium and fewer recurrent cardiac events than patients with symptomatic ischemia.

Adult↗
PubMed1996

Cytomegalovirus (CMV) DNA amplification from plasma compared with CMV pp65 antigen (ppUL83) detection in leukocytes for early diagnosis of symptomatic CMV infection in kidney transplant patients.

BACKGROUND: Rapid laboratory methods for the early detection of cytomegalovirus (CMV) are needed for the prevention of CMV disease in transplant recipients. These methods should not only be able to detect the virus but also be highly predictive for CMV disease. OBJECTIVE: The clinical value of a simple and rapid nested plasma polymerase chain reaction (PCR) was evaluated by comparing the results with CMV pp65 antigen detection in leukocytes (CMV antigenemia assay), virus isolation from leukocytes, CMV IgG and IgM antibody response and clinical data. STUDY DESIGN: A total of 471 EDTA blood samples were collected from 85 kidney transplant patients during a 3-4 month period after transplantation. CMV DNA was amplified directly from 10 microliters of plasma while 150000 separated leukocytes were stained for CMV pp65 antigen by each of two monoclonal antibodies. A total of one million leukocytes were used for virus isolation. The PCR protocol used in the present study involves a simple alkaline lysis technique for isolating DNA directly from plasma which is easy and rapid to perform. RESULTS: Twenty-eight patients developed symptomatic CMV infection while asymptomatic infection occurred in 29 patients. CMV pp65 antigen detection had a 75% sensitivity and a 57% positive predictive value for CMV disease development, compared with 64% and 79% sensitivity and 49% and 46% positive predictive value for CMV DNA and viremia, respectively. The median time until detection of CMV in patients with symptomatic CMV infection was 26 days after transplantation, compared with 49 days in asymptomatic patients by any of the methods used. Early appearance (within 8 weeks) of CMV pp65 antigen and CMV DNA had high predictive values for symptomatic infection; repeated detection of pp65 antigen and CMV DNA were more common in symptomatic patients. CONCLUSIONS: CMV antigenemia assay and plasma PCR can be used for pre-symptomatic diagnosis of CMV infection. Virus isolation and CMV serology in most cases provide a post-symptomatic diagnosis. The best marker for monitoring kidney transplant patients might be the quantitative CMV antigenemia assay.

Adolescent↗
PubMed2003

Cytokine levels during symptomatic viral upper respiratory tract infection.

BACKGROUND: Previous studies suggest a role for locally produced proinflammatory cytokines in the development and expression of illness during experimental infection with a variety of respiratory viruses. However, most of these studies fail to make comparisons between symptomatic and asymptomatic infected subjects. OBJECTIVE: To compare the pattern of nasal cytokine elaboration in asymptomatic and symptomatic subjects experimentally infected with rhinovirus-39 (RV-39). METHODS: Healthy adults underwent experimental intranasal inoculation with a safety-tested clinical isolate of RV-39. Nasal lavages were collected, nasal symptoms were recorded, and expelled nasal secretions were weighed before and then daily for 6 days after challenge. Nasal lavages were submitted for viral culture and assayed for cytokine protein levels by enzyme-linked immunosorbent assay. RESULTS: Twenty-nine subjects were enrolled in the study. All subjects were infected as evidenced by viral shedding and/or seroconversion. Sixteen subjects were symptomatic and 13 were asymptomatic as evaluated by subject self-report. During infection, significant increases in mean levels of nasal interleukin 6 (IL-6) (P = .01) and IL-1 (P = .02) were observed in symptomatic but not asymptomatic subjects. In symptomatic subjects, these increases were temporally related to the development of nasal symptoms and production of secretions. Mean levels of IL-8, IL-10, and tumor necrosis factor a were not increased in either group during infection. CONCLUSIONS: The results of this study demonstrate elevations in certain locally produced cytokines during symptomatic but not asymptomatic respiratory infection with RV-39. Future studies using selected anticytokine therapies may help elucidate the precise role of cytokines in mediating disease expression.

Adolescent↗
PubMed1996

Increased levels of free serotonin in plasma of symptomatic asthmatic patients.

BACKGROUND: Previous research has shown that symptomatic asthmatic patients have increased levels of norepinephrine, epinephrine, dopamine, free serotonin, and cortisol in plasma when compared with asymptomatic patients. OBJECTIVE: We investigated the relationship between plasma levels of catecholamines, free serotonin, and cortisol and clinical status and pulmonary function in symptomatic and asymptomatic patients with asthma. METHODS: We compared clinical severity, spirometry, and neuroendocrine factors at weeks 0, 1, 2, 3, and 4 in 57 symptomatic (forced expiratory volume in one second [FEV1] < 70%) and 72 asymptomatic (FEV1 > 80%) asthmatic patients. We used multiple analyses of variance (repeated measures) to interpret the data. In addition, we used the Pearson Product Moment Test to investigate correlations among the different variables. RESULTS: The clinical severity rating and levels of free serotonin, norepinephrine, epinephrine, dopamine, and cortisol were significantly higher in symptomatic asthmatic patients than those in asymptomatic patients (P < .001, in all cases). FEV1 was significantly lower in symptomatic patients than in asymptomatic patients. In symptomatic patients, the level of free serotonin correlated positively with the clinical severity rating (r = .564, P < .01) and negatively with FEV1 (r = -.959, P < .001). In addition, the clinical severity rating showed a negative correlation with FEV1 (r = -.359, P < .01). No significant correlations were found in asymptomatic patients. CONCLUSION: Our finding that free serotonin was the only neuroendocrine factor closely associated with clinical severity and pulmonary function suggests that this factor plays an important role in the pathophysiology of acute asthma.

Adolescent↗
PubMed2004

Reliability of ultrasonography for the cervical multifidus muscle in asymptomatic and symptomatic subjects.

A test-retest and inter-tester study was designed to assess the reliability of ultrasonography to depict the size of the cervical multifidus muscle in asymptomatic and symptomatic subjects. Ten asymptomatic women (range 19-48 years) and 10 women with chronic whiplash associated disorder (WAD), grade II, (range 19-49 years), matched for height and weight participated. The women were imaged by ultrasonography on two separate occasions by two different testers. On each occasion the cross-sectional area (CSA), and the transverse versus the anterior-posterior dimensions (shape ratio) at the C4 level were measured. The repeated measurements of the CSA were plotted against their means to reveal the limit of agreement. Good agreement was found for the asymptomatic group measurements and the intra-tester agreement for the symptomatic group. The inter-tester agreement for the symptomatic group was questionable. The size of the multifidus muscle was significantly reduced in the symptomatic group ( P<0.05 ). The results indicate that loss of clarity of the fascial layer between the semispinalis cervicis muscle and the cervical multifidus muscle may be a diagnostic sign of muscle atrophy. Ultrasonography can be used to precisely measure the size of the cervical multifidus muscle at the C4-level in asymptomatic young female subjects; it is also reliable for symptomatic subjects if the same tester performs the measurements. Additional criteria are recommended to improve the inter-tester agreement for symptomatic subjects.

Adult↗
PubMed2001

Pretreatment gastric histology is helpful to predict the symptomatic response after H. pylori eradication in patients with nonulcer dyspepsia.

This study aimed to test whether pretreatment gastric pathology in H. pylori-infected nonulcer dyspepsia (HpNUD) patients is relevant to and predictive of the symptomatic response after H. pylori eradication. Anti-H. pylori triple therapy was administered to 250 HpNUD patients, enrolled as the therapy group. In addition, 60 patients were enrolled as the control group, in which omeprazole was an alternatives to the triple therapy. Pretreatment gastric histology was evaluated thoroughly by the updated Sydney system. A [13C] urea breath test was also performed to evaluate the H. pylori eradication two months and 12 months later. For each patient, the baseline, month 2, and month 12 symptom scores were assessed for the month 2 or month 12 residual symptom ratio (RSR-2m or RSR-12m), calculated from: 100% x month 2 or month 12 score/baseline score. Based on either RSR-2m or RSR-12m, patients were categorized as good response (RSR < 50%), moderate response (50-70%), and poor response (> 70%) subgroups in both therapy and control groups to define the short-term and long-term symptomatic responses. Patients with successful H. pylori eradication in the therapy group showed a higher incidence of good symptomatic response (RSR < 50%) than those from the control group (month 2: 30.3 vs 12%, P < 0.05; month 12: 34.7 vs 17.1%, P < 0.05). Univariate and multivariate analysis disclosed that patients with a higher acute inflammation score (AIS) and the lowest incidence of lymphoid follicles (LF) at pretreatment gastric histology are predisposed to having a good symptom response after H. pylori eradication (P < 0.05). For HpNUD patients who have an AIS of more than three and an absence of LF at gastric histology, more than 85% had good short-term (month 2) and long-term (month 12) symptomatic relief after H. pylori eradication. In conclusion, nearly 30% of HpNUD patients can obtain symptomatic relief following H. pylori eradication. The pretreatment gastric histology of HpNUD can be helpful to monitor the symptomatic response after H. pylori eradication.

Adult↗
PubMed2000

A comparative analysis of the cost-effectiveness of treatment based on parasitological and symptomatic screening for Schistosoma mansoni in Burundi.

OBJECTIVES: To assess the cost-effectiveness of three alternative screening strategies in delivering treatment to patients presenting with symptoms suggestive of S. mansoni, using data collected from 17 PHCCs in the Rusizi Plain, Burundi. The three strategies were: (1) screening all symptomatic patients using a Kato-Katz smear and treating only the ones found positive; (2) treating all symptomatic patients or (3) treating only those presenting with symptoms of severe diarrhoea (blood in stool). METHODS: The database consisted of 41 051 visits of symptomatic patients to the 17 PHCCs during 1990. Effectiveness was measured as the number of infected patients treated (gold standard: 25-mg Kato-Katz smear). Cost-effectiveness ratios (CERs) (cost in US$ per infected patient treated) were used to compare the control strategies. Sensitivity analysis was performed to assess the effect of drug price and prevalence of infection on the CERs. RESULTS: The overall prevalence of S. mansoni infection was 9.5% (95% CI = 9.1%, 9.9%). Treating only those with severe symptoms of infection would have left 92% of infected patients untreated. Performing a Kato-Katz smear to confirm the diagnosis was more cost-effective than treating all symptomatic patients on a presumptive basis, with CERs of 4.2 US$ and 12.43 US$ per infected person treated, respectively. Sensitivity analysis showed that, for a cost of 0.99 US$ per dose of praziquantel, the Kato-Katz option remained the most cost-effective approach for prevalences under 76%. For a drug price of 0.21 US$ per dose, both strategies would have become equivalent. The latter value varied extensively per PHCC (range 0.17 US$ to 0.51 US$), due to the different prevalences of infection (range 0.5% to 34.3%). CONCLUSION: We found that using severe diarrhoea as an indicator for infection was not appropriate, and that screening symptomatic patients with the Kato-Katz method remained the most cost-effective approach in the given setting. The CER of treating all symptomatic patients on a presumptive basis depended very much on the drug price and the endemic level.

Adolescent↗
PubMed2002

Does laparoscopic fenestration provide long-term alleviation for symptomatic cystic disease of the liver?

BACKGROUND: The use of laparoscopic technique for management of symptomatic liver cysts is documented to be a feasible and safe procedure with good short-term symptomatic relief. However, it cannot be recommended as the standard of care as long-term results are scarce. The present study was initiated to review the long-term results of this approach in the management of symptomatic liver cysts. METHODS: A retrospective review of all patients with symptomatic liver cysts that were treated by laparoscopic fenestration in our department over an 8-year period from 1993 to 2001. The clinical and radiographical data were analysed at follow-up to assess the -outcome. RESULTS: Eleven patients were treated using a laparoscopic approach; 10 patients with solitary cysts and one with adult polycystic liver disease. All patients achieved short-term alleviation of symptoms and an uneventful postoperative course. The mean hospital stay was 3 days. Long-term follow up was available for 9 patients with a mean of 44 months. Histologically, one of the patients was diagnosed with a biliary cystadenoma and she had a symptomatic recurrence and a liver resection at 20 months. In the other seven patients, there was no clinical recurrence but a radiographical recurrence of 28.5%. The patient with adult polycystic liver disease had two symptomatic recurrences: at 26 months where he underwent a repeat laparoscopic fenestration and at 43 months where he underwent an open fenestration. CONCLUSION: The present study confirms that with adequate patients election, long-term alleviation of symptoms can be achieved with the laparoscopic approach for solitary simple liver cysts but not for polycystic liver disease or cystic tumours of the liver.

Adult↗
PubMed1998

A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture.

BACKGROUND: The indications for transfusion have never been evaluated in an adequately sized clinical trial. A pilot study was conducted to plan larger clinical trials. STUDY DESIGN AND METHODS: Hip fracture patients undergoing surgical repair who had postoperative hemoglobin levels less than 10 g per dL were randomly assigned to receive 1) symptomatic transfusion: that is, transfusion for symptoms of anemia or for a hemoglobin level that dropped below 8 g per dL or 2) threshold transfusion: that is, patients receive 1 unit of packed RBCs at the time of random assignment and as much blood as necessary to keep the hemoglobin level above 10 g per dL. Outcomes were 60-day mortality, morbidity, functional status, and place of residence. RESULTS: Among 84 eligible patients enrolled, mean (+/- SD) prerandomization hemoglobin was 9.1 (+/- 0.6) g/ dL. The median number of units transfused in the threshold transfusion group was 2 (interquartile range, = 1-2), and that in the symptomatic transfusion group was 0 (6; interquartile range, = 0-2) (p < 0.001). Mean hemoglobin levels were approximately 1 g per dL higher in the threshold group than in the symptomatic group: for example, on Day 2, 10.3 (+/- 0.9) g per dL versus 9.3 (+/- 1.2) g per dL, respectively (p < 0.001). At 60 days, death or inability to walk across the room without assistance occurred in 16 (39.0%) of the symptomatic transfusion group and 19 (45.2%) of the threshold transfusion group. Death occurred by 60 days in 5 (11.9%) of the symptomatic transfusion group and 2 (4.8%) in the threshold transfusion group (relative risk = 2.5; 95% CI, 0.5-12.2). Other outcomes were similar for the two groups. CONCLUSIONS: Symptomatic transfusion may be an effective blood-sparing protocol associated with the transfusion of appreciably fewer units of RBCs and lower mean hemoglobin levels than are associated with the threshold transfusion policy. However, it is unknown whether these two clinical strategies have comparable mortality, morbidity, or functional status. A definitive trial is needed.

Adult↗
PubMed2000

Symptomatic and asymptomatic accessory navicular bones: findings of Tc-99m MDP bone scintigraphy.

AIM: The accuracy of bone scintigraphy in diagnosing symptomatic accessory navicular bones has not been well studied. We conducted a retrospective study to explore the results and use of scintigraphy in symptomatic and asymptomatic accessory navicular bones. MATERIALS AND METHODS: Thirteen patients with a total of 13 symptomatic and 10 asymptomatic accessory navicular bones were included in the study. We used a scoring system to grade the scintigraphic abnormalities. The patients' symptoms and scintigraphic findings were recorded. RESULTS: Though focally increased radiopharmaceutical uptake was observed in all symptomatic accessory naviculars, half of the asymptomatic accessory navicular bones had the same manifestations. The scoring system was of no value in differentiating symptomatic from asymptomatic accessory navicular bones. CONCLUSION: Bone scintigraphy is a sensitive but not a specific tool for diagnosing a symptomatic accessory navicular.

Adolescent↗
PubMed2003

The relationship between socio-economic status, geography, symptomatic carotid territory disease and carotid endarterectomy.

OBJECTIVE: recent evidence suggests a strong association between socio-economic status and atherosclerosis. However, little information exists on the relationship between socio-economic status, symptomatic carotid disease and rates of carotid endarterectomy (CEA). The aim was to evaluate the Carstair Deprivation Score (CDS) of (1) patients admitted with symptomatic carotid disease, and (2) those undergoing CEA in one health board. METHOD: the CDS score was determined from the post-codes of all patients admitted with a diagnosis of transient ischaemic attack (TIA) or stroke due to cerebral infarction (ISD 9 codes 433.1, 433.09, 435, 437.1; ICD-10: 165.2, 163, 163.2, G45.1, G45.3, G45.9) between 1st April 1995 and 31st March 2000. Expected and actual rates for each of the CDS (1 to 7) were determined by direct and indirect methods of standardisation allowing for age and sex. A similar analysis was performed for patients undergoing carotid endarterectomy. Results were analysed using the Mantel-Haenszel test. Only first time admissions and CEA were included. RESULTS: 1203 patients were admitted with the main diagnosis of symptomatic carotid disease. The admission rate of symptomatic patients was less than expected in the more affluent group (Carstair 1, p < 0.005) and significantly higher in the most deprived group (Carstair 7, p < 0.001). In comparison 192 patients underwent CEA. There were no differences between the expected and actual rates of CEA in each CDS, but the rates tended to be higher in the most affluent group. Geographical variation was also demonstrated with an increased rate of CEA in those patients living in the cities and a reduced rate in those in the rural communities. CONCLUSION: patients from deprived socio-economic groups had a higher rate of symptomatic carotid disease, but this was not matched by an increased rate of CEA. This suggests that socio-economic inequalities in the prevalence of symptomatic carotid artery disease and treatment exist.

Carotid Artery Diseases↗
PubMed1995

Virologic characteristics of subclinical and symptomatic genital herpes infections.

BACKGROUND: The frequency, pattern, and anatomical sites of subclinical shedding of herpes simplex virus (HSV) in the genital tract, along with factors that predict such shedding, have not been well characterized. METHODS: We studied prospectively the clinical and virologic course of genital herpes in 110 women. The women kept symptom diaries and provided daily samples from the vulva, cervix, and rectum for viral culture. RESULTS: During a median follow-up of 105 days, subclinical shedding of virus was identified in 36 of 65 women (55 percent) with HSV type 2 (HSV-2), in 16 of 31 women (52 percent) with HSV type 1 (HSV-1) and HSV-2, and in 4 of 14 women (29 percent) with only HSV-1. Among women with genital HSV-2 infection, subclinical shedding occurred on a mean of 2 percent of the days. The mean duration of viral shedding during subclinical episodes was 1.5 days, as compared with 1.8 days during symptomatic episodes. HSV was isolated from several sites in the genital tract and rectum in 17 percent of subclinical episodes and 22 percent of symptomatic episodes. Half the episodes of subclinical shedding of HSV occurred within seven days of a symptomatic recurrence. The risk of subclinical shedding increased with the frequency of symptomatic recurrences. Subclinical shedding was more frequent among women with more than 12 recurrences per year than among those with no symptomatic recurrences (odds ratio, 3.3; 95 percent confidence interval, 1.4 to 7.9); it was also more frequent among women who had recently acquired genital herpes (odds ratio for women with HSV acquired in the past year as compared with those who had had the infection for a year or more, 1.85; 95 percent confidence interval, 1.1 to 3.1). CONCLUSIONS: Among women with a history of genital herpes infection, subclinical shedding of HSV is common and accounts for nearly one third of the total days of reactivation of HSV infection in the genital tract. Women with frequent symptomatic recurrences also have frequent subclinical shedding and may be at high risk for transmitting HSV.

Adolescent↗