Evaluation of additive effect of quantitative fetal fibronectin to cervical length for prediction of spontaneous preterm birth among asymptomatic low-risk women.

INTRODUCTION: Our objective was to evaluate the possible additive effect of quantitative fetal fibronectin to transvaginal ultrasound cervical length measurement between 18(0/7) and 23(6/7)  weeks for prediction of spontaneous preterm birth at <37(0/7)  weeks among asymptomatic low-risk women. MATERIAL AND METHODS: A prospective observational study was performed of asymptomatic women with singleton gestations between 18(0/7) and 23(6/7)  weeks and no prior spontaneous preterm birth. Women with multiple gestations, rupture of membranes, vaginal bleeding, intercourse or vaginal exam within 48 h of enrollment were excluded. Physicians were blinded to the quantitative fetal fibronectin levels, but the cervical length measurements were made available. The primary outcome was spontaneous preterm birth at <37(0/7)  weeks. RESULTS: Of the 528 asymptomatic low-risk women who were prospectively enrolled, 36 (6.82%) had spontaneous preterm birth at <37(0/7)  weeks. Using the receiver-operating characteristic curve, fetal fibronectin value of ≥5 ng/mL was identified as the optimal cut-off for predicting spontaneous preterm birth at <37(0/7)  weeks. As compared with cervical length ≥20 mm alone, with the use of cervical length ≤20 mm or quantitative fetal fibronectin ≥5 ng/mL as screening criteria for prediction of spontaneous preterm birth at <37(0/7)  weeks; sensitivity improved from 11.11 to 61.11%, specificity decreased from 99.59 to 55.08%, positive predictive value decreased from 66.67 to 9.05%, negative predictive value marginally improved from 93.87 to 95.09% and predictive accuracy decreased from 93.56 to 55.49%. CONCLUSIONS: Although the sensitivity improved, other predictive statistics and predictive accuracy did not improve by the addition of mid-trimester quantitative fetal fibronectin to cervical length measurement. Therefore, addition of mid-trimester quantitative fetal fibronectin to cervical length measurement cannot be recommended at this time for prediction of spontaneous preterm birth at <37(0/7)  weeks in asymptomatic low-risk women.

Adjuvant versus salvage radiation therapy for prostate cancer patients with adverse pathologic features: comparative analysis of long-term outcomes.

OBJECTIVES: To compare long-term outcomes of men with adverse pathologic features after adjuvant radiation therapy (ART) versus salvage radiation therapy (SRT) after radical prostatectomy at our institution. METHODS: Patients treated with postprostatectomy radiation therapy with pT3 tumors, or pT2 with positive surgical margins, were identified. Cumulative freedom from biochemical failure (FFBF), freedom from metastatic failure (FFMF), and overall survival rates were estimated utilizing the Kaplan-Meier method. Multivariate analyses were performed to determine independent prognostic factors correlated with study endpoints. Propensity score analyses were performed to adjust for confounding because of nonrandom treatment allocation. RESULTS: A total of 186 patients with adverse pathologic features treated with ART or SRT were identified. The median follow-up time after radical prostatectomy was 103 and 88 months after completion of radiation therapy. The Kaplan-Meier estimates for 10-year FFBF was 73% and 41% after ART and SRT, respectively (log-rank, P=0.0001). Ten-year FFMF was higher for patients who received ART versus SRT (98.6% vs. 80.9%, P=0.0028). On multivariate analyses there was no significant difference with respect to treatment group in terms of FFBF, FFMF, and overall survival after adjusting for propensity score. CONCLUSIONS: Although unadjusted analyses showed improved FFBF with ART, the propensity score-adjusted analyses demonstrated that long-term outcomes of patients treated with ART and SRT do not differ significantly. These results, with decreased effect size of ART after adjusting for propensity score, demonstrate the potential impact of confounding on observational research.

High dose rate brachytherapy boost for prostate cancer: a systematic review.

Studies of dose-escalated external beam radiation therapy (EBRT) and low dose rate brachytherapy (LDR-BT) have shown excellent rates of tumor control and cancer specific survival. Moreover, LDR-BT combined with EBRT (i.e. "LDR-BT boost") is hypothesized to improve local control. While phase II trials with LDR-BT boost have produced mature data of outcomes and toxicities, high dose rate (HDR)-BT has been growing in popularity as an alternative boost therapy. Boost from HDR-BT has theoretical advantages over LDR-BT, including improved cancer cell death and better dose distribution from customization of catheter dwell times, locations, and inverse dose optimization. Freedom from biochemical failure rates at five years for low-, intermediate-, high-risk, and locally advanced patients have generally been 85-100%, 80-98%, 59-96%, and 34-85%, respectively. Late Radiation Therapy Oncology Group grade 3-4 toxicities have also been encouraging with <6% of patients experiencing any toxicity. Limitations of current HDR-BT boost studies include reports of only single-institution experiences, and unrefined reports of toxicity or patient quality of life. Comparative effectiveness research will help guide clinicians in selecting the most appropriate treatment option for individual patients based on risk-stratification, expected outcomes, toxicities, quality of life, and cost.

Risk stratification for the development of post-ERCP pancreatitis by sphincter of Oddi dysfunction classification.

OBJECTIVES: To explore whether there is a difference in the frequency of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients with manometrically confirmed sphincter of Oddi dysfunction (SOD) types I, II, and III. METHODS: A retrospective review of all of the patients who underwent an ERCP with SOD type I or patients with manometrically confirmed SOD type II or type III (mean basal sphincter pressure ≥ 40 mm Hg) from 2006 to 2010 was performed. The primary outcome measure was development of post-ERCP acute pancreatitis in each of the SOD groups. Factors associated with acute pancreatitis in each group were examined by univariate analysis. RESULTS: We identified 147 patients with SOD. Biliary sphincterotomy was performed in all of the patients, and pancreatic sphincterotomy was performed in 68 of the 147 (46%). All of the patients underwent stenting of the pancreatic duct. Post-ERCP pancreatitis occurred in 23% of the study cohort. Patients with SOD type III had a higher frequency of post-ERCP pancreatitis compared with the SOD type I and type II groups (31% vs 20% vs 6%, respectively; P = 0.024). Those with SOD type III had a greater frequency of post-ERCP pancreatitis (odds ratio 6.7; P = 0.05) compared with those with SOD type I. Patients with SOD type III had a two times greater frequency of developing post-ECRP pancreatitis compared with those with SOD type II. CONCLUSIONS: SOD type III is strongly associated with the development of post-ERCP pancreatitis compared with SOD type I.

A randomized controlled trial of a tailored navigation and a standard intervention in colorectal cancer screening.

BACKGROUND: This randomized, controlled trial assessed the impact of a tailored navigation intervention versus a standard mailed intervention on colorectal cancer screening adherence and screening decision stage (SDS). METHODS: Primary care patients (n = 945) were surveyed and randomized to a Tailored Navigation Intervention (TNI) Group (n = 312), Standard Intervention (SI) Group (n = 316), or usual care CONTROL GROUP (n = 317). TNI Group participants were sent colonoscopy instructions and/or stool blood tests according to reported test preference, and received a navigation call. The SI Group was sent both colonoscopy instructions and stool blood tests. Multivariable analyses assessed intervention impact on adherence and change in SDS at 6 months. RESULTS: The primary outcome, screening adherence (TNI Group: 38%, SI Group: 33%, CONTROL GROUP: 12%), was higher for intervention recipients than controls (P = 0.001 and P = 0.001, respectively), but the two intervention groups did not differ significantly (P = 0.201). Positive SDS change (TNI Group: +45%, SI Group: +37%, and CONTROL GROUP: +23%) was significantly greater among intervention recipients than controls (P = 0.001 and P = 0.001, respectively), and the intervention group difference approached significance (P = 0.053). Secondary analyses indicate that tailored navigation boosted preferred test use, and suggest that intervention impact on adherence and SDS was attenuated by limited access to screening options. CONCLUSIONS: Both interventions had significant, positive effects on outcomes compared with usual care. TNI versus SI impact had a modest positive impact on adherence and a pronounced effect on SDS. IMPACT: Mailed screening tests can boost adherence. Research is needed to determine how preference, access, and navigation affect screening outcomes.

Change in intrathoracic impedance measures during acute decompensated heart failure admission: results from the Diagnostic Data for Discharge in Heart Failure Patients (3D-HF) Pilot Study.

BACKGROUND: Despite the high number of admissions for acute decompensated heart failure (ADHF), there are no specific criteria for discharge readiness. A number of patients have implantable devices that might provide data to assist in determining readiness for discharge. METHODS AND RESULTS: The 3D-HF (Diagnostic Data for Discharge in Heart Failure Patients) study was a prospective observational pilot study enrolling HF patients with Optivol-capable cardiac devices within 48 hours of a hospital admission characterized by worsening HF symptoms. The primary end point was the difference in times from admission to 50% improvement in impedance and to when patient was medically ready for discharge. The nonparametric sign test was used to determine if the difference was significant. A total of 20 subjects were enrolled over a 24-month period. The median ADHF length of stay was 7 days. Of the 20 subjects, 18 achieved the intrathoracic impedance improvement threshold before discharge. The time to reach the threshold for improvement was 2.5 days (interquartile range 2.0-6.0). The difference between days to 50% impedance and days to provider's discharge decision was 3.0 (P = .0072). CONCLUSIONS: Intrathoracic impedance changes were evident over a short duration in the majority of patients admitted for ADHF and may be a potential criterion for discharge readiness.

Lymph node ratio is an important and independent prognostic factor for patients with stage III melanoma.

INTRODUCTION: The incidence of melanoma is dramatically increasing worldwide. We hypothesized that the ratio of metastatic to examined lymph node ratio (LNR) would be the most important prognostic factor for stage III patients. METHODS: We retrospectively reviewed our institutional database of melanoma patients and identified 168 patients who underwent lymph node dissection (LND) for stage III disease between 1993 and 2007. Patients were divided into three groups based on LNR (≤10%, n = 93; 10-≤25%, n = 45; and >25%, n = 30). Univariate and multivariate analysis was performed using Cox proportional hazards model. RESULTS: The median survival time of the entire group of patients was 34 months. The median number of positive nodes was 2 (range = 1, 55), and the median number of examined nodes was 22 (range = 5-123). Tumor characteristics of the primary melanoma (such as thickness, ulceration, and primary site) were not significant predictors of survival in this analysis. By univariate analysis, LNR was an important prognostic factor. Patients with LNR 10-25% and >25% had decreased survival compared to those patients with LNR ≤10% (HR = hazard ratio = 2.0 and 3.1, respectively; P ≤ 0.005). The number of positive lymph nodes also impacted on survival (P = 0.001). In multivariate analysis, LNR of 10-25% and >25% predicted survival (HR = 2.5 and 4.0, respectively). CONCLUSION: LNR is an important prognostic factor in patients undergoing LND for stage III melanoma. It can be used to stratify patients being considered for adjuvant therapy trials and should be evaluated using a larger prospective database.

Safety of iodinated intravenous contrast medium administration in sickle cell disease.

BACKGROUND: Increased sickling of erythrocytes following intravenous iodinated contrast has been described in patients with sickle cell disease. In vitro, the effect is correlated with the tonicity, viscosity, acidity, and ionic nature of contrast media. Less erythrocyte sickling is observed in vitro with second-generation low- and iso-osmolar contrast agents. Clinical impact of these newer intravenous contrast agents has not been investigated. PURPOSE: To review adverse outcomes following contrast administration in a cohort of patients with sickle cell disease. METHODS: Inpatients with sickle cell disease who received iodinated intravenous were identified. Medical records were reviewed for evidence of worsening crisis and occurrence of adverse events within 48 hours of contrast administration. Data points were further analyzed with the goal of identifying predictors of adverse outcome. RESULTS: There were 132 imaging studies that met inclusion criteria in 79 patients, mostly with homozygous hemoglobin S. The low-osmolar contrast Optiray (Coviden Imaging Inc., Hazelwood, Mo) was used in 45%. Administration of fluids, Mucomyst (Bristol-Myers Squibb, New York, NY), oxygen, or blood transfusion preceded 58% of studies. Minor adverse events followed 16% of studies, with new or worsening pain being most common (12%). Contrast-induced nephropathy occurred in 1.5%, resolving in all cases. Prehydration was associated with a decreased incidence of adverse events (P=.02). CONCLUSION: Adverse events related to intravenous contrast occur in sickle cell disease patients at a rate similar to the general population, without an increase in contrast-induced nephropathy. Subjective reports of new or worsening pain crisis do not translate to objective findings. Beneficial diagnostic imaging can be performed without increased risk of serious complication in this population.

Controlled and cardiac-restricted overexpression of the arginine vasopressin V1A receptor causes reversible left ventricular dysfunction through Gαq-mediated cell signaling.

BACKGROUND: [Arg8]-vasopressin (AVP) activates 3 G-protein-coupled receptors: V1A, V2, and V1B. The AVP-V1A receptor is the primary AVP receptor in the heart; however, its role in cardiac homeostasis is controversial. To better understand AVP-mediated signaling in the heart, we created a transgenic mouse with controlled overexpression of the V1A receptor. METHODS AND RESULTS: The V1A receptor transgene was placed under the control of the tetracycline-regulated, cardiac-specific α-myosin heavy chain promoter (V1A-TG). V1A-TG mice had a normal cardiac function phenotype at 10 weeks of age; however, by 24 weeks of age, tetracycline-transactivating factor/V1A-TG mouse hearts had reduced cardiac function, cardiac hypertrophy, and dilatation of the ventricular cavity. Contractile dysfunction was also observed in isolated adult cardiac myocytes. When V1A receptor transgene was induced to be expressed in adult mice (V1A-TG(Ind)), left ventricular dysfunction and dilatation were also seen, albeit at a later time point. Because the V1A receptor mediates cell signaling through Gα(q) protein, we blocked Gα(q) signaling by crossing tetracycline-transactivating factor/V1A mice with transgenic mice that expressed a small inhibitory peptide against Gα(q). Gα(q) blockade abrogated the development of the heart failure phenotype in tetracycline-transactivating factor/V1A-TG mice. The heart failure phenotype could be reversed by administration of doxycycline. CONCLUSIONS: Our results demonstrate a role for V1A-mediated signaling in the development of heart failure and support a role for V1A blockade in the treatment of patients with elevated levels of vasopressin.

Obesity and other predictors of absenteeism in Philadelphia school children.

BACKGROUND: Limited data indicate that obese children are absent from school more than their normal-weight peers. We analyzed administrative data from a large urban school district to investigate the association of obesity and student sociodemographic characteristics with absenteeism. METHODS: We analyzed 291,040 records, representing 165,056 unique students (grades 1-12). Obesity status was classified according to Centers for Disease Control and Prevention age- and sex-specific percentiles for body mass index (BMI) and analyses were based on negative binomial regression. RESULTS: Overall rates of overweight and obesity were 17% and 20%, respectively, and the estimated absence rate was 17 absences per 180 student-days. Obesity was weakly associated with increased school absences. The association was present mainly among the most obese students (BMI >99th percentile), who had an 11% greater absence rate compared to normal-weight students. Compared to white students, Hispanics and African Americans had higher absence rates (14% and 10%, respectively), and Asians had lower absence rates (43%). Students eligible for free or reduced-cost meals had 24% higher absence rates than those who were not eligible. CONCLUSIONS: Overweight and obesity do not seem strongly associated with school absence, except among extremely obese children. Race and poverty appear to affect absences to a greater extent than overweight and obesity. Additional research is needed to investigate the contribution of contextual factors in schools and neighborhoods. This study suggests that data routinely collected in schools could be used to track childhood obesity and to efficiently evaluate public health interventions designed to decrease childhood obesity.

Race and response to colon cancer screening interventions.

OBJECTIVE: We report race-related differences in response to behavioral interventions in colorectal cancer (CRC) screening. METHODS: From 2002 through 2005, a total of 1430 primary care patients (578 whites and 852 African Americans) from Jefferson Family Medicine Associates, a large primary care practice affiliated with Thomas Jefferson University, completed a baseline survey and were randomized to 1 of 4 groups, as follows: control (usual care), standard intervention (SI), tailored intervention (TI), or tailored intervention plus phone (TIP). The SI group received a targeted print intervention by mail. The TI group received the targeted intervention and tailored message pages that addressed perceptions related to screening. The TIP group received the targeted intervention, tailored message pages, and a telephone reminder. RESULTS: CRC screening rates for whites and African Americans were comparable in usual care (33% versus 32%, respectively). In response to intervention, however, whites exhibited significantly higher (p=0.005) screening rates than African Americans (53% versus 43%, respectively; adjusted OR=1.44; 95% CI=1.12-1.86). This effect is largely explained by differential response to mailed print interventions. CONCLUSIONS: Whites and African Americans may respond differently to mailed interventions intended to increase CRC screening. Research is needed on methods that can both increase screening and racial equity in screening.

Relationships of total adiponectin and molecular weight fractions of adiponectin with free testosterone in African men and premenopausal women.

Adiponectin, a protein secreted by adipose tissue, has anti-inflammatory, antithrombogenic, and antidiabetogenic effects. Lower plasma adiponectin levels are present in diabetes, obesity, and the metabolic syndrome. Adiponectin levels are higher in women compared with men. The purpose of this study was to determine whether there is a relationship between total adiponectin, or the molecular weight fractions of adiponectin, and testosterone levels in African American men and premenopausal women. A sample (N=48) of men and premenopausal women was selected based on high and low serum-free testosterone level. All patients had data on blood pressure, metabolic risk factors, and sex hormone levels. Stored plasma samples were assayed for total adiponectin. Molecular weight fractions of adiponectin were separated by gel electrophoresis and quantified by Western blot. Data analysis compared adiponectin (total and fractions) levels with androgen status in both sexes. Among men with high testosterone levels, all fractions of adiponectin were significantly lower than those in men with low testosterone (P<.05). In women with high testosterone, total adiponectin (P=.02) and all fractions of molecular weight adiponectin (P<.05) were lower compared with those in women with low testosterone. Plasma adiponectin levels are lower in both men and premenopausal women with relatively higher testosterone levels.

Factors associated with colorectal cancer screening decision stage.

OBJECTIVE: This paper reports on factors associated with colorectal cancer (CRC) screening decision stage (SDS) in screening-eligible primary care patients. METHODS: Baseline telephone survey data (i.e., sociodemographic background, CRC screening perceptions, and SDS) were obtained for 1515 patients in a randomized behavioral intervention trial. Respondents reported SDS, a measure of proximity to actual screening, after listening to descriptions of screening stool blood testing and flexible sigmoidoscopy as had never heard of (NHO), were not considering or were undecided (NCU), or decided to do (DTD) each test. Polychotomous regression analyses were performed to differentiate participants by SDS. RESULTS: At baseline, SDS was distributed as follows: NHO (8%), NCU (41%), and DTD (51%). We found that individuals who had DTD compared to those who were NCU about screening were older (OR=0.64), had prior cancer screening (OR=1.43), believed screening is important (OR=3.44), and had high social support (OR=2.49). Persons who were NCU compared to NHO participants were female (OR=2.18), were white (OR=2.35), had prior cancer screening (OR=2.81), and believed screening is important (OR=2.44). CONCLUSIONS: Prior screening and belief in screening importance were found to be consistently associated with SDS across comparisons, while older age, gender, race, and social support were not.

Electronic medical records as a research tool: evaluating topiramate use at a headache center.

BACKGROUND: Electronic medical records (EMRs) are used in large healthcare centers to increase efficiency and accuracy of documentation. These databases may be utilized for clinical research or to describe clinical practices such as medication usage. METHODS: We conducted a retrospective analysis of EMR data from a headache clinic to evaluate clinician prescription use and dosing patterns of topiramate. The study cohort comprised 4833 unique de-identified records, which were used to determine topiramate dose and persistence of treatment. RESULTS: Within the cohort, migraine was the most common headache diagnosis (n = 3753, 77.7%), followed by tension-type headache (n = 338, 7.0%) and cluster or trigeminal autonomic cephalalgias (n = 287, 5.9%). Physicians prescribed topiramate more often for subjects with migraine and idiopathic intracranial hypertension (P < .0001) than for those with other conditions, and more often for subjects with coexisting conditions including obesity, bipolar disorder, and depression. The most common maintenance dose of topiramate was 100 mg/day; however, approximately 15% of subjects received either less than 100 mg/day or more than 200 mg/day. More than a third of subjects were prescribed topiramate for more than 1 year, and subjects with a diagnosis of migraine were prescribed topiramate for a longer period of time than those without migraine. CONCLUSIONS: Findings from our study using EMR demonstrate that physicians use topiramate at many different doses and for many off-label indications. This analysis provided important insight into our patient populations and treatment patterns.

Does intraoperative radiation therapy improve local tumor control in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma? A propensity score analysis.

BACKGROUND: Locoregional recurrence (LRR) is an important factor after pancreaticoduodenectomy (PD) for pancreatic cancer. Intraoperative radiation therapy (IORT) administered to the resection bed may improve local tumor control. METHODS: We performed a retrospective analysis of patients who underwent PD at Thomas Jefferson University Hospital (TJUH) between 1995 and 2005 to identify patients who underwent resection with and without IORT. Data collected included age, gender, complications, margin status, stage, survival, and recurrence. Unadjusted analyses of the IORT and non-IORT groups were performed using Fisher's chi-square method for discrete variables and Wilcoxon rank sum test for continuous variables. To account for biases in patient selection for IORT, a propensity score was calculated for each patient and adjusted statistical analyses were performed for survival and recurrence outcomes. RESULTS: Between January 1995 and November 2005, 122 patients underwent PD for periampullary tumors, including 99 pancreatic cancers. Of this group, 37 patients were treated with IORT, and there was adequate follow-up information for a group of 46 patients who underwent PD without IORT. The IORT group contained a higher percentage of Stage IIB or higher tumors (65%) than in the non-IORT group (39.1%), though differences in stage did not reach significance (P = .16). There was a nonsignificant decrease in the rate of LRR in patients who had IORT (39% non-IORT vs. 23% IORT, P = .19). The median survival time of patients who received IORT was 19.2 months, which was not significantly different than patients managed without IORT, 21.0 months (P = .78). In the propensity analyses, IORT did not significantly influence survival or recurrence after PD. CONCLUSIONS: IORT can be safely added to management approaches for resectable pancreatic cancer, with acceptable morbidity and mortality. IORT did not improve locoregional control and did not alter survival for patients with resected pancreatic cancer. IORT is an optional component of adjuvant chemoradiation for pancreatic cancer. In the future, IORT may be combined with novel therapeutic agents in the setting of a clinical trial in order to attempt to improve outcomes for patients with pancreatic cancer.

Impact of obesity on perioperative morbidity and mortality after pancreaticoduodenectomy.

BACKGROUND: Obesity has been implicated as a risk factor for perioperative and postoperative complications. The aim of this study was to determine the impact of obesity on morbidity and mortality in patients undergoing pancreaticoduodenectomy (PD). STUDY DESIGN: Between January 2000 and July 2007, 262 patients underwent PD at Thomas Jefferson University Hospital, of whom 240 had complete data, including body mass index (BMI; calculated as kg/m(2)) for analysis. Data on BMI, preoperative parameters, operative details, and postoperative course were collected. Patients were categorized as obese (BMI >or= 30), overweight (BMI >or= 25 and < 30), or normal weight (BMI < 25). Complications were graded according to previously published scales. Other end points included length of postoperative hospital stay, blood loss, and operative duration. Analyses were performed using univariate and multivariable models. RESULTS: There were 103 (42.9%) normal-weight, 71 (29.6%) overweight, and 66 (27.5%) obese patients. There were 5 perioperative deaths (2.1%), with no differences across BMI categories. A significant difference in median operative duration and blood loss between obese and normal-weight patients was identified (439 versus 362.5 minutes, p = 0.0004; 650 versus 500 mL, p = 0.0139). In addition, median length of stay was significantly longer for BMI (9.5 versus 8 days, p = 0.095). Although there were no significant differences in superficial wound infections, obese patients did have an increased rate of serious complications compared with normal-weight patients (24.2% versus 13.6%, respectively; p = 0.10). CONCLUSIONS: Obese patients undergoing PD have a substantially increased blood loss and longer operative time but do not have a substantially increased length of postoperative hospital stay or rate of serious complications. These findings should be considered when assessing patients for operation and when counseling patients about operative risk, but they do not preclude obese individuals from undergoing definitive pancreatic operations.

Meta-analysis: A brief introduction.

Meta-analysis is the process of combining data from multiple sources and analyzing it together to increase power and provide a clearer picture of the effect of intervention or exposure on an outcome. The process is not complicated, but requires a great deal of attention to detail. A specific set of inclusion criteria for studies must be defined. Published or available study results may be affected by publication bias of several different types, so the researcher should be sure to conduct a thorough search of available databases in order to include unpublished findings. Following selection, the group of studies should be examined using funnel plots or statistical tests. Meta-analysis models themselves must be selected to properly reflect the combined studies. Both fixed- and random-effects modeling are discussed. Two case studies are presented, illustrating a well-conducted meta-analysis and a meta-analysis that was more controversial.

Pretreatment FDG-PET standardized uptake value as a prognostic factor for outcome in head and neck cancer.

BACKGROUND: We studied the potential prognostic significance of pretreatment 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) standardized uptake value (SUV) in squamous cell carcinoma of the head and neck (SCCHN). METHODS: A retrospective review of the pretreatment FDG-PET scans of 60 patients with SCCHN was performed. All patients received radiotherapy and 37 also received concurrent chemotherapy. SUV was calculated by 2 nuclear-medicine physicians who were blinded to the clinical data. Disease-free survival (DFS) was analyzed with respect to SUV (and other potential prognostic factors). RESULTS: The median SUV was 7.2 (range, 1-24.7); 34 patients (57%) had SUV < 9.0 compared with 26 patients (43%) with an SUV > or = 9.0. The group with low SUV had significantly better 2-year DFS compared with the high SUV group (72% vs 37%), p = .007. On multivariate analysis, stage and age were also associated with DFS, but SUV remained an independent predictor of DFS (hazard ratio: 1.08; p = .016). CONCLUSION: SUV was significantly associated with outcome after modern definitive therapy of SCCHN.

Relationship of inferior vena cava filter usage in post-surgical patients by various surgical and medical subspecialists.

Venous thromboembolism is a common and often fatal problem in postsurgical patients. These patients are usually treated with either therapeutic anticoagulation or the placement of inferior vena cava (IVC) filters. Controversy surrounds the use of IVC filters, because no data exist proving survival benefit. In this study, 264 inpatient medical records of patients who underwent major surgical procedures and had the diagnosis of deep venous thrombosis or pulmonary embolism were examined. Among these patients, those who received IVC filters were identified, and the documented indications for filter placement were reviewed. Rates of IVC filter placement per venous thromboembolism event and specific indications were examined across surgical subspecialties and by type of medical consultant. Sixty percent of patients received IVC filters. IVC filter placement rates varied significantly across surgical subspecialties (p <0.0001), with the highest rate in the orthopedic surgery subgroup (80%). Rates of IVC filter use also differed significantly (p <0.0007) between medical consultants who specialized in antithrombotic medicine (46.8%) and those who did not (68.3%). Significant differences also existed in specific indications for filter placement between medical and surgical subspecialties. In conclusion, most of this study's population received IVC filters. Rates of IVC filter placement varied by the specialties of surgeons and medical consultants. The heterogeneity of treatment strategies coupled with the lack of data for this patient population highlights the need for future prospective studies to guide evidence-based treatment.

Use of over-the-counter analgesics in patients with chronic liver disease: physicians' recommendations.

BACKGROUND: Over-the-counter analgesics (OTCAs), principally paracetamol (acetaminophen)-containing compounds and NSAIDs, are commonly used medications. Guidelines for the use of these agents in patients with chronic liver disease (CLD) are not available, despite the possibility that such patients may be more susceptible to the effects of an adverse reaction. Notwithstanding the lack of guidelines for healthcare providers, patients are often counselled to modify their use of these drugs. Therefore, the primary aim of this study was to assess healthcare providers' recommendations on how OTCAs should be used by patients with CLD. METHODS: An 11-question web-based survey was distributed via email to healthcare providers participating in four healthcare networks in the US, to determine what recommendations they make to patients with cirrhosis (compensated and decompensated) and chronic hepatitis regarding the use of paracetamol and NSAIDs. Healthcare providers were also queried about the recommendations they make to patients with cirrhosis regarding pain control, and on the use of paracetamol for patients who consume alcohol daily. RESULTS: Overall, a 12% response rate was obtained. Internal medicine, family practice, paediatrics, and gastroenterology were the most represented practice types. Recommendations against the use of NSAIDs were significantly less common than recommendations against paracetamol use, in cases of both compensated and decompensated cirrhosis (p = 0.001). Non-gastroenterologists and non-primary care physicians were the least likely to recommend against NSAID use (p = 0.001), while gastroenterologists were the least likely to recommend against paracetamol in these patients (p = 0.001). It was the recommendation of most respondents that OTCAs should be avoided in patients with cirrhosis, and that paracetamol should be avoided or its dose reduced in the setting of daily alcohol use. CONCLUSIONS: Significant variability exists among healthcare providers on their recommendations for OTCA use in the setting of chronic liver disease. Non-gastroenterologists are more likely to recommend against the use of paracetamol than NSAIDs, and patients with chronic liver disease may be under-treated for pain.