Application of the Kaiser score to increase diagnostic accuracy in equivocal lesions on diagnostic mammograms referred for MR mammography.

INTRODUCTION: We aimed to interpret MR mammography (MRM) using the Kaiser scores for equivocal or inconclusive lesions on mammography (MG). METHODS: Retrospective IRB-approved evaluation of 3623 MG for which MRM was deployed as a problem-solving tool, after inclusion-exclusion criteria were met. Three readers with different levels of experience assigned a final score from 1 to 11 based on the previously established tree classification system. Area under the curve (AUC) derived from receiver operating characteristic (ROC) analysis was used to determine the overall diagnostic performance for all lesions and separately for mass and non-mass enhancement. Sensitivity, specificity, and likelihood ratio values were obtained at different cut-off values of >4, > 5, and > 8 to rule in and rule out malignancy. RESULT: Histopathology of 183 mass and 133 non-mass enhancement (NME) lesions show benign etiology in 95 and malignant in 221. The AUC was 0.796 [0.851 for mass and 0.715 for NME]. Applying the Kaiser score upgraded 202 lesions with correct prediction in 77 %, and downgraded 28 lesions with correct prediction in 60.8 %. Using a score <5 instead of <4 to rule out malignancy improved our diagnostic ability to correctly identify 100 % benign lesions. Applying Kaiser score correctly downgraded 60.8 % (17/28) lesions; thus avoiding biopsies in these. Using a high cut-off value>8 to rule-in malignancy, we correctly identified 59.7 % of lesions with 80 % specificity and positive likelihood ratio of 3. CONCLUSION: The Kaiser score has clinical translation benefits when used as a problem-solving tool for inconclusive MG findings.

Value of diffusion MR imaging in differentiation of recurrent head and neck malignancies from post treatment changes.

PURPOSE: Role of diffusion-weighted (DW) MR imaging in differentiating residual or recurrent neck malignancies from postoperative/post-radiation changes with histopathological correlation and comparison with PET-CT. METHODS AND MATERIALS: Prospective observational study for a period of 1 year in 62 post-radiation/post-operative patients suspected to have residual/recurrent tumors of neck with lesion diameter more than 5 mm measured on MRI. RESULTS: Mean ADC for recurrent/residual tumors: 1.008 ±â€¯0.220 × 10-3 mm2/s - significantly lower than mean ADC value for post-treatment changes of 1.69 ±â€¯0.40 × 10-3 mm2/s (p < 0.0001). The overall diagnostic accuracy, positive predictive value (PPV) and negative predictive value (NPV) of the qualitative assessment for the use of DWI in differentiating tumors recurrence from post-treatment changes were 96.6%, 96% and 83.3%, respectively. Upon quantitative analysis of the DW imaging data, a threshold ADC value of 1.3 × 10-3 mm2/s used for differentiating between post-treatment changes and recurrent cancers showed the highest combined sensitivity of 94%, specificity of 83.3%, accuracy of 93.6%, positive predictive value of 95.9%, and negative predictive value of 83.3%. CONCLUSION: DW MRI is a promising non-invasive MRI technique used to differentiate recurrent/residual head and neck malignancies from posttreatment changes based on ADC values. DWI offers advantage as it has a short scanning time and can be safely added to standard MRI protocol with minimum patient discomfort. Complementary use of DWI and PET/CT imaging may increase diagnostic confidence for differentiating recurrent disease from radiation therapy-induced changes after 6-12 months in posttreatment cases.

Improvement of early detection of breast cancer through collaborative multi-country efforts: Observational clinical study.

AIM: The aim of this paper is to present baseline imaging data and the improvement that was achieved by the participating centers after applying practice-specific interventions that were identified during the course of a multicentric multinational research coordinated project. INTRODUCTION: The incidence and mortality rates from breast cancer are rising worldwide and particularly rapidly across the countries with limited resources. Due to lack of awareness and screening options it is usually detected at a later stage. Breast cancer screening programs and even clinical services on breast cancer have been neglected in such countries particularly due to lack of available equipment, funds, organizational structure and quality criteria. MATERIALS AND METHODS: A harmonized form was designed in order to facilitate uniformity of data collection. Baseline data such as type of equipment, number of exams, type and number of biopsy procedures, stage of cancer at detection were collected from 10 centers (9 countries: Bosnia-Herzegovina, Costa Rica, Egypt, India, North Macedonia, Pakistan, Slovenia, Turkey, Uganda) were collected. Local practices were evaluated for good practice and specific interventions such as training of professionals and quality assurance programs were identified. The centers were asked to recapture the data after a 2-year period to identify the impact of the interventions. RESULTS: The data showed increase in the number of training of relevant professionals, positive changes in the mammography practice and image guided interventions. All the centers achieved higher levels of success in the implementation of the quality assurance procedures. CONCLUSION: The study has encountered different levels of breast imaging practice in terms of expertise, financial and human resources, infrastructure and awareness. The most common challenges were the lack of appropriate quality assurance programs and lack of trained skilled personnel and lack of high-quality equipment. The project was able to create higher levels of breast cancer awareness, collaboration amongst participating centers and professionals. It also improved quality, capability and expertise in breast imaging particularly in centers involved diagnostic imaging.

Role of ADC values in assessing clinical response and identifying residual disease post-chemo radiation in uterine cervix cancer.

OBJECTIVES: To evaluate the role of apparent diffusion coefficient (ADC) values in assessing response after chemo-radiotherapy in cervix cancer and investigate the utility of ADC as a tool to identify residual disease, after the treatment completion. METHODS: A prospective study was done in 100 patients with histopathologically proven cancer of uterine cervix who were classified as either complete response (CR) or residual disease posttreatment. MRI was done pretreatment and after 6 weeks post-treatment with chemo-radiation. 53 patients among the cohort also underwent a fluoro-deoxy glucose positron-emission computed tomography (FDG-PET CT). ADC values, change in ADC values, and metabolic activity obtained from FDG-PET CT were correlated with clinical outcome, and statistical analysis was done to determine the better tool for assessing response evaluation between ADC and PET-CT. RESULTS: Residual lesions have notably lower ADC value than that of posttreatment changes. The mean ADC values of residual tumors: 1.26 ± 0.238 × 10-3 mm2/s and mean ADC values of lesions due to posttreatment changes: 1.540 ± 0.218 × 10-3 mm2/s (statistically significant difference between malignant and posttreatment lesions, P < 0.05). ADC has 67% sensitivity, 83% specificity, 35% positive predictive values (PPV), 95% negative predictive values (NPV), and 81% accuracy in differentiating residual disease from post treatment changes. PPV, NPV, sensitivity, and specificity with PET-CT were 93%, 89%, 98%, and 73%, respectively. PPV, NPV, sensitivity, and specificity of contrast MRI were 16%, 91%, 58%, and 59%, respectively. CONCLUSION: Diffusion imaging differentiates residual cervix malignancies from post treatment changes based on ADC values and can be a promising and evocative biomarker. Complimentary use of ADC and PET/CT may increase diagnostic confidence.

Comparing the diagnostic efficacy of full field digital mammography with digital breast tomosynthesis using BIRADS score in a tertiary cancer care hospital.

INTRODUCTION: Breast cancer is one of the leading cancers in females worldwide, and its incidence has been rising at an exponential pace in the last 10 years even in India. Mammography has been the mainstay for detection of breast cancer over decades and has gradually advanced from screen film to full-field digital mammography. Recently, tomosynthesis has evolved as an advanced imaging investigation for early diagnosis of breast lesions in both diagnostic and screening settings. AIM OF STUDY: To compare and evaluate the impact of digital breast tomosynthesis (DBT) compared to full-field digital mammography (FFDM) in the interpretation of BIRADS score in both diagnostic and screening settings. SETTINGS AND DESIGN: A 1-year prospective longitudinal study was conducted in the Department of Radio-diagnosis in our institute using Hologic Selenia Dimensions for mammography as well as tomosynthesis. MATERIALS AND METHODS: One hundred women known or suspected (opportunistic screening) for breast cancer were evaluated either with FFDM alone or both FFDM and DBT. Sensitivity, specificity, positive predictive value, negative predictive value, and P value were used to assess the various diagnostic criteria in our study. RESULTS: Addition of DBT to FFDM results in a statistically significant increase in the sensitivity, specificity, and positive predictive value, and a statistically significant decrease in the false positive rates. Similar results were noted in both diagnostic and screening cases. It was observed that, in most cases, i.e. a total of 47, DBT did not change the BIRADS scoring; however, its addition increased the diagnostic confidence. BIRADS was upgraded and downgraded in 14 and 31 cases, respectively, with the addition of DBT to FFDM. New lesions were seen with addition of DBT to FFDM in 8 cases. CONCLUSION: Addition of DBT to FFDM results in increase in sensitivity, specificity, positive predictive value, and a statistically significant decrease in false positive rates in both diagnostic and screening cases. As addition of tomosynthesis results in a significant decrease in recall rate, it should be added, at least, in all screening mammography programs.

Improvement of early detection of breast cancer through collaborative multi-country efforts: Medical physics component.

PURPOSE: The International Atomic Energy Agency (IAEA) through a Coordinated Research Project on "Enhancing Capacity for Early Detection and Diagnosis of Breast Cancer through Imaging", brought together a group of mammography radiologists, medical physicists and radiographers; to investigate current practices and improve procedures for the early detection of breast cancer by strengthening both the clinical and medical physics components. This paper addresses the medical physics component. METHODS: The countries that participated in the CRP were Bosnia and Herzegovina, Costa Rica, Egypt, India, Kenya, the Frmr. Yug. Rep. of Macedonia, Mexico, Nigeria, Pakistan, Philippines, Slovenia, Turkey, Uganda, United Kingdom and Zambia. Ten institutions participated using IAEA quality control protocols in 9 digital and 3 analogue mammography equipment. A spreadsheet for data collection was generated and distributed. Evaluation of image quality was done using TOR MAX and DMAM2 Gold phantoms. RESULTS: QC results for analogue equipment showed satisfactory results. QC tests performed on digital systems showed that improvements needed to be implemented, especially in thickness accuracy, signal difference to noise ratio (SDNR) values for achievable levels, uniformity and modulation transfer function (MTF). Mean glandular dose (MGD) was below international recommended levels for patient radiation protection. Evaluation of image quality by phantoms also indicated the need for improvement. CONCLUSIONS: Common activities facilitated improvement in mammography practice, including training of medical physicists in QC programs and infrastructure was improved and strengthened; networking among medical physicists and radiologists took place and was maintained over time. IAEA QC protocols provided a uniformed approach to QC measurements.

Tricyclic Antidepressants Found in Pilots Fatally Injured in Civil Aviation Accidents.

Prevalence of tricyclic antidepressants (TCAs) has not been explored in pilots. The National Transportation Safety Board (NTSB) aviation accident and the Federal Aviation Administration's Civil Aerospace Medical Institute (CAMI) toxicology and medical certification databases were searched for pilots fatally injured in aviation accidents. During 1990-2012, CAMI received bio-samples of pilots from 7037 aviation accidents. Of these, 2644 cases were positive for drugs. TCAs were present in 31. TCA blood concentrations ranged from therapeutic to toxic levels. The NTSB determined that the use of drugs and ethanol as the probable cause or contributing factor in 35% (11 of 31) of the accidents. None of the 31 pilots reported the use of TCAs during their aviation medical examination. The prevalence of TCAs in aviators was less than 0.5% (31 of 7037 cases). There is a need for aviators to fully disclose the use of medications at the time of their medical examination.

Ethanol and Drugs Found in Civil Aviation Accident Pilot Fatalities, 1989-2013.

BACKGROUND: Biological specimens from pilots fatally injured in civil aviation accidents are analyzed for ethanol and drugs at the Civil Aerospace Medical Institute (CAMI). Prevalence of these substances in the pilots has been evaluated at 5-yr intervals since 1989. In continuation, a fifth 5-yr study (2009-2013) was conducted. METHODS: The CAMI toxicology/medical certification and National Transportation Safety Board (NTSB) aviation accident databases were searched. RESULTS: During 2009-2013, samples from 1169 pilots were analyzed. Aircraft involved in the accidents were primarily operating under general aviation. Most airmen were private pilots and held third-class medical certificates. In relation to the first 5-yr (1989-1993) period, the pilot fatality cases decreased by 37% and the presence of ethanol and/or drugs in the pilots increased by 239% in the fifth 5-yr period. The ethanol usage was unchanged, but increases were 267% and 583% with illicit and prescription drugs, respectively. The use of ethanol and/or drugs by aviators, along with underlying medical conditions, was determined by the NTSB to be cause/factors in 5% of the accidents. CONCLUSION: The observed decrease in the fatality cases does not necessarily suggest the decrease in aviation accidents, as active airmen numbers also declined. The increase in the drug positive cases is primarily attributed to the continuous rise in the use of prescription drugs. Although prevalence of ethanol and drugs has been evaluated in fatally injured aviators, such evaluation has not been performed in active pilots not involved in accidents. This type of comparative study would be crucial in assessing aviation safety.

Distribution of ∆(9)-Tetrahydrocannabinol and 11-Nor-9-Carboxy-∆(9)-Tetrahydrocannabinol Acid in Postmortem Biological Fluids and Tissues From Pilots Fatally Injured in Aviation Accidents.

Little is known of the postmortem distribution of ∆(9)-tetrahydrocannabinol (THC) and its major metabolite, 11-nor-9-carboxy-∆(9)-tetrahydrocannabinol (THCCOOH). Data from 55 pilots involved in fatal aviation accidents are presented in this study. Gas chromatography/mass spectrometry analysis obtained mean THC concentrations in blood from multiple sites, liver, lung, and kidney of 15.6 ng/mL, 92.4 ng/g, 766.0 ng/g, 44.1 ng/g and mean THCCOOH concentrations of 35.9 ng/mL, 322.4 ng/g, 42.6 ng/g, 138.5 ng/g, respectively. Heart THC concentrations (two cases) were 184.4 and 759.3 ng/g, and corresponding THCCOOH measured 11.0 and 95.9 ng/g, respectively. Muscle concentrations for THC (two cases) were 16.6 and 2.5 ng/g; corresponding THCCOOH, "confirmed positive" and 1.4 ng/g. The only brain tested in this study showed no THC detected and 2.9 ng/g THCCOOH, low concentrations that correlated with low values in other specimens from this case. This research emphasizes the need for postmortem cannabinoid testing and demonstrates the usefulness of a number of tissues, most notably lung, for these analyses.

In vitro absorption of atmospheric carbon monoxide and hydrogen cyanide in undisturbed pooled blood.

Blood samples from aircraft accident victims are analyzed for carboxyhemoglobin (COHb) and cyanide ion (CN(-)). Such victims often suffer open wounds near the autopsy blood collection sites. Many aircraft crashes result in fires that fill the victim's atmosphere with smoke that is rich in carbon monoxide (CO) and hydrogen cyanide (HCN). It is important to determine whether pooled blood in those wounds may have absorbed these gases after death, which could lead one to erroneously conclude that the presence of COHb and CN(-) in blood was the result of breathing in these gases. A laboratory desiccator was used as a chamber to establish whether CO or HCN may be absorbed in undisturbed, pooled blood. COHb levels were 4.3-11.0% after exposure to CO (5,532, 8,298, 11,064, 22,129 and 33,193 ppm) for 30 and 60 min. Blood CN(-) concentrations (1.43-5.01 µg/mL) increased with exposure to HCN at 100 and 200 ppm, each at 15, 30, 45 and 60 min. The observed COHb increases do not exclude the possibility for higher COHb levels in blood exposed to highly CO-rich atmospheres, but there is a strong potential for CN(-) levels to increase by the absorption of atmospheric HCN. Thus, postmortem COHb and CN(-) levels should be carefully interpreted.

Toxicological findings in fatally injured pilots of 979 amateur-built aircraft accidents.

BACKGROUND: Specimens from aviation accident pilot fatalities are submitted to the Civil Aerospace Medical Institute (CAMI) for toxicological analyses. Trends of fatal amateur-built aircraft accidents and toxicological findings in the associated pilot fatalities have not been examined. METHODS: Fatal amateur-built aircraft accidents that occurred during 1990-2009 were evaluated by retrieving information from the CAMI toxicology database. Probable cause/factor in the amateur-built aircraft mishaps were obtained from the National Transportation Safety Board's (NTSB's) aviation accident database. RESULTS: Of 6309 fatal aviation accidents from which CAMI received postmortem samples, 979 (16%) were related to amateur-built aircraft. There was a decreasing trend in non-amateur-built aircraft accidents, but an increasing trend in amateur-built aircraft accidents. In the 979 accidents, 392 pilots (40%) were positive for ethanol and/or drugs. In these 392 accidents also, the review showed a decreasing trend with non-amateur-built aircraft and an increasing trend with amateur-built aircraft. Percentages of pilots with prescription drugs were 26% for amateur-built aircraft, 16% for non-amateur-built aircraft, and 18% for all aircraft. Ethanol/drug use and medical condition were determined to be a cause/factor in 42 (11%) of the 385 ethanol/ drug-positive amateur-built aircraft accidents investigated by the NTSB. DISCUSSION: Drugs found in the pilots were consistent with commonly used medications in the general population. The contributory role of mechanical malfunction of home-built aircraft cannot be ruled out in the observed increasing trends in their accidents, with or without ethanol and/or drugs. Regardless, the increasing trends of such accidents are of significant concern.

Effects of fluid load on human urine characteristics related to workplace drug testing.

During workplace drug testing, urine is tested for dilution, substitution and adulteration. Donors argue that these findings are due to medical, health or working conditions or diet and genetic differences. There is a paucity of data correlating changes in urine characteristics after a fluid load to various body parameters. Therefore, five urine specimens (one in the morning, one prior to drinking 800 mL of a beverage, and three time intervals thereafter) from 12 males and 12 females were tested for four different beverages on separate occasions. Of the 480 samples, 376 were in sufficient amounts. Of these 376, 36 (10%) had creatinine <20 mg/dL but ≥2 mg/dL; 27 (75%) of 36 had specific gravity <1.0030 but >1.0010. Thus, these 27 samples can be considered to be dilute; 20 (74%) of 27 were from females. For males with at least one dilute sample, body fat was 11% less and resting metabolic rate (RMR) was 29% more than males with no dilute samples (p > 0.05); for females with at least one dilute sample, height was 8% less and weight 20% less than females with no dilute samples (p > 0.05). Individuals with a higher RMR appear to have a greater potential for producing dilute urine specimens than those with a lower RMR. Thus, a dilute sample does not necessarily indicate that it was intentionally diluted. Such samples must be carefully evaluated in consideration with recent consumption of liquid by donors to avoid false accusations.

Drugs and alcohol found in civil aviation accident pilot fatalities from 2004-2008.

INTRODUCTION: The Federal Aviation Administration (FAA) Office of Aerospace Medicine sets medical standards needed to protect the public and pilots from death or injury due to incapacitation of the pilot. As a part of this process, toxicology testing is performed by the FAA on almost every pilot who is fatally injured in an aviation accident to determine the medical condition of the pilot, medications used by the pilot at the time of the accident, and the extent of impairment, if any. METHOD: The data were extracted from the FAA toxicology database for all pilots who died from 2004 to 2008 in aviation accidents. RESULTS: The laboratory received and tested specimens from 1353 pilots who died in aviation accidents between 2004 and 2008; 507 of these pilots were found to be taking drugs and 92 had ethanol in excess of 0.04 g x dl(-1). DISCUSSION: This study was conducted to determine the extent of drug use in pilots who have died in aviation accidents from 2004 to 2008 and to determine the types of drugs most commonly found. A comparison of previously published reports with this study's report was made to determine trends in drug use by pilots who have died in aviation accidents over the past 20 yr. Factors were discussed that could influence drug trends. Diphenhydramine, an H1 antihistamine with impairing properties, is the most commonly found drug in pilots who died in an aviation accident.

Toxicological findings in 889 fatally injured obese pilots involved in aviation accidents.

Prevalence of drugs in fatally injured obese pilots involved in aviation accidents has not been evaluated. Therefore, toxicological findings in such pilots (body mass index ≥30 kg/m(2) ) were examined in a data set derived from the Civil Aerospace Medical Institute's (CAMI's) Scientific Information System for 1990-2005. Aeromedical histories of these aviators were retrieved from the CAMI medical certification and toxicology databases, and the cause/factors in the related accidents from the National Transportation Safety Board's database. In 311 of the 889 pilots, carbon monoxide, cyanide, ethanol, and drugs were found, and glucose and hemoglobin A(1c) were elevated. Of the 889 pilots, 107 had an obesity-related medical history. The health and/or medical condition(s) of, and/or the use of ethanol and/or drugs by, pilots were the cause/factors in 55 (18%) of the 311 accidents. Drugs found were primarily for treating obesity-related medical conditions such as depression, hypertension, and coronary heart disease.

Aerospace toxicology overview: aerial application and cabin air quality.

Aerospace toxicology is a rather recent development and is closely related to aerospace medicine. Aerospace toxicology can be defined as a field of study designed to address the adverse effects of medications, chemicals, and contaminants on humans who fly within or outside the atmosphere in aviation or on space flights. The environment extending above and beyond the surface of the Earth is referred to as aerospace. The term aviation is frequently used interchangeably with aerospace. The focus of the literature review performed to prepare this paper was on aerospace toxicology-related subject matters, aerial application and aircraft cabin air quality. Among the important topics addressed are the following: · Aerial applications of agricultural chemicals, pesticidal toxicity, and exposures to aerially applied mixtures of chemicals and their associated formulating solvents/surfactants The safety of aerially encountered chemicals and the bioanalytical methods used to monitor exposures to some of them · The presence of fumes and smoke, as well as other contaminants that may generally be present in aircraft/space vehicle cabin air · And importantly, the toxic effects of aerially encountered contaminants, with emphasis on the degradation products of oils, fluids, and lubricants used in aircraft, and finally · Analytical methods used for monitoring human exposure to CO and HCN are addressed in the review, as are the signs and symptoms associated with exposures to these combustion gases. Although many agricultural chemical monitoring studies have been published, few have dealt with the occurrence of such chemicals in aircraft cabin air. However, agricultural chemicals do appear in cabin air; indeed, attempts have been made to establish maximum allowable concentrations for several of the more potentially toxic ones that are found in aircraft cabin air. In this article, I emphasize the need for precautionary measures to be taken to minimize exposures to aerially encountered chemicals, or aircraft cabin air contaminants and point out the need for future research to better address toxicological evaluation of aircraft-engine oil additives.

The Attitudes of Indian Palliative-care Nurses and Physicians to Pain Control and Palliative Sedation.

AIM: We wanted to assess Indian palliative-care nurses and physicians' attitudes toward pain control and palliative sedation. MATERIALS AND METHODS: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programs in New Delhi, using a semi-structured questionnaire, and following grounded-theory methodology (Glaser and Strauss). RESULTS: The interviewees did not consider administration of painkillers in large doses an ethical problem, provided the pain killers are properly titrated. Mild palliative sedation was considered acceptable. The interviewees disagreed whether palliative sedation can also be deep and continuous. Arguments mentioned against deep continuous palliative sedation were the conviction that it may cause unacceptable side effects, and impedes basic daily activities and social contacts. A few interviewees said that palliative sedation may hasten death. CONCLUSION: Due to fears and doubts regarding deep continuous palliative sedation, it may sometimes be too easily discarded as a treatment option for refractory symptoms.

Resolution of aviation forensic toxicology findings with the aid of DNA profiling.

Body components of aviation accident fatalities are often scattered, disintegrated, commingled, contaminated, and/or putrefied at accident scenes. These situations may impose difficulties in victim identification/tissue matching. The prevalence of misidentification in relation to aviation accident forensic toxicology has not been well established. Therefore, the Civil Aerospace Medical Institute (CAMI) toxicology database was searched for the 1998-2008 period for those cases wherein DNA profiling was performed to resolve identity issue of the samples submitted to CAMI for toxicological evaluation. During this period, biological samples from the casualties of a total of 3523 accidents were submitted to CAMI. The submitted samples were primarily from pilots. Out of the 3523 accidents, at least, one fatality had occurred in 3366 (≈ 96%) accidents; thus, these accidents were considered fatal accidents. Accordingly, biological samples from 3319 pilots (3319 of the 3366 accidents) were received at CAMI for toxicological testing. Of these 3319 pilots, 3275 (≈ 99%) were fatally injured. DNA profiling was performed in 15 (≈ 0.5%) of the 3319 accidents. The profiling was conducted upon the requests of families in two accidents, accident investigators in three, and pathologists in four. In six accidents, contradictory toxicological findings led CAMI to initiate DNA profiling. The requests made by families and investigators were primarily triggered by inconsistency between the toxicological results and the history of drug use of the victims, while by pathologists because of commingling of samples. In three (20%) of the 15 accidents, at least one submitted sample was misidentified or mislabeled. The present study demonstrated that the number of aviation accident cases requiring DNA profiling was small and this DNA approach was effectively applied in resolving aviation toxicology findings associated with those accidents.

Can curative or life-sustaining treatment be withheld or withdrawn? The opinions and views of Indian palliative-care nurses and physicians.

INTRODUCTION: Decisions to withdraw or withhold curative or life-sustaining treatment can have a huge impact on the symptoms which the palliative-care team has to control. Palliative-care patients and their relatives may also turn to palliative-care physicians and nurses for advice regarding these treatments. We wanted to assess Indian palliative-care nurses and physicians' attitudes towards withholding and withdrawal of curative or life-sustaining treatment. METHOD: From May to September 2008, we interviewed 14 physicians and 13 nurses working in different palliative-care programmes in New Delhi, using a semi-structured questionnaire. For the interviews and analysis of the data we followed Grounded-Theory methodology. RESULTS: Withholding a curative or life-sustaining treatment which may prolong a terminal cancer patient's life with a few weeks but also has severe side-effects was generally considered acceptable by the interviewees. The majority of the interviewees agreed that life-sustaining treatments can be withdrawn in a patient who is in an irreversible coma. The palliative-care physicians and nurses were of the opinion that a patient has the right to refuse life-saving curative treatment. While reflecting upon the ethical acceptability of withholding or withdrawal of curative or life-sustaining treatment, the physicians and nurses were concerned about the whole patient and other people who may be affected by the decision. They were convinced they can play an important advisory role in the decision-making process. CONCLUSION: While deciding about the ethical issues, the physicians and nurses do not restrict their considerations to the physical aspects of the disease, but also reflect upon the complex wider consequences of the treatment decisions.

Postmortem aviation forensic toxicology: an overview.

An overview of the subtopic aviation combustion toxicology of the field of aerospace toxicology has been published. In a continuation of the overview, the findings associated with postmortem aviation forensic toxicology are being summarized in the present overview. A literature search for the period of 1960-2007 was performed. The important findings related to postmortem toxicology were evaluated. In addition to a brief introduction, this overview is divided into the sections of analytical methods; carboxyhemoglobin and blood cyanide ion; ethanol; drugs; result interpretation; glucose and hemoglobin A(1c); and references. Specific details of the subject matter were discussed. It is anticipated that this overview will be an outline source for aviation forensic toxicology within the field of aerospace toxicology.