Early-stage Mycosis Fungoides: Epidemiology and Prognosis.

Most patients with mycosis fungoides are diagnosed with early-stage disease. However, prevalence of early-stage disease is unknown, and evidence of its burden is scarce. The aim of this study is to estimate the prevalence of early-stage mycosis fungoides, how long patients live with early-stage disease and to characterise these patients. Data were obtained from 4 key publications and from US cancer registries (Surveillance, Epidemiology and End Results Program; SEER). The derived incidence of early-stage mycosis fungoides was 0.26/100,000 (UK), 0.29/100,000 (US) and 0.38/100,000 (US-SEER) and the prevalence was 4.8/100,000 (UK), 5.2/100,000 (US) and 6.6/100,000 (US-SEER). Early-stage disease may last for 18 years. From SEER registries, 3,132 were diagnosed at early stage (mostly stage IA). Median age at diagnosis was 58 years. Compared with stage IA, the relative risk of death was 1.3 for stage IB and 3.5 for stage IIA. We confirm the rarity of early-stage mycosis fungoides, a differential prognosis and the potential for elevated burden of disease.

NEUROLOGIC AND COMPUTED TOMOGRAPHY FINDINGS IN SEA TURTLES WITH HISTORY OF TRAUMATIC INJURY.

Boat strikes have been widely documented as a major cause of anthropogenic trauma and mortality in sea turtles. Axial trauma in these species involves the head and/or carapace and may cause severe damage to the nervous and pulmonary systems. The aims of this study were to develop an updated protocol for neurologic examinations in sea turtles, to describe computed tomography (CT) findings in sea turtles with sustained trauma, and to associate CT findings with neurologic status in sea turtles with and without traumatic injury. Ten sea turtles were examined, six green (Chelonia mydas) and four loggerhead (Caretta caretta) turtles: seven underwent neurologic and CT examinations, two had CT examinations only, and one had a neurologic examination only. The updated neurologic examination protocol was considered useful in differentiating normal from abnormal neurologic status, however some of these tests remain unreliable in sea turtles. Sea turtles with no history of trauma were found to have normal carapace shape, vertebral column, and neurologic status. Sea turtles with history of traumatic injury (more than 10 years prior to examination) had findings dependent on trauma site. Those with head trauma had variable presentations dependent on location of injury; while those with carapace trauma had varying degrees of kyphosis, lordosis, and scoliosis of the carapace, vertebral fractures, and paraparesis. Kyphosis of the carapace was associated with vertebral fractures detected on CT; however, the severity of vertebral abnormalities was not associated with the severity of neurologic deficits. These findings suggest that a combination of neurologic and CT examination may be beneficial in determining clinical significance of carapace deformation and associated neurologic deficits in sea turtles with traumatic injury.

Measurement of Quality of Life in Patients with Mycosis Fungoides/Sézary Syndrome Cutaneous T-Cell Lymphoma: Development of an Electronic Instrument.

BACKGROUND: Although the quality of life (QoL) plays an important role in treatment decision making and clinical management of mycosis fungoides (MF) or Sézary syndrome (SS) subtypes of cutaneous T-cell lymphomas (MF/SS-CTCLs), an MF- or SS-specific measure of QoL does not exist. OBJECTIVE: The objective of this research was to develop and validate the first QoL instrument for MF/SS-CTCL using a patient-centered approach. METHODS: A conceptual framework for the MF/SS-CTCL QoL was developed through a literature review and interviews with key opinion leaders. Concept elicitation with patients was utilized to refine the conceptual model and generate preliminary items. The items were then revised based on qualitative and quantitative feedback obtained through cognitive debriefing surveys and interviews with patients. Next, participants (N=126) completed the preliminary MF/SS-CTCL QoL and a comparator measure of health-related QoL (Skindex-29) through the PatientsLikeMe Open Research Exchange. The MF/SS-CTCL QoL was completed again 5 days later by 66 participants for the purposes of evaluating test-retest reliability. The MF/SS-CTCL QoL was finalized based on results from an empirical evaluation, which included both classical and modern test theory approaches. Specifically, this included evaluation of (1) the optimal item response theory measurement model; (2) item fit; (3) unidimensionality; (4) rating scale performance; (5) reliability; (6) test information (precision); (7) person-to-item map; (8) convergent and discriminant validity; and (9) presence of bias via differential item function. RESULTS: Results from the comprehensive psychometric evaluation utilizing a Rasch-Grouped Rating Scale model yielded a final 12-item instrument. The rating scale functioned as expected, and the instrument exhibited adequate person reliability (.87), good to excellent test-retest reliability (r=.89, P<.001), high levels of measurement precision, and good person-to-item targeting. The correlation between the MF/SS-CTCL QoL and the Skindex-29 (r=.852, P<.001) was significantly greater than the correlation between the MF/SS-CTCL QoL and syndrome stage (r=.260, P<.001), providing support for convergent and discriminant validity. Items did not show significant bias based on gender, age, or race. Rasch scores were converted to scaled scores with qualitative descriptive categories for ease of interpretation. CONCLUSIONS: Empirical evaluation demonstrated strong evidence of excellent psychometric properties. Utilizing a patient-centered measure development approach ensures that this QoL instrument captures the information that is most meaningful and clinically relevant to patients.

Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.

OBJECTIVE:  To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding. DESIGN:  International multicentre prospective study. SETTING:  Six large hospitals in Europe, North America, Asia, and Oceania. PARTICIPANTS:  3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding. MAIN OUTCOME MEASURES:  Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined. RESULTS:  The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P<0.001). A Glasgow Blatchford score of ≤1 was the optimum threshold to predict survival without intervention (sensitivity 98.6%, specificity 34.6%). The Glasgow Blatchford score was better at predicting endoscopic treatment (AUROC 0.75) than the AIMS65 (0.62) and admission Rockall scores (0.61) (both P<0.001). A Glasgow Blatchford score of ≥7 was the optimum threshold to predict endoscopic treatment (sensitivity 80%, specificity 57%). The PNED (AUROC 0.77) and AIMS65 scores (0.77) were best at predicting mortality, with both superior to admission Rockall score (0.72) and Glasgow Blatchford score (0.64; P<0.001). Score thresholds of ≥4 for PNED, ≥2 for AIMS65, ≥4 for admission Rockall, and ≥5 for full Rockall were optimal at predicting death, with sensitivities of 65.8-78.6% and specificities of 65.0-65.3%. No score was helpful at predicting rebleeding or length of stay. CONCLUSIONS:  The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited.Trial registration Current Controlled Trials ISRCTN16235737.

Prevalence of Presenting Conditions in Grey Seal Pups (Halichoerus grypus) Admitted for Rehabilitation.

A retrospective survey was performed on the presenting conditions of 205 live grey seal pups (Halichoerus grypus) admitted to the Cornish Seal Sanctuary in Gweek, United Kingdom between May 2005 and March 2011. The purpose of the survey was to examine the prevalence of various presenting signs at the sanctuary. The presenting signs were classified into nine non-mutually exclusive categories: ocular disorders, nasal disorders, oral disorders, respiratory disorders, orthopaedic disorders, puncture wounds, abrasions, netting injuries, and onychia. The sex ratio of seal pups in this study was 1.35 males per female. Of the 205 examined for rehabilitation, 22 (10.73%) did not survive to release. 68.78% of grey seal pups presented with puncture wounds, 47.80% with respiratory disorders, 46.34% with ocular disorders, 42.63% malnourished, 36.59% with abrasions, 25.37% with oral disorders, 23.90% with nasal disorders, 11.71% with orthopaedic disorders, 9.27% with onychia, and 3.41% presented with netting injuries. 52% were normothermic, 42% were hyperthermic, and 5% were hypothermic. Associations between gender, outcome of rehabilitation, hospitalisation time and presenting disorders were examined. In addition, admissions rates were found to display seasonality. The results of this study will aid in future preparation of grey seal rehabilitation facilities.

Hematologic and biochemical reference intervals for wild osprey nestlings (Pandion haliaetus).

A retrospective study of blood samples from 95 osprey (Pandion haliaetus) nestlings from Scotland and England, collected opportunistically over a 10-yr period, was performed to determine hematologic and plasma biochemistry reference intervals. The age of the sampled nestlings was estimated to be between 4 and 8 wk. Ninety-five percent reference intervals were determined for all hematologic and biochemical variables using parametric and nonparametric methods as appropriate. No blood parasites were detected. This is the first published study providing baseline reference data for osprey nestlings, and it is hoped the data will be of use to wildlife veterinarians and biologists in assessing the health of this species.

Systemic mucormycosis in a hooded seal (Cystophora cristata).

A 4-yr-old male captive hooded seal (Cystophora cristata), previously diagnosed as hypothyroid, died after a 3-wk period of lethargy and inappetance despite treatment that included intramuscular administration of antibiotics and multivitamins. Gross pathologic findings included extensive muscle necrosis over the left flank, an underlying necrotic iliac lymph node, two necrotic pulmonary masses and a necrotic bronchial lymph node. Routine cultures yielded a number of bacterial isolates and a heavy pure fungal growth from the necrotic iliac lymph node; wet preparations of which revealed sporangiophores typical of Mucor sp. Histopathology of necrotic muscle, pulmonary lesions and bronchial and iliac lymph nodes revealed necrosis with a marked pyogranulomatous and eosinophilic inflammatory cell infiltrate and fungal hyphae consistent with a Zygomycete species. This is believed to be the first report of systemic mucormycosis in a pinniped likely to have originated from an injection site reaction.

Emergency management of pediatric convulsive status epilepticus: a multicenter study of 542 patients.

OBJECTIVE: To perform a multicenter study examining the presentations and emergency management of children with convulsive status epilepticus (CSE) to sites within the Paediatric Research in Emergency Departments International Collaborative. METHODS: Retrospective review of children presenting to emergency departments (EDs) with convulsive seizures of at least 10 minutes' duration. Eight sites within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand participated. Patients were identified through a search of ED electronic records for the period January 2000 to December 2004. RESULTS: Data were obtained from 542 eligible episodes of CSE. Demographics and seizure history were similar across all sites. One third of children with CSE presented with their first seizure. A preexisting diagnosis that predisposed to seizures was present in 59%. Median duration of seizures before hospitalization was 45 minutes, and median duration of treatment in ED before termination was 30 minutes. Prehospital duration did not seem to influence the timing of key ED interventions such as the administration of second-line anticonvulsants or progression to rapid sequence induction (RSI) of anesthesia and intubation. Convulsive status epilepticus was terminated after first-line treatment in 42%, second-line treatment in 35%, and RSI in 22%. One third of the patients had persistent seizure activity beyond 40 minutes of ED treatment. Marked variation in the use of RSI for refractory seizures was observed between sites. CONCLUSIONS: Convulsive status epilepticus is an important neurological emergency, with many children experiencing prolonged seizures in both the prehospital and hospital phases. Persistent seizure activity beyond 40 minutes contrasts with current published guidelines. There is a need to adopt a widely accepted approach to the management of children who fail to respond to standard anticonvulsant therapy.

Quantification of urinary oxalate by liquid chromatography-tandem mass spectrometry with online weak anion exchange chromatography.

BACKGROUND: Urinary oxalate is commonly measured with an enzymatic assay that is specific but requires a manual clean-up step to reduce ascorbic acid interference. We developed a urinary oxalate assay that uses liquid chromatography-tandem mass spectrometry (LC-MS/MS) with anion exchange chromatography and simple sample preparation. METHODS: We added calibrator or urine sample (10 microL) to 10 microL of (13)C2 oxalate and 400 microL of water and performed separation on a Waters OASIS WAX column, flow rate 0.6 mL/min, and then elution for 0.3 min with water containing 2 mmol/L ammonium acetate and 1 mL/L formic acid and for 1.0 min with 750 mL/L methanol containing 20 mL/L ammonia. We detected multiple reaction monitoring transitions m/z 88.6 > 60.5 and m/z 90.5 > 61.5 for oxalic acid and 13C2-oxalate, respectively, with a Quattro micro tandem mass spectrometer in electrospray-negative mode. RESULTS: Oxalate and 13C2-oxalate eluted at 1.2 min. Mean recovery was 95%, limit of detection 3.0 micromol/L, lower limit of quantification 100.0 micromol/L, linearity to 2212 micromol/L, imprecision <6%, and bias <3% at 166, 880, and 1720 micromol/L. Oxalate eluted after the main area of ion suppression. Mean response ratios for urine and aqueous samples, enriched at 200 and 1000 micromol/L, were 3.7% and 5.4%, respectively. No interference was observed from other organic acids. Passing and Bablock regression analysis comparing the Trinity Biotech enzymatic reagent set and LC-MS/MS showed LC-MS/MS = 1.06 (enzymatic assay) -21.2, r = 0.964, n = 110. Bland Altman analysis showed general agreement, with a mean bias of -1.9 mumol/L. CONCLUSION: This LC-MS/MS assay is applicable for quantifying urinary oxalate excretion.

Emergency contraceptive pill (ECP) and sexual risk behaviour.

The study describes a cross-section of women using the emergency contraceptive pill (ECP), with regard to demographics, ECP use, sexual health, sexually transmitted infection (STI)/HIV risk perception and attitudes to condom use. All women attending a London hospital for the ECP over a four-month period were invited to complete a 30-item questionnaire anonymously. Of the 150 women attending, 88 (59%) took part. Over 60% needed the ECP because of unprotected sexual intercourse (UPSI). A third had had UPSI in the previous three months, 70% had used ECP previously. The vast majority (>95%) did not think they were at high risk of STIs or HIV infection, and though the most likely explanations for UPSI were that it is more enjoyable and that people get 'carried away'. There are concerns that women are using the ECP as a form of contraception and are putting themselves at risk of STIs and HIV infection. Information regarding risk behaviour needs to be routinely given with the ECP in order to avoid further large increases in infection.