Long-Term Outcomes of Cervical Cancer Patients Treated With Definitive Chemoradiation Following a Complete Metabolic Response.

AIMS: A complete metabolic response (CMR) on early post-treatment 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a positive prognostic factor for cervical cancer patients treated with definitive chemoradiation, but long-term outcomes of this group of patients are unknown. Patterns of failure and risk subgroups are identified. MATERIALS AND METHODS: Patients who received curative-intent chemoradiation from 1998 to 2018 for International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IVA cervical cancer and had a CMR on post-treatment FDG-PET within 5 months of treatment completion were included. Cox proportional hazards models determined factors associated with locoregional and distant failure. Kaplan-Meier estimates of freedom from any recurrence (FFR) of patient subgroups were compared with Log-rank tests. RESULTS: There were 402 patients with a CMR after chemoradiation on FDG-PET. Initial T stage was T1 (38%)/T2 (40%)/T3 (20%)/T4 (2%); initial FDG-avid nodal status was no nodes (50%)/pelvic lymph nodes (40%)/pelvic and para-aortic lymph nodes (10%). After a median follow-up of 6 years, 109 (27%) recurred. The pattern of recurrence was locoregional (27%), distant (61%) or both (12%). No factors were associated with locoregional failure. Distant recurrence was more likely in patients with T3-4 lesions (hazard ratio = 2.4, 95% confidence interval 1.5-3.8) and involvement of pelvic (hazard ratio = 1.6, 95% confidence interval 1.0-2.7) or para-aortic lymph nodes (hazard ratio = 2.7, 95% confidence interval 1.4-5.0) at diagnosis. The 5-year FFR rates for T1-2 patients with no nodes, pelvic nodes alone or para-aortic nodes at diagnosis were 85, 76 and 62%, respectively (P = 0.04, none versus para-aortic nodes). The 5-year FFR for T3-4 patients with no nodes, pelvic nodes alone or para-aortic nodes at diagnosis were 68, 56 and 25%, respectively (P = 0.09, none versus para-aortic nodes). CONCLUSIONS: T3-4 tumours and para-aortic nodal involvement at diagnosis are poor prognostic factors, even after a CMR following chemoradiation.

The effects of Hurricane Sandy on trauma center admissions.

BACKGROUND: Hurricane Sandy was a particularly unusual storm with regard to both size and location of landfall. The storm landed in New Jersey, which is unusual for a tropical storm of such scale, and created hazardous conditions which caused injury to residents during the storm and in the months following. This study aims to describe differences in trauma center admissions and patterns of injury during this time period when compared to a period with no such storm. METHODS: Data were collected for this study from patients who were admitted to the trauma center at Morristown Medical Center during Hurricane Sandy or the ensuing cleanup efforts (patients admitted between 29 October 2012 and 27 December 2012) as well as a control group consisting of all patients admitted to the trauma center between 29 October 2013 and 27 December 2013. Patient information was collected to compare the admissions of the trauma center during the period of the storm and cleanup to the control period. RESULTS: A total of 419 cases were identified in the storm and cleanup period. 427 were identified for the control. Striking injuries were more common in the storm and cleanup group by 266.7% (p = 0.0107); cuts were more common by 650.8% (p = 0.0044). Medical records indicate that many of these injuries were caused by Hurricane Sandy. Self-inflicted injuries were more common by 301.3% (p = 0.0294). There were no significant differences in the total number of patients, mortality, or injury severity score between the two cohorts. CONCLUSION: The data we have collected show that the conditions caused by Hurricane Sandy and the following cleanup had a significant effect on injury patterns, with more patients having been injured by being struck by falling or thrown objects, cut while using tools, or causing self-inflicted injuries. These changes, particularly during the cleanup period, are indicative of environmental changes following the storm which increase these risks of injury.

[Analysis of the German state medical examination regarding psychiatrically relevant topics]. / Staatsexamensanalyse hinsichtlich psychiatrisch relevanter Themen.

BACKGROUND: The second part of the state medical examination is an essential part of medical education in Germany. From 2006 until 2013, the second and third parts of the licensing examination were combined, thus earning this examination the reputation of being notoriously difficult to pass. The aim of this exploratory study was to examine psychiatric and psychotherapeutic questions in the written part of the second examination. OBJECTIVES: This study analyzed the proportion of psychiatric and psychotherapeutic questions in the written part of the second leg of the German state medical examination. In a second step, a more detailed analysis aimed to identify more specific subject areas and to allocate diagnoses according to ICD-10, allowing a detailed overview of the presence of psychiatric topics. MATERIAL AND METHODS: A total of 8 examinations from fall 2010 up to spring 2014 a were included in the analysis. Every examination comprised 320 questions, thus a total of 2560 questions were analyzed. All questions pertaining to psychiatric or psychotherapeutic topics were included. Questions were categorized according to a predefined set of subject areas and an ICD-10 diagnosis. RESULTS: Out of the total of 2560 questions analyzed, 166 were categorized as being in psychiatry or psychotherapy, with each examination comprising an average of 20.75 (SD = 5.80) relevant questions. Most questions were allocated to the subject area of pharmacology (n = 53), followed by psychopathologic assessment (n = 27) and psychotherapy (n = 12). Sorted according to ICD-10 criteria, most questions could be assigned to the F3 category, the affective disorders group (21.9 %, n = 35). CONCLUSION: In comparison to the actual strain placed on the healthcare system, the results indicate an underrepresentation of psychiatric disorders in the second part of the German state medical examination. The distribution of specific disorders mirrors the actual distribution at least in part; however, certain practically relevant disorders are severely underrepresented.

Creation and piloting of a new hospital capacity assessment tool in a major urban area.

OBJECTIVES: Crowded hospital emergency departments (EDs) can undermine the ability of a region's safety net to provide safe, timely care. However, data to measure hospital capacity community-wide is generally unavailable. This study aimed to assess hospital crowding, capacity and patient flow in an urban community using the newly developed hospital capacity assessment tool (HCAT). STUDY DESIGN: A survey of the eight acute care hospitals in the District of Columbia (DC) with active EDs. METHODS: Existing emergency care assessment tools were reviewed. Eighteen of the 57 questions on the HCAT were adapted from existing hospital surveys, while the remaining 39 questions were constructed de novo for use in this assessment. Hospitals were provided with paper and electronic versions of the HCAT. RESULTS: All eight DC hospitals completed the HCAT; however, three hospitals were unable to answer many of the questions due to a lack of regular data collection. The HCAT data shows throughput times in DC hospitals that are substantially longer than national averages. CONCLUSIONS: The HCAT is a promising tool for evaluating community-wide emergency care. Findings from the HCAT allowed for the introduction of new ED performance data into the local decision-making process.

The effect of age on prostaglandin-synthesizing enzymes in the development of gingivitis.

BACKGROUND AND OBJECTIVE: The aim of this study was to identify the expression of cyclooxygenase-1, cyclooxygenase-2, cyclooxygenase-3, and microsomal prostaglandin E synthase-1 in young and elderly subjects. MATERIAL AND METHODS: Periodontally healthy subjects were divided into young (18-30 years, n = 7) and elderly (46-77 years, n = 7). A gingival biopsy was taken at baseline. After experimental gingivitis, clinical examination was repeated and a second biopsy was taken. The expression of cyclooxygenase-1, cyclooxygenase-2, cyclooxygenase-3, and microsomal prostaglandin E synthase-1 was analyzed by means of immunohistochemistry. RESULTS: In both healthy age groups, cyclooxygenase-1 and microsomal prostaglandin E synthase-1 were expressed in epithelial cells, endothelial cells and fibroblast-like connective tissue cells. Cyclooxygenase-1 was found in Langerhans' cells of the epithelium. Cyclooxygenase-2 expression was observed in cells exhibiting the morphology of epithelial mitosis cells, and the expression of cyclooxygenase-2 in periodontally healthy elderly subjects was significantly lower (p < or = 0.05). Following experimental gingivitis, cyclooxygenase-1 and microsomal prostaglandin E synthase-1 expression did not change. However, the expression of cyclooxygenase-2 was significantly increased in both age groups (p < or = 0.05). Cyclooxygenase-3 was not detected in any group investigated. CONCLUSION: Cyclooxygenase-1 and microsomal prostaglandin E synthase-1 were expressed constitutively in gingival tissue, and expression was unaffected by age or inflammation states. In contrast, the expression of cyclooxygenase-2 was weaker in elderly subjects. In the course of experimental gingivitis, cyclooxygenase-2 was induced in both age groups.

Being a webcam.

Searching through studies of schizophrenic delusions with a view to the new media, we came across the case of a young woman who integrated the Internet in her delusional system. Analysing the story she told, we recognised a psychotic symptom, which we preliminarily called 'perception broadcast'. Perception broadcast shows a more complex structure than the related first rank symptom 'thought broadcast' described by Kurt Schneider. In our view the existence of a structure like perception broadcast depends on the existence of new technologies, such as the World Wide Web and 'virtual reality', creating new cultural patterns which themselves are associated with collective perceptions of derealisation.

St. John's wort (Hypericum perforatum)--is it safe during breastfeeding?

Both doctors and patients often treat postnatal depression with herbal preparations derived from St. John's wort. Because these preparations are available to patients as "natural" over-the-counter drugs for depression, they are popularly assumed to be safe. However, no systematic information exists regarding treatment of postnatal depression, infant's safety or pharmacokinetics of hypericum constituents in human breast milk or infant plasma. A mother with post-natal depression was admitted at our service. Her pharmacist had recommended taking a St. John's wort preparation three times a day (Jarsin 300, Lichtwer Pharma AG, Berlin, Germany). Four breast-milk samples (fore and hind milk) during an 18-hour period were analyzed to measure concentration of hypericin and hyperforin. Only hyperforin is excreted into breast milk at a low level, hyperforin and hypericin (two major active components) were below the lower limit of quantification (BLQ: below lower limit of quantification, LQ hypericin: 0.20 ng/ml, LQ hyperforin: 0.50 ng/ml) in this infant's plasma. No side effects were seen in the mother or infant. Before recommending St John's wort for the treatment of depression to women who breastfeed, long-term studies of outcome in infants are needed.

Effects of intravenous secretin on language and behavior of children with autism and gastrointestinal symptoms: a single-blinded, open-label pilot study.

BACKGROUND: Autism is a severe developmental disorder with poorly understood etiology. A recently published case series describes 3 autistic children with gastrointestinal symptoms who underwent endoscopy and intravenous administration of secretin and were subsequently noted by their parents to demonstrate improved language skills over a 5-week period. This report sparked tremendous public interest, and investigators at several sites moved quickly to design controlled trials to test the efficacy of secretin as a therapy for autistic children. However, this is the first effort specifically designed to replicate the initial reported findings in terms of patient age, presenting symptoms, and drug administration. OBJECTIVE: To rigorously apply the scientific method by assessing the reproducibility of the reported effects of intravenous secretin on the language of young children with autism and gastrointestinal symptoms. METHODS: We performed a single-blinded, prospective, open-label trial by conducting formal language testing and blinded behavioral rating both before and repeatedly after a standardized infusion of secretin. We selected autistic children who were similar in age and profile to those described in the published retrospective case review. Inclusion criteria for study participation included age (3-6 years), confirmed diagnosis of autism, and reported gastrointestinal symptoms (16 had chronic diarrhea, 2 had gastroesophageal reflux, and 2 had chronic constipation). Twenty children (18 male) were admitted to the Pediatric Clinical Research Center at the University of California, San Francisco after administration of the Preschool Language Scale-3 (PLS-3). A 3 CU/kg dose of secretin (Secretin-Ferring) was administered intravenously (upper endoscopy was not performed). Behavioral ratings were derived using the Autism Observation Scale applied to a 30-minute time sample of the child's behavior consisting of a videotape of the PLS-3 (structured setting) and a second free play session with a standard set of developmentally appropriate toys. Participants then returned for follow-up evaluations, with readministrations of the PLS-3 at 1, 2, 3, and 5 weeks' postinfusion, and videotaping of each session for later blinded review by 2 independent observers using the Autism Observation Scale, uninformed about week of posttreatment. We also surveyed parents of our study children about their impressions of the effects of secretin using a 5-point Likert scale for parents to rate changes seen in their child. RESULTS: With a total study completion rate across all participants of 96%, repeated measures analyses of variance revealed no significant increases in children's language skills from baseline across all 5 study time periods after a single infusion of secretin. Similarly, neither significant decreases in atypical behaviors nor increases in prosocial behaviors and developmentally appropriate play skills emerged. Furthermore, no relationship was found between parental reports of change and observable improvement in the sample. Despite the objective lack of drug effect, 70% of parents in our study reported moderate to high change in their child's language and behavior. Furthermore, 85% of parents reported that they felt that their child would obtain at least some additional benefits from another infusion of secretin. CONCLUSIONS: The results of our pilot study indicate that intravenous secretin had no effects in a 5-week period on the language and behavior of 20 children with autism and gastrointestinal symptoms. The open-label, prospective design of our study with blinded reviews of patients both before and after secretin administration follows the scientific method by seeking to reproduce an observed phenomenon using validating and reliable outcome measures. Pilot studies remain a mandatory step for the design of future randomized, clinical trials investigating potential treatments for children with autism.

[Health care services for women with postpartum mental disorders--assessment of current options in Austria]. / Versorgungsstrukturen für Frauen mit postpartalen psychischen Störungen--Eine Bestandsaufnahme für Osterreich.

For many women childbirth is one of the most impressive life-events, but this period of life may also be a phase of increased vulnerability for psychiatric illness. 10-15% of women develop a postnatal depression (PND) after the birth of a child, and 1@1000 suffer from a puerperal psychosis. Despite the high prevalence, with estimates of approximately 10,000 women suffering annually from postnatal psychiatric disturbances in Austria, there has been a lack of medical attendance for these women and their children. Motivated by a research initiative from the EU on transcultural aspects of postnatal depression (PND) with 17 participating research centers world-wide, a research team at the Vienna University Clinic for Psychiatry initiated the investigation of conditions for mother-child-admissions at 31 psychiatric wards in Austria. These departments were asked about the possibility of conjoint mother-child-admission, and their experiences with this form of admission; 23 departments (74.2%) provided information. A total of 12 departments responded that they theoretically accepted mothers with their babies; however, they also indicated that until now these conjoint admissions had been performed only very rarely or not at all. Based on many years of experience in the field of postpartum mental health in Great Britain, British researchers have developed guidelines for need assessment and health care provision for women with postpartum psychiatric disorders. With the help of these guidelines, the Viennese team of psychiatrists tried to develop fundamental concepts for need assessment, diagnosis, and treatment of patients suffering from postpartum mental illness in Austria.

Lymph node staging by positron emission tomography in patients with carcinoma of the cervix.

PURPOSE: The aim of this study was to compare the results of computed tomography (CT) and positron emission tomography (PET) with [18F]-fluoro-2-deoxy-D-glucose (FDG) for lymph node staging in patients with carcinoma of the cervix and to evaluate the relationship of the imaging findings to prognosis. PATIENTS AND METHODS: We retrospectively compared the results of CT lymph node staging and whole-body FDG-PET in 101 consecutive patients with carcinoma of the cervix. Patients were treated with standard irradiation and chemotherapy (as clinically indicated) and observed at 3-month intervals for a median of 15.4 months (range, 2.5 to 30 months). Progression-free survival was evaluated by the Kaplan-Meier method. RESULTS: CT demonstrated abnormally enlarged pelvic lymph nodes in 20 (20%) and para-aortic lymph nodes in seven (7%) of the 101 patients. PET demonstrated abnormal FDG uptake in pelvic lymph nodes in 67 (67%), in para-aortic lymph nodes in 21 (21%), and in supraclavicular lymph node in eight (8%). The 2-year progression-free survival, based solely on para-aortic lymph node status, was 64% in CT-negative and PET-negative patients, 18% in CT-negative and PET-positive patients, and 14% in CT-positive and PET-positive patients (P <.0001). A multivariate analysis demonstrated that the most significant prognostic factor for progression-free survival was the presence of positive para-aortic lymph nodes as detected by PET imaging (P =.025). CONCLUSION: This study demonstrates that FDG-PET detects abnormal lymph node regions more often than does CT and that the findings on PET are a better predictor of survival than those of CT in patients with carcinoma of the cervix.

Localized two-dimensional shift correlated MR spectroscopy of human brain.

A two-dimensional (2D) chemical shift correlated MR spectroscopic (COSY) sequence integrated into a new volume localization technique (90 degrees -180 degrees -90 degrees ) is proposed for whole-body MR spectroscopy (MRS). Using the product operator formalism, a theoretical calculation of the volume localization as well as the coherence transfer efficiencies in 2D MRS is presented. Phantom model solutions were used to test and optimize the efficiency of the proposed sequence. A combination of different MRI transmit/receive RF coils was used: a head MRI coil and a 3" surface coil receive combined with a body coil transmit. The J cross-peaks due to N-acetyl aspartate (NAA), glutamate/glutamine (Glx), myo-inositol (mI), creatine (Cr), choline (Ch), aspartate (Asp), gamma-aminobutyrate (GABA), taurine (Tau), glutathione (GSH), threonine (Thr), and macromolecules (MM) were identified. The cross-peak intensities excited by the proposed 2D sequence were asymmetric with respect to the diagonal peaks. Localized COSY (L-COSY) spectra of cerebral prefrontal and occipital gray/white matter regions in 15 healthy controls are presented. Magn Reson Med 46:58-67, 2001.

Metabolic flare: indicator of hormone responsiveness in advanced breast cancer.

PURPOSE: The purpose of this study was to investigate whether positron emission tomography (PET) with the glucose analog [(18)F]fluorodeoxyglucose (FDG) and the estrogen analog 16 alpha-[(18)F]fluoroestradiol-17 beta (FES), performed before and after treatment with tamoxifen, could be used to detect hormone-induced changes in tumor metabolism (metabolic flare) and changes in available levels of estrogen receptor (ER). In addition, we investigated whether these PET findings would predict hormonally responsive breast cancer. PATIENTS AND METHODS: Forty women with biopsy-proved advanced ER-positive (ER(+)) breast cancer underwent PET with FDG and FES before and 7 to 10 days after initiation of tamoxifen therapy; 70 lesions were evaluated. Tumor FDG and FES uptake were assessed semiquantitatively by the standardized uptake value (SUV) method. The PET results were correlated with response to hormonal therapy. RESULTS: In the responders, the tumor FDG uptake increased after tamoxifen by 28.4% +/- 23.3% (mean +/- SD); only five of these patients had evidence of a clinical flare reaction. In nonresponders, there was no significant change in tumor FDG uptake from baseline (mean change, 10.1% +/- 16.2%; P =.0002 v responders). Lesions of responders had higher baseline FES uptake (SUV, 4.3 +/- 2.4) than those of nonresponders (SUV, 1.8 +/- 1.3; P =.0007). All patients had evidence of blockade of the tumor ERs 7 to 10 days after initiation of tamoxifen therapy; however, the degree of ER blockade was greater in the responders (mean percentage decrease, 54.8% +/- 14.2%) than in the nonresponders (mean percentage decrease, 19.4% +/- 17.3%; P =.0003). CONCLUSION: The functional status of tumor ERs can be characterized in vivo by PET with FDG and FES. The results of PET are predictive of responsiveness to tamoxifen therapy in patients with advanced ER(+) breast cancer.

Survival of patients evaluated by FDG-PET before hepatic resection for metastatic colorectal carcinoma: a prospective database study.

OBJECTIVE: To present the survival results for patients with colorectal carcinoma metastases who have undergone liver resection after being staged by [(18)F] fluoro-2-deoxy-D-glucose-positron emission tomography (FDG-PET). SUMMARY BACKGROUND DATA: Hepatic resection is standard therapy for colorectal metastases confined to the liver, but recurrence is common because of the presence of undetected cancer at the time of surgery. FDG-PET is a sensitive diagnostic tool that identifies tumors based on the increased uptake of glucose by tumor cells. To date, no survival results have been reported for patients who have actually had liver resection after being staged by FDG-PET. METHODS: Forty-three patients with metastatic colorectal cancer were referred for hepatic resection after conventional tumor staging with computed tomography. FDG-PET was performed on all patients. Laparotomy was performed on patients not staged out by PET. Resection was performed at the time of laparotomy unless extrahepatic disease or unresectable hepatic tumors were found. Patients were examined at intervals in the preoperative period. RESULTS: FDG-PET identified additional cancer not seen on computed tomography in 10 patients. Surgery was contraindicated in six of these patients because of the findings on FDG-PET. Laparotomy was performed in 37 patients. In all but two, liver resection was performed. Median follow-up in the 35 patients undergoing resection was 24 months. The Kaplan-Meier estimate of overall survival at 3 years was 77% and the lower 95% confidence limit of this estimate of survival was 60%. This figure is higher than 3-year estimate of survival found in previously published series. The 3-year disease-free survival rate was 40%. CONCLUSIONS: Preoperative FDG-PET lessens the recurrence rate in patients undergoing hepatic resection for colorectal metastases to the liver by detection of disease not found on conventional imaging.

Delusions in first-admitted patients: gender, themes and diagnoses.

Whether there is a specific link between certain delusional symptoms and particular etiologies has not yet been completely clarified. In this study, 639 first ever admitted deluded patients were investigated in order to find out whether age and gender are associated with certain delusional contents, whether age at first admission may be linked to certain etiologies and whether it is possible to detect indicators particularly related to basic dysfunctions. At first admission, delusional female patients were older than men with a significant predomination of delusions of persecution, while men presented significantly more frequently delusions of jealousy and grandiosity. Within delusions of persecution, of religious or metaphysical content and of grandiosity, women were even significantly older than men. Religious or metaphysical and grandiosity contents occurred significantly more frequently in ICD-8 schizophrenia, indicating that these themes seem to be particularly linked to ICD-8 schizophrenia. Additionally, some target symptoms not included in the delusional symptomatology were investigated to test the relationship between delusions and schizophrenia. Overall, the results of the present investigation indicate that delusions are not specific for schizophrenia, and therefore, other symptomatological criteria should be applied for the nosographic attribution.