Observational study of the medical management of patients with peripheral artery disease.

BACKGROUND: Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification. METHODS: The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD. RESULTS: Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained. CONCLUSION: The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.

MRI grading versus histology: predicting survival of World Health Organization grade II-IV astrocytomas.

BACKGROUND AND PURPOSE: Histologic grading of intracranial astrocytomas is affected by sampling error and substantial inter- and intraobserver variability. We proposed that incorporating MR imaging into grading will predict patient survival more accurately than histopathology alone. MATERIALS AND METHODS: Patients with a new diagnosis of World Health Organization grades II-IV astrocytoma or mixed oligoastrocytoma diagnosed between September 2007 and December 2010 were identified. Two hundred forty-five patients met the inclusion criteria. Preoperative MRIs were independently reviewed by 2 readers blinded to the histologic grade, and an MR imaging grade was given. The MR imaging and histopathologic grades were compared with patient survival. RESULTS: Patients with grade II or III astrocytomas on histology but evidence of necrosis on MR imaging (consistent with a grade IV tumor) had significantly worse survival than patients with the same histology but no evidence of necrosis on MR imaging (P = .002 for grade II histology and P = .029 for grade III). Their survival was not significantly different from that in patients with grade IV tumors on histology (P = .164 and P = .385, respectively); this outcome suggests that all or most are likely to have truly been grade IV tumors. MR imaging evidence of necrosis was less frequent in grade II and III oligoastrocytomas, preventing adequate subgroup analysis. CONCLUSIONS: MR imaging can improve grading of intracranial astrocytomas by identifying patients suspected of being undergraded by histology, with high interobserver agreement. This finding has the potential to optimize patient management, for example, by encouraging more aggressive treatment earlier in the patient's course.

Preoperative evaluation of oral tongue squamous cell carcinoma with intraoral ultrasound and magnetic resonance imaging-comparison with histopathological tumour thickness and accuracy in guiding patient management.

The aim of this study was to investigate the correlation between tumour thickness (TT) on intraoral ultrasound (US) and magnetic resonance imaging (MRI) with the histologically determined TT of tongue cancers. Secondary objectives included evaluation of potential confounders that affect this association and the predictive value for simultaneous neck dissection. Eighty-eight consecutive patients referred to the study institution between January 2007 and August 2012 with the presumptive diagnosis of invasive squamous cell carcinoma (SCC) of the tongue were analyzed. Seventy-nine patients had preoperative US and 81 had MRI. Correlation between image-determined TT and histological TT was assessed by Bland-Altman plot and Pearson's correlation coefficient. Potential confounders were assessed by subgroup analysis. Preoperative TT as determined by US demonstrated high correlation and MRI moderate correlation with histological TT. With subgroup analysis, negative associations were biopsy prior to imaging and resection diagnosis other than invasive SCC. Our experience suggests that US could be considered the initial modality of choice for preoperative assessment of TT.

Peripheral T-cell lymphoma mimicking 5-aminosalicylate hypersensitivity in ulcerative colitis.

5-aminosalicylates (5-ASA) remain an important strategy in the induction and maintenance of remission of inflammatory bowel diseases especially in ulcerative colitis. The prototypical drug of this class, sulfasalazine is generally well tolerated with severe hypersensitivity reactions and hepatotoxicity also described within the literature. When approaching a patient with an adverse reaction to 5-ASA, it can be difficult to differentiate clinically between a sulfa allergy versus a 5-ASA allergy versus a malignancy. We report on a case with initial signs and symptoms suggestive of a sulfa/5-ASA allergy that was subsequently found to be malignant in nature.

Anemia increases the risk of renal cortical and medullary hypoxia during cardiopulmonary bypass.

INTRODUCTION: Anemia is an independent predictor of acute kidney injury (AKI) following cardiopulmonary bypass (CPB), possibly due to inadequate renal oxygen delivery. The objective of this study was to investigate the effects of CPB and anemia on tissue oxygen tension (pO2) and blood flow in the renal cortex and medulla. METHODS: Rats (n=6/group) underwent 1 hr of normothermic cardiopulmonary bypass (CPB), with target hemoglobin concentrations (Hb) of 10 g/dL (CPB) or 6.5 g/dL (anemia-CPB). Renal blood flow (RBF) and tissue PO2 were measured before, during and after 1 hr of CPB. To confirm the observed differences in renal cortical and medullary PO2, HIF-1α (ODD) luciferase mice were exposed to 8% O2 (hypoxia) and HIF-1α dependent luminescence was measured in the renal cortex and medulla (n=5). RESULTS: Renal tissue PO2 values decreased initially and returned towards baseline, however, values at the end of CPB. Anemia-CPB resulted in a significant increase in both renal cortical and medullary blood flow, PO2 remained significantly reduced throughout anemia-CPB. Renal medullary HIF-1α-dependent luminescence confirmed a greater degree of hypoxia in the renal medulla. DISCUSSION: During CPB, renal O2 delivery was transiently jeopardized, but recovered after 1 hr. Anemia-CPB resulted in a dramatic and sustained reduction in renal cortical and medullary PO2, which suggests an increased risk of renal hypoxic injury with anemia. CONCLUSION: The clear difference in the degree of hypoxia in the renal cortex and medulla may be useful in understanding the progress of medullary hypoxia during CPB with anemia and the potential development of AKI. Further studies should aim at identifying early markers of medullary hypoxia and potential agents that may decrease the work and O2 consumption in the renal medulla to reduce the risk of hypoxic damage during CPB and anemia.

Quantitative assessment of brain microvascular and tissue oxygenation during cardiac arrest and resuscitation in pigs.

Cardiac arrest is associated with a very high rate of mortality, in part due to inadequate tissue perfusion during attempts at resuscitation. Parameters such as mean arterial pressure and end-tidal carbon dioxide may not accurately reflect adequacy of tissue perfusion during cardiac resuscitation. We hypothesised that quantitative measurements of tissue oxygen tension would more accurately reflect adequacy of tissue perfusion during experimental cardiac arrest. Using oxygen-dependent quenching of phosphorescence, we made measurements of oxygen in the microcirculation and in the interstitial space of the brain and muscle in a porcine model of ventricular fibrillation and cardiopulmonary resuscitation. Measurements were performed at baseline, during untreated ventricular fibrillation, during resuscitation and after return of spontaneous circulation. After achieving stable baseline brain tissue oxygen tension, as measured using an Oxyphor G4-based phosphorescent microsensor, ventricular fibrillation resulted in an immediate reduction in all measured parameters. During cardiopulmonary resuscitation, brain oxygen tension remained unchanged. After the return of spontaneous circulation, all measured parameters including brain oxygen tension recovered to baseline levels. Muscle tissue oxygen tension followed a similar trend as the brain, but with slower response times. We conclude that measurements of brain tissue oxygen tension, which more accurately reflect adequacy of tissue perfusion during cardiac arrest and resuscitation, may contribute to the development of new strategies to optimise perfusion during cardiac resuscitation and improve patient outcomes after cardiac arrest.

Are wider surgical margins needed for early oral tongue cancer?

BACKGROUND: Traditionally, a 1-cm surgical resection margin is used for early oral tongue tumours. METHODS: All tumour stage one (n = 65) and stage two (n = 13) oral tongue cancers treated between January 1999 and January 2009 were followed for a median of 38 months (minimum 12 months). The sites of close and involved margins were histologically reviewed. RESULTS: Involved and close margins occurred in 14 and 55 per cent of cases, respectively. The number of involved vs clear or close margins was equivalent in tumour stage one (90 vs 82 per cent), node-negative (100 vs 84 per cent) and perineural or lymphovascular invasion (20 vs 21 per cent) cases. Close or involved margins were similarly likely to be posterior (59 per cent) as anterior (41 per cent, p = 0.22), lateral (57 per cent) as medial (43 per cent, p = 0.34), and mucosal (59 per cent) as deep (41 per cent, p = 0.22). Local recurrence occurred in 28 per cent of cases at a median of 12 months, and was more likely in cases with involved (50 per cent) than clear or close margins (25 per cent, p = 0.10). Disease-free survival was worse in involved margins cases (p = 0.002). CONCLUSION: Involved margins are common in early tongue tumours, and are associated with increased local recurrence and worse survival. Close or involved margins occur in all directions and all tumour types. A wider margin may be justified.

Sexually Transmitted Infection (STI) screening, case and contact treatment, and condom promotion resulting in STI reduction two years later in rural Malawi.

As part of a longitudinal cohort study in rural Malawi in 2000, 469 men and 758 women were asked to respond to a series of surveys, were tested for gonorrhea and chlamydia, and received their results and treatment, if applicable, for themselves and up to 2 partners if positive for either sexually transmitted infection (STI). Two years later, in 2002, 328 men and 525 women were again asked to respond to survey questions, tested again for gonorrhea and chlamydia, and were also tested for HIV--of these, 247 men and 453 women had also given urine samples in 2000. In 2000, the gonorrhea and chlamydia prevalence was 6.2% and 5.8% among men, and 3.6% and 4.9% among women. Two years later, prevalence of gonorrhea and chlamydia was 0.7% and 1.4% among men, and 1.3% and 1.1% among women. Although we did not test for HIV in the first round, the HIV prevalence in 2002 was 19.2%. The implications of the findings are discussed in the context of interventions for STI prevention and to reduce HIV transmission in sub-Saharan Africa.

Metastatic prostate adenocarcinoma invading an atypical meningioma.

Although prostate adenocarcinoma is the most commonly diagnosed cancer in men, intracranial metastases are rare. We describe a 72-year-old patient with known metastatic prostate cancer, presenting with a dural-based parafalcine lesion on radiological imaging, following a seizure. Total macroscopic excision of the lesion was achieved at surgery, with histopathology confirming prostate adenocarcinoma embedded in an atypical (World Health Organization Grade II) meningioma, fulfilling all the criteria for true tumour-to-tumour metastasis. To our knowledge, this is the first report of prostate cancer metastasising to an atypical meningioma.

Outcomes of patients with adenoid cystic carcinoma of the minor salivary glands.

Adenoid cystic carcinoma is a tumour of glandular cells responsible for 10% of salivary gland neoplasms. It has a high rate of perineural spread but limited involvement of regional lymphatics even in late stage disease. Early survival is typically good (60-90%) although long term survival is poor with spread to distant sites in 40-60% of cases. The authors performed a retrospective review of clinical and pathological records for 24 patients managed by their institution over a 22-year period. The overall 5, 10 and 20-year survival rates in this study were 92%, 72% and 54%, respectively. Perineural invasion was seen in 63% and close or positive margins seen in 64% of all primary resection specimens although survival was not associated with any clinical factor other than the initial size of lesion. Most patients presented complaining of a lump, whilst a burning neuralgia-type pain was the second most common symptom. The study confirms the conclusion of previous studies that tumour size at diagnosis is the most important predictor of outcome.

Experiences with fistula repair surgery among women and families in Malawi.

Fistula treatment through surgery is reported to be successful in 80-90% of cases. Success in fistula repair has been defined by medical professionals in terms of clinical outcomes; beyond these definitions, it is important to understand how women perceive a positive clinical outcome and how it affects her family and home environment. This research was conducted in the Mangochi District of Malawi to answer these questions through interviews with women living with fistula and after surgical repair, as well as their partners and families. Over 104 interviews were conducted in June and October 2007. While eventually experiencing clinically successful surgical outcomes, women reported difficulty in seeking and receiving healthcare. Bureaucratic challenges were complicated by community misperceptions about the condition and fear of the healthcare system. Perspectives of women's families suggest that burdens and social disabilities caused by fistula extended beyond the individual to affect these family members. When women experienced surgical treatment, positive outcomes spread to her family and community. Positive experiences with the healthcare system turned women into advocates for healthcare in their communities. These findings illustrate that issues of obstetric fistula are not limited to individual women, but can dramatically affect their families, partners and communities.

HIV infection and contraceptive need among female Ethiopian voluntary HIV counseling and testing clients.

Despite political endorsement of voluntary HIV counseling and testing (VCT), and family planning integration in Ethiopia, little is known about the reproductive health needs of VCT clients. We estimated contraceptive prevalence and need among 646 Ethiopian female VCT clients. We compared socio-demographic characteristics of contracepting VCT clients to those with unmet need and examined how these characteristics are associated with having unmet contraceptive need and being HIV-positive using multinomial logistic regression. We also assessed the quality of VCT services from clients' reports of reproductive health topics discussed in VCT sessions. Nearly 34% of female VCT clients have unmet contraceptive need. Three socio-demographic characteristics are consistently associated with both risk for unintended pregnancy and HIV: older age, marriage, and lower education. In the multivariate analysis, older age, marriage, and belonging to a minority ethnic group are significantly associated with being both HIV-positive and having unmet contraceptive need. Conversely, higher education, larger families, and frequent sexual activity are associated with reduced likelihood of experiencing these two adverse health outcomes. VCT clients report infrequent reproductive health counseling, although HIV-positive women are more likely than HIV-negative women to have discussions about contraception with VCT counselors. At the time of this study, family planning was not offered as part of VCT programs, although VCT clients demonstrate considerable need for contraceptive services.

HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia.

Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2-13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counsellor-levels were 1.9-7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard material and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics.

The role of delayed childbearing in the prevention of obstetric fistulas.

OBJECTIVE: To examine the role of delayed childbearing in the prevention of obstetric fistulas (OFs). METHODS: Data on 4798 deliveries in Niger (1995-1998), 3552 in Nigeria (1996-1999), and 6789 in Tanzania (1991-1996) were analyzed with logistic regression models. RESULTS: Young maternal age and primiparous status were identified as correlates of prolonged/obstructed labor. The annual incidence of OFs in Nigeria was found to be 2.11 per 1000 births, with 9817 cases developing each year, 28% in women and girls younger than 20 years. The predicted proportion of women experiencing prolonged/obstructed labor would be reduced by 11.2% in Niger, 11.4% in Nigeria, and 13.1% in Tanzania if the risks associated with young maternal age at first delivery and primiparity were eliminated. CONCLUSIONS: Community programs to educate young, newly married women about delaying childbearing until they reach physical maturity should be implemented in countries with a high incidence of OFs.

Prevalence of self-reported symptoms of reproductive tract infections among recently pregnant women in Uttar Pradesh, India.

This study examines the prevalence of self-reported reproductive tract infections (RTIs) and treatment seeking among married, recently pregnant women in Uttar Pradesh state, India. Associations between RTI symptom reporting and background characteristics are examined in a population-based sample of 18,506 married women with a pregnancy in the 3 years prior to a 1995 statewide survey. Logistic regression analyses are used to assess the effects of sociodemographic covariates on the probability of reporting an RTI symptom. Nearly one out of four women reports experiencing at least one RTI symptom, with the most common symptoms being abnormal vaginal discharge and pain during urination. Reporting of RTI symptoms significantly increases if the woman's last pregnancy did not end in a live birth or if she has low economic status. Symptom reports also increase with age and decrease with parity. Only one-third of women reporting an RTI symptom sought treatment. The results indicate that survey interviews can be a cost-effective option for measuring the magnitude of RTI symptoms experienced and identifying sociodemographic influences. The findings suggest the need for improved RTI screening procedures and treatment at health facilities in this populous state of northern India.

Unintended pregnancy and low birthweight in Ecuador.

OBJECTIVES: This study assessed the relationship between unintended pregnancy and infant birthweight in Ecuador, differentiating between unwanted and mistimed pregnancies. METHODS: Analyses focused on a subsample of women (n = 2490) interviewed in the 1994 Ecuador Demographic and Maternal-Child Health Survey. Logistic regression was used to assess the relationship between pregnancy intention status and low birthweight after control for other factors. RESULTS: Infants from unwanted pregnancies were more likely than infants from planned pregnancies to have low birthweight (odds ratio = 1.64, 95% confidence interval = 1.22, 2.20). Mistimed pregnancy was not associated with low birthweight. CONCLUSIONS: Unwanted pregnancy, but not mistimed pregnancy, is associated with low birthweight in Ecuador. Further research is needed to understand the mechanism through which pregnancy intention status affects birthweight.

The relationship between prenatal care and subsequent modern contraceptive use in Bolivia, Egypt and Thailand.

Determinants of modern contraceptive use are usually examined in isolation of the effect of exposure to other aspects of health care systems. Maternal interaction with organised health service provision during post-conception and postpartum stages of reproduction can provide an opportunity to transfer contraceptive service information and counselling. We found that living in a community in which women have widespread health service contact is related to both prenatal care use and subsequent modern contraceptive use. After controlling for effects of living in high health service contact areas and various demographic and background factors, our results suggest that prior use of prenatal care has a strong influence on subsequent use of modern contraception in Bolivia, Egypt and Thailand.

Assessing survey measures of infant birth weight and birth size in Ecuador.

The purpose of this study was to assess the utility of using maternal assessments of infant birth size as proxy measures for birth weight in Ecuador, a country in which a sizeable proportion of births take place at home, where birth weight is typically not recorded. Four thousand and seventy-eight women who experienced a live singleton birth between January 1992 and August 1994 were interviewed in the Ecuador Demographic and Maternal-Child Health Survey. All women were asked if their child was weighed at birth, his/her weight, and what they considered to be his/her birth size relative to other newborns. The consistency between birth size and birth weight measures was assessed, and the differences between infants with and without reported birth weights were explored. The authors conclude that maternal assessments of birth size are poor proxy indicators of birth weight. Estimates of low birth weight based on maternal assessments of birth size as very small should be recognized as underestimates of the actual prevalence of low birth weight. Moreover, infants for whom birth weights are missing should not be considered similar to those for whom weight was reported. Those without reported birth weights are more likely to be low birth weight. Thus, relying solely on reports of numeric birth weight will underestimate the prevalence of low birth weight.