Pre-procedural pacing bias among transcatheter aortic valves with higher post-procedure pacing rates: evidence from the UK TAVI Registry.

Rates of permanent pacemaker (PPM) implantation following transcatheter aortic valve implantation (TAVI) are higher than following surgery and are dependent on patient factors and valve type. There is an increasing trend towards pre-emptive PPM insertion in patients with significant conduction disease prior to TAVI. We report results from the British Cardiovascular Intervention Society (BCIS) on pre- and post-procedural PPM implantation in the TAVI population. All centres in the United Kingdom performing TAVI are required to submit data on all TAVI procedures to the National database which are then reported annually. During 2015, there were 2373 TAVI procedures in the UK. 22.4% of TAVI patients had a PPM implanted either pre-procedure (including the distant past), or during the in-hospital procedural episode. Of these, 7.9% were pre-procedure and 14.5% post-procedure. Overall PPM rates were Edwards Sapien (13.5%), Medtronic CoreValve (28.2%) and Boston Lotus (42.1%; p < 0.01). Pre-procedure pacing rates were Edwards Sapien (6.0%), Medtronic CoreValve (9.1%) and Boston Lotus (12.3%; p < 0.01). Pre-procedural pacing rates for the Boston Lotus valve have risen year-on-year from 5.8% (2013) to 8.6% (2014) to 12.3% (2015). The UK TAVI Registry demonstrates a pre-procedural permanent pacing bias amongst patients receiving transcatheter valves with higher post-procedure pacing rates. Pre-emptive permanent pacing is likely to be responsible for this difference.

Thyroid hormone receptor beta-1 expression in early breast cancer: a validation study.

PURPOSE: Preliminary data suggest that high expression of the TRß1 tumor suppressor is associated with longer survival among women with early breast cancer. We undertook this study to validate these findings. METHODS: In this prospective cohort study, we analyzed the prognostic significance of TRß1 protein expression in the breast tumors of 796 women who had undergone breast surgery in the Henrietta Banting Breast Cancer database. All women were recruited after undergoing primary surgical therapy at Women's College Hospital (Toronto, ON, Canada) between January 1987 and December 2000. Details regarding patient age at diagnosis, systemic, and local therapies, as well as pathological features of their tumor have been systematically recorded. Clinical outcomes including breast cancer recurrence and death have been updated at least once each year with a median follow-up of 9.6 years (range 0.1-21 years). RESULTS: High TRß1 expression (> 4 on the Allred score) was associated with a longer breast cancer-specific survival with a HR 0.45 (95% CI 0.33-0.61), p < 0.0001 in a univariable Cox regression model. This was maintained in a multivariable model adjusted for age, tumor size, nodal status, chemotherapy, hormone therapy, radiotherapy, surgery, and ER status with a HR of 0.61 (95% CI 0.44-0.85), p = 0.004. CONCLUSIONS: High expression of TRß1 is associated with longer breast cancer-specific survival independent of other prognostic factors. Given that low TRß expression is associated with chemotherapy resistance in-vitro, TRß1 may also serve as a predictive biomarker or even a therapeutic target given the availability of TRß agonists.

Rapid passage signals induced by chirped quantum cascade laser radiation: K state dependent-delay effects in the nu2 band of NH3.

In this Letter, a 10 microm quantum cascade laser operating in the intrapulse mode is used observe rapid passage (RP) effects within a 40 cm single-pass gas cell containing low pressures of NH(3). The laser tuning range allows the rotational states J=2 with K=0, 1, and 2 to be probed. We show that the RP structures change as a function of optical density and that the magnitude of the delay in the switch from absorption to emission as a function of increased gas pressure is dependent upon the initial value of K. These measurements are qualitatively well modeled using the Maxwell-Bloch equations.

One-stage tubeless antegrade ureteric stenting: a safe and cost-effective option?

INTRODUCTION: Antegrade insertion of ureteric stent has become an established mode of management of upper tract obstruction secondary to ureteric pathology. It is conventionally performed as a two-stage procedure for various reasons but, more recently, a one-stage approach has been adopted. PATIENTS AND METHODS: We discuss our experience of primary one-stage insertion of antegrade ureteric stent as a safe and cost-effective option for the management of these difficult cases in this retrospective observational case cohort study of patients referred to a radiology department for decompression of obstructed upper tracts. Data were retrieved from case notes and a radiology database for patients undergoing one-stage and two-stage antegrade stenting. It was followed by telephone survey of regional centres about the prevalent local practice for antegrade stenting. Outcome measures like hospital stay, procedural costs, requirement of analgesia/antimicrobials and complication rates were compared for the two approaches. RESULTS: a one-stage approach was found to be suitable in most cases with many advantages over the two-stage approach with comparable or better outcomes at lower costs. Some of the limitations of the study were retrospective data collection, more than one radiologist performing stenting procedures and non-availability of interventional radiologist falsely raising the incidence of two-stage procedures. CONCLUSIONS: In the absence of any clinical contra-indications and subject to availability of an interventional radiologist's support, one-stage antegrade stenting could easily be adopted as a routine approach for the management of benign or malignant ureteric obstruction.

Digital subtraction angiography of the superior mesenteric artery: identifying arterial branches.

This "problem in diagnostic imaging" provides an overview of the technique of digital subtraction angiography. The possibility of artefacts arising from movement subsequent to the taking of the masking image is discussed. It is also important that contrast medium is allowed to backflow into the parent vessel (in this case the aorta) to ensure that there has been filling of the proximal branches of the vessel of interest (in this case the superior mesenteric artery). An accessory middle colic artery is demonstrated. Detection of such variant vessels is important not only to surgeons but also to specialist radiologists carrying out therapeutic embolization.

Successful intra-arterial alteplase infusion is a predictor of 12-month limb survival in patients with lower limb arterial occlusion.

AIM: To determine the factors predicting amputation of the affected lower limb 12 months after thrombolysis for acute arterial occlusion. MATERIALS AND METHODS: The clinical endpoints of 39 patients (24 men, 15 women; average age 69 years) 1 year after catheter-directed thrombolysis with alteplase (mean dose 30 mg, mean duration 24h) for lower limb arterial occlusion (30 native arteries, nine grafts) from January 2001 to June 2005 were assessed. The amputation rate at 12 months was analysed in relation to the thrombolytic outcome, type of vessel occluded, presence or absence of complications, and subsequent requirement for additional surgery on an elective basis using Fischer's exact test. RESULTS: Successful thrombolysis, defined as complete clot dissolution based on angiographic imaging, was achieved in 64.1% of cases (19 native artery, six bypass graft) with a total complication rate of 23% (n=9). The incidence of major haemorrhage was 7.5% (n=3, hypotension and haematemesis, groin haematoma and hypotension, haematemesis). No patient had an intracranial bleed. One year after thrombolysis, 28.2% (n=11) had further surgery (bypass graft, fasciotomy, embolectomy) and the amputation rate was 20.5% (n=8). Statistical analysis showed that the amputation rate was significantly higher for patients with failed compared with successful thrombolysis (p=0.02). The amputation rates did not reach statistical significance in relation to native artery or graft occlusion, presence or absence of complications, and whether or not additional surgery was required. CONCLUSION: Successful thrombolysis was a predictor for limb survival up to 12 months post-thrombolysis regardless of the type of vessel occlusion, presence of complications or additional surgical requirement.

Measuring psychological consequences of screening: adaptation of the psychological consequences questionnaire into Dutch.

OBJECTIVE: To assess the psychometric properties of a Dutch adaptation of an originally Australian instrument measuring the psychological impact of breast cancer screening. METHODS: The three subscales (emotional, physical, social) of the Psychological Consequences Questionnaire (PCQ) underwent formal linguistic and cultural translation. A total of 524 women under intensive surveillance because of increased breast cancer risk were asked to complete the questionnaire at 2 months prior to screening, at the day of the screening visit preceding the screening, and 1-4 weeks after screening. Acceptability, score distribution, internal consistency, scale structure, responsiveness to change and construct validity were analysed. RESULTS: Response rates were high (98-94%) and there were very few missing answers and non-unique answers. All scales had Cronbach's alphas > 0.70. The physical and social subscale showed ceiling effects. The item-own scale correlations were only slightly higher than the corresponding item-other scale correlations. Factor analysis showed that the assumed three separate subscales were replicated in our study. Pre- and post-screening effect sizes for the emotional scale were larger than for the other two scales. All PCQ scales correlated with the scales of two other psychological measures (p

Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction.

BACKGROUND: We prospectively compared laparoscopic gastrojejunostomy with duodenal stenting as a means of palliating malignant gastric outflow obstruction. METHODS: A total of 27 patients with malignant gastric outflow obstruction were randomized to either laparoscopic gastrojejunostomy (LGJ) or duodenal stenting (DS) over a 3-year period. RESULTS: Thirteen patients underwent successful LGJ and 10 had successful DS. Eight patients had complications after LGJ, but none had complications after DS. Patients who underwent LGJ had a significant increase in visual analog pain score at day 1 (p = 0.05), and also had a longer hospital stay compared to those who underwent DS (11.4 vs. 5.2 days, p = 0.02). After DS, patients experienced an improvement in physical health at 1 month as measured using the Short Form-36 (SF-36) questionnaire (p < 0.01). There was no change following LGJ. CONCLUSION: Duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. It offers significant advantages for patients compared with minimal-access surgery.

How to recognize and manage psychological distress in cancer patients.

Psychological distress is common in cancer patients, however, it is often unrecognized and untreated. We aimed to identify barriers to cancer patients expressing their psychological concerns, and to recommend strategies to assist oncologists to elicit, recognize, and manage psychological distress in their patients. Medline, Psychlit, and the Cochrane databases were searched for articles relating to the detection of emotional distress in patients. Patients can provide verbal and non-verbal information about their emotional state. However, many patients may not reveal emotional issues as they believe it is not a doctor's role to help with their emotional concerns. Moreover, patients may normalize or somatize their feelings. Anxiety and depression can mimic physical symptoms of cancer or treatments, and consequently emotional distress may not be detected. Techniques such as active listening, using open questions and emotional words, responding appropriately to patients' emotional cues, and a patient-centred consulting style can assist in detection. Screening tools for psychological distress and patient question prompt sheets administered prior to the consultation can also be useful. In conclusion, the application of basic communication techniques enhances detection of patients' emotional concerns. Training oncologists in these techniques should improve the psychosocial care of cancer patients.

Non-valvular atrial fibrillation and stroke: implications for nursing practice and therapeutics.

Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance and is increasing in prevalence due to the ageing of the population, and rates of chronic heart failure. Haemodynamic compromise and thromboembolic events are responsible for significant morbidity and mortality in Australian communities. Non-valvular AF is a significant predictor for both a higher incidence of stroke and increased mortality. Stroke affects approximately 40,000 Australians every year and is Australia's third largest killer after cancer and heart disease. The burden of illness associated with AF, the potential to decrease the risk of stroke and other embolic events by thromboprophylaxis and the implications of this strategy for nursing care and patient education, determine AF as a critical element of nursing practice and research. A review of the literature was undertaken of the CINAHL, Medline, EMBASE and Cochrane Databases from 1966 until September 2002 focussing on management of atrial fibrillation to prevent thrombotic events. This review article presents key elements of this literature review and the implications for nursing practice.

A leiomyosarcoma of the oesophagus presenting incidentally without dysphagia.

Leiomyosarcoma is a rare tumour that accounts for 0.5% oesophageal sarcomas. The most common presenting symptom is dysphagia. This report presents a case of oesophageal leiomyosarcoma in a 56-year-old Caucasian man found incidentally while being investigated for refractory cough. There was no history of dysphagia in spite of tumour mass occupying most of the oesophageal lumen. The leiomyosarcoma was managed successfully with surgical resection and adjuvant radiotherapy. The patient remains disease free after 15 months after surgical intervention. The unusual case presentation is discussed and the surgical management of this rare condition reviewed.

Investigating breast symptoms in primary care: enhancing concordance with current best advice.

The purpose of this study was to determine whether a targeted intervention could improve primary care practitioners' concordance with guidelines regarding management of women with breast symptoms. One hundred and twelve practitioners from randomly selected areas around Australia prospectively audited their investigations for each woman with a new breast symptom over two 12-week periods, before and five months after the release of national guidelines. Between the two audits, doctors received feedback on practice in relation to peers and attended one seminar in their local areas led by specialists from the Royal Australasian College of Physicians and the Royal Australasian College of Surgeons. For five recommendations, there were statistically significant improvements at the second audit in line with standard Investigation of a New Breast Symptom (INBS) guidelines. All these were for investigations of breast lumps. At first audit, there were seven recommendations where practitioners were already managing more than 80% of women in accordance with the INBS, and where there were no statistically significant increases in concordance at second audit. Another six recommendations had lower concordance with the recommendations prior to the release of the guidelines and did not significantly improve at second audit. These tended to be for less-common presentations and where clinical findings were not consistent with other test results. We concluded that a targeted intervention improved physician concordance with current best advice for investigating women who present with new breast symptoms in a primary care setting. Further educational programs are needed to improve investigations for rarer symptoms, and to enhance physicians' confidence in the results of their clinical examinations.

Inflammatory endobronchial polyposis with bronchiectasis in cystic fibrosis.

An unusual case of endobronchial polyposis associated with extensive bronchiectasis in the context of cystic fibrosis (CF) has been described. A 15-yr-old female patient with CF underwent partial pneumonectomy for extensive bronchiectasis and frequent infective pulmonary exacerbations. Cylindrical bronchiectasis with associated purulent bronchitis and bronchiolitis, together with inflammatory polyposis, was noted in the resected lung. To the best of the authors' knowledge, this is the first report of multiple endobronchial polyposis and may represent a rare complication of bronchiectasis in a patient with cystic fibrosis. On-going infection and the cellular composition of the polyps are discussed in relation to their possible aetiological relevance and relationship to upper respiratory tract polyps.

Primary pulmonary osteosarcoma: case report and molecular analysis.

BACKGROUND: Primary pulmonary osteosarcoma is an extremely rare malignancy. To date, only 12 cases have been reported, with a high mortality rate. The authors report on a newly diagnosed patient and describe investigations that were performed using immunohistochemistry and comparative genomic hybridization (CGH). METHODS: The clinical course of a woman age 37 years is presented. Along with routine histologic examination, immunohistochemistry was used to demonstrate differentiation-associated proteins, oncoproteins, and other markers; CGH analysis for genomic alterations; and histochemistry to demonstrate alkaline phosphatase activity. RESULTS: Immunohistochemical analysis showed varying expression patterns using antibodies against a panel of tumor markers. Most notable was high overexpression of BCL-2 and cyclin D. CGH analysis showed that this neoplasm contained a much higher level of genetic aberrations compared with skeletal osteosarcoma. CONCLUSIONS: This tumor exhibited features common to skeletal osteosarcomas but also had some unique features. Genome analysis suggests that this tumor has several genetic aberrations in common with extraskeletal osteosarcoma. The novel regions of instability identified within the tumor genome may contribute toward the unique tumor phenotype and relative chemoresistance.

Expression of CD44v6 but not E-cadherin or beta-catenin influences prognosis in primary pulmonary adenocarcinoma.

Primary pulmonary adenocarcinoma was studied, looking for relationships between the expression of cell adhesion molecules (CAMs) E-cadherin, beta-catenin and CD44v6, and clinicopathological tumour parameters and patient post-operative survival. Formalin-fixed, paraffin-embedded tissue from 120 primary lung adenocarcinomas, including 23 poorly differentiated tumours, 17 of probable bronchial origin, and 29 with a prominent bronchioloalveolar pattern, together with nodal metastatic tumour from 34 of these patients was stained using monoclonal antibodies and immunohistochemistry. Sections were scored either high level (>10% cells positive) or low level (<10% positive). High level expression of CD44v6 was retained in 28.4% (34/120) of tumours, while high levels of E-cadherin (57.5%, 69/120) and beta-catenin (80. 8%, 97/120) were more frequent. For all CAMs, staining levels did not correlate with nodal status, stage or tumour type. The apical or basal staining seen in normal bronchial and alveolar epithelium was often seen in papillary, glandular, and bronchioloalveolar areas of tumour, while solid invasive tumour more often showed pericellular staining. When the staining for each CAM in 34 nodal metastases was compared with that in the corresponding primary tumour, a high degree of concordance was found, with no tendency for metastases to show less staining than the primary tumour. Expression of E-cadherin and beta-catenin in the primary tumour had no influence on post-operative survival, but patients whose tumours had low level CD44v6 expression had a poorer post-operative survival than those with high levels of CD44v6 (p=0.0014 for all patients, p=0.0012 for stage I patients only). In primary pulmonary adenocarcinoma, the levels of expression of E-cadherin, beta-catenin, and CD44v6 are not associated with lymph node metastases or tumour stage but the staining pattern is associated with tumour morphology. Low levels of CD44v6 expression predict a poor post-operative survival, independently of stage, while there is no such relationship with the expression of E-cadherin or beta-catenin.

A general practice-based recruitment strategy for colorectal cancer screening.

OBJECTIVE: To determine whether a screening recruitment strategy for first degree relatives of people with colorectal cancer is effective in enabling eligible relatives to request screening from their general practitioner (GP) and to assess acceptability to GPs and patients. METHODS: Thirty GPs, from 26 practices, and 303 of their patients aged over 50 who were first degree relatives of a person with colorectal cancer, participated in a randomised controlled trial of a GP-based recruitment strategy, in the Newcastle Area of New South Wales, Australia. RESULTS: The proportion of relatives requesting screening was statistically significantly higher in the intervention group than in the control group (18% compared to 4%, respectively; p = 0.01). CONCLUSIONS: Interest in the study by GPs was low, however for GPs who were involved, the recruitment strategy did prompt first degree relatives to discuss screening. The strategy may be even more effective when combined with other interventions such as a media campaign. The results may be generalizable to feasibility studies of general population screening for colorectal cancer in Australia. IMPLICATIONS: The results of this work are potentially informative to public health practice in Australia given the ensuing pilot programs of colorectal cancer screening.

Preoperative histological classification of primary lung cancer: accuracy of diagnosis and use of the non-small cell category.

AIMS: To compare the preoperative classification of lung carcinoma made on cytological and histological specimens with the postoperative classification made on the resected specimen. In addition, to find out how often the term "non-small cell lung cancer, not otherwise specified" (NSCLC) was used, and in such cases to note the final diagnosis. METHODS: Between 1991 and 1995, 303 patients had a lung resection in Aberdeen for primary carcinoma. For each patient, the departmental records were examined for preoperative specimens (cytological and histological). A note was made of whether each specimen was positive or negative for malignancy and, if positive, what the cell type was. Where patients had more than one sample submitted, the most specific result was taken. RESULTS: Fifty four per cent of patients had a correct specific preoperative diagnosis of malignancy, whereas 34% were labelled as NSCLC. Patients with squamous carcinoma were more likely to have a diagnosis of malignancy (88%) that was specifically correct (75%). Patients who had adenocarcinoma were less likely to have a preoperative diagnosis of malignancy (64%) that was specifically correct (35%). For those in whom a diagnosis of NSCLC was made, 55% turned out to have adenocarcinoma whereas 24% had squamous carcinoma. CONCLUSIONS: By adhering strictly to criteria, a high accuracy of diagnosis can be achieved for squamous carcinoma, but the diagnosis of adenocarcinoma seems to be more of a challenge. NSCLC is a useful and appropriate classification, the use of which reduces the rate of inaccurate specific diagnosis. There are occasions when pathologists can provide a more accurate diagnosis by being less precise.

Reliability and validity of women's recall of mammographic screening.

OBJECTIVE: To assess the reliability and validity of self-reported attendance for mammographic screening. METHODS: To assess reliability of recall of attendance for a screening mammogram, 100 women selected at random were interviewed twice (approximately one week apart). To assess validity, 127 women who reported having a mammogram within the national breast screening program (BreastScreen Australia) consented to having their reports verified by the national program. RESULTS: Test-retest reliability for the question "Have you ever had a mammogram?" was perfect (agreement 100%, kappa 1). Validity was also high. About one-quarter of women (24.4%) recalled the exact date of their last mammogram and a further third (39.4%) correctly reported the month in which the mammogram was done. Almost all (91.3%) women reported the mammogram date accurately to within 12 months of the recorded date. CONCLUSIONS: These data suggest that Australian women provide reliable and valid information in relation to mammographic screening attendance. IMPLICATIONS: Self-reported data about attendance for mammographic screening are likely to provide reliable and valid estimates for research and health services evaluation purposes.

Can compliance with nonpharmacologic treatments for cardiovascular disease be improved?

OBJECTIVE: To critically review the literature regarding the effectiveness of interventions aimed at improving cardiovascular patient compliance with nonpharmacologic treatments. METHODS: We searched Medline, Healthplan, and Psychlit from 1985 to 1996; searched the bibliographies of located studies; contacted Australian government departments and nongovernment organizations; and two experts examined the resulting study list. We selected 27 studies, which randomly allocated patients to groups and were published in English, and we evaluated interventions aimed at increasing compliance with nonpharmacologic treatments for cardiovascular disease. These trials were critically appraised against eight methodologic criteria and, subsequently, classified as of good, fair, or poor quality. Information about target groups, samples, trial intervention strategies and their effectiveness were extracted from the 18 good- and fair-quality trials. Interrater reliability was high on the 20% of references that were double-coded. The 18 studies reviewed described the effectiveness of 27 intervention strategies at improving compliance with dietary, smoking-cessation, exercise, weight-loss, stress-reduction, general lifestyle, relaxation, and blood pressure screening programs. RESULTS: Tentative recommendations were made for or against most trial strategies: partner-focused and structural strategies showed the most consistent benefits, physician-focused strategies were unanimously unsuccessful, and patient-focused strategies were of mixed benefit. CONCLUSIONS: The methodologic quality of many of the located trials was less than optimal. Therefore, further good-quality, randomized trials are necessary to clarify the effectiveness of those strategies identified as potentially useful in this review.