Evaluation of the Accuracy of a New Geometric Approach to Implant Guidance.

PURPOSE: Implant surgical guides are often fabricated using CBCT technology. In this study, an alternative technique is proposed. The aim of this in vitro study was to compare the accuracy of the guide sleeve corrections of a geometric approach to guided surgery to the accuracy of in vitro studies of stereolithographic guides. MATERIALS AND METHODS: Four arch forms were milled from acrylic blocks each with 12 root form sites. Root form inserts were made. Holes were milled in the inserts at arbitrary angles. Guide posts were placed in these sites. Guide sleeves were placed on the posts and connected with light-cured resin to form verification jigs. The goal was to correct the angles of the guide sleeves to a vertical position 90 degrees from the base of the arch forms. The initial angles from the vertical and horizontal positions of the center of each guide sleeve were determined radiographically and geometrically. Horizontal and angle corrections were made using two-piece guide posts. Guide sleeves placed over the corrected guide posts were connected with light-cured resin, forming new verification jigs. The accuracy of the angle correction and the coronal horizontal and apical horizontal deviations of the 3-mm guide sleeves were determined. The experimental sites were divided into two groups to determine if the size of the initial angles of the guide sleeves had any effect on the accuracy of the corrections. RESULTS: The initial angles of the guide sleeves before corrections revealed the mean difference between the two methods of measurements in groups 1 and 2 as 0.36 degrees (P = .14) and 0.69 degrees (P = .07), respectively. A comparison of the angle error measurements from 90 degrees after corrections between the two groups in the mesiodistal and buccolingual planes was not significant. The coronal and apical horizontal deviations after corrections revealed a significant difference between the two groups at the coronal level (P = .005) but not at the apical level (P = .14). In comparison of the methods of the two measurements of the angle error from vertical after corrections, the mean difference was 1.23 degrees (P = .01) and 0.69 degrees (P = .02). CONCLUSION: The in vitro accuracy of the guide sleeve corrections made with the geometric approach for implant guidance was compared to the results of the meta-analyses of in vitro studies of implant placement with stereolithographic guides. The mean errors were smaller and within the recommendations of the EAO Consensus Conference of 2012.

Neck of femur fracture: who gets a total hip replacement? A review of 230 eligible patients.

PURPOSE: To investigate patient-specific factors that predict Total Hip Replacement (THR) in patients with fracture neck of femur (NOF), fulfilling the National Institute of Health and Care Excellence (NICE) criteria. METHODS: Hip fracture database from a district general hospital and university hospital was retrospectively reviewed to identify patients fulfilling NICE criteria for THR after fracture NOF. Patient demographics, Nottingham Hip Fracture score (NHFS), complications, re-operations, revision, 30 days and one-year mortality was obtained from patient-records. Independent predictors correlating with the outcome of surgery were identified. A logistic regression analysis was used to predict the type of surgery in these patients. RESULTS: A total of 230 (114 WMH and 116 MH) were identified; 133 (57.8 per-cent) received hip hemiarthroplasty (HA), and 97 (42.2 per-cent) received THR. Patients receiving THR (mean 73.5 years, 95% CI 72-74.8) were significantly younger in comparison to patients receiving HA (mean 81.7 years, 95% CI 80.5-82.8). A negative correlation is noted between NHFS and type of surgery (Pearson's correlation - 0.537, p < 0.01), implying higher NHFS decreased the likelihood of receiving THR. Regression analysis showed NHFS (p-0.001) and walking ability (p-0.001) as significant predictors for the type of surgery (Nagelkerke R2-0.472). A log-rank test showed higher estimated survival time in patients with THR in comparison to HA (p-value 0.002). CONCLUSIONS: NHFS and walking ability can be used as an adjunct to the NICE criteria for selecting patients for THR after fracture NOF. Carefully selected patients treated with THR survive longer and have a better outcome in comparison to HA.

BAP1 Immunoreactivity Correlates with Gene Expression Class in Uveal Melanoma.

BACKGROUND: Uveal melanoma (UM) is the most common intraocular tumour in adults. Currently there are different tests available to determine the risk of UM for metastasis, among which include BRCA1-associated protein-1 (BAP1) immunohistochemistry (IHC) and gene expression profiling (GEP). BAP1 is a deubiquitylating enzyme (DUB) that has tumour suppressor activity, the loss of which therefore is associated with higher risk for tumour growth and metastasis. OBJECTIVES: To compare and correlate the prognostic significance of BAP1-IHC staining patterns and GEP in the prediction of UM's risk for metastasis. METHODS: This is a retrospective chart review with prospective follow-up of patients with primary UM who underwent enucleation from the year 2008 to 2018. Clinical history, histopathologic findings, GEP classification, BAP1-IHC of the formalin-fixed paraffin-embedded tissues, and follow-up data for metastasis were collected and statistically analysed. RESULTS: A total of 30 enucleated eyes with UM were included in the study. All class 1a tumours had high nuclear BAP1 expression and all class 2 had low nuclear BAP1 expression. Fifty percent of the class 1b tumours had low nuclear BAP1 expression. Among the tumours with low nuclear BAP1 expression, 68% developed metastasis, while 9% developed metastasis among high nuclear expression. Fifty-five percent developed metastasis in tumours with high cytoplasmic expression and 42% for low cytoplasmic expression. Predictive values for metastasis (positive predictive value, negative predictive value) are as follows: (1) nuclear BAP1-IHC (68%, 91%), (2) cytoplasmic BAP1-IHC (55%, 58%), and (3) GEP (73%, 80%). Nuclear BAP1-IHC and GEP had the same accuracy rate of 77% and cytoplasmic BAP1-IHC had an accuracy of 57%. CONCLUSION: Low nuclear BAP1-IHC strongly correlates with GEP class 2 and was equally accurate in the prediction of metastasis.

Density of PAS positive patterns in uveal melanoma: Correlation with vasculogenic mimicry, gene expression class, BAP-1 expression, macrophage infiltration, and risk for metastasis.

Purpose: Periodic acid-Schiff (PAS) positive patterns of vasculogenic mimicry (VM) have been associated with poor prognosis in uveal melanoma (UM). We examined these patterns with digital image analysis and transmission electron microscopy, and correlated them with BAP-1 expression, gene expression class, macrophage infiltration, and metastatic disease in full tumor cross-sections and intratumor regions. Methods: Thirty-two enucleated eyes with UM were stained immunohistochemically (BAP-1, laminin, CD31, and CD68) and with PAS without hematoxylin counterstain. Retrospective data on gene expression class and patient survival were retrieved. Tumor sections were digitally scanned and analyzed with the QuPath Bioimage analysis software, and imaged with transmission electron microscopy. Results: The mean area proportion covered by CD31, laminin, and PAS positive patterns in tumor cross-sections was 0.9% (SD 0.6), 3.0% (SD 1.9), and 8.4% (SD 5.9), respectively. PAS density was statistically significantly greater in tumors with gene expression class 2 (p=0.02). The cumulative 5-year metastasis-free survival decreased for each quartile of increased PAS density (1.0, 0.75, 0.40, and 0.17, p=0.004). Forty percent of the tumors had heterogeneous BAP-1 expression. Intratumor regions with low BAP-1 expression were more likely to harbor VM (p<0.0001), and had statistically significantly greater PAS density (p<0.0001) and number of CD68 positive cells (p=0.01). Conclusions: PAS positive patterns in UM are composed of a mixture of blood vessels and extracellular matrix (ECM), including VM. Increased density of PAS positive patterns correlated with gene expression class and metastasis, and colocated to tumor regions with macrophage infiltration and low BAP-1 expression.

Digital Image Analysis of BAP-1 Accurately Predicts Uveal Melanoma Metastasis.

PURPOSE: Reduced nuclear expression of BRCA1 associated protein 1 (BAP-1) is associated with a high risk for metastasis in uveal melanoma. Manual assessment of the expression level may face issues with interobserver reproducibility. This could be improved with digital image analysis (DIA). METHODS: Thirty enucleated eyes with uveal melanoma from the Emory Eye Center (Atlanta, GA; years 2009-2017) were included and stained with BAP-1. Retrospective data on patient and tumor characteristics were retrieved. Patients were randomized to a training or validation cohort. Their tumor sections were digitally scanned and scored for percentage of BAP-1-positive cells with the QuPath Bioimage analysis software. RESULTS: Interobserver concordance was 75% (Cohen's κ 0.52) with manual BAP-1 scoring and 88% to 94% with DIA (Cohen's κ 0.75-0.88). Positive and negative predictive values for metastasis were 90% and 100% with DIA, 80% and 86% with manual scoring, and 78% and 88% with gene expression class 2. In binary logistic regression, manual and DIA of BAP-1 and gene expression class 2 were associated with metastasis, but none retained significance in multiple regression. Metastasis-free survival was significantly shorter with low BAP-1 expression as defined by DIA (log-rank P = 0.02), but not with manual scoring (log-rank P = 0.36) or with gene expression class 2 (log-rank P = 0.17). CONCLUSIONS: DIA of BAP-1 is a competitive alternative to manual assessment as well as gene expression profiling in prognostication of enucleated specimens with uveal melanoma. TRANSLATIONAL RELEVANCE: The emerging scope for automatization of qualified diagnostic tasks is applied to uveal melanoma.

A plasma cell-based pericardial effusion leading to tamponade in a patient with multiple myeloma - a case report and review of the literature.

A rare case of extramedullary multiple myeloma causing cardiac tamponade secondary to a plasma cell-based pericardial effusion is described. A systematic search using PubMed (National Library of Medicine) was used to identify a further 27 cases dating back to 1970. Case characteristics, treatment strategies, and survival time following tamponade are discussed. Linear regression demonstrated a weak but statistically significant correlation between survival time following tamponade and treatment with systemic chemotherapy and steroids (ß=16.8 weeks, P=.009). However, this manifestation of extramedullary multiple myeloma still conveys a dismal prognosis with a median survival following tamponade of only 6 weeks based on our review.

Intraoperative mannitol during robotic-assisted-laparoscopic partial nephrectomy.

Mannitol is routinely used during partial nephrectomies due to its renoprotective properties. With minimally invasive techniques, the need for mannitol has been questioned. Robotic-assisted laparoscopic partial nephrectomy (RALPN) has been shown to decrease warm ischemia time, which may potentially minimize the benefit of mannitol. To date, no prospective, randomized, controlled trials have investigated the use of mannitol in only robotic procedures. We hypothesize that the intraoperative mannitol use during RALPN provides no statistically significant benefit for post-operative renal function outcomes. We conducted a randomized, controlled, double-blinded, single surgeon, prospective study to assess renal function after RALPN. Patients were randomized into a control group with intravenous normal saline infusion prior to clamping of the vessels or to an experimental group with an infusion of mannitol. Estimated glomerular filtration rate (eGFR) were obtained prior to the surgery as well as post operatively at 24 h, 1 week, and 30 days. Preoperative eGFR showed no statistical differences between the groups and evaluation of median percent change in eGFR after surgery did not indicate a statistical difference between the groups after RALPN. After prospective analysis of the change in post-operative renal function of randomized groups who received 12 g of mannitol following RALPN, we determined that infusion of mannitol does not provide significant improvement of maintenance of renal functions after RALPN. Based on our results, we recommend discontinuing routine use of mannitol during RALPN.

Quality improvement in melanoma care: Multidisciplinary quality program development and comparison of care before and after implementation.

INTRODUCTION: Adherence to guideline-based care for melanoma remains suboptimal. This study describes the development of a quality monitoring program and compares the quality of care before and after its implementation. METHODS: Thirty quality metrics were adopted. An abstraction tool, manual and electronic database were developed. Metrics were analyzed from 1/1/2008-8/31/2013 (Group A) and compared to melanoma care from 9/1/2013-12/31/2017 (Group B). RESULTS: A total of 311 patients were treated from 2008 to 2017. Demographic data were similar between the groups. 21.7% of patients in Group A had clinical stage (TNM) documented before surgery compared to 100% in Group B. 86.9% of patients in Group A had surgical margins documented in the operative report compared to 100% of Group B. Appropriate surgical margins were obtained in 85.7% of Group A compared to 99.5% in Group B. Pathology reporting of margin status, satellitosis, regression and mitotic rates improved from ∼60% Group A to >92% in Group B. Multidisciplinary process and structural metrics were unchanged. CONCLUSIONS: A comprehensive melanoma quality program has produced significantly improved guideline-based multidisciplinary care.

Altering the Approach: Open Minimally Invasive Renal Transplant in Obese Patients Through the Anterior Rectus Sheath.

OBJECTIVE: To retrospectively analyze the wound issues for obese renal transplant patients, as well as post-transplant outcomes including graft and patient survival, hypothesizing improvement over the standard approach. As the obese population has expanded, minimally invasive renal transplant techniques have attempted to improve the issues of complications related to wounds and hernias. The anterior rectus sheath approach, which facilitates a minimal incision, has been adopted at our center for all renal transplants, including obese patients. METHODS: Between January 1, 2011 and December 31, 2014, 166 renal transplants were performed at the Charleston Area Medical Center with the new approach adopted in November 2012. Of the extraperitoneal transplants, 71 adult patients were classified as morbid/severe (≥35) or obese (30-34.9) by body mass index. Demographics, perioperative results, and outcomes were retrospectively collected for the conventional (CON) and anterior rectus sheath (ARS) approaches until August 21, 2015. RESULTS: The ARS and CON groups comprised 40 of 71 (56%) and 31 of 71 (44%) patients, respectively. The majority of demographics and perioperative data indicated no significant statistical differences between procedures (P < .05). Wound complications, incision length, operative time, and glomerular filtration rate at 6 and 12 months were significantly different. Multivariate calculations indicated procedure as the only variable expected to affect wound healing in obese patients. CONCLUSION: For obese patients, the ARS approach was shown to be an effective option that reduced wound complications and operative times. This easily adopted approach provides the obese and morbidly obese with comparable overall graft outcomes and significant improvement on wound complications.

The effect of cigarette smoking on the oral and nasal microbiota.

BACKGROUND: The goal of the study was to investigate whether cigarette smoking alters oral and nasal microbial diversity, composition, and structure. Twenty-three current smokers and 20 never smokers were recruited. From each subject, nine samples including supra and subgingiva plaque scrapes, saliva, swabs from five soft oral tissue sites, and one nasal swab from both the anterior nares were collected. 16S rRNA V3-V4 region was sequenced for microbial profiles. RESULTS: We found that alpha diversity was lower in smokers than in nonsmokers in the buccal mucosa, but in other sample sites, microbial diversity and composition were not significantly different by smoking status. Microbial profiles differed significantly among eight oral sites. CONCLUSIONS: This study investigates the effect of cigarette smoking on different sites of the oral cavity and shows a potential effect of cigarette smoking on the buccal mucosa microbiota. The marked heterogeneity of the oral microbial ecosystem that we found may contribute to the stability of the oral microbiota in most sites when facing environmental perturbations such as that caused by cigarette smoking.

First experience: Open small incision rectus sheath approach renal transplant: A case series.

BACKGROUND: Prevention of wound complications is an important goal in surgery, and reduction of modifiable risks factors are an important step towards protecting patients from further complications. Renal transplantation has sought to be more inclusive giving access to transplantation to complex patient populations, many of which have an increased risk of complications specifically obese recipients. Surgical techniques continue to advance and may contribute to reducing complications. We hypothesized that the Anterior Rectus Sheath (ARS) Approach would provide an open transplant with minimal damage and less wound complications, including fluid collections such as lymphoceles, when compared to the conventional technique (CON) with equivalent graft function and survival. MATERIALS AND METHODS: The ARS approach was adopted at our center in November of 2012. Medical records for 44 patients that underwent kidney transplantation at our Center between May 1, 2012 and March 31, 2013 were reviewed with data collected up to August 2015. Two were excluded (2 intraperitoneal transplants), leaving 22 in the ARS group and 20 in the CON group. RESULTS: Demographics, data, and perioperative factors were found to be similar, but operative and post-operative findings indicated significant differences between the groups. Significant reductions of wound complications, including fluid collections, were observed and operative time, incision length, and drain usage were improved with the ARS technique. Secondary outcome assessing overall patient outcomes showed no significant difference. CONCLUSION: This retrospective review case series quantified that this easily adopted modification of the conventional transplant technique is a safe, effective, and swift approach to renal transplantation with favorable graft results and improved surgical outcomes with less post-operative wound complications.

A randomized, placebo-controlled trial of preemptive antifungal therapy for the prevention of invasive candidiasis following gastrointestinal surgery for intra-abdominal infections.

BACKGROUND: Patients undergoing emergency gastrointestinal surgery for intra-abdominal infection are at risk of invasive candidiasis (IC) and candidates for preemptive antifungal therapy. METHODS: This exploratory, randomized, double-blind, placebo-controlled trial assessed a preemptive antifungal approach with micafungin (100 mg/d) in intensive care unit patients requiring surgery for intra-abdominal infection. Coprimary efficacy variables were the incidence of IC and the time from baseline to first IC in the full analysis set; an independent data review board confirmed IC. An exploratory biomarker analysis was performed using logistic regression. RESULTS: The full analysis set comprised 124 placebo- and 117 micafungin-treated patients. The incidence of IC was 8.9% for placebo and 11.1% for micafungin (difference, 2.24%; [95% confidence interval, -5.52 to 10.20]). There was no difference between the arms in median time to IC. The estimated odds ratio showed that patients with a positive (1,3)-ß-d-glucan (ßDG) result were 3.66 (95% confidence interval, 1.01-13.29) times more likely to have confirmed IC than those with a negative result. CONCLUSIONS: This study was unable to provide evidence that preemptive administration of an echinocandin was effective in preventing IC in high-risk surgical intensive care unit patients with intra-abdominal infections. This may have been because the drug was administered too late to prevent IC coupled with an overall low number of IC events. It does provide some support for using ßDG to identify patients at high risk of IC. CLINICAL TRIALS REGISTRATION: NCT01122368.

Leveraging state cancer registries to measure and improve the quality of cancer care: a potential strategy for California and beyond.

Despite recent increased attention to healthcare performance and the burden of disease from cancer, measures of quality of cancer care are not readily available. In 2013, the California HealthCare Foundation convened an expert workgroup to explore the potential for leveraging data in the California Cancer Registry (CCR), one of the world's largest population-based cancer registries, for measuring and improving the quality of cancer care. The workgroup assessed current registry operations, the value to be gained by linking CCR data with health insurance claims or encounter data and clinical data contained in health system electronic health records, and potential barriers to these linkages. The workgroup concluded that: 1) The CCR mandate should be expanded to include use of its data for quality of cancer care measurement and public reporting; and 2) a system should be developed to support linkage of registry data with both claims data and provider electronic health record data.

Randomized trial of micafungin for the prevention of invasive fungal infection in high-risk liver transplant recipients.

BACKGROUND: Invasive fungal infection (IFI) following liver transplant is associated with significant morbidity and mortality. Antifungal prophylaxis is rational for liver transplant patients at high IFI risk. METHODS: In this open-label, noninferiority study, patients were randomized 1:1 to receive intravenous micafungin 100 mg or center-specific standard care (fluconazole, liposomal amphotericin B, or caspofungin) posttransplant. The primary endpoint was clinical success (absence of a proven/probable IFI and no need for additional antifungals) at end of prophylaxis (EOP). Noninferiority (10% margin) of micafungin vs standard care was assessed in the per protocol and full analysis sets. Safety assessments included adverse events and liver and kidney function tests. RESULTS: The full analysis set comprised 344 patients (172 micafungin; 172 standard care). Mean age was 51.2 years; 48.0% had a Model for End-Stage Liver Disease score ≥20. At EOP (mean treatment duration, 17 days), clinical success was 98.6% for micafungin and 99.3% for standard care (Δ standard care - micafungin [95% confidence interval], 0.7% [-2.7% to 4.4%]) in the per protocol set and 96.5% and 93.6%, respectively (-2.9% [-8.0% to 1.9%]), in the full analysis set. Incidences of drug-related adverse events for micafungin and standard care were 11.6% and 16.3%, leading to discontinuation in 6.4% and 11.6% of cases, respectively. At EOP, liver function tests were similar but creatinine clearance was higher in micafungin- vs standard care-treated patients. CONCLUSIONS: Micafungin was noninferior to standard care as antifungal prophylaxis in liver transplant patients at high risk for IFI. Adverse event profiles and liver function at EOP were similar, although kidney function was better with micafungin. CLINICAL TRIALS REGISTRATION: NCT01058174.

Longitudinal neuropsychological findings in amyloid beta-related angiitis (AßRA): a case report.

Amyloid ß-related angiitis (AßRA) is a clinicopathological diagnosis of primary central nervous system angiitis theoretically triggered by vascular deposition of amyloid ß peptide. Deposits of Aß are associated with degeneration of the vasculature, thereby increasing risks of a stroke and/or cognitive impairment. Despite this, no prior studies have presented a detailed neuropsychological profile associated with AßRA. We present longitudinal neuropsychological findings for the case of a 58-year-old man with biopsy-diagnosed AßRA. Neuropsychological test results and clinical presentation demonstrated a mild to moderate dysexecutive syndrome implicating dorsolateral frontal and orbitofrontal-subcortical systems involvement. Despite prior reports of cognitive decline following a diagnosis of AßRA, cognitive functioning remained relatively stable over a 15-month period after immunosuppressive treatment. For the most part, objective measures did not demonstrate a measurable change in cognitive functioning, except for a mild decline in memory. There were subjective reports of improvement in cognitive and adaptive functioning from the patient and his spouse over this time period. The clinical significance of these results is discussed in the context of theories of executive dysfunction, and with reference to previously-published cases of AßRA.

Dedicated dual-head gamma imaging for breast cancer screening in women with mammographically dense breasts.

PURPOSE: To compare performance characteristics of dedicated dual-head gamma imaging and mammography in screening women with mammographically dense breasts. MATERIALS AND METHODS: Asymptomatic women (n = 1007) who had heterogeneously or extremely dense breasts on prior mammograms and additional risk factors provided informed consent to enroll in an institutional review board-approved HIPAA-compliant protocol. Participants underwent mammography and gamma imaging after a 740-mBq (20-mCi) technetium 99m sestamibi injection. Reference standard (more severe cancer diagnosis or 12-month follow-up findings) was available for 936 of 969 eligible participants. Diagnostic yield, sensitivity, specificity, and positive predictive values (PPVs) were determined for mammography, gamma imaging, and both combined. RESULTS: Of 936 participants, 11 had cancer (one with mammography only, seven with gamma imaging only, two with both combined, and one with neither). Diagnostic yield was 3.2 per 1000 (95% confidence interval [CI]: 1.1, 9.3) for mammography, 9.6 per 1000 (95% CI: 5.1, 18.2) for gamma imaging, and 10.7 per 1000 (95% CI: 5.8, 19.6) for both (P = .016 vs mammography alone). One participant had a second ipsilateral cancer detected with gamma imaging only. Prevalent screening gamma imaging demonstrated equivalent specificity relative to incident screening mammography (93% [861 of 925] vs 91% [840 of 925], P = .069). Of eight cancers detected with gamma imaging only, six (75%) were invasive (median size, 1.1 cm; range, 0.4-5.1 cm); all were node negative. The ratio of the number of patients with breast cancer per number of screening examinations with abnormal findings was 3% (three of 88) for mammography and 12% (nine of 73) for gamma imaging (P = .01). The number of breast cancers diagnosed per number of biopsies performed was 18% (three of 17) for mammography and 28% (10 of 36) for gamma imaging (P = .36). CONCLUSION: Addition of gamma imaging to mammography significantly increased detection of node-negative breast cancer in dense breasts by 7.5 per 1000 women screened (95% CI: 3.6, 15.4). To be clinically important, gamma imaging will need to show equivalent performance at decreased radiation doses.

Revision hip arthroplasty in nonagenarians.

The results of a series of revision hip arthroplasties in nonagenarians performed at a single institution over an 8 year period are presented. All data was collected prospectively. The indications for surgery, ASA grade, co-morbid medical conditions, post operative complications, blood transfusion requirements, length of in-patient stay, and discharge deposition, were recorded. Thirty day, one year and current mortality rates were calculated. Fifteen patients were identified with a mean follow-up of 3 years. There were 14 single-stage and 1 two-stage revisions. The mean age at the time of surgery was 92 years. The mean ASA grade was 2. The average inpatient stay was 14 days. Sixty three percent of patients required a period of further rehabilitation. The rate of complications was high (63%) as was the need for blood transfusion (75%). Mortality at 30 days was 7% (1/15),at 1 year 20% (3/15), and at 3 years 33% (5/15). If indicated, revision hip arthroplasty can still be considered in very elderly patients; however, a higher than usual complication rate is to be expected.

Evaluating an organized palliative care approach in patients with severe stroke.

BACKGROUND: A recent survey found few guidelines on the provision of palliative care following stroke; none examined the efficacy or results of any such process. The role of the patient's family in decision making and in conflicts with staff has not been evaluated. We sought to formally evaluate the use of locally-developed palliative care guidelines on our Acute Stroke Unit (ASU). METHODS: We retrospectively examined records of 104 patients who died on our ASU over a two-year period to determine if our existing palliative guidelines were reflected in clinical practice, and to identify conflicts that arose. Data on medical and nursing care, palliative decisions, and medication use were compared to the ASU's existing palliative care guidelines. Family concerns about the palliative process were also reviewed. RESULTS: Of patients admitted to the stroke unit, 104 (16% of total admissions) died. Ninety-four (90.4%) of these were palliated; all received routine nursing and comfort care prior to death. Median time from admission to palliation was 3.6 days; median time from admission to death was 8.5 days. Most had vital signs (98.9%), investigations (100%) and non-palliative medications (95.7%) stopped, and had nasogastric feeding (96.8%) and intravenous fluids (87.2%) withdrawn or never begun. Most were treated with morphine (93.6%) and scopolamine (81.9%). Concerns raised by family members centered around hydration and feeding (45.7%), doubts about palliative care (27.8%) and patient comfort (18.2%). CONCLUSIONS: A formal approach to palliation results in timely decisions regarding end of life care with relatively few conflicts. Further work to address the specific concerns of families is needed.

Increases in antihypertensive prescriptions and reductions in cardiovascular events in Canada.

The Canadian Hypertension Education Program, an extensive professional education program to improve the management of hypertension, was started in 1999. There were very large increases in diagnosis and treatment of hypertension in the first 4 years after initiation of the program. The purpose of this study was to examine the association between the changes in antihypertensive therapy with changes in hospitalization and death from major hypertension-related cardiovascular diseases in Canada between 1992 and 2003. Using various national databases, Canadian standardized yearly mortality and hospitalization rates per 1000 for stroke, heart failure, and acute myocardial infarction were calculated for individuals aged >or=20 years and regressed against antihypertensive prescription rates. Changes in rates were examined in a time series analysis. There were significant reductions (P<0.0001) in the rate of death from stroke, heart failure, and myocardial infarction starting in 1999. There was also a reduction in hospitalization rate from stroke (P<0.0001) and heart failure (P<0.0001) but not myocardial infarction in 1999. The changes in death (P<0.001 for all 3 diseases) and hospitalization (P<0.0001 for stroke and heart failure; P=0.018 for acute myocardial infarction) were associated with the increases in antihypertensive prescriptions. This study demonstrates that the reduction in cardiovascular death and hospitalization rates is associated with an increase in antihypertensive prescriptions and that it coincides with the introduction of the Canadian Hypertension Education Program. The Canadian Hypertension Education Program educational model for improving health care could be adopted by other countries with well-developed professional and scientific societies.

Molecular breast imaging: use of a dual-head dedicated gamma camera to detect small breast tumors.

OBJECTIVE: Molecular breast imaging with a single-head cadmium zinc telluride (CZT) gamma camera has previously been shown to have good sensitivity for the detection of small lesions. To further improve sensitivity, we developed a dual-head molecular breast imaging system using two CZT detectors to simultaneously acquire opposing breast views and reduce lesion-to-detector distance. We determined the incremental gain in sensitivity of molecular breast imaging with dual detectors. SUBJECTS AND METHODS: Patients with BI-RADS category 4 or 5 lesions < 2 cm that were identified on mammography or sonography and scheduled for biopsy underwent molecular breast imaging as follows: After injection of 740 MBq of technetium-99m ((99m)Tc) sestamibi, 10-minute craniocaudal and mediolateral oblique views of each breast were acquired. Blinded reviews were performed using images from both detectors 1 and 2 and images from detector 1 only (simulating a single-head system). Lesions were scored on a scale of 1-5; 2 or higher was considered positive. RESULTS: Of the 150 patients in the study, 128 cancers were confirmed in 88 patients. Averaging the results from the three blinded readers, the sensitivity of dual-head molecular breast imaging was 90% (115/128), whereas the sensitivity from review of only single-head molecular breast imaging was 80% (102/128). The sensitivity for the detection of cancers < or = 10 mm in diameter was 82% (50/61) for dual-head molecular breast imaging and 68% (41/61) for single-head molecular breast imaging. On average, 13 additional cancers were seen on dual-head images and the tumor uptake score increased by 1 or more in 60% of the identified tumors. CONCLUSION: Gains in sensitivity with the dual-head system molecular breast imaging are partially due to increased confidence in lesion detection. Molecular breast imaging can reliably detect breast lesions < 2 cm and dual-head molecular breast imaging can significantly increase sensitivity for subcentimeter lesions.