Fear of progression in chronic illnesses other than cancer: a systematic review and meta-analysis of a transdiagnostic construct.

Fear of cancer recurrence (FCR) is the most common psychosocial issue amongst cancer survivors. However, fear of progression (FoP) has rarely been studied outside of the cancer context. This review aimed to: (1) meta-synthesise qualitative studies of FoP in illnesses other than cancer; and (2) quantify the relationship between FoP and anxiety, depression, and quality of life (QoL) in non-cancer chronic illnesses. We identified 25 qualitative and 11 quantitative studies in a range of chronic illnesses. Participants described fears of progression and recurrence of their illness, including fears of dying, and fears of becoming a burden to family. Fears were often triggered by downward comparison (i.e., seeing people worse off than themselves). Participants coped in different ways, including by accepting the illness or seeking knowledge. Those for whom these fears caused distress reported hypervigilance to physical symptoms and avoidance. Distress, and seeking information, were associated with adherence. In quantitative analyses, FoP was moderately associated with QoL, and strongly associated with anxiety and depression. These results suggest that FoP in illnesses other than cancer is similar to FCR. FoP appears to be an important transdiagnostic construct associated with distress. Evidence-based FCR interventions could be adapted to better manage FoP in other illnesses.

Injection parameters and virus dependent choice of promoters to improve neuron targeting in the nonhuman primate brain.

We, like many others, wish to use modern molecular methods to alter neuronal functionality in primates. For us, this requires expression in a large proportion of the targeted cell population. Long generation times make germline modification of limited use. The size and intricate primate brain anatomy poses additional challenges. We surved methods using lentiviruses and serotypes of adeno-associated viruses (AAVs) to introduce active molecular material into cortical and subcortical regions of old-world monkey brains. Slow injections of AAV2 give well-defined expression of neurons in the cortex surrounding the injection site. Somewhat surprisingly we find that in the monkey the use of cytomegalovirus promoter in lentivirus primarily targets glial cells but few neurons. In contrast, with a synapsin promoter fragment the lentivirus expression is neuron specific at high transduction levels in all cortical layers. We also achieve specific targeting of tyrosine hydroxlase (TH)- rich neurons in the locus coeruleus and substantia nigra with a lentvirus carrying a fragment of the TH promoter. Lentiviruses carrying neuron specific promoters are suitable for both cortical and subcortical injections even when injected quickly.

Effects of broad-spectrum antimycobacterial therapy on chronic pulmonary sarcoidosis.

BACKGROUND: Sarcoidosis is an idiopathic, granulomatous disease for which molecular and immunologic studies have shown an association between it and mycobacterial antigens. Microbial antigens can reduce expression of the tyrosine kinase Lck, which has been associated with sarcoidosis severity. Here we investigate the efficacy of Concomitant Levofloxacin, Ethambutol, Azithromycin, and Rifampin (the CLEAR regimen) for treatment of chronic, pulmonary sarcoidosis. METHODS: Fifteen chronic, pulmonary sarcoidosis patients with forced vital capacities (FVC) between 45-80% of predicted were enrolled in this open-label trial. The primary efficacy endpoint was change in absolute FVC from baseline to completion of therapy. Secondary endpoints were change in functional capacity measured by Six Minute Walk Distance (6MWD) and quality of life assessment measured by St. George's Respiratory Questionnaire (SGRQ). RESULTS: Of 15 patients enrolled, 11 completed 4 weeks of therapy, and 8 completed 8 weeks of therapy. The CLEAR regimen was associated with an increase in FVC of 0.23 liters at 4 weeks and 0.42 liters at 8 weeks (P=0.0098 and 0.016, respectively). The 6MWD increased by 87 meters from baseline to 8 weeks (p=0.0078). The mean score of the validated SGRQ was improved at 8 weeks over baseline (p=0.023). Normalized expression of Lck and NF-κB was observed in those with clinical improvement. CONCLUSIONS: The CLEAR regimen is associated with improved absolute FVC, as well as increased functional capacity and quality-of-life in selected chronic pulmonary sarcoidosis patients. Larger, randomized, controlled trials are needed to confirm these findings and to identify patients most likely to benefit from therapy. ClinicalTrials.gov number NCT01169038.

Unusual facet cyst containing struvite and hydroxyapatite.

This case report describes a patient with severe back pain and radiculopathy. She was found to have a facet cyst within the lumbar spine that appeared to contain calcium on MRI and CT. Upon aspiration the cyst was found to contain calcium ammonium phosphate (struvite) and calcium phosphate (hydroxyapatite). Ammonia production in the presence of urease-producing bacteria is responsible for the production of struvite in the human body. We postulate that there was a prior infection of the facet with urease-producing bacteria, thus accounting for the production of the struvite within the facet cyst.

Practice variation in the diagnosis and treatment of osteoporosis: a case for more effective physician education in primary care.

Bone mineral density (BMD) performed by dual energy x-ray absorptiometry (DEXA) has been used at our institution as a screening test for osteoporosis since 1986. Of 2789 bone densitometry tests done between 1992 and 1996 on women aged 51-75 years, 1743 (62.5%) were ordered by general internists (GIM), endocrinologists (ENDO), rheumatologists (RHEUM), and a metabolic bone disease specialist (MBDS). We compared the percentage of densitometry tests ordered by GIM, ENDO, RHEUM, and MBDS resulting in one of three possible diagnoses (normal, osteopenia, or osteoporosis). Applying the World Health Organization's (WHO) definition of normal (< 1 standard deviation [SD] below the mean for young, adult women), osteopenia (> or = 1 SD-< 2.5 SD below the mean), and osteoporosis (> or = 2.5 SD below the mean), we found that 34% of patients tested between 1992 and 1996 were osteoporotic, 42% were osteopenic, and 24% had normal bone density results. The rate of osteoporosis diagnosis was highest in the MBDS cohort (chi 2 = 9.19, p = 0.002) compared with patients in the other cohorts. To explore trends in management of this condition, a random sample of osteoporotic women aged 51-75 who had densitometry in 1996 (n = 82) was obtained. Review of medical records revealed that 73% were on some form of osteoporosis treatment (bisphosphonate, estrogen, or calcitonin, with or without calcium and vitamin D supplementation). Treatment rates differed significantly, however, by the ordering physician specialty (96% for MBDS, 63% for ENDO, 75% for RHEUM, and 53% for GIM, chi (2)3df = 11.37, p = 0.01). There were no significant differences in selected clinical or demographic characteristics between patients treated by GIM and MBDS. This variation in treatment rates suggests that an opportunity to enhance primary care physicians' recognition and treatment of osteoporosis exists. Making osteoporosis management an educational focus may help narrow differences in practice and improve the effectiveness of a larger number of physicians treating patients with this problem.

Etiology of peripheral arterial thromboembolism in young patients.

BACKGROUND: No prior studies have explored the etiology of peripheral arterial thromboembolic events (PATE) in younger patients. Therefore, we analyzed the sources of these events in patients <50 years of age over a recent 10-year period. Diagnostic and work-up strategies will be proposed based on the presence of cardiac or atherosclerotic risk factors. PATIENTS AND METHODS: The sources of emboli were classified as (1) conventional (cardiac or arterioarterial), (2) unconventional, or (3) unknown. A statistical analysis of risk factors that, if absent, would suggest an unconventional cause was performed. Risk factors included those for cardiac and atherosclerotic disease: coronary artery disease (CAD), valvular disease, smoking, arrhythmia, hypertension, or diabetes mellitus. RESULTS: Overall, 51 patients were identified. Twenty-nine patients (57%) had unconventional causes (8 paradoxical emboli, 4 possible paradoxical emboli, 12 hypercoagulable states, 3 white clot syndromes, and 2 cervical ribs), 17 (33%) had conventional causes, and 5 (10%) were unknown. When the number of cardiac risk factors was < or =1, excluding smoking, the probability of a conventional source was zero, in contrast to 100% if the number of risk factors was >1. When the following risk factors were absent, there were significantly more unconventional than conventional sources of emboli (P < 0.001): smoking (100% versus 0%), CAD (93% versus 7%), arrhythmias (83% versus 17%), hypertension (93% versus 7%), and diabetes mellitus (81% versus 19%). Patients with a conventional source were significantly older (44 versus 38 years). CONCLUSIONS: The "unconventional" causes of PATE were responsible for a higher percentage of cases in young patients. An analysis of the number of risk factors was useful in predicting which patients suffered embolic events from conventional sources, with the critical number being >1 (excluding smoking). Therefore, when younger patients present with PATE, and are found to have < or =1 identifiable cardiac risk factor, their work-up should be directed toward the unconventional sources first.

Laparoscopy-associated mesenteric vascular events: description of an evolving clinical syndrome.

Over the past few years, several cases of acute mesenteric ischemic events following laparoscopy have appeared in the literature. To date, no formal description of this phenomenon has been provided. In this article, we summarize and analyze the features of the five reported cases to date as well as a sixth case encountered at our institution. The probable cause of this complication involves changes in splanchnic hemodynamics related to elevated intra-abdominal pressure. A review of the relevant literature is provided.

Effect of contralateral severe stenosis or carotid occlusion on duplex criteria of ipsilateral stenoses: comparative study of various duplex parameters.

PURPOSE: This study compares the accuracy of various duplex parameters in grading ipsilateral carotid stenoses in patients with contralateral severe stenoses or occlusion. METHODS: Four duplex criteria were correlated to arteriography in 356 carotid arteries in blind fashion: (1) standard criteria: a peak systolic frequency (PSF) of the internal carotid artery (ICA) of > or = 4 kHz was used to diagnose > or = 50% stenosis; (2) new criteria: a PSF of the ICA of > or = 4.5 kHz was used; (3) Fujitani criteria: a PSF of the ICA of > 4.5 kHz and an end-diastolic frequency of < 5.0 kHz was used; (4) internal carotid/common carotid artery (ICA/CCA) PSF ratio of > or = 1.5 was used. RESULTS: The standard method overestimated 56 (16%) of 356 stenoses in contrast to 3% for the new method (p < 0.001), and this effect was most evident in the 50% to < 80% stenosis category (30%). The Fujitani method underestimated 97 (27%) of 356 stenoses, and the ICA/CCA ratio overestimated stenoses in 77 (22%) of 356. The overall exact correlation was 94%, 82%, 70%, and 75% for the new, standard, Fujitani, and ICA/CCA ratio, respectively. The kappa statistic and corresponding confidence intervals for the new method (kappa = 0.923, +/- 0.016) are significantly higher (p < 0.001) than those for the standard method (kappa = 0.760, +/- 0.027), the Fujitani method (kappa = 0.608, +/- 0.031), and the ICA/CCA ratio method (kappa = 0.642, +/- 0.051). The overall accuracy in diagnosing > or = 50% ipsilateral stenosis in the whole series was 85% for the standard method, 97% for the new method, 95% for the Fujitani method, and 81% for the ICA/CCA ratio. The new method was superior to the standard and ICA/CCA ratio methods (p < 0.001) and the Fujitani method (p = 0.024). CONCLUSIONS: The presence of significant contralateral stenosis (> or = 50%) can lead to overestimation of ipsilateral stenosis if the standard criteria are used; however, this problem can be avoided by using a PSF of the ICA of > or = 4.5 kHz for the diagnosis of > or = 50% stenosis.

Congenital cystic supratentorial hemangioblastoma. Case report.

The first documented case of congenital supratentorial hemangioblastoma is presented, occurring in a 3-week-old infant. Extensive review of the literature revealed approximately 83 cases of supratentorial hemangioblastoma; however, only one of these occurred in the first year of life, and that case was not presented in detail.

Prospective study of osseous, articular, and meniscal lesions in recent anterior cruciate ligament tears by magnetic resonance imaging and arthroscopy.

Fifty-four patients with anterior cruciate ligament tears that were arthroscopically reconstructed within 3 months of initial injury were prospectively evaluated. Patients with grade 3 medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament tears were excluded. Eighty percent of our patients had a bone bruise present on the magnetic resonance image, with 68% in the lateral femoral condyle. Two of the latter findings--an abnormal articular cartilage signal (P = 0.02) and a thin and impacted subchondral bone (P = 0.03)--had a significant relationship with injury to the overlying articular cartilage. Meniscal tears were found in 56% of the lateral menisci and 37% of the medial menisci. A significant association was present between bone bruising on the lateral femoral condyle and the lateral tibial plateau (P = 0.02). Results of our study support the concept that the common mechanism of injury to the anterior cruciate ligament involves severe anterior subluxation with impaction of the posterior tibia on the anterior femur. Determination of the significance of bone bruising, articular cartilage injury, or meniscal tears will require a long-term followup that includes evaluation for arthritis, stability, and function. These 54 patients represent the first cohort evaluated in this ongoing prospective clinical study.

Application of an artificial neural network in radiographic diagnosis.

The description of 44 cases of bone tumors was used by an artificial neural network to rank the likelihood of 55 possible pathologic diagnoses. The performance of the artificial neural network was compared with the performance of experienced (3 or more years of radiology training) residents and inexperienced (less than 1 year of radiology training) residents. The artificial neural network was trained using descriptions of 110 radiographs of bone tumors with known diagnoses. The descriptions of a separate set of 44 cases were used to test the neural network. The neural network ranked 55 possible pathologic diagnoses on a scale from 1 to 55. Experienced and inexperienced residents also ranked the possible diagnoses in the same 44 cases. Inexperienced residents had a significantly lower mean proportion of diagnoses ranked first or second than did the neural network. Experienced residents had a significantly higher proportion of correct diagnoses ranked first than did the network. Otherwise, a significant difference between the performance of the network and experienced or inexperienced residents was not identified. These results demonstrate that artificial neural networks can be trained to classify bone tumors. Whether neural network performance in classification of bone tumors can be made accurate enough to assist radiologists in clinical practice remains an open question. These preliminary results indicate that further investigation of this technology for interpretation assistance is warranted.

Total knee replacement: radiologic findings in failure of porous-coated metal-backed patellar component.

One technique for replacing the articular surface of the patella in total knee replacement is the use of a cementless porous-coated metal-backed polyethylene component. Anteroposterior, lateral, and Merchant or skyline radiographs in 10 cases of porous-coated metal-backed components that failed were evaluated for component alignment, component displacement, radiolucencies, loose beads, and integrity of the patellar component. Component failure was documented by surgery in all 10 cases. Seven cases of failure involved the patellar pegs or junction of the pegs with the metal backing and three cases involved the polyethylene portion. In the seven cases of peg-metal backing failure, three cases showed loose beads before failure and seven cases showed displacement of the metal backing at time of failure. All three cases of polyethylene failure showed narrowing or displacement of the polyethylene portion. Our experience shows that displacement of the metal backing, displacement of the polyethylene, and disruption of patellar pegs are seen in failed porous-coated metal-backed patellar components. Loose beads may be seen before peg-metal backing failure.

Bone quality. Roentgenographic versus histologic assessment of hip bone structure.

Bone quality is an accepted criterion for determining fixation options for total hip arthroplasty (THA). Eighty patients with 95 uncemented THAs were evaluated by comparing preoperative roentgenographic assessment with histologic evaluation of bone biopsy specimens obtained from the ipsilateral iliac crest. Roentgenographic analysis of bone quality was performed using the Singh and Engh indices. Histologic evaluation employed a quantitative analysis of static and dynamic parameters of bone turnover on undecalcified sections. Extensive statistical analysis comparing roentgenographic with histologic parameters of bone quality showed: (1) no relationship of the two roentgenographic indices to trabecular bone volume and most other histologic parameters and (2) a high incidence of bone abnormalities. Bone quality is an imprecise term and is inadequately measured by these roentgenographic indices. Histologic measurement offers a more precise means of analyzing the relationship of the bone environment to the performance of the THA.

Problems in applying expert system technology to radiographic image interpretation.

A prototype expert system was developed to study the problems applying expert system technology to radiographic image interpretation. The Radiographic Image Interpretation System (RIIS) was developed on a microcomputer using Turbo Prolog, a low cost implementation of the prolog programming language. The present implementation of RIIS was developed to highlight potential problems in applying expert system technology in the evaluation of radiographic images. It was believed that the evaluation of this prototype expert system should include a large number of users unfamiliar with the program's use as this would probably be the case in clinical use of an image interpretation expert system. At present, the expert system deals with a limited domain of focal bony lesions. Twenty cases of pathologically proven bony lesions of varying difficulty were used to evaluate potential problems in the use of this expert system technology. RIIS, with the 20 sample cases, was presented as an exhibit at the 1987 Radiological Society of North America (RSNA) meeting to evaluate the potential problems with inexperienced users. These results were compared with those of experienced users. When a musculoskeletal radiologist, familiar with the programs use, provided the "proper description," the program averaged the correct diagnosis in the top five 80% of the time. During the program's use at the RSNA meeting, the program selected the correct diagnosis in the top five 22% of the time.

Hepatobiliary imaging to demonstrate drainage patterns in a patient with an indwelling hepatic catheter.

The presence of normal biliary flow was established in a patient with an indwelling hepatic catheter placed to drain an intrahepatic cyst cavity with the use of sequential hepatobiliary scintiscans. In the initial study drainage was demonstrated from the indwelling catheter; when the catheter was clamped, drainage was observed in the native biliary system. Serial biliary scintigraphy not only confirmed the patency of the hepatobiliary system, but served as a guide in the removal of the intrahepatic catheter.

CT findings of hypervascular malignant peritoneal mesothelioma.

A case of peritoneal mesothelioma is presented in which CT demonstrated abnormal regions of increased vascularity in the omentum corresponding to hypervascular omental lesions shown by angiography. This CT appearance has not been described in prior reports of CT in peritoneal mesothelioma.