Is Follow-up Co-Morbidity Assessment via Laboratory Investigations in Older High Energy Trauma Patients Justified? - A Prospective-Retrospective Study.

Introduction: The objective of the current study was to test our hypothesis that older patients sustaining high energy trauma need to be evaluated for their comorbidities similar to geriatric patients sustaining low energy trauma. Materials and methods: This study was a retrospective-prospective analysis of 173 patients of more than 50 years of age enrolled between November 2017 and December 2018. Herewith, we have compared retrospectively collected laboratory investigations of 124 fragility fracture patients with prospectively collected laboratory investigations of 49 patients with high energy trauma. The laboratory investigations, including the liver function tests, renal function tests, indices of calcium metabolism, serum electrolytes, complete blood counts, and bone mineral density (BMD) scores. Results: Both groups were similar to each other as far as baseline demographic characteristics were concerned. The proportion of female patients and patients with non-osteoporotic range BMD (T-score >-2.5) was significantly higher in the high-energy fracture group (P value <0.05). Hypoalbuminemia (<3.4gm/dl) 17.3%, abnormalities sodium (<135mmol/L or >148mmol/L) 23.2%, Anaemia (<10g/dl) 12.7%, Hypercalcemia (>10.4mg/dl) 16.3%, Vitamin D deficiency (<20ng/ml) 17.3% are the common laboratory abnormality found in study population. No statistically significant difference was found among the two groups in terms of laboratory investigation abnormalities. Conclusion: The laboratory investigation abnormality in an older patient with a clinical fracture is independent of the mechanism of injury. The results of the current study emphasise the need for a comprehensive laboratory workup in older patients with either high- energy fractures or fragility fractures.

Assessment of carbonaceous aerosols at Mukteshwar: A high-altitude (~2200 m amsl) background site in the foothills of the Central Himalayas.

The present study examined the equivalent black carbon (eBC) mass concentrations measured over 10.5 years (September 2005-March 2016) using a 7-wavelength Aethalometer (AE-31) at Mukteshwar, a high-altitude and regional background site in the foothills of Indian central Himalayas. The total spectral absorption coefficient (babs) was divided into three categories: black carbon (BC) and brown carbon (BrC); fossil fuels (FF) and wood/biomass burning (WB/BB); and primary and secondary sources. At the wavelength of 370 nm, a significant BrC contribution (25 %) to the total babs is identified, characterized by a pronounced seasonal variation with winter (December-January-February) maxima (31 %) and post-monsoon (October and November) minima (20 %); whereas, at 660 nm, the contribution of BrC is dramatically less (9 %). Climatologically, the estimated BCFF at 880 nm ranges from 0.25 ± 0.19 µg m-3 in July to 1.17 ± 0.80 µg m-3 in May with the annual average of 0.67 ± 0.63 µg m-3, accounting for 79 % of the BC mass. The maximum BCFF/BC fraction reaches its peak value during the monsoon (July and August, 85 %), indicating the dominance of local traffic emissions due to tourism activities. Further, the highest BCWB concentration observed during pre-monsoon (March-May) suggests the influence of local forest fires along with long-range transported aerosols from the low-altitude plains. The increased contribution of BrC (26 % at 370 nm) and WB absorption (61 % at 370 nm) to the total absorption at the shorter wavelengths suggests that wood burning is one of the major sources of BrC emissions. Secondary BrC absorption accounts for 24 % [91 %] of the total absorption [BrC absorption] at 370 nm, implying the dominance of secondary sources in BrC formation. A trend analysis for the measured BC concentration shows a statistically significant increasing trend with a slope of 0.02 µgm-3/year with a total increase of about 22 % over the study period. A back trajectory-based receptor model, potential source contribution function (PSCF), was used to identify the potential regional source region of BC. The main source regions of BC are the northwest states of India in the IGP region and the northeast Pakistan region.

Algorithms for Colinear Chaining with Overlaps and Gap Costs.

Colinear chaining has proven to be a powerful heuristic for finding near-optimal alignments of long DNA sequences (e.g., long reads or a genome assembly) to a reference. It is used as an intermediate step in several alignment tools that employ a seed-chain-extend strategy. Despite this popularity, efficient subquadratic time algorithms for the general case where chains support anchor overlaps and gap costs are not currently known. We present algorithms to solve the colinear chaining problem with anchor overlaps and gap costs in Õ(n) time, where n denotes the count of anchors. The degree of the polylogarithmic factor depends on the type of anchors used (e.g., fixed-length anchors) and the type of precedence an optimal anchor chain is required to satisfy. We also establish the first theoretical connection between colinear chaining cost and edit distance. Specifically, we prove that for a fixed set of anchors under a carefully designed chaining cost function, the optimal "anchored" edit distance equals the optimal colinear chaining cost. The anchored edit distance for two sequences and a set of anchors is only a slight generalization of the standard edit distance. It adds an additional cost of one to an alignment of two matching symbols that are not supported by any anchor. Finally, we demonstrate experimentally that optimal colinear chaining cost under the proposed cost function can be computed orders of magnitude faster than edit distance, and achieves correlation coefficient >0.9 with edit distance for closely as well as distantly related sequences.

Assessment of paediatric quality of life in temporomandibular joint ankylosis patients after interpositional arthroplasty: a pilot study.

A comprehensive evaluation of treatment outcomes in paediatric temporomandibular joint (TMJ) ankylosis patients should include the assessment of quality of life (QoL) along with the traditional clinical indicators. This longitudinal retrospective descriptive study evaluated the impact on QoL of interpositional arthroplasty for the treatment of TMJ ankylosis in 18 patients between 8 and 10 years of age. The subjects completed the Child Perceptions Questionnaire (CPQ 8-10) while their parents/primary caregivers completed the Parental/Caregiver Perceptions Questionnaire (PCPQ), once before and then at 3 months after the surgery. There was a significant improvement in mean cumulative scores for both questionnaires. Significant improvements were seen in the oral symptoms, functional limitation (P<0.02), and social wellbeing domains (P<0.05) of the CPQ, and in the oral symptoms and functional limitation (P<0.05) domains of the PCPQ. The improvements in the physical domains were considered important for treatment success by both groups. The psychosocial domains were observed to be largely unaffected by the condition. The level of agreement between the two groups was higher for physical domains as compared to psychosocial domains. This study indicates that QoL outcomes in paediatric TMJ ankylosis patients are largely influenced by the physical factors, while the psychosocial factors play a secondary role.

Quality of life assessment in temporomandibular joint ankylosis patients after interpositional arthroplasty: a prospective study.

Temporomandibular joint (TMJ) ankylosis significantly impacts both physical and psychosocial patient wellbeing. A complete evaluation of treatment outcomes necessitates knowing the extent to which a patient's quality of life (QoL) is impacted. This study was performed to evaluate the impact of TMJ ankylosis on QoL in 25 TMJ ankylosis patients treated by interpositional arthroplasty. The patients completed OHIP-14 and UWQoL questionnaires once before and then at 3 months after the surgery. There was a significant improvement in mean cumulative scores for both questionnaires. With the exception of functional limitation, all OHIP domains showed significant improvement. Preoperatively, the worst scores were found in the psychological distress domain, followed by the social handicap, physical pain and physical disability domains. More than half of the subjects (56%) reported having suicidal thoughts. Amongst the individual UWQoL domains, appearance, chewing, anxiety (P < 0.01), recreation and mood (P < 0.05) showed improved scores. Appearance and chewing were the top ranked priority domains before and after surgery. No significant change was found in speech, taste, sleep, or breathing. Psychosocial factors were found to play a much bigger role than previously thought. The physical, psychological, and social factors were intricately related and dynamically interacted with each other. Surgical treatment produced a definitive QoL improvement in the patients.

In vitro assessment of gentamicin and azithromycin-based combination therapy against Neisseria gonorrhoeae isolates in India.

PURPOSE: The public health burden of infections caused by Neisseria gonorrhoeae is magnified due to high rates of resistance to traditional antimicrobials. The aim of this study was to evaluate the in vitro efficacy of an alternative dual therapy comprising gentamicin and azithromycin. METHODOLOGY: The E-test method was used to determine the minimum inhibitory concentrations (MICs) of gentamicin and azithromycin individually prior to testing in combination using the cross or 90o angle formation method. A total of 70 clinical isolates of N.gonorrhoeae displaying varying ceftriaxone MICs along with 2 reference strains (WHO K and P) and 1 ceftriaxone-resistant QA isolate were examined. The fractional inhibitory concentration index (FICI) was calculated and the results were interpreted using the following criteria: synergy, FICI ≤0.5; indifference or additive, FICI >0.5 to ≤4.0; and antagonism, FICI >4.0. RESULTS: A total of 54 (77.1 %) isolates displayed indifference, while 16 (22.9 %) demonstrated synergy. When azithromycin was tested alone, the MICs ranged from 0.016 to 2 µg ml-1 . However, in combination with gentamicin, the mean MIC value of all isolates decreased from 0.275 µg ml-1 to 0.090 µg ml-1 (P=0.05).When gentamicin was tested alone, the MICs ranged from 0.25 to 8 µg ml-1, with a mean MIC of 4.342 µg ml-1, whereas in combination with azithromycin it decreased significantly to 2.042 µg ml-1 (P=0.04). CONCLUSION: No antagonism was observed in this combination, suggesting that it could be a future treatment option as we prepare for a post-cephalosporin era. However, comprehensive in vivo evaluations are warranted and recommendations should be made based on clinical trials.

Assessment of Automatic Thoughts in Patients with Depressive Illness at a Tertiary Hospital in Nepal.

INTRODUCTION: Cognitive functions have significant influence on psycho-social and general wellbeing. The quality, content and processing of negative thoughts initiate depressive symptoms; i.e. low mood, decreased self-worth and diminished interest in pleasurable activities. The study assessed the automatic thoughts of patients having depressive illness and evaluated and compared the changes after therapy; i.e. Psychotherapy and pharmacotherapy. METHODS: Diagnosed cases of depressive illness (n=135), according to ICD-10 and study criteria, attending the out-patient clinic of Department of Psychiatry and Mental Health, Tribhuvan University Teaching Hospital, were included. Beck Depression Inventory was used to screen level of depressive symptoms. Automatic thoughts were assessed by the Automatic Thought Questionnaire-Revised before initiating therapy and after completion of therapy for comparison. Depressive patients received either of the three treatment procedures after randomization of the study sample into three different treatment groups; i.e. Cognitive behavior therapy, pharmacotherapy or combined therapy receiving both cognitive behavior therapy and pharmacotherapy. RESULTS: Among the total 135 patients, 53 (39.3%) had moderate, 47 (34.8%) had severe depressive and 35 (25.9%) had mild depressive symptoms before therapeutic interventions. Negative automatic thoughts were significantly present in depressed patients and reduced after all three interventions. Negative automatic thoughts of hopelessness, anxiety and inability coping were significantly reduced after therapy. CONCLUSIONS: Automatic negative thoughts were significantly correlated with depressive disorder. Combined therapy CBT with pharmacotherapy or CBT alone was found to be more effective in modifying automatic negative thoughts than pharmacotherapy alone, ultimately reducing depressive symptoms to a significant degree.

The future cost of cancer in South Africa: An interdisciplinary cost management strategy.

The exponential rise in cancer costs in South Africa (SA) was illustrated in a recent Sunday Times article entitled 'The cost of cancer can be a debt sentence'. Our Minister of Health talks of a 'war' against the high costs of cancer drugs, and epidemiologists project a sharply rising incidence. Eminent international medical journals, such as The Lancet, underline the fact that cancer cost is a growing international problem that confronts even the richest countries. If richer countries in the world are battling to cover the costs of cancer, what is the prognosis for SA?

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke.

BACKGROUND AND PURPOSE: Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke. MATERIALS AND METHODS: Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively. RESULTS: Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes. CONCLUSIONS: Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

A reliable and cost effective approach for radiographic monitoring in nutritional rickets.

OBJECTIVE: Radiological scoring is particularly useful in rickets, where pre-treatment radiographical findings can reflect the disease severity and can be used to monitor the improvement. However, there is only a single radiographic scoring system for rickets developed by Thacher and, to the best of our knowledge, no study has evaluated radiographic changes in rickets based on this scoring system apart from the one done by Thacher himself. The main objective of this study is to compare and analyse the pre-treatment and post-treatment radiographic parameters in nutritional rickets with the help of Thacher's scoring technique. METHODS: 176 patients with nutritional rickets were given a single intramuscular injection of vitamin D (600 000 IU) along with oral calcium (50 mg kg(-1)) and vitamin D (400 IU per day) until radiological resolution and followed for 1 year. Pre- and post-treatment radiological parameters were compared and analysed statistically based on Thacher's scoring system. RESULTS: Radiological resolution was complete by 6 months. Time for radiological resolution and initial radiological score were linearly associated on regression analysis. The distal ulna was the last to heal in most cases except when the initial score was 10, when distal femur was the last to heal. CONCLUSION: Thacher's scoring system can effectively monitor nutritional rickets. The formula derived through linear regression has prognostic significance. ADVANCES IN KNOWLEDGE: The distal femur is a better indicator in radiologically severe rickets and when resolution is delayed. Thacher's scoring is very useful for monitoring of rickets. The formula derived through linear regression can predict the expected time for radiological resolution.

Review of the bioenvironmental methods for malaria control with special reference to the use of larvivorous fishes and composite fish culture in central Gujarat, India.

Mosquito control with the use of insecticides is faced with the challenges of insecticide resistance in disease vectors, community refusal, their high cost, operational difficulties, and environmental concern. In view of this, integrated vector control strategies with the use of larvivorous fishes such as Guppy (Poecilia reticulata) and Gambusia (G. affinis) as biological control agents were used in controlling mosquito breeding in different types of breeding places such as intradomestic containers, various types of wells, rice-fields, pools, ponds and elsewhere in malaria prone rural areas of central Gujarat. Attempts were also made to demonstrate composite fish culture in unused abandoned village ponds by culturing Guppy along with the food fishes such as Rohu (Labeo rohita), Catla (Catla catla) and Mrigal (Cirrhinus mrigala). Income generated from these ponds through sale of fishes was utilized for mosquito control and village development. The technology was later adopted by the villagers themselves and food fish culture was practised in 23 ponds which generated an income of Rs 1,02,50,992 between 1985 and 2008. The number of villages increased from 13 to 23 in 2008 and there was also gradual increase of income from Rs 3,66,245 in 1985-90 to Rs 55,06,127 in 2002-08 block. It is concluded that larvivorous fishes can be useful tool in controlling mosquito breeding in certain situations and their use along with composite fish culture may also generate income to make the programme self-sustainable.

Arabic version of the Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC): a validity and feasibility study.

Mental health services are far from satisfactory in the Eastern Mediterranean Region. The Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC) is a semi-structured, computerized clinical assessment tool that was developed to assist health workers in making quick, convenient and comprehensive standardized mental health assessments. A study was carried out in the United Arab Emirates to evaluate the validity and feasibility of the Arabic version of the GMHAT/PC. Mental health nurses administered the GMHAT/PC Arabic version to 50 patients in mental health and rehabilitation settings and their GMHAT/PC diagnosis was compared with the psychiatrist's independent ICD-10 based clinical diagnosis on the same patients. The nurses found GMHAT/PC easy to administer in an average of 16 minutes. The GMHAT/PC-based diagnosis had a good agreement with the psychiatrist's diagnosis (kappa = 0.91) and a high sensitivity (97%) and specificity (94%).

Usefulness of EQ-5D for evaluation of health-related quality of life in young adults with first-episode psychosis.

PURPOSE: To evaluate the psychometric properties of the EQ-5D and the usefulness of this instrument in psychiatric practice as a measure of health-related quality of life (HRQoL) in a sample of young adults with first-episode psychosis. METHODS: The validity of individual questionnaire items is studied using an Item Response/Latent Trait Theory modeling approach. Sensitivity of response patterns on EQ-5D items to particular diagnostic subtypes of psychosis is investigated using a finite mixture modeling approach through latent class analysis. Finally, a structural equation modeling framework is used to study differential item functioning via a multigroup approach. RESULTS: Results suggest that the data closely correspond to the Rasch Rating Scale Model, and therefore that EQ-5D latent scores are equal interval measures. Despite comprising relatively few items, the instrument yields reliable measures of HRQoL for group comparisons and cost-effectiveness evaluation, but EQ-5D score is too imprecise for the assessment of HRQoL for clinical purposes at the individual level. A significant relationship was found between EQ-5D responses and type of psychosis due to inclusion of item anxiety/depression in EQ-5D. Two items (anxiety/depression, functioning in usual activities) showed an ethnicity bias. CONCLUSIONS: Psychometric evidence confirmed the EQ-5D to be a valid, interval measure that is scalable according to Rasch principles.

Arabic version of the Global Mental Health Assessment Tool-Primary Care version [GMHAT/PC]: a validity and feasibility study

Mental health services are far from satisfactory in the Eastern Mediterranean Region. The Global Mental Health Assessment Tool-Primary Care version [GMHAT/PC] is a semi-structured, computerized clinical assessment tool that was developed to assist health workers in making quick, convenient and comprehensive standardized mental health assessments. A study was carried out in the United Arab Emirates to evaluate the validity and feasibility of the Arabic version of the GMHAT/PC. Mental health nurses administered the GMHAT/PC Arabic version to 50 patients in mental health and rehabilitation settings and their GMHAT/PC diagnosis was compared with the psychiatrist's independent ICD-10 based clinical diagnosis on the same patients. The nurses found GMHAT/PC easy to administer in an average of 16 minutes. The GMHAT/PC-based diagnosis had a good agreement with the psychiatrist's diagnosis [kappa = 0.91] and a high sensitivity [97%] and specificity [94%]

Battling malaria iceberg incorporating strategic reforms in achieving Millennium Development Goals & malaria elimination in India.

Malaria control in India has occupied high priority in health sector consuming major resources of the Central and State governments. Several new initiatives were launched from time to time supported by foreign aids but malaria situation has remained static and worsened in years of good rainfall. At times malaria relented temporarily but returned with vengeance at the local, regional and national level, becoming more resilient by acquiring resistance in the vectors and the parasites. National developments to improve the economy, without health impact assessment, have had adverse consequences by providing enormous breeding grounds for the vectors that have become refractory to interventions. As a result, malaria prospers and its control is in dilemma, as finding additional resources is becoming difficult with the ongoing financial crisis. Endemic countries must contribute to make up the needed resources, if malaria is to be contained. Malaria control requires long term planning, one that will reduce receptivity and vulnerability, and uninterrupted financial support for sustained interventions. While this seems to be a far cry, the environment is becoming more receptive for vectors, and epidemics visit the country diverting major resources in their containment, e.g. malaria, dengue and dengue haemorrhagic fevers, and Chikungunya virus infection. In the last six decades malaria has taken deep roots and diversified into various ecotypes, the control of these ecotypes requires local knowledge about the vectors and the parasites. In this review we outline the historical account of malaria and methods of control that have lifted the national economy in many countries. While battles against malaria should continue at the local level, there is a need for large scale environmental improvement. Global Fund for AIDS, Tuberculosis and Malaria has provided huge funds for malaria control worldwide touching US$ 2 billion in 2011. Unfortunately it is likely to decline to US$ 1.5 billion in the coming years against the annual requirement of US$ 5 billion. While appreciating the foreign assistance, we wish to highlight the fact that unless we have internal strength of resources and manpower, sustained battles against malaria may face serious problems in achieving the final goal of malaria elimination.

Toxicity assessment of free form of heavy metals in aqueous media on earthworm Eudrillus eugeniae.

Metals are found in free and also in combined forms. In order to get information on the effect of free forms of heavy metals on earthworms the aqueous extracts of metals were tested on earthworms both in individual form and also in combined form. Different concentrations, i.e. 1 ppm, 5 ppm, and 10 ppm, were selected arbitrarily and were used in the experiments. Metals like copper, cadmium, chromium, zinc and lead were used. Earthworms' Eudrillus eugeniae activity, i.e. their response to the toxicity of metals, was monitored continuously for 5 h. It can be concluded that free form/ionic form/dissolved form of heavy metals are more toxic for earthworms, concurrent with findings of workers who have drawn same inference during studies on aquatic organisms. Earthworms can serve as biomarkers for wastewater and sludge treatment studies as they have shown typical adverse body reactions and symptoms altogether different in reaction to each of the metals during aqueous medium studies. It can be inferred that, if earthworms are utilised for treating wastewater and sludges containing these five heavy metals, one can ascertain the presence of individual metal concentrations in the wastewaters and sludges by studying the typical body reactions of earthworms during the treatment.

Application of ethyl chloroformate derivatization for solid-phase microextraction-gas chromatography-mass spectrometric determination of bisphenol-A in water and milk samples.

A simple and rapid analytical method based on in-matrix ethyl chloroformate (ECF) derivatization has been developed for the quantitative determination of bisphenol-A (BPA) in milk and water samples. The samples containing BPA were derivatised with ECF in the presence of pyridine for 20 s at room temperature, and the non-polar derivative thus formed was extracted using polydimethylsiloxane solid-phase microextraction (SPME) fibres with thicknesses of 100 µm followed by analysis using gas chromatography-mass spectrometry. Three alkyl chloroformates (methyl, ethyl and isobutyl chloroformate) were tested for optimum derivatisation yields, and ECF has been found to be optimum for the derivatisation of BPA. Several parameters such as amount of ECF, pyridine and reaction time as well as SPME parameters were studied and optimised in the present work. The limit of detection for BPA in milk and water samples was found to be 0.1 and 0.01 µg L(-1), respectively, with a signal-to-noise ratio of 3:1. The limit of quantitation for BPA in milk and water was found to be 0.38 and 0.052 µg L(-1), respectively, with a signal-to-noise ratio of 10:1. In conclusion, the method developed was found to be rapid, reliable and cost-effective in comparison to silylation and highly suitable for the routine analysis of BPA by various food and environmental laboratories.

Donor-transmitted malignancies in organ transplantation: assessment of clinical risk.

The continuing organ shortage requires evaluation of all potential donors, including those with malignant disease. In the United States, no organized approach to assessment of risk of donor tumor transmission exists, and organs from such donors are often discarded. The ad hoc Disease Transmission Advisory Committee (DTAC) of the Organ Procurement and Transplantation Network/United Network for Organ Sharing (OPTN/UNOS) formed an ad hoc Malignancy Subcommittee to advise on this subject. The Subcommittee reviewed the largely anecdotal literature and held discussions to generate a framework to approach risk evaluation in this circumstance. Six levels of risk developed by consensus. Suggested approach to donor utilization is given for each category, recognizing the primacy of individual clinical judgment and often emergent clinical circumstances. Categories are populated with specific tumors based on available data, including active or historical cancer. Benign tumors are considered in relation to risk of malignant transformation. Specific attention is paid to potential use of kidneys harboring small solitary renal cell carcinomas, and to patients with central nervous system tumors. This resource document is tailored to clinical practice in the United States and should aid clinical decision making in the difficult circumstance of an organ donor with potential or proven neoplasia.

Assessment of response to neoadjuvant therapy in esophageal cancer: an updated systematic review of diagnostic accuracy of endoscopic ultrasonography and fluorodeoxyglucose positron emission tomography.

For assessing response to neoadjuvant therapy in patients with esophageal cancer, both endoscopic ultrasonography (EUS) and fluorodeoxyglucose positron emission tomography (FDG-PET) are commonly used, and despite few controlled trials, it is not known if one imaging modality is superior to the other. Also, relative diagnostic accuracy of early (during the course of neoadjuvant therapy) and FDG-PET after completion of neoadjuvant therapy has not been reviewed. The aim of this study was to perform a systematic review of published information to compare diagnostic accuracy of EUS and FDG-PET in this setting. A search of the MEDLINE, EMBASE, and Cochrane databases was performed along with a manual search of cross-references of eligible articles. Data on the accuracy of the imaging modalities were compared by constructing summary receiver-operating characteristic curves. Seven studies with EUS and 15 with FDG-PET were included in the final analysis (N= 966). The sensitivity of EUS and FDG-PET ranged from 20 to 100% and 42 to 100%, respectively. The specificity ranged from 36 to 100% and 27 to 100%, respectively. The areas under the curve were 0.86 (95% confidence interval [CI]: 0.77-0.96) for EUS and 0.80 (95% CI: 0.72-0.89) for FDG PET (P= 0.37). The maximum joint sensitivity and specificity (Q* index) values for EUS and FDG-PET were 0.79 (95% CI: 0.70-0.88) and 0.74 (95% CI: 0.66-0.81), respectively (P= 0.38). There was no difference in accuracy between early FDG-PET and FDG-PET after completion of neoadjuvant therapy. EUS and FDG-PET have similar overall diagnostic accuracy for assessment of response to neoadjuvant therapy in patients with esophageal cancer.

An economic analysis of endoscopic ablative therapy for management of nondysplastic Barrett's esophagus.

BACKGROUND AND AIMS: Advances have occurred in the development of safe and effective ablative therapies for Barrett's esophagus. The aim of the current study was to perform an economic analysis evaluating the cost-effectiveness of endoscopic ablation of nondysplastic Barrett's esophagus. METHODS: A Markov model evaluated three competing strategies in a hypothetical 50-year-old cohort with nondysplastic Barrett's esophagus from a societal perspective. Strategy I -- natural history of Barrett's disease (without surveillance); Strategy II -- surveillance performed according to the American College of Gastroenterology practice guidelines; Strategy III -- endoscopic ablative therapy. The model was biased against ablative therapy with a conservative estimate of complete response and continued standard surveillance even after complete ablation. All potential complications were accounted for, and an incomplete histological response after ablation was presumed to have the same risk of progression as untreated Barrett's. Transitional probabilities, discounted cost, and utility values to estimate quality-adjusted life-years (QALY) were obtained from published information. Direct costs were used in our analysis. RESULTS: In baseline analysis, the ablative strategy yielded the highest QALY and was more cost-effective than endoscopic surveillance. In a Monte Carlo analysis, the relative risk of developing cancer in the strategy based on endoscopic ablation was decreased compared with the other strategies. In threshold analysis, the critical determinants of cost-effectiveness of the ablative strategy were rate of complete response to ablation, total cost of ablation, and risk of progression to dysplasia. CONCLUSIONS: Within the limits of the model, ablation for nondysplastic Barrett's esophagus is more cost-effective than endoscopic surveillance. Clinical trials of ablative therapy in nondysplastic Barrett's esophagus are needed to establish its effectiveness in reducing cancer risk.