The potential utility of abbreviated breast MRI (FAST MRI) as a tool for breast cancer screening: a systematic review and meta-analysis.

AIM: To synthesise evidence comparing abbreviated breast magnetic resonance imaging (abMRI) to full-protocol MRI (fpMRI) in breast cancer screening. MATERIALS AND METHODS: A systematic search was undertaken in multiple databases. Cohort studies without enrichment, presenting accuracy data of abMRI in screening, for any level of risk (population, moderate, high risk) were included. Level of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Meta-analyses (bivariate random effects model) were performed for abMRI, with fpMRI and histology from fpMRI-positive cases as reference standard, and with follow-up to symptomatic detection added to the fpMRI. The review also covers evidence comparing abMRI with mammographic techniques. RESULTS: The title and abstract review retrieved 23 articles. Five studies (six articles) were included (2,763 women, 3,251 screening rounds). GRADE assessment of the evidence was very low because the reference standard was interpreted with knowledge of the index test and biopsy was not obtained for all abMRI positives. The overall sensitivity for abMRI, with fpMRI (and histology for fpMRI positives) as reference standard, was 94.8% (95% confidence interval [CI] 85.5-98.2) and specificity as 94.6% (95% CI: 91.5-96.6). Three studies (1,450 women, 1,613 screening rounds) presented follow-up data, enabling comparison between abMRI and fpMRI. Sensitivities and specificities for abMRI did not differ significantly from those for fpMRI (p=0.83 and p=0.37, respectively). CONCLUSION: A very low level of evidence suggests abMRI could be accurate for breast cancer screening. Research is required, with follow-up to interval cancer, to determine the effect its use could have on clinical outcome.

Pacemaker Use in New Zealand - Data From the New Zealand Implanted Cardiac Device Registry (ANZACS-QI 15).

BACKGROUND: The New Zealand Cardiac Implanted Device Registry (Device) has recently been developed under the auspices of the New Zealand Branch of the Cardiac Society of Australia and New Zealand. This study describes the initial Device registry cohort of patients receiving a new pacemaker, their indications for pacing and their perioperative complications. METHODS: The Device Registry was used to audit patients receiving a first pacemaker between 1st January 2014 and 1st June 2015. RESULTS: We examined 1611 patients undergoing first pacemaker implantation. Patients were predominantly male (59%), and had a median age of 70 years. The most common symptom for pacemaker implantation was syncope (39%), followed by dizziness (30%) and dyspnoea (12%). The most common aetiology for a pacemaker was a conduction tissue disorder (35%), followed by sinus node dysfunction (22%). Atrioventricular (AV) block was the most common ECG abnormality, present in 44%. Dual chamber pacemakers were most common (62%), followed by single chamber ventricular pacemakers (34%), and cardiac resynchronisation therapy - pacemakers (CRT-P) (2%). Complications within 24hours of the implant procedure were reported in 64 patients (3.9%), none of which were fatal. The most common complication was the need for reoperation to manipulate a lead, occurring in 23 patients (1.4%). CONCLUSION: This is the first description of data entered into the Device registry. Patients receiving a pacemaker were younger than in European registries, and there was a low use of CRT-P devices compared to international rates. Complications rates were low and compare favourably to available international data.

Variation in Arterial Access for Invasive Coronary Procedures in New Zealand: A National Analysis (ANZACS-QI 5).

BACKGROUND: Radial arterial access (RA) and femoral arterial access (FA) rates for invasive coronary angiography (ICA) vary widely internationally. The European Society of Cardiology (ESC) suggests default RA is feasible. We aim to investigate the variation in RA rates across all New Zealand public hospitals. METHODS AND RESULTS: Patient characteristics, procedural details, and inpatient outcome data were collected in the All New Zealand Acute Coronary Syndrome - Quality Improvement (ANZACS-QI) registry on consecutive patients undergoing ICA over five months. Of the 5894 ICAs 81% were via RA. Hospitals averaged 25 - 176 procedures/month (46.5% - 96.4% via RA). Operators averaged 17 procedures/month. Those performing more than 20 ICAs/month had RA rates between 61% - 99%. Of the 75 operators, 69% met the ESC recommendation. After multivariable adjustment higher operator (RR 1.12, CI 1.09 - 1.30) and hospital (RR 1.21, CI 1.15 - 1.28) volume were independent predictors of RA. Those with prior CABG (RR 0.51, CI 0.45 - 0.57), STEMI <12h (RR 0.91, CI 0.87 - 0.96), and female sex (RR 0.96, CI 0.94 - 0.99) were less likely to receive RA. CONCLUSIONS: New Zealand has a high RA rate for ICAs. Rates vary substantially between both operators and centres. Radial arterial was highest amongst the highest volume operators and centres.

Prevalence and significance of CYP2C19*2 and CYP2C19*17 alleles in a New Zealand acute coronary syndrome population.

BACKGROUND: High on-treatment platelet reactivity has been associated with poor outcomes following acute coronary syndromes (ACS). Both the loss of function CYP2C19*2 allele and the gain of function CYP2C19*17 allele along with a range of clinical characteristics have been associated with variation in the response to clopidogrel. AIM: The study aims to examine the frequency of CYP2C19 variants and understand the factors associated with on-treatment platelet reactivity in a New Zealand ACS population. METHODS: We prospectively enrolled 312 ACS patients. We collected clinical characteristics and measured on-treatment platelet reactivity using two validated point-of-care assays, VerifyNow and Multiplate. DNA was extracted and CYP2C19*2 and *17 alleles were identified using real-time polymerase chain reaction. RESULTS: CYP2C19*2 or CYP2C19*17 alleles were observed in 101 (32%) and 106 (34%) of patients, respectively, with significant differences in distribution by ethnicity. In Maori and Pacific Island patients, 47% (confidence interval (CI) 31-63%) had CYP2C19*2 and 11% (CI 4-19%) CYP2C19*17 compared with 26% (CI 19-32%) and 41% (CI 32-49%) in white people. Carriage of CYP2C19*2 alleles was associated with higher levels of platelet reactivity measured by either assay, but we observed no relationship between platelet reactivity and CYP2C19*17. In multivariate analysis diabetes, clopidogrel dose and CYP2C19*2 status were all significant independent predictors of platelet reactivity. CONCLUSIONS: Both CYP2C19*2 and *17 were common in a New Zealand ACS population, with CYP2C19*2 observed in almost half the Maori and Pacific Island patients. CYP2C19*2, diabetes and clopidogrel dose were independent contributors to on-treatment platelet reactivity.

Use of tunnelled active fixation leads allows reliable temporary pacing over prolonged periods.

Temporary tunnelled pacing (TTP) is an alternative method of providing temporary pacing in which an active fixation permanent pacing lead is placed fluoroscopically through percutaneous venous access, tunnelled subcutaneously and connected to a resterilized external pulse generator. Our study shows that temporary tunnelled pacing is a safe and reliable method of achieving prolonged temporary pacing. We believe that temporary tunnelled pacing should be considered as an option in all patients who have an indication for prolonged temporary pacing.

Medications for the secondary prevention of ischaemic heart disease and heart failure are underutilized in dialysis patients.

We determined the prescription rates of medications for the secondary prevention of ischaemic heart disease and left ventricular systolic dysfunction in stable dialysis patients. In patients with established ischaemic heart disease, statins, beta-blockers and renin-angiotensin-aldosterone system blockers were substantially underprescribed. Furthermore, beta-blockers and renin-angiotensin-aldosterone system blockers were prescribed in less than half of those with left ventricular systolic dysfunction. Contraindications to treatment were infrequent and did not explain these findings.

Impact of perioperative hyperbaric oxygen therapy on the quality of life of maxillofacial patients who undergo surgery in irradiated fields.

From 2001 to 2005, 66 patients referred for perioperative hyperbaric oxygen therapy (HBO2) for debridement of necrotic tissue or prevention of radionecrosis were assessed with quality of life measures, before and after completion of HBO2 and surgery. The Medical Outcomes Short Form 36 (SF-36) and Hospital Anxiety and Depression Scale (HADS) showed no significant changes. The European Organisation for Research and Treatment of Cancer Core (EORTC-C30) questionnaire showed significant improvement in pain, global health, and dyspnoea (p=0.011; p=0.027; p=0.008, respectively). The Head and Neck sub-module (H&N35) identified significant improvements in teeth, dry mouth and social contact (p=0.002; p=0.038; p=0.029, respectively). The University of Washington Scale (UW), showed significant changes in relation to chewing and shoulders (p=0.031; p=0.047). When sub-group analysis using 'osteoradionecrosis' and 'dental extraction or implants' was performed on the EORTC and UW data, variations in the patterns of significance were found. Adjunctive HBO2 should be considered for the treatment and prevention of some of the long-term complications of radiotherapy.

The trajectory of positive psychological change in a head and neck cancer population.

A stressful event may be sufficient to challenge a strongly held set of assumptions about the world and the self. In some people this may lead to post-traumatic stress disorder (PTSD) and in others to positive psychological change (PPC), whereby a person's reactions to the challenge are beneficial. Little research has investigated PPC in people who have had head and neck cancer (HNC). The aim of this study was to identify demographic, clinical, and psychological factors associated with PPC over time. A cross-sequential study collected data over 5 years. Participants were sent the Silver Lining Questionnaire (SLQ; a measure of PPC), the University of Washington HNC quality of life measure, and the Medical Outcomes Short-Form 12 each year. Additional data were collected from clinical records. Analysis using linear mixed-effects modelling revealed that participants with lower stage tumours and those who only had a surgical intervention reported greater PPC over time. Multivariable modelling adjusting for psychosocial variables found that PPC had a quadratic relationship with time since diagnosis, increasing initially and levelling off after 18 months. These findings build on the minimal PPC research with people following HNC. In particular it demonstrates a model of trajectories for the development of PPC longitudinally over time.

Repression of lignin biosynthesis promotes cellulose accumulation and growth in transgenic trees.

Because lignin limits the use of wood for fiber, chemical, and energy production, strategies for its downregulation are of considerable interest. We have produced transgenic aspen (Populus tremuloides Michx.) trees in which expression of a lignin biosynthetic pathway gene Pt4CL1 encoding 4-coumarate:coenzyme A ligase (4CL) has been downregulated by antisense inhibition. Trees with suppressed Pt4CL1 expression exhibited up to a 45% reduction of lignin, but this was compensated for by a 15% increase in cellulose. As a result, the total lignin-cellulose mass remained essentially unchanged. Leaf, root, and stem growth were substantially enhanced, and structural integrity was maintained both at the cellular and whole-plant levels in the transgenic lines. Our results indicate that lignin and cellulose deposition could be regulated in a compensatory fashion, which may contribute to metabolic flexibility and a growth advantage to sustain the long-term structural integrity of woody perennials.

Abnormal glucose metabolism and features of the metabolic syndrome are common in patients presenting for elective cardiac catheterization.

BACKGROUND: Abnormalities of glucose metabolism and the metabolic syndrome, including excess bodyweight, are potentially modifiable risk factors for cardiac morbidity and mortality. This study aimed to determine the prevalence of these in a group of patients presenting for elective cardiac catheterization or percutaneous intervention. METHODS: Data were prospectively collected on 297 consecutive patients presenting for elective cardiac catheterization or percutaneous intervention at a single tertiary referral centre. Demographic data, risk factors, medications and coronary angiogram results were recorded. Fasting lipids, fasting glucose, HbA1c levels were measured and if necessary an oral glucose tolerance test was carried out. Logistic regression and contingency table analysis examined associations of these with ethnicity. RESULTS: Impaired glucose metabolism (diabetes, impaired glucose tolerance or impaired fasting glucose) was present in 46.1% with our screening programme detecting previously unknown impaired glucose metabolism in 22.9%. Impaired glucose metabolism was strongly associated with non-European ethnicity (P < 0.0001). The metabolic syndrome was present in 49.2%. When defined by ethnic specific cut-offs, overweight or obesity was present in >80% of patients in all ethnic groups. CONCLUSION: There is a very high prevalence of impaired glucose metabolism and the metabolic syndrome in patients presenting for cardiac catheterization. Impaired glucose metabolism is particularly prevalent in the Polynesian and the Indian and the Sri Lankan ethnic groups. Screening of patients undergoing elective cardiac catheterization identifies a significant number of patients with undiagnosed impaired glucose metabolism and should be carried out routinely.

Upregulation of the CD40/CD40 ligand dyad and platelet-monocyte aggregation in cigarette smokers.

BACKGROUND: Smoking is a potent cardiovascular risk factor and is associated with proinflammatory and prothrombotic responses. The CD40/CD40 ligand (CD40L) dyad and platelet-monocyte aggregation mediate a range of proinflammatory and prothrombotic processes thought to be important in atherothrombosis. We investigated whether expression of the CD40/CD40L dyad and platelet-monocyte aggregation are altered in cigarette smokers. METHODS AND RESULTS: C-reactive protein (CRP), soluble (s) CD40L, and surface expression of CD40L on platelets and T cells and of CD40 on monocytes and platelet-monocyte aggregates were compared in 25 cigarette smokers and 25 age- and gender-matched nonsmokers. Cigarette smokers had increased serum CRP (2.47+/-2.60 versus 0.94+/-0.96 mg/L, P=0.008) and appeared to have elevated plasma sCD40L (0.8+/-1.09 versus 0.37+/-0.21 ng/mL, P=0.07) concentrations. Smokers also had increased surface expression of CD40 on monocytes (45.9+/-7.7% versus 39.9+/-6.5%, P=0.006), of CD40L on platelets (2.9+/-1.0% versus 2.3+/-0.6%, P=0.03), and of platelet-monocyte aggregates (26.6+/-10.9% versus 19.7+/-8.6%, P=0.02). Plasma cotinine concentrations correlated with monocyte CD40 expression, platelet CD40L expression, and platelet-monocyte aggregates. CONCLUSIONS: Cigarette smokers have upregulation of the CD40/CD40L dyad and platelet-monocyte aggregation that may account for the atherothrombotic consequences of this major cardiovascular risk factor.

Prasugrel inhibits platelet-enhanced pro-inflammatory CD4+ T cell responses in humans.

While platelets have well characterized effects on monocytes, the effect of platelet activation on CD4+ T-cell differentiation and cytokine production is not clear. To examine the effects of platelet T-cell interactions on T-cell phenotype, and whether these interactions were altered by prasugrel, we conducted a randomized, double-blind, placebo-controlled crossover study in healthy subjects. At baseline the addition of platelets to CD4+ T-cells resulted in an increase in the release of pro-inflammatory cytokine IFN-γ (192% increase in IFN-γ levels, p = 0.01) and pro-inflammatory CD4+ phenotypes, (38% and 58% increase in Th1 and Th17 phenotypic markers respectively, p = 0.01) but no change in Tregs. Prasugrel abolished the effects of platelets on CD4+ T-cells with similar levels of pro-inflammatory cytokines and cell numbers to T-cells stimulated. Antiplatelet therapy may provide therapeutic benefit both from direct platelet inhibition and also through indirect effects on immune response development.

Increased CD40 ligand and platelet-monocyte aggregates in patients with type 1 diabetes mellitus.

BACKGROUND: Diabetes mellitus is a major risk factor for cardiovascular disease and is associated with a proinflammatory and prothrombotic state. We investigated whether CD40 ligand (L) expression and platelet-monocyte aggregation are increased in patients with type 1 diabetes. METHODS: Serum C-reactive protein (CRP) and soluble (s) CD40L concentrations, platelet surface CD40L expression and platelet-monocyte aggregates were measured in 22 patients with uncomplicated type 1 diabetes and 22 age- and sex-matched non-diabetic control subjects. RESULTS: In comparison to controls, patients with type 1 diabetes had higher serum CRP concentrations (3.29 +/- 0.9 mg/L versus 0.99 +/- 0.2mg/L, P = 0.01), serum sCD40L concentrations (10.0 +/- 1.4 ng/mL versus 4.6 +/- 0.6 ng/mL, P = 0.006), and platelet surface expression of CD40L (13.8 +/- 0.9% versus 8.5 +/- 1.1%, P < 0.001). Platelet-monocyte aggregates were also significantly elevated in type 1 diabetes (35.9 +/- 3.3% versus 26.4 +/- 2.9%, P = 0.005; n = 10). We also observed a significant correlation between plasma glucose and serum CRP (r = 0.53, P = 0.01) as well as platelet-monocyte aggregates (r = 0.69, P = 0.03). CONCLUSIONS: Type 1 diabetes is associated with increased CD40L expression and platelet-monocyte aggregation, which may contribute to the proinflammatory and prothrombotic state as well as the accelerated atherogenesis associated with this disorder.

Platelet support for cardiopulmonary bypass surgery.

After we discontinued the use of fresh blood for cardiopulmonary bypass surgery, we routinely provided platelet concentrates for the patients. To ascertain if this was necessary, patients paired for procedure and age were given either 4 units of platelets (Group I) or no platelets (Group II). Platelet counts were obtained preoperatively; hourly during bypass; immediately, 1/2 hour, and 3 to 4 hours after bypass; and daily for 7 postoperative days. In the 60 patients evaluated, a significant difference between mean platelet counts could not be demonstrated at any time. Total blood use and the total time required for postbypass hemostasis was not significantly different between the two groups. The degree of thrombocytopenia could not be correlated by bypass time. Platelet concentrates or fresh blood are not needed prophylactically for cardiopulmonary bypass surgery, and their usage should be reserved for the occasional patient who manifests thrombocytopenia as well as hemorrhagic complications.

Three serologic tests for candidiasis. Diagnostic value in distinguishing deep or disseminated infection from superficial infection or colonization.

One hundred fifty-one sera from 100 hospitalized patients with positive cultures for yeasts were assayed using whole-cell agglutination (Aggl.), agar gel diffusion (AGD), and counterimmunoelectrophoresis (CEP) to determine the relative diagnostic values of three serologic tests for anti-Candida antibodies. Serial samples were obtained from 29 patients. Tests were read blindly; correlations of the three test results with culture results and clinical findings were determined only after all data had been accumulated. Thirty-five of 100 patients had Aggl. titers of 1:160 or greater, although 13/35 had no evidence of deep or disseminated disease. Twenty-four of 100 patients had clinical or autopsy evidence of deep or disseminated candidiasis; 22/24 had Aggl. titers of 1:160 or greater. Twenty of the 24 patients were CEP-positive, whereas 18/24 were AGD-positive. In five patients CEP became positive earlier (10--21 days) than AGD. Three patients had false-positive precipitin tests, two by both CEP and AGD and the third by CEP only. In this population, a positive CEP and a positive AGD test showed good correlation with deep or disseminated candidiasis, whereas a negatvie Aggl. test showed the best correlation for excluding deep or systemic candidiasis.

Cystic chromomycosis due to Wangiella dermatitidis.

Chromomycosis is a chronic, slowly progressive disease of the skin and subcutaneous tissue produced by several species of dematiaceous or pigmented fungi, especially Phialophora gougeroti. Verrucous nodules and flattened annular plaques are the most frequently reported skin lesions in chromomycosis, but deep abscesses and cystic lesions have also been reported. We describe herein a case of cystic chromomycosis due to Wangiella dermatitidis that developed following a nonprenetrating injury to the thumb.

Orbital tuberculosis.

A 37-year-old man had epistaxis, headache, intermittent swelling of the periorbital region, proptosis, epiphora, and chronic sinusitis. X-ray films showed marked erosion of the midline facial bones, total opacification of both maxillary sinuses, and clouding of the sphenoid and left ethmoid sinuses. He also had a cutaneous-maxillary sinus fistula and a purulent discharge. A histopathologic examination disclosed areas of acute and chronic inflammation with occasional noncaseating granulomas. Biopsy specimens and postoperative sputum cultures grew Mycobacterium tuberculosis, although the patient had no obvious signs of systemic disease. Because tuberculosis of the orbit is rare in developed countries, it is often overlooked in the diagnosis of granulomatous inflammation of the orbit. This can lead to exacerbation of the disease by corticosteroid treatment.

Radiation dermatitis: a case report.

A unique form of vasculitis occurring six months after radiation therapy for postoperative breast cancer is described herein. This rare, unexplainable reaction is a very unusual occurrence.