Daily Clinical Care Research Articles

The ATLS® classification of hypovolaemic shock: A well established teaching tool on the edge?

Uncontrolled bleeding is the leading cause of shock in trauma patients and delays in recognition and treatment have been linked to adverse outcomes. For prompt detection and management of hypovolaemic shock, ATLS® suggests four shock classes based upon vital signs and an estimated blood loss in percent. Although this classification has been widely implemented over the past decades, there is still no clear prospective evidence to fully support this classification. In contrast, it has recently been shown that this classification may be associated with substantial deficits. A retrospective analysis of data derived from the TraumaRegister DGU® indicated that only 9.3% of all trauma patients could be allocated into one of the ATLS® shock classes when a combination of the three vital signs heart rate, systolic blood pressure and Glasgow Coma Scale was assessed. Consequently, more than 90% of all trauma patients could not be classified according to the ATLS® classification of hypovolaemic shock. Further analyses including also data from the UK-based TARN registry suggested that ATLS® may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. This finding was independent from pre-hospital treatment as well as from the presence or absence of a severe traumatic brain injury. Interestingly, even the underlying trauma mechanism (blunt or penetrating) had no influence on the number of patients who could be allocated adequately. Considering these potential deficits associated with the ATLS® classification of hypovolaemic shock, an online survey among 383 European ATLS® course instructors and directors was performed to assess the actual appreciation and confidence in this tool during daily clinical trauma care. Interestingly, less than half (48%) of all respondents declared that they would assess a potential circulatory depletion within the primary survey according to the ATLS® classification of hypovolaemic shock. Based on these observations, a critical reappraisal of the current ATLS® classification of hypovolaemic seems warranted.

FRI0294 Biologic Monotherapy: A Treatment Option for Elderly RA Patients with Multimorbid Conditions

BackgroundThe treatment of RA with biologic (b)DMARDs should usually be combined with the non-biologic (nb)DMARD methotrexate (MTX). Randomized controlled trials showed superior efficacy of combination therapy in RA patients. Nevertheless,...

Evaluation of the Usefulness of 2 Prediction Models of Clinical Prediction Models in Physical Therapy: A Qualitative Process Evaluation

ObjectiveThe purposes of this study were to (1) evaluate the usefulness of 2 prediction models by assessing the actual use and advantages/disadvantages of application in daily clinical practice and (2) propose recommendations to enhance their implementation. MethodsPhysical therapists working in 283 practices in the area of Breda (the Netherlands) were invited to participate in this study. Two prediction models were presented: (1) to predict persistent shoulder pain and (2) to predict the preferable treatment in nonspecific neck pain. Participants were asked to apply both models in practice. After 2 months, their opinions about the usefulness of both models were gathered during a focus group meeting or by using an online questionnaire in order to identify the most important advantages/disadvantages of each prediction model. ResultsIn total, 46 physical therapists (13.8%) of 39 practices participated. Evaluative data were available from 32 participants who used the shoulder model 102 times and the neck model 126 times. For the shoulder model, the most frequent advantage (mentioned 14 times) was that it enabled physical therapists to estimate a motivated prognosis, that is, a prognosis based on the score of the model. The most frequent mentioned disadvantage was that participants expressed their doubts about the validity of the model because the model initially was developed for usage in a general practice setting. For the neck model, the most frequently mentioned advantage (29 times) was that the model was easy to interpret. The most important disadvantage (mentioned 14 times) was that the model only takes a few treatment options into account. ConclusionsThe physical therapists participating in this study reported that both models evaluated in this study were not easy to use in daily practice. Based on the findings of this study, we recommend that these models are modified to meet the practical needs of the therapist, before assessing their impact on daily clinical care and patient outcomes.

Genotyping upper gastrointestinal cancer in daily clinical care.

e15004 Background: Cancer is driven by somatic genetic alterations. Recently molecular subtypes have been identified in a number of different cancer types such as lung cancer, melanoma or GIST. Lit...

Improvement and problems in appropriate use of cardiac CT: 2003, 2007 and 2011 use of CT-based on ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac CT

The healthcare community needs to understand how to best incorporate cardiac CT into daily clinical care. The American College of Cardiology Foundation (ACCF)/Society of Cardiovascular Computed Tomography (SCCT)/American College of Radiology (ACR)/ American Heart Association (AHA)/American Society of Echocardiography (ASE)/American Society of Nuclear Cardiology (ASNC)/ North American Society for Cardiovascular Imaging (NASCI)/Society for Cardiovascular Angiography and Interventions (SCAI)/Society for Cardiovascular Magnetic Resonance (SCMR) appropriate use criteria for cardiac CT were updated in 2010 [1], and there is increased interest in the specific benefits of cardiac CT. It is important for physicians to recognize these criteria and perform cardiac CT based on these criteria. In this study, we evaluated the appropriateness of cardiac CT use retrospectively in patients from 2003 and 2007 (16 slice CT, Light Speed Ultra 16, GE Healthcare) and from 2011 (320 slice CT, Aquilion one, ToshibaMedical) basedupon the 2010ACCF/SCCT/ACR/AHA/ASE/ASNC/ NASCI/SCAI/SCMR criteria in order to investigate problems and improvements in the appropriate use of cardiac CT. We retrospectively analyzed the purpose of cardiac CT in a total of 720 subjects in our institute. Subjects were recruited consecutively at this institute in 2003 (218 subjects), in 2007 (201 subjects), and 2011 (301 subjects). On baseline characteristics, there were significant differences of percentage of hyperlipidemia and smoking habits but therewere no significant differences of age and percentage of diabetes mellitus among 2003, 2007, and 2011 groups (Table 1). The appropriateness of purpose of cardiac CT acquisition was classified into 3 groups based upon the 2010 ACCF/SCCT/ACR/AHA/ ASE/ASNC/NASCI/SCAI/SCMR criteria [1]: appropriate, uncertain, and inappropriate [1]. We classified the purpose of CT acquisition into the following four groups based upon the 2010 ACCF/SCCT/ACR/AHA/ASE/ASNC/ NASCI/SCAI/SCMR criteria [1], 1) detection of coronary artery disease including symptomatic patients, asymptomatic patients, other scenarios, and prior test results, 2) evaluation of cardiac structure and function, 3) risk assessment post-revascularization, and 4) risk assessment preoperative evaluation. CT acquisition for the evaluation of aortic disease was not included because this purpose was not included in the 2010 ACCF/ SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR criteria for cardiac CT. Percentage of appropriate CT use was 55.1% of subjects in 2003, and improved to 75.6% in 2007 and 80.7% in 2011 (Fig. 1). Percentage of appropriate use of CT for the detection of coronary artery disease was 42.4% in 2003, and improved to 54.7% in 2007 and 76.5% in 2011 (Fig. 2). In sub analysis, percentage of appropriate use of CT for the detection of coronary artery disease for symptomatic patients was 57.5% in 2003, and improved to 85%

A22: Consensus Treatment Plans for Induction Therapy in Childhood Proliferative Lupus Nephritis—Status of Use in Daily Clinical Care

Background/Purpose:Consensus treatment plans (CTPs) serve as an alternative strategy to randomized controlled trials for assessing treatment effects. The CTPs for induction therapy of childhood proliferative lupus nephritis (cLN) were developed for use in clinical care; they are based on best available evidence and endorsed by CARRA Pediatric Rheumatologists. They specify two options for immunosuppressive therapy (IV Cyclophosphamide (CP) and oral Mycophenolate (MMF)) and three options for steroid therapy (primarily oral regimen, primarily IV regimen and mixed oral/IV regimen).The purpose of this pilot study was to assess the use of and adherence to the cLN‐CTPs, and to estimate rates of renal response and safety and tolerability. Preliminary results are presented here.Methods:Providers at 14 participating CARRA sites agreed to utilize the induction cLN‐CTPs for eligible patients. Eligible patients were <20 years old and had biopsy‐proven newly diagnosed proliferative cLN; however the CTPs were not intended for patients with concurrent infections, pregnancy or other severe SLE manifestations that would dictate specific therapies different from the cLN‐CTPs. Patients were invited to enroll in the CARRA registry for periodic collection of standard clinical SLE and renal outcome measures.Results:To date, 71 potential SLE patients with newly diagnosed proliferative cLN were cared for at 13 sites (87% female, mean age 14.6 yrs, mixed ethnicity [37% Hispanic] and race [41% Caucasian, 30% African American, 9% Asian, 20% other/unknown]). 41 (58%) patients were enrolled in the CARRA registry, a prerequisite for study participation. Reasons for non‐enrollment in the registry included failure of being approached in a timely fashion (34%), patients/parents declined participation (4%), and failure to complete consent due to not speaking English (1%). Among the 41 patients who were enrolled in the registry, 29 (43%) were treated according to one of the cLN‐CTPs. For induction immunosuppressive therapy, providers selected the CP CTP for 61%, and the MMF CTP for 39% of patients. For induction steroid therapy, providers selected the primarily IV regimen for 43%, mixed IV/oral regimen for 35%, and primary oral regimen for 17% of the patients. Reasons for not using one of the options specified in the CTPs included patients not meeting eligibility characteristics for their use (35%), providers choosing not to use the cLN‐CTP (13%), treatment initiated at another institution (7%), and the prescribing physician being unaware of the cLN‐CTPs (1.5%).Conclusion:A minority of patients with newly diagnosed proliferative cLN received therapy according to the cLN‐CTPs, which are considered the best therapeutic regimen based on available scientific evidence and expert opinion. Important outcome data from many patients was missed by patients not being approached for enrollment in the registry. This suggests that additional efforts are necessary to promote implementation of the cLN‐CTPs as we endeavor to perform comparative effectiveness studies and improve the prognosis for children with cLN.

An internally and externally validated prognostic score for metastatic breast cancer: analysis of 2269 patients.

The prognosis of metastatic breast cancer (MBC) is extremely heterogeneous. Although patients with MBC will uniformly die to their disease, survival may range from a few months to several years. This underscores the importance of defining prognostic factors to develop risk-adopted treatment strategies. Our aim has been to use simple measures to judge a patient's prognosis when metastatic disease is diagnosed. We retrospectively analyzed 2269 patients from four clinical cancer registries. The prognostic score was calculated from the regression coefficients found in the Cox regression analysis. Based on the score, patients were classified into high-, intermediate-, and low-risk groups. Bootstrapping and time-dependent receiver operating characteristic curves were used for internal validation. Two independent datasets were used for external validation. Metastatic-free interval, localization of metastases, and hormone receptor status were identified as significant prognostic factors in the multivariate analysis. The three prognostic groups showed highly significant differences regarding overall survival from the time of metastasis [intermediate compared with low risk: hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.36-2.27, P < 0.001; high compared with low risk: HR 3.54, 95% CI 2.81-4.45, P < 0.001). The median overall survival in these three groups were 61, 38, and 22 months, respectively. The external validation showed congruent results. We developed a prognostic score, based on routine parameters easily accessible in daily clinical care. Although major progress has been made, the optimal therapeutic management of the individual patient is still unknown. Besides elaborative molecular classification of tumors, simple clinical measures such as our model may be helpful to further individualize optimal breast cancer care.

Genomics education for the public: perspectives of genomic researchers and ELSI advisors.

For more than two decades genomic education of the public has been a significant challenge. As genomic information becomes integrated into daily life and routine clinical care, the need for public education is even more critical. We conducted a pilot study to learn how genomic researchers and ethical, legal, and social implications advisors who were affiliated with large-scale genomic variation studies have approached the issue of educating the public about genomics. Semi-structured telephone interviews were conducted with researchers and advisors associated with the SNP/HAPMAP studies and the Cancer Genome Atlas Study. Respondents described approach(es) associated with educating the public about their study. Interviews were audio-recorded, transcribed, coded, and analyzed by team review. Although few respondents described formal educational efforts, most provided recommendations for what should/could be done, emphasizing the need for an overarching entity(s) to take responsibility to lead the effort to educate the public. Opposing views were described related to: who this should be; the overall goal of the educational effort; and the educational approach. Four thematic areas emerged: What is the rationale for educating the public about genomics?; Who is the audience?; Who should be responsible for this effort?; and What should the content be? Policy issues associated with these themes included the need to agree on philosophical framework(s) to guide the rationale, content, and target audiences for education programs; coordinate previous/ongoing educational efforts; and develop a centralized knowledge base. Suggestions for next steps are presented. A complex interplay of philosophical, professional, and cultural issues can create impediments to genomic education of the public. Many challenges, however, can be addressed by agreement on a guiding philosophical framework(s) and identification of a responsible entity(s) to provide leadership for developing/overseeing an appropriate infrastructure to support the coordination/integration/sharing and evaluation of educational efforts, benefiting consumers and professionals.

Recommendations for the use of ultrasound in rheumatoid arthritis: literature review and SONAR score experience

Ultrasound (US) has become a useful tool in the detection of early disease, differential diagnosis, guidance of treatment decisions and treatment monitoring of rheumatoid arthritis (RA). In 2008, the Swiss Sonography in Arthritis and Rheumatism (SONAR) group was established to promote the use of US in inflammatory arthritis in clinical practice. A scoring system was developed and taught to a large number of Swiss rheumatologists who already contributed to the Swiss Clinical Quality Management (SCQM) database, a national patient register. This paper intends to give a Swiss consensus about best clinical practice recommendations for the use of US in RA on the basis of the current literature knowledge and experience with the Swiss SONAR score. Literature research was performed to collect data on current evidence. The results were discussed among specialists of the Swiss university centres and private practice, following a structured procedure. Musculoskelatal US was found to be very helpful in establishing the diagnosis and monitoring the evolution of RA, and to be a reliable tool if used by experienced examiners. It influences treatment decisions such as continuing, intensifying or stepping down therapy. The definite modalities of integrating US into the diagnosis and monitoring of RA treatments will be defined within a few years. There are, however, strong arguments to use US findings as of today in daily clinical care. Some practical recommendations about the use of US in RA, focusing on the diagnosis and the use of the SONAR score, are proposed.

The detection of oxygen saturation in the healthy newborn

The birth of a physiological newborn occurs in the daily clinical care, but in the minds of every parent, in a comfortable environment where the adoption of behaviors are expected to respect the natural childbirth. It is preferred to minimize the interference of clinical practices, which may in any way restrict the free expression of the triad parents/newborn. It is true that in a hospital setting, at the same time, it is required to guarantee the safety with respect to possible, although rare, adverse events – whether related to the care practices or health condition of the infant or the mother.

Steps for PM&R Residents: Is Daily Clinical Care Enough Physical Activity to Maintain Cardiovascular Health?

PM&RVolume 5, Issue 9S p. S224-S224 Musculoskeletal and Sports Medicine Steps for PM&R Residents: Is Daily Clinical Care Enough Physical Activity to Maintain Cardiovascular Health? Dan Cushman MD, Dan Cushman MD Rehabilitation Institute of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL, United StatesSearch for more papers by this authorZack McCormick MD, Zack McCormick MD Rehabilitation Institute of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL, United StatesSearch for more papers by this authorJames A. Sliwa DO, James A. Sliwa DO Rehabilitation Institute of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL, United StatesSearch for more papers by this author Dan Cushman MD, Dan Cushman MD Rehabilitation Institute of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL, United StatesSearch for more papers by this authorZack McCormick MD, Zack McCormick MD Rehabilitation Institute of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL, United StatesSearch for more papers by this authorJames A. Sliwa DO, James A. Sliwa DO Rehabilitation Institute of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL, United StatesSearch for more papers by this author First published: 17 September 2013 https://doi.org/10.1016/j.pmrj.2013.08.344Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume5, Issue9SSeptember 2013Pages S224-S224 RelatedInformation

Multiple circulating microRNAs improve prognostication in subjects with stable heart failure

Background and aim: Certain circulating microRNAs have been proposed as novel biomarkers in heart failure (HF). Current data mostly derives from relatively small cohorts. Accordingly, we directly compared these different circulating microRNAs in a large cohort of patients with stable HF and long-term follow-up. Methods: The study included 834 patients: mean age, 68.1±12.7 years; main etiology of HF ischemic heart disease, 43.8%; NYHA II/III (68%/24%), and mean LVEF, 35.4±13.6%. We measured 14 microRNAs in plasma samples by standard Q-PCR. Results: During a median follow-up of 2.79 years, 328 patients died. Circulating levels of miR 423-5p, miR-129-5p, miR 22\_3p and miR 320 all differed highly significantly between HF decedents versus survivors (p<0.001 for each), while circulating levels of miR-133a and miR-378 differed with p-values <0.05. miR-208a, miR-622 and miR 1254 did not differ significantly. Next, we compared these circulating microRNAs in a multivariable analysis including established prognosticators of HF like age, hemoglobin, serum creatinin and NTproBNP. In this multivariable analysis, combination of different microRNAs provided independent significant prognostication, with miR 22\_3p and miR423-5p providing most significant independent prognostic information. Conculsions: This large study shows that multiple circulating microRNAs provide additional prognostic information in a multivariable model beyond established biomarkers like NTproBNP. Recently, new platforms have emerged to clinically measure multiple circulating microRNAs in an affordable, quick and reliable manner. This opens the exciting possibility to measure a mini-microRNA profile in daily clinical care as a novel way to prognosticate HF.

THU0536 A Comparison of Self Reported Health Status in Rheumatoid Arthritis, Psoriasis Arthritis and Axial Spondyloarthritis in Outpatient Clinic – What’s the Status in 2012?

BackgroundOver the last decade, the use of outcome measures in daily clinical care has been endorsed by the rheumatology community and use of biologic treatment has become a part of...

SAT0316 Routine Assessment of Patient Index Data 3 (Rapid3) is a Valid Index for Routine Care in Patients with Osteoarthritis

BackgroundRAPID3 (routine assessment of patient index data) is an arithmetic composite index of three Core Data Set, patient self-report, measures: physical function (0-3 converted to 0-10), pain (0-10), and patient...

Rhinoplasty planning with an iPhone app: analysis of otolaryngologists response

The field of medical applications is currently one of the most dynamic in medicine due to the great potential for improving clinical practice they hold. However, clinicians' opinion around their usability in daily clinical care has not been thoroughly addressed. This study aimed to analyze the otolaryngologists response to a rhinoplasty application. It was designed as a survey of 21 otolaryngologists with regards to a rhinoplasty planning application for the iPhone with the capacity to project potential surgery outcomes through tactile morphing software compared to a photo tracing method used as the gold standard. The participants were asked to rate the usefulness of the two technologies on a visual analog scale from 0-10. Questions addressed included four topics: physician-patient communication; imaging process time; perceived usefulness for preoperative planning; and perceived usefulness for surgery. A one sample t-test was applied to compare the scores of both methods for each question. The test subjects (mean age 43.21 years) rated the utility of the iPhone application as superior to that of the photo tracing method (p < 0.05) concluding that the iPhone application could facilitate an immediate preliminary analysis of the options for nasal improvement.

Routine Assessment of Patient Index Data 3 (RAPID3) is a Valid Index for Routine Care in Patients with Osteoarthritis

Background RAPID3 (routine assessment of patient index data) is an arithmetic composite index of three Core Data Set, patient self-report, measures: physical function (0-3 converted to 0-10), pain (0-10), and patient global estimate (0-10) for a total of 0-30. It can be completed in the waiting room and can be calculated in only few seconds. Objectives Aim of this study was to compare RAPID3 with the Western Ontario and Mc-Master Universities Osteoarthritis Index (WOMAC) in patients with knee or hip osteoarthritis (OA) Methods patients with symptomatic knee or hip osteoarthritis as main rheumatologic diagnosis (VAS pain > 50 on a visual scale 0-100mm) according to the ACR (American College of Rheumatology) criteria and with stage 2 or 3 according to the Kellgren-Lawrence radiographic criteria were eligible. All subjects were clinically evaluated individually by an experienced rheumatologist and were asked to complete the self-report questionnaires (the original version of the WOMAC for hip or knee osteoarthritis and the RAPID3). There was no specific order in which the tests were completed; rather, each participant selected the order. Agreement between WOMAC and RAPID3 scores was estimated with rho Spearman correlation statistic. Cronbach’s alpha also was determined to evaluate the internal consistency of RAPID3 items Results 218 patients (63 males, 155 females) with hip (n=93) or knee (n=125) osteoarthritis were enrolled in daily practice clinical care during 2010-2012. Mean age (±SD) was 62±7.4 years old. Mean score was 58±8.1 for WOMAC and 7.2±1.5 for RAPID3. RAPID3 and WOMAC have shown a global correlation rho index of 0.78 (p 0.05). The Spearman’s rho was 0.78 for hip osteoarthritis (p Conclusions Up to date there’s not literature about the use of RAPID3 in patients with OA. In our study we found a strong correlation between RAPID3 and WOMAC in patients with either hip and knee OA. RAPID3 provide informative quantitative data for patient status from one visit to the next comparable to other self-reported questionnaire as WOMAC in a time sparing manner Disclosure of Interest None Declared

Dealing with tobacco use and dependence within primary health care: time for action

Main text Primary health care has an operational advantage in overall health promotion, as preventive activities and the management of multimorbidity are placed highly within its agenda. A key component of health promotion is tobacco prevention and smoking cessation, which in the developed world, is the largest preventable cause of death and disability, and estimated to cause 6 million preventable and premature deaths every year [1]. With the above dire number in mind, the World Health Organization has called for smoking cessation to be integrated into primary health care globally [2,3]. Patient centered primary care is seen as the most suitable health system “environment” for providing advice on smoking cessation and general practitioners/family physicians thus have a framework to advocate for smoking cessation within their daily practice [4]. Based on this framework, guidelines have been issued and promoted within primary care practice [4,5]. The first step in handling tobacco control and smoking cessation within daily clinical care is to identify smokers a practice has been shown to increase the likelihood of smokers being provided with help to quit [5], and provide primary care practitioners the chance to refer smokers to a cessation program [6]. Indeed, within the UK, 73% of new patients within primary care were reported to have their smoking status recorded within 90 days of registering an indicator of smoker engagementwith 44% of these entries being recorded on the day of registration [7] The above numbers, although promising, are still far from those that primary care can potentially achieve. Literature frequently reports failure to advise on smoking cessation during clinical visits and this opportunity may be largely missed by clinicians, especially in developing countries or in countries under fiscal constraints [8]. This gap in engagement has been

Endoscopic papillectomy: Data of a prospective observational study

To investigate the clinical value of endoscopic papillectomy indicated by feasibility and safety of the procedure in various diseases of the papilla in a representative number of patients in a setting of daily clinical and endoscopic practice and care by means of a systematic prospective observational study. Through a defined time period, all consecutive patients with tumor-like lesions of the papilla, who were considered for papillectomy, were enrolled in this systematic bicenter prospective observational study, and subdivided into 4 groups according to endoscopic and endoscopic ultrasonography (EUS) findings as well as histopathological diagnosis: adenoma; carcinoma/neuroendocrine tumor (NET)/lymphoma; papilla into which catheter can not be introduced; adenomyomatosis, respectively. Treatment results and outcome were characterized by R0 resection, complication, recurrence rates and tumor-free survival. Over a 7-year period, 58 patients underwent endoscopic papillectomy. Main symptoms prompting to diagnostic measures were unclear abdominal pain in 50% and cholestasis with and without pain in 44%. Overall, 54/58 patients [inclusion rate, 93.1%; sex ratio, males/females = 25/29 (1:1.16); mean age, 65 (range, 22-88) years] were enrolled in the study. Prior to papillectomy, EUS was performed in 79.6% (n = 43/54). Group 1 (adenoma, n = 24/54; 44.4%): 91.6% (n = 22/24) with R0 resection; tumor-free survival after a mean of 18.5 mo, 86.4% (n = 19/22); recurrence, 13.6% (n = 3/22); minor complications, 12.5% (n = 3/24). Group 2 (carcinoma/NET/lymphoma, n = 18/54; 33.3%): 75.0% (n = 10/18) with R0 resection; tumor-free survival after a mean of 18.5 (range, 1-84) mo, 88.9% (n = 8/9); recurrence, 11.1% (n = 1/9). Group 3 (adenomyomatosis, n = 4/54; 7.4%). Group 4 (primarily no introducible catheter into the papilla, n = 8; 14.8%). The overall complication rate was 18.5% (n = 10/54; 1 subject with 2 complications): Bleeding, n = 3; pancreatitis, n = 7; perforation, n = 1 (intervention-related mortality, 0%). In summary, EUS is a sufficient diagnostic tool to preoperatively clarify diseases of the papilla including suspicious tumor stage in conjunction with postinterventional histopathological investigation of a specimen. Endoscopic papillectomy with curative intention is a feasible and safe approach to treat adenomas of the papilla. In high-risk patients with carcinoma of the papilla with no hints of deep infiltrating tumor growth, endoscopic papillectomy can be considered a reasonable treatment option with low risk and an approximately 80% probability of no recurrence if an R0 resection can be achieved. In patients with jaundice and in case the catheter can not be introduced into the papilla, papillectomy may help to get access to the bile duct. Endoscopic papillectomy is a challenging interventional approach but a suitable patient- and local finding-adapted diagnostic and therapeutic tool with adequate risk-benefit ratio in experienced hands.

The lipid phenotype of breast cancer cells characterized by Raman microspectroscopy: towards a stratification of malignancy.

Although molecular classification brings interesting insights into breast cancer taxonomy, its implementation in daily clinical care is questionable because of its expense and the information supplied in a single sample allocation is not sufficiently reliable. New approaches, based on a panel of small molecules derived from the global or targeted analysis of metabolic profiles of cells, have found a correlation between activation of de novo lipogenesis and poorer prognosis and shorter disease-free survival for many tumors. We hypothesized that the lipid content of breast cancer cells might be a useful indirect measure of a variety of functions coupled to breast cancer progression. Raman microspectroscopy was used to characterize metabolism of breast cancer cells with different degrees of malignancy. Raman spectra from MDA-MB-435, MDA-MB-468, MDA-MB-231, SKBR3, MCF7 and MCF10A cells were acquired with an InVia Raman microscope (Renishaw) with a backscattered configuration. We used Principal Component Analysis and Partial Least Squares Discriminant Analyses to assess the different profiling of the lipid composition of breast cancer cells. Characteristic bands related to lipid content were found at 3014, 2935, 2890 and 2845 cm−1, and related to lipid and protein content at 2940 cm−1. A classificatory model was generated which segregated metastatic cells and non-metastatic cells without basal-like phenotype with a sensitivity of 90% and a specificity of 82.1%. Moreover, expression of SREBP-1c and ABCA1 genes validated the assignation of the lipid phenotype of breast cancer cells. Indeed, changes in fatty acid unsaturation were related with the epithelial-to-mesenchymal transition phenotype. Raman microspectroscopy is a promising technique for characterizing and classifying the malignant phenotype of breast cancer cells on the basis of their lipid profiling. The algorithm for the discrimination of metastatic ability is a first step towards stratifying breast cancer cells using this rapid and reagent-free tool.

Medical apps for smartphones: lack of evidence undermines quality and safety

Increasing numbers of healthcare professionals are using smartphones and their associated applications (apps) in daily clinical care. While these medical apps hold great potential for improving clinical practice, little is...