Diagnosis Of Primary Disease Research Articles

Prognostic value of β1 integrin expression in metastatic melanoma

The expression of integrin-type cell adhesion receptors is frequently changed in malignant transformation. Despite their important role in cancer cell behaviour, the value of integrins as prognostic markers is mostly unknown. We have examined the expression of beta1 integrins in 38 metastatic melanomas obtained from 27 patients treated with combined chemoimmunotherapy. On the basis of beta1 integrin expression, the melanoma samples were divided into two groups: beta1-negative tumours (<10% beta1 integrin immunostained cells) and beta1-positive tumours (with > or = 10% positive cells). Patients with beta1-positive tumours (n = 15) had significantly longer disease-free survival (median 38 versus 7 months, P < 0.0001) and overall survival (median 70 versus 23 months, P = 0.0001) evaluated after the diagnosis of primary disease compared with patients with beta1-negative metastases (n = 11). Moreover, the survival of the patients with beta1-positive tumours after the initiation of chemoimmunotherapy was significantly prolonged (median 18 versus 9 months, P = 0.017). The independent nature of beta1 integrin expression as a significant prognostic factor for survival after therapy was confirmed using Cox's multivariate analysis (P = 0.014). Our results indicate that the expression of beta1 integrins might have some major tumour growth regulatory role and can be used as a predictor for prognosis in patients with metastatic melanoma.

Prognostic value of β1 integrin expression in metastatic melanoma

The expression of integrin-type cell adhesion receptors is frequently changed in malignant transformation. Despite their important role in cancer cell behaviour, the value of integrins as prognostic markers is mostly unknown. We have examined the expression of β1 integrins in 38 metastatic melanomas obtained from 27 patients treated with combined chemoimmunotherapy. On the basis of β1 integrin expression, the melanoma samples were divided into two groups: β1-negative tumours (< 10% β1 integrin immunostained cells) and β1-positive tumours (with ≥ 10% positive cells). Patients with β1-positive tumours (n= 15) had significantly longer disease-free survival (median 38 versus 7 months,P< 0.0001) and overall survival (median 70 versus 23 months,P= 0.0001) evaluated after the diagnosis of primary disease compared with patients with β1-negative metastases (n= 11). Moreover, the survival of the patients with β1-positive tumours after the initiation of chemoimmunotherapy was significantly prolonged (median 18 versus 9 months,P= 0.017). The independent nature of β1 integrin expression as a significant prognostic factor for survival after therapy was confirmed using Cox's multivariate analysis (P= 0.014). Our results indicate that the expression of β1 integrins might have some major tumour growth regulatory role and can be used as a predictor for prognosis in patients with metastatic melanoma.

The primary care diagnosis of gastroesophageal reflux disease

The primary care diagnosis of gastroesophageal reflux disease

Risk of acute hospitalization among long-term home care patients

To determine the factors that influence acute hospitalization among long-term home care patients, all patients (N = 59) who were provided home visiting nursing and/or medical care from a 169-bed community hospital in Saitama, Japan, between May 1989 and April 1993 were followed until November 1993. Data on patients concerning age, sex, diagnosis of primary disease, ability to perform activities of daily living (ADL), intellectual impairment, serum albumin, frequency of home visiting medical care, medical and nursing care provided at the patient's home were collected from the medical charts of each subject. The main outcome measure was onset of acute hospitalization during a one-year period after initiation of home visiting medical care. Thirty-five patients (59%) were admitted due to acute illness. Compared with patients who were not in need of acute hospitalization. Cox's proportional hazard model revealed that patients who were completely dependent for eating, dressing, and using the toilet (Hazard ratio (HR) = 3.13, 95% confidence interval (CI) = 1.34-7.35) and serum albumin less than 3.5 g/dl (HR = 3.05, 95% CI = 1.37-6.77) were more likely to be hospitalized. Evaluating a patient's physical conditions at the beginning of home visiting care may allow us to predict whether the patients will have to be hospitalized during the following one-year period.

Pharmacy’s Contribution to Public Health in the 20th Century

Cholecystectomy is the most commonly performed procedure in sickle cell disease (SCD) patients, but outcomes after cholecystectomy have not been well studied. Our aim was to explore the characteristics and outcomes of cholecystectomy in patients with SCD compared with patients without SCD, and assess whether acuity of presentation played a role.Patients younger than age 35, with the primary diagnosis of gallbladder disease, who underwent cholecystectomy, were identified in the Nationwide Inpatient Sample (2005 to 2014). Patients were grouped into treatment groups by sickle cell status and acuity of surgery. Patient demographics, length of stay, hospital charges, and complications were evaluated. Descriptive and multivariate regression analyses were performed to compare these groups.There were 149,415 patients analyzed; 1,225 (0.82%) had SCD. SCD was associated with higher complication rates (2.69% vs 1.12%), longer lengths of stay (3 days vs 2 days), and higher median hospital charge ($29,170 vs $25,438) (all p < 0.01). Stratified by level of acuity, comparing the SCD group with the non-SCD group, higher complication rates were seen in the acute presentation group (3.92% vs 1.00%, p < 0.01), but were not demonstrated in the elective group (0.98% vs 1.95%, p = 0.114).SCD patients appear to have a longer length of stay, higher hospital spending, and increased complication rates compared with non-SCD patients undergoing cholecystectomy. This difference is pronounced among patients who underwent surgery in the acute setting. The data suggest that planned cholecystectomy may be beneficial in improving postoperative outcomes in SCD patients.

Paradoxical response to dexamethasone in the diagnosis of primary pigmented nodular adrenocortical disease.

Primary pigmented nodular adrenocortical disease causes the Cushing syndrome in children and young adults and is most frequently associated with the Carney complex. To evaluate diagnostic tests for primary pigmented nodular adrenocortical disease. Retrospective cohort study. Tertiary care center. 21 patients with primary pigmented nodular adrenocortical disease. The control groups consisted of 9 patients with macronodular adrenocortical disease and 15 patients with primary unilateral adrenocortical disease (single adenomas). Clinical characteristics, radiologic imaging, and a 6-day Liddle test with determination of urinary free cortisol and 17-hydroxycorticosteroid excretion. Adrenal imaging and other tests were of limited value for the diagnosis of primary pigmented nodular adrenocortical disease. The Liddle test, however, distinguished patients with this disorder from those with other primary adrenocortical lesions. An increase of 50% or more in urinary free cortisol levels on day 6 of the Liddle test identified 9 of 13 patients (69.2% [95% CI, 46.6% to 91.8%]) with primary pigmented nodular adrenocortical disease, excluded all patients with macronodular adrenocortical disease, and was present in only 3 of the 15 patients with single adrenocortical adenomas (20% [CI, 0% to 40.2%]). An increase in urinary free cortisol excretion of 100% or more on day 6 of the Liddle test identified only patients with primary pigmented nodular adrenocortical disease. Patients with primary pigmented nodular adrenocortical disease responded to dexamethasone with a paradoxical increase in glucocorticoid excretion during the Liddle test. This feature distinguishes such patients from those who have the Cushing syndrome caused by other primary adrenal disorders and may lead to timely detection of the Carney complex (a potentially fatal disorder) in asymptomatic patients.

Mitomycin chemotherapeutic pleurodesis to palliate malignant pleural effusions secondary to gynecological cancer

To assess the efficacy of mitomycin pleurodesis in women with end stage malignant effusion. Retrospective analysis. Of the 13 patients treated six had ovarian, six had endometrial and one had cervical adenocarcinoma. The median time of onset of effusion from diagnosis of primary disease was 12 months (range 1-75). Ten patients were evaluable for response. The median age of the patients was 59 years (range 42 to 74). Ten (77%) of them had repeated thoracocentesis prior to mitomycin pleurodesis. The median duration and volume of drainage was 4 days (range 2-11) and 3.1 liters (range 1.2-10.2) respectively. One of two patients developed a pneumothorax and required the insertion of an additional chest drain. Overall, seven patients (70%) responded - one completely (CR) and six partially (PR), while three did not respond. Four of five patients with ovarian cancer had a partial response, two of four patients with endometrial cancer (one CR and one PR) responded. The only patient with cervical cancer had a partial response. Nine patients (69%) had enough symptomatic improvement to be discharged home. The drug cost of bleomycin 60 units (US$191), another commonly used agent, was more than twice as expensive as mitomycin 30 mg (US$84). Mitomycin pleurodesis can palliate 70% of patients for at least 1 month. It offers cheap and effective palliation. There is a suggestion that patients' quality of life is improved.

A comparative study of outcomes in patients with chronic obstructive pulmonary disease

Accreditation and certification agencies are demanding outcomes data, managed care companies are concerned with outcomes, and consumers have the right to be informed about outcomes. The Health Care Financing Administration (HCFA) is proposing an outcome-based assessment data system, the Outcomes Assessment information System (OASIS). This retrospective study compares outcome data derived from the OASIS tool with data compiled from the Omaha system by means of a chart review of 10 discharged patients with a primary diagnosis of chronic obstructive pulmonary disease (COPD). Results of this study indicate the Omaha system provides a more complete tool for measuring patient outcomes than OASIS. Outcomes knowledge guides home health nurses toward improved professional practice.

The effect at one teaching hospital of interns' workloads on the satisfaction of their patients.

To explore whether the amount of workload of first-year residents (interns) affects the satisfaction of their patients. The authors collected data from January through May 1995 for 145 patients admitted to Lexinton Veterans Affairs Medical Center with the primary diagnosis of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Workload was measured as the number of other patients for whom the intern had primary responsibility on the day of the studied patient's admission. A questionnaire measured the patients' satisfaction on the day of discharge. The authors analyzed the data using Pearson correlation and multiple linear regression. For the 89 patients with COPD (controlling for patient age, severity of illness, and sex of intern), greater workloads for their interns was a significant predictor of decreased patients' satisfaction (p = .001). No association was found for the 56 patients with CHF. Interns' workloads on the day their patients are admitted can influence their patients' subsequent satisfaction.

The epidemiology and cost of inpatient care for peripheral vascular disease, infection, neuropathy, and ulceration in diabetes.

To describe the epidemiology and costs of the acute care of peripheral vascular disease, infection, neuropathy, and ulceration in a U.K. population with special consideration of those patients with diabetes. Routine data describing inpatient care for a 4-year period were analyzed (financial years 1991/1992 to 1994/1995). These data had undergone record-linkage to draw together records from the same patients, and records of patients with diabetes were flagged. Cost estimates were determined by attributing a diagnosis-related group cost-weight to each record. A total of 4,245 admissions (1.2% of all admissions) had a primary diagnosis of peripheral vascular disease, infection, neuropathy, or ulceration, and 7,379 (2.1%) admissions had these categories recorded in any one of six diagnostic fields. These figures were generated by 3,159 and 4,751 patients, respectively. This represented a range of crude annual incidence of admission of between 1.9 and 2.9 per 1,000 people. Patients with diabetes accounted for 625 (15.4%) of primary admissions, a crude annual incidence of admission of 18.8 per 1,000. The age-standardized relative risk of admission for patients with diabetes to the nondiabetic population was 7.61 for men and 6.85 for women. The length of stay for patients with diabetes was almost twice that of the nondiabetic population (15.5 vs. 8.7 days). The relative risk of hospital mortality (diabetes vs. non-diabetes) was 2.83. Surgical procedures were carried out on 857 patients, 272 (31.2%) with diabetes. This represented an age-standardized relative risk of 31.19. The estimated cost of admissions for primary diagnoses in these categories over 4 years was 6,128,211 pounds ($9,743,855). Patients with diabetes accounted for 1,236,623 pounds ($1,966,230), an excess of 87% attributable to the diabetic state. Diabetes is confirmed as a significant risk factor for peripheral vascular disease, infection, neuropathy, and ulceration. The severity of these disorders in terms of increased risk of hospital mortality, length of stay, and risk of surgical procedure is also demonstrated for those patients with diabetes.

Fungaemia caused by Hansenula anomala--an outbreak in a cancer hospital.

Yeasts belonging to the genus Hansenula are rarely encountered as the cause of infection in clinical practice. A wide spectrum of infections caused by these fungi can be seen, ranging from asymptomatic fungaemia to severe disease. We describe an outbreak of 24 cases of infection due to H. anomala in an oncological hospital in Rio de Janeiro, Brazil. The median age of the patients was 11 years, of whom 54.2% were female; 91.7% of the Hansenula fungaemia occurred in the haematology unit. The most frequent primary disease diagnosis was leukaemia (62.5%), and all of those infected had had a central venous catheter or peripheral venous catheter and had been treated previously with broad-spectrum antibiotics. Numerous other risk factors were observed in our cases: previous use of steroids, chemotherapy, radiation therapy and neutropenia (data not shown). No deaths could be attributed to Hansenula.

Frailty and hospitalization of long-term stay nursing home residents.

To determine the relationship between characteristics of older, long-term stay nursing home patients and hospitalization. A cohort study. One hundred three proprietary nursing homes. All residents of these nursing homes aged 65 or older admitted between January 1, 1991, and December 30, 1993, who had no transitions out of the nursing home during the first 6 months of their stay. Among the cohort of 3782 residents, 931 (25%) were hospitalized at least once during the second 6 months of their nursing home stay. In a logistic regression model, severe functional impairment (adjusted odds ratio (AOR) 1.20, 95% confidence interval (CI) 1.01, 1.43), worsening ADL self-performance (AOR 1.22, 95% CI 1.04, 1.43), presence of a decubitus ulcer (AOR 1.62, 95% CI 1.17, 2.24), presence of a feeding tube (AOR 2.03, 95% CI 1.54, 2.67), primary diagnosis of congestive heart failure (AOR 1.61, 95% CI 1.11, 2.34), and primary diagnosis of respiratory disease (AOR 1.77, 95% CI 1.24, 2.54) were associated with hospitalization. No form of advance directive was associated with a lower rate of hospitalization. Physically frail patients, who may be the least likely to benefit from hospitalization, are the most likely to be hospitalized. The lack of an association between "Do not-hospitalize" orders and lower rates of hospitalization suggests that there are substantial barriers to providing acute care in the nursing home. The association between recent functional decline, primary diagnoses of congestive heart failure and respiratory disease, and hospitalization indicates, however, that certain patient groups may be targeted successfully to reduce hospitalization rates.

Genomic PCR detects tumor cells in peripheral blood from patients with myxoid liposarcoma.

Myxoid liposarcoma (MLS) is the most common subtype of liposarcoma. The cytogenetic hallmark of MLS is the pathognomonic t(12;16)(q13;p11), present in more than 85% of cases. The translocation leads to the fusion of the CHOP and FUS genes at 12q13 and 16p11, respectively, and the generation of a FUS/CHOP hybrid protein. The presence of a tumor-specific chimeric gene makes it possible to identify MLS cells by polymerase chain reaction (PCR). We have analyzed peripheral blood samples obtained during a 10-year period at diagnosis of primary and/or recurrent disease in 19 MLS patients with t(12;16) and in one MLS patient with t(12;22;20), resulting in the fusion of the CHOP and EWS genes. Nested PCR on genomic DNA from blood samples amplified FUS/CHOP hybrid fragments in three patients and EWS/CHOP in the patient with t(12;22;20). There was no obvious association between PCR findings and clinical outcome, but larger series are needed to draw any firm conclusions.

Clinical Review Primary Care Diagnosis of Thyroid Disease

Clinical Review Primary Care Diagnosis of Thyroid Disease

Primary Cutaneous Hodgkin's Disease with Evolution to Systemic Disease

Hodgkin's disease rarely involves the skin and when it does is an indication of advanced stage disease. Primary cutaneous Hodgkin's disease is exceedingly rare, and only a few cases are reported. We describe a patient who developed multiple cutaneous lesions of Hodgkin's disease 2 years before manifesting nodal disease of mixed cellularity subtype. Reed-Sternberg cells in the skin as well as lymph nodes and bone marrow were positive for Epstein-Barr viral transcripts and expressed viral latent membrane protein. Epstein-Barr virus has not previously been demonstrated in primary cutaneous Hodgkin's disease, and its presence in lesions in all sites in this case supports a diagnosis of primary cutaneous disease with subsequent evolution into systemic disease.

OUTCOME OF ECMO VS NEAR MISS ECMO PATIENTS AT FIVE YEARS OF AGE:† 1640

A total of one hundred and sixteen ECMO patients have been evaluated in our center at five years of age. Excluding the patients with primary diagnosis of congenital diaphragmatic hernia and sepsis, allowed us to compare 76 of five-year-old ECMO patients with 20, five-year-old Near Miss ECMO patients with similar primary diagnosis. Both groups were similar in gestational age, sex, Apgar scores and their primary diagnosis of pulmonary disease. Mean birth weight of ECMO patients (3.40 ± 0.60 Kg) was significantly higher than Near Miss group (3.02 ± 0.68 Kg) (p 40 was similar in both groups (22 ± 26 vs 26± 42), the Near Miss group spent longer time on PIP over 30 (75± 81 vs 42 ± 31), FiO2>0.70 (121 ± 81 vs 51± 34) and FiO2 of 1.00 (55 ± 71 vs 38 ± 23), and had longer duration of PCO2<30 (93 ± 64 vs 32 ± 35) respectively. Both groups had similar ethnic distribution and socioeconomic status as it was assessed by number of patients living in a single parent family, level of maternal education and home screening questionnaire. All 76 ECMO patients and 10 of the 20 Near Miss patients had neuroimaging studies. Total of 9 ECMO patients and 2 of the Near Miss patients that were studied had major neuroimaging abnormalities. Mean Full Scale IQ in ECMO patients was 96.88 ± 20.09 vs 91.50 ± 22.34 in Near Miss ECMO (p=.32). Academic screening for reading, writing, and arithmetic was similar in both groups with 46% of ECMO and 56% of Near Miss patients being at risk for school failure (p=.47). Parental reporting of psychosocial problems was similar for behavior adjustment and level of maternal stress, although parents of Near Miss patients reported an increased rate of child immaturity compared to ECMO patients (p=.005).

Acute Retroviral Disease Masquerading as Bacterial Sepsis: The “Bands” Play On

We describe a case of acute human immunodeficiency virus infection that initially appeared to be bacterial sepsis. A marked increase in band forms was seen in the peripheral blood of our patient, with no increase in atypical lymphocytes. Having reviewed the most recent literature, we find this to be common, particularly in the first few days of acute retroviral illness. We suggest that the absence of atypical lymphocytes in the peripheral blood can be misleading in some cases and may militate against the primary diagnosis of acute retroviral disease.

Current management of acute bronchitis in ambulatory care: The use of antibiotics and bronchodilators.

To examine the treatment regimens for acute bronchitis in adults in a Medicaid population seen in ambulatory care settings. Cross-sectional sample of Kentucky Medicaid claims (July 1, 1993, through June 30, 1994). Individuals 18 years old or older seen in an ambulatory setting for acute bronchitis. Anyone with a primary diagnosis of asthma or chronic obstructive pulmonary disease within the time frame was excluded. Twelve hundred ninety-four individuals accounted for 1635 separate outpatient and emergency department encounters for acute bronchitis. Outpatient visits accounted for 89% (n=1448) of the encounters. In 22% (n=358) of the encounters, no medication was prescribed; in 61% (n=997), antibiotics alone were prescribed, in 3% (n=43), bronchodilators alone were prescribed; and in 14% (n=237), both antibiotics and bronchodilators were prescribed. Some type of medication was more likely to be prescribed in emergency departments than in outpatient settings (P=.04), and antibiotic/bronchodilator combination therapy was more likely to be prescribed in rural practices than in urban practices (P<.001). Broad-spectrum were more likely than narrow-spectrum antibiotics to be used in combination with a bronchodilator (P=.001). Penicillins were the most widely used antibiotics (37%), but broad-spectrum agents, such as second- and third-generation cephalosporins (10%) and fluoroquinolones (5%), were also prescribed. Although evidence suggests that antibiotic treatment is not usually indicated for treatment of acute bronchitis, these results indicate that antibiotics are still the predominant treatment regimen in ambulatory care. Furthermore, the evidence suggesting that bronchodilators are effective symptomatic treatments has not been widely adopted. These results have significant implications for the production of antibiotic-resistant bacteria and suggest investigation into why physicians have not used this information in their treatment of acute bronchitis.

Pulmonary artery diastolic-occlusion pressure gradient is increased in acute pulmonary embolism

To assess the pulmonary artery (PA) diastolic-occlusion (wedge) pressure gradient in patients with acute pulmonary embolism and to evaluate this variable's diagnostic utility. Retrospective, clinical review. Intensive care and cardiac catheterization units of a university medical center. None. A series of 19 acute pulmonary embolism patients with concurrent right heart catheterization. Control groups consisted of 19 age-, sex-, and heart rate-matched critically ill controls who also underwent right heart catheterization, eight patients suspected of having pulmonary embolism who had negative pulmonary angiography and concurrent right heart catheterization, and 255 patients with a primary diagnosis of coronary artery disease who underwent right heart catheterization at the time of left heart catheterization. Initial hemodynamics (systolic, diastolic, and mean systemic and pulmonary arterial pressures, occlusion pressure, PA diastolic-occlusion pressure gradient, cardiac output, systemic and pulmonary vascular resistances) were compared between cohorts. Other than differences in the PA diastolic-occlusion pressure gradients, no significant differences were identified between cohorts. Pulmonary embolism patients were found to have increased PA diastolic-occlusion pressure gradients (10 +/- 5 vs. 3 +/- 2 mm Hg for the critically ill controls [p < .0002], and 4 +/- 4 mm Hg for the coronary artery disease cohort [p < .0005]). However, no significant difference in PA diastolic-occlusion pressure gradient values was identified when patients with proven pulmonary embolism were compared with patients in whom pulmonary embolism was clinically suspected yet not confirmed by angiograms (10 +/- 9 mm Hg; NS). For three of 19 pulmonary embolism patients, no occlusion pressure could be obtained due to an inability to wedge the balloon tip; 13 of 16 patients had PA diastolic-occlusion pressure gradients of > or = 8 mm Hg. In the pulmonary embolism cohort, PA diastolic-occlusion pressure gradient correlated well with pulmonary vascular resistance (r2 = .50; p < .05), but not with cardiac output or heart rate. In the large number of patients with right heart catheters in whom the question of pulmonary embolism is raised, an increased PA diastolic-occlusion pressure gradient (especially > or = 8 mm Hg) may provide a clue to the diagnosis of pulmonary embolism, but is not specific for this diagnosis.

Treatment selection factors for stereotactic radiosurgery of intracranial metastases

To define treatment selection criteria for patients with intracranial metastases treated with stereotactic radiosurgery. Between August 1989 and July 1993, 25 patients with intracranial metastases (28 lesions) were treated with stereotactic radiosurgery at the University of Florida. Thirteen patients were treated for progressive intracranial disease after external-beam radiotherapy, and 12 were treated with radiosurgery as an adjunct to initial treatment. Minimum eligibility criteria included histologic verification of primary disease, Karnofsky performance status 50% or greater, three or fewer intracranial metastases, radiographically distinct lesion(s) 4 cm or less in diameter, and reasonably well-controlled primary disease. Univariate and multivariate analyses tested the prognostic significance of Karnofsky performance status, lesion volume, number of lesions, treatment dose (both external beam and stereotactic), histology, site of primary disease, and time interval (less than or greater than 1 year) from primary diagnosis to development of intracranial metastasis or from treatment of intracranial disease to recurrence. Local control was achieved in 84% of 28 lesions treated. The only significant prognostic indicator among the tested variables was the interval to development or recurrence of intracranial metastasis. Although stereotactic radiosurgery improves local control rates and is likely to offer improved palliation for a select cohort of patients, the selection criteria for such patients remain poorly defined. Our data suggest that an interval of greater than 1 year from primary disease diagnosis to development of intracranial metastasis, or from treatment of intracranial metastasis to its recurrence, defines a patient cohort that is more likely to benefit from this treatment technique.