Equivocal Group Research Articles

Equivocal Ureteropelvic Junction Obstruction on Diuretic Renogram—Should Minimally Invasive Pyeloplasty be Offered to Symptomatic Patients?

Equivocal ureteropelvic junction obstruction refers to clinical symptoms and/or other radiological suggestions of possible ureteropelvic junction obstruction but with inconclusive results of obstruction on diuretic renogram. We evaluated long-term outcomes in patients with equivocal ureteropelvic junction obstruction treated with minimally invasive pyeloplasty. We retrospectively analyzed the records of 125 consecutive patients who underwent minimally invasive pyeloplasty as performed by a single surgeon from May 2004 to July 2013. Of 98 patients with followup those with more than 6-month followup were included in analysis. Equivocal ureteropelvic junction obstruction, defined as half-life less than 20 minutes on diuretic renogram, was identified in 23 patients. All patients underwent transperitoneal minimally invasive pyeloplasty. We evaluated patient demographics, preoperative and postoperative symptoms and renal function. The 16 female and 7 male patients with equivocal ureteropelvic junction obstruction had flank pain and associated hydronephrosis on imaging. At a median followup of 20.2 months (range 7 to 75) 95.7% of patients with equivocal obstruction achieved complete symptom resolution. Mean ± SD preoperative and postoperative half-life was 14.1 ± 3.7 and 7.4 ± 4.2 minutes, respectively, for an improvement of 6.7 minutes (p < 0.001). In 1 patient (4.3%) with equivocal obstruction of a complicated iatrogenic etiology treatment ultimately failed postoperatively and endopyelotomy was required. There was no statistically significant difference in clinical or radiological success between the equivocal obstruction group and the 75 patients treated with minimally invasive pyeloplasty for definitive ureteropelvic junction obstruction (p = 0.44 and 0.07, respectively). In patients with radiographic equivocal ureteropelvic junction obstruction and flank pain minimally invasive pyeloplasty efficaciously provides symptomatic relief and functional preservation. Results are comparable to those in patients with high grade obstruction.

The role of ultrasound in the management of patients with occult groin hernias

Introduction: Groin ultrasound scanning is commonly used to examine patients with obscure groin pain or swelling. A recent study has shown ultrasound has a poor positive predictive value (PPV) in diagnosing groin hernias although earlier studies reported PPV values as high as 100%. Our aims were to calculate ultrasound's accuracy in diagnosing occult groin hernias in symptomatic patients and assess how management of these patients is affected by ultrasound result. Methods: We retrospectively analysed 375 symptomatic adult patients, who between February 2008 and March 2010, had ultrasound to diagnose groin hernias when clinical examination was inconclusive. Patients were identified on a prospective radiology database and all groin ultrasounds were performed by either one consultant radiologist or one radiographer. Results: Ultrasound was positive in 199 patients, of which 118 underwent surgery. Using operative findings as the gold standard, ultrasound's PPV for groin hernias was 70% (95% CI: 62–78%). Ultrasound was equivocal in 42 patients of which hernias were diagnosed in 7 of the 10 who had surgery. Ultrasound was negative in 151 patients of which none were later diagnosed with hernias during 3 years' median follow-up. Conclusion: Ultrasound is poor in diagnosing occult groin hernias with a PPV of 70% suggesting a 30% chance of negative groin exploration. The equivocal ultrasound group requires careful follow-up as a considerable number were later diagnosed with hernia. The absence of subsequent hernia diagnosis in the negative ultrasound group suggests it may be a useful rule-out test to exclude occult groin hernias in symptomatic patients.

ACUTE MYOCARDIAL ISCHEMIA IN ADULTS SECONDARY TO MISSED KAWASAKI DISEASE IN CHILDHOOD

Coronary artery aneurysms that occur in 25% of untreated Kawasaki disease (KD) patients may remain clinically silent for decades and then thrombose resulting in myocardial infarction. Although KD is now the most common cause of acquired heart disease in children in Asia, the United States, and Western Europe, the incidence of KD in Egypt is unknown. We tested the hypothesis that young adults in Egypt presenting with acute myocardial ischemia may have coronary artery lesions because of KD in childhood. We reviewed a total of 580 angiograms of patients ≤40 years presenting with symptoms of myocardial ischemia. Coronary artery aneurysms were noted in 46 patients (7.9%), of whom 9 presented with myocardial infarction. The likelihood of antecedent KD as the cause of the aneurysms was classified as definite (n = 10), probable (n = 29), or equivocal (n = 7). Compared with the definite and probable groups, the equivocal group had more traditional cardiovascular risk factors, smaller sized aneurysms, and fewer coronary arteries affected. In conclusion, in a major metropolitan center in Egypt, 6.7% of adults aged ≤40 years who underwent angiography for evaluation of possible myocardial ischemia had lesions consistent with antecedent KD. Because of the unique therapeutic challenges associated with these lesions, adult cardiologists should be aware that coronary artery aneurysms in young adults may be because of missed KD in childhood.

Effect of conduction block in classification and prognosis of Guillain-Barre syndrome

Aim: The aim was to investigate the electro-physiological characteristics in disease progression of Guillain-Barre syndrome (GBS) and observe the effect of conduction block (CB) in classification and severity of the disease. Methods: Two hundred and ninety-four patients with GBS were divided into acute inflammatory demyelinating poly-neuropathy (AIDP) group, acute motor axonal neuropathy (AMAN) group and equivocal group according to their electro-physiological results and then reclassificated after electro-physiological review. All of the patients were followed for 6 months since their attacks. Results: Bad prognosis is more pronounced in AMAN group than in AIDP group ( P P P > 0.05). Conclusion: CB in the early phase of GBS indicates the probability of AIDP transforming into AMAN; it suggests that patients with CB in the early phase of the disease might be in serious conditions in a certain extent.

Outcome Of Patients with Positive Heparin-Platelet Factor 4 Antibodies: A Retrospective Observational Study

▪ IntroductionHeparin-induced thrombocytopenia (HIT) is a rare but potentially serious complication of heparin use. Immunoassay (EIA) can detect the presence of antibodies directed toward heparin-platelet factor 4 (H-PF4) complexes, but provide no information about their ability to activate platelets and have only modest specificity. Significance of positive H-PF4 antibodies without clinical HIT is not known. This study evaluates the outcomes of patients with positive H-PF4 antibodies expressed in optical density (OD) units. ObjectivesTo examine the correlation between positive H-PF4 antibodies, mortality and thrombotic events in hospitalized patients with suspected HIT. MethodsA retrospective electronic medical record review was conducted in two institutions. Patients with H-PF4 antibodies detected by commercial ELISA during 2006 - 2010 were identified. We compared 30-day, 90-day and 1-year mortality in patients with negative, equivocal, and positive H-PF4 test and evaluated the relationship between H-PF4 status and rate of thrombosis. One-way ANOVA and Chi square tests were used testing continuous and categorical variables respectively. A multivariate logistic regression model was fitted to estimate relationships between patient characteristics, laboratory findings, and H-PF4 antibody test status. The Kaplan-Meier method and log-rank tests were used to compare survival between groups. ResultsA total of 417 patients were included in the study, of which 44 patients had equivocal (OD value 0.4-0.9) and 21 had positive (OD value ≥1) H-PF4 antibody test result. 30-day, 90-day and 1-year mortalities were 13.6% (48/352), 33.2% (117/352), 46.3% (163/352) respectively for H-PF4 negative patients, 4.5% (2/44), 45.4 % (20/44), 56.8% (25/44) respectively for patients with equivocal H-PF4 status and 14.3% (3/21). 33.3% (7/21), 42.8% (9/21) respectively for H-PF4 positive patients. There were no statistically significant differences in mortality between patients with negative, equivocal, and positive results at all 3 time points (p-value 0.222, 0.273, 0.385, respectively); even after excluding patients with thrombosis (p-value 0.222, 0.248, 0.310 respectively). Age and Charlson score were associated with increased in-hospital, three-months and 1 year mortality; odds ratios were 1.018 and 1.170 (p-value >0.05) for in-hospital mortality, 1.034 and 1.247 (p-value <0.05) for three-months mortality, 1.04 and 1.289 for 1 year mortality (p-value <0.05). Multiple regression analysis showed that age, gender and Charlson score had no statistically significant effect on the occurrence of thrombosis in negative, equivocal, or positive groups. There was a significant correlation between the occurrence of thrombosis and H-PF4 result. Using logistic regression analysis odds ratio of having thrombosis was 2.476 for equivocal vs. negative and positive vs. equivocal results (p <0.0001) (Table 2). ConclusionOur results suggest no association between H-PF4 status positivity and mortality, as well as no difference in survival over one year between the positive and negative groups. H-PF4 positivity however showed positive correlation with thrombosis risk. Disclosures:No relevant conflicts of interest to declare.

Predictive value of C‐reactive protein with Alvarado score in acute appendicitis

The aim of the study was to evaluate whether C-reactive protein (CRP) level on admission could aid the diagnostic accuracy of Alvarado score in acute appendicitis. We retrospectively evaluated hospital records and database of 234 patients (men 116, women 118, median age 28 years, range 15-87 years) who underwent appendicectomy for acute appendicitis. Patients were categorized into three groups retrospectively based on the Alvarado score. Group I: score 7-10 (n = 155), group II: score 4-6 (n = 71), group III: score less than 3 (n = 10). Negative (NPV) and positive predictive values (PPV) of CRP was calculated. Overall, 169 of 234 (72.2%) had histopathological confirmation of acute appendicitis. The predicted accuracy of Alvarado score was 84.5% in group I, 50.7% in group II and 25% in group III. The PPV of high CRP and NPV of normal CRP for group I was 88% and 36.4%, in group II, 63% and 72%, in group III, 33% and 86%, respectively. The Alvarado score and CRP taken together improve the predictive value of diagnosing acute appendicitis. Having a normal CRP in the equivocal group of Alvarado 4-6, should be further evaluated by advanced imaging before proceeding to appendicectomy.

Seroprevalence survey on measles, mumps, rubella and varicella antibodies in healthcare workers in Japan: sex, age, occupational-related differences and vaccine efficacy

A seroprevalence survey on measles, mumps, rubella and varicella was conducted on healthcare workers (HCWs) at Shimane University Hospital, Japan utilizing an enzyme immunoassay. Of 1811 HCWs tested, 91.8% were seropositive to measles, 92.1% to mumps, 89.5% to rubella and 96.3% to varicella. Sex-related differences in seroprevalence were found in rubella (males vs. females: 84.7 vs. 92.2%, P < 0.001). Moreover, males aged 30-39 years were most susceptible to rubella (22.4%), which may be attributed to the design of childhood immunization programmes in Japan. Individuals aged ≤ 29 years were more susceptible to measles (14.3%) and mumps (10.9%), compared to other age groups. There were no significant sex- and age-related differences in varicella seroprevalence. The physician occupational group was more susceptible to rubella, but no significant occupational-related difference was observed in the other diseases. Susceptible subjects, with negative or equivocal serological results were given a vaccine which induced seroconversion in most vaccinees. Seroconversion occurred more frequently in the equivocal group than in the negative group. These findings provide a new insight for the seroprevalence survey of vaccine-preventable diseases in Japanese HCWs with special reference to vaccine efficacy.

Added value of ultrasound re-evaluation for patients with equivocal CT findings of acute appendicitis: a preliminary study

To prospectively estimate the additional diagnostic value of ultrasound (US) re-evaluation for patients with equivocal computed tomography (CT) findings of acute appendicitis. Between April 2011 and October 2011, 869 consecutive patients with suspected appendicitis who were referred for CT were included. The likelihood of appendicitis was prospectively categorized into five categories. US re-evaluation was recommended for patients in the 'equivocal appendix' and 'probably not appendicitis' groups. The overall negative appendectomy rate during the study period was compared with the rate of the previous year, and negative appendectomy rates of the US and non-US evaluation groups were also compared. Among 869 patients, 71 (8.2 %) had equivocal appendicitis findings and 63 (7.2 %) were diagnosed as probably not appendicitis. The sensitivity and specificity of CT combined with US re-evaluation group (100 % and 98.1 %, respectively) exceeded those of the CT alone group (93 % and 99 %; equivocal group considered as negative appendicitis, 100 % and 89.9 %; as positive, respectively, P < 0.0001). After adding US re-evaluation, the overall negative appendectomy rate in our institution decreased from 3.4 to 2.3 %. For patients with equivocal CT findings of acute appendicitis, US re-evaluation can improve diagnostic accuracy and decrease the rate of negative appendectomies. • Misdiagnosis of appendicitis still occurs, especially in patients with equivocal radiological findings. • The sensitivity and specificity of CT followed by US exceeded those of CT alone. • After US re-evaluation, the negative appendectomy rate decreased from 3.4 to 2.3 %. • US re-evaluation in equivocal cases helps diagnostic confidence and further management.

Effect of Transurethral Resection of the Prostate Based on the Degree of Obstruction Seen in Urodynamic Study

PurposeWe retrospectively investigated the effect of transurethral resection of the prostate (TURP) on the basis of the degree of obstruction seen in preoperative urodynamic study in patients with benign prostatic hyperplasia (BPH) who complained of lower urinary tract symptoms (LUTS).Materials and MethodsThe subjects of this study were 285 patients who were diagnosed with BPH with LUTS and who subsequently underwent TURP. The Abrams-Griffiths number was calculated from the urodynamic results to divide the patients into the following groups: unobstructed, equivocal, and obstructed. There were 26 patients (9.1%) in the unobstructed group, 98 patients (34.4%) in the equivocal group, and 161 patients (56.5%) in the obstructed group. The preoperative and postoperative uroflowmetry, residual urine, International Prostate Symptom Score (IPSS), and quality of life (QoL) score were compared between the three groups to evaluate the outcome of the treatment.ResultsThe reduction in the IPSS was 14.4 in the obstructed group, which was higher than the reductions of 12.7 in the equivocal group and 9.5 in the unobstructed group, but this difference was not statistically significant (p=0.227). The QoL score was also not significantly different across the three groups (p=0.533). The postoperative maximum flow rate was significantly improved in all three groups. The obstructed group had an improvement of 7.8±7.2 mL/s, which was higher than the improvement of 3.7±6.2 mL/s in the unobstructed group (p=0.049) but was not significantly different from the improvement of 5.6±6.9 mL/s in the equivocal group (p=0.141).ConclusionsTURP led to an improvement in the maximum flow rate and LUTS even in BPH patients without BOO. Therefore, TURP can be expected to improve LUTS in BPH patients without definite urodynamic obstruction.

Eosinophilia: A Poor Predictor of Strongyloides Infection in Refugees

Canada resettles 10,000 to 12,000 refugees annually. Despite this being a highly vulnerable population, there are little Canadian data on subclinical tropical diseases harboured in this population over the past 20 years. To determine the seroprevalence and predictors of Strongyloides infection in refugees arriving in Edmonton, Alberta. A retrospective chart review of all refugees seen at the New Canadians Clinic between March 2009 and April 2010 was performed. Demographic, symptom and physical examination data were collected from the charts. Laboratory results were obtained from the electronic laboratory records. A total of 350 subjects were studied. The overall seroprevalence of strongyloidiasis was 4.6%. Equivocal results were found in 6.3%. In the positive group, the majority were male (62.5%); 75% were born in Africa (P=0.004) and 81.2% lived in refugee camps in Africa (P=0.002). Eosinophilia was present in 25% of the positive subjects (P=0.05), in none of the equivocal group and in 8.7% of the negative group. Persistent asymptomatic Strongyloides infection is maintained for years through autoinfection. Traditionally, eosinophilia was used as one of the key tools to diagnose chronic but stable diseases, but it was shown to have a poor predictive value for strongyloidiasis in returning expatriates as well as in those presenting with a disseminated form of the disease. It is important to raise awareness of the severe limitations of eosinophilia as a marker for strongyloidiasis when managing patients who either are immunocompromised, or about to start immunosuppressive therapy. The present study indicated that eosinophilia is a poor predictor of seropositivity and, thus, Strongyloides infection. Residence in Africa (birth/refugee camps) proved to be a significantly better predictor of Strongyloides seropositivity.

The diagnosis of rupture of fetal membranes (ROM): a meta-analysis

The aim of this study was to compare the performance of tests based on the detection of insulin-like growth factor binding protein 1 (IGFBP-1) and placental α-microglobulin-1 (PAMG-1) in diagnosing rupture of fetal membranes (ROM) across different patient populations. A meta-analysis was conducted on prospective observational or cohort studies investigating ROM tests based on the detection of IGFBP-1 and PAMG-1 meeting the following criteria: (1) performance metrics calculated by comparing results to an adequate reference method; (2) sensitivity thresholds of the investigated tests matching those of the currently available tests; (3) study population, as a minimum, included patients between 25 and 37 weeks of gestation. Sensitivities, specificities, and diagnostic odds ratios were calculated. Across all patient populations, the analyzed performance measures of the PAMG-1 test were significantly superior compared with those of the IGFBP-1 test. Of particular clinical relevance, PAMG-1 outperformed IGFBP-1 in the equivocal group, which comprised patients with uncertain rupture of membranes (sensitivity, 96.0% vs. 73.9%; specificity, 98.9% vs. 77.8%; PAMG-1 vs. IGFBP-1 tests, respectively). Compared with its performance in women with known membrane status, the accuracy of the IGFBP-1 test decreases significantly when used on patients whose membrane status is unknown. In this latter clinically relevant population, the PAMG-1 test has higher accuracy than the IGFBP-1 test.

How many biopsy fragments will be necessary to assess HER2 status for gastric cancer?

40 Background: Trastuzumab (T) has been shown to confer overall survival benefit adding to capecitabine or 5-FU and CDDP in HER2-positive advanced gastric cancer in ToGA study. Data from the study, overexpression of HER2 according to immunohistochemistry (IHC) has been confirmed as potential responders. HER2 scoring is essential to decide the strategy of the personalized therapy with T. There are some differences in details to assess HER2 score between surgically resected materials and the biopsy fragments. Moreover it is not unclear how many biopsy fragments will be necessary to assess HER2 status. In this study we attemped to prove the optimal biopsy for HER2 scoring of gastric cancer. Methods: HER2 status was evaluated in 30 cases who were scored HER2 as 3+ and 44 cases who were selected for reference as HER2 score of 2+, 1+, 0 in previous tests of surgical specimens. In total 74 cases of 232 biopsies we investigated HER2 protein expression by IHC using HercepTest (DAKO) and assessed according to Gastric Cancer Scoring System. We analyzed the concordance of HER2 score between surgically specimens and the biopsy fragments. Results: Average numbers of biopsy fragments were 3.13(1-6)/case. The concordances between surgical specimens and biopsy specimens were 80.0% in HER2 3+ group of surgical specimens, 47.8% and 47.6% in HER2 2+ and 1+ or 0. The concordances per each biopsy were 73.5%, 34.7% and 69.1%, respectively. Both concordances in HER2 positive group were significant higher than those in HER 2 negative or equivocal groups. There were not statistic differences of the concordances between 3 or less fragments of biopsy and 4 or more. Conclusions: Our data suggested in HER2 score 3+ according to surgical materials, the concordance of HER2 scoring between surgically resected materials and the prior biopsy specimens was high and at least 3 fragments were seemed enough to assess whether IHC HER2 is positive in biopsy. Other hands in HER 2 negative or equivocal groups, the concordances were low.

Reliability of admission cardiotocography for intrapartum monitoring in low resource setting

BackgroundTo evaluate the role of admission cardiotocography in intrapartum patients in detecting fetal hypoxia already present and to correlate the results of admission cardiotocography with perinatal outcome.Materials and Methods:It was a cross-sectional study conducted in the Labor and Maternity ward during the period 2007-2009. The study included 176 pregnant women (both high risk and low risk), admitted to the emergency department or through the outpatient department with period of gestation ≥36 weeks, in first stage of labor with fetus in cephalic presentation. All of them were subjected to an admission test, a 20 min recording of fetal heart rate and uterine contractions on cardiotocograph machine at the time of admission.Results:The results of the admission test were ‘reactive’ in 82.38%, ‘equivocal’ in 10.22%, and ‘ominous’ in 7.38% women. Women with the reactive admission test had low risk of intrapartum fetal distress (6.9%) as compared to 39.9% in the equivocal and 84.6% in the ominous group (P<0.001). Incidence of moderate to thick meconium stained liqor were more in ominous (61.5%) and equivocal group (33.3%) in compared to reactive group (4.8%) (P<0.001). Incidence of NICU admission was also significantly high (62%) in babies delivered from mother with ominous test group compared to those with equivocal (28%) and reactive test (3.45%) group babies. Neonatal mortality was also seen in babies born to mothers with equivocal (5.5%) and ominous (7.6%) admission test groups. Operative delivery for fetal distress was required in only 5.5% (8 of 145) woman of the reactive group, in 27.8% (5 of 18) woman of the equivocal group and in 84.6% (11 of 13) women of the ominous group.Conclusion:The admission cardiotocography is a simple non-invasive test that can serve as screening tool to detect fetal distress already present or likely to develop and prevent unnecessary delay in intervention. The test has high specificity and can help in ‘triaging’ fetuses in obstetric wards of developing countries with a heavy workload and limited resources.

Comparison of in situ hybridization methods for the assessment of HER-2/neu gene amplification status in breast cancer using a tissue microarray

BackgroundThis project compared HER-2/neu gene status in breast cancers, as demonstrated by FISH (fluorescent in situ hybridization) and CISH (chromogenic in situ hybridization) and using a tissue microarray (TMA). The study also aimed to show whether the TMA technique could be used in clinical diagnostics, rather than remain a scientific tool. Materials and methodsA TMA was constructed using 121 breast cancer specimens, 6 cores from each specimen. Demonstration and assessment of HER-2/neu gene status was by FISH (Vysis Path) and CISH (DAKO Duo CISH). ResultsThe 121 breast cancer specimens were divided into 3 groups by HER-2 status, as determined by immunohistochemistry. In the HER-2 negative group no amplification was observed in 36 out of 40 cases. 3 cases showed amplification by both methods and one by CISH alone. The equivocal HER-2 group showed no amplification in 30 out of 41 cases and amplification in 9 cases. One case was FISH negative CISH positive and one was discarded. In the HER-2 positive group, amplification was confirmed in 37 of the 40 cases by both methods. 3 cases were unsuitable for assessment. ConclusionsThis study indicated that CISH is a sensitive alternative to FISH in detecting HER2 gene amplification and may replace FISH in HER2 testing. Good agreement was observed between methods (98.5% – 119 out of 121 cases).Furthermore, as only 4 out of 121 cases were unsuitable for assessment (no signal or missing TMA cores) – it may be feasible to use TMA in diagnostics.

HER2 Status by Standardized Immunohistochemistry and Silver-EnhancedIn SituHybridization in Korean Breast Cancer

PurposeAmplification of the human epidermal growth factor receptor 2 (HER2) gene occurs in 18% to 20% of breast cancers, and it is recognized as a prognostic and predictive marker. We investigated the HER2 status in Korean breast cancer by immunohistochemistry (IHC) and silver-enhanced in situ hybridization (SISH), as the first step toward building a nationwide quality assurance program for HER2 testing.MethodsA total of 1,198 breast carcinoma samples were collected from six institutions and IHC and SISH were performed using tissue microarrays in central laboratories. The results were compared to those of local laboratories.ResultsAvailable data were obtained from 959 samples. Central IHC results were negative, equivocal, and positive for 756 (78.8%; range among institutions, 76.8-81.8%), 37 (3.9%; 1.9-6.2%), and 166 (17.3%; 13.6-20%), respectively. SISH results were negative, equivocal, and positive for 756 (78.8%; 77.4-79.9%), 2 (0.2%; 0-0.7%), and 201 (21%; 20.1-22.2%), respectively. HER2 gene amplification was observed in 4.4%, 19%, and 73.9% of the negative, equivocal and positive groups stratified by local IHC results, respectively. When central SISH was considered to be the gold standard method for measuring HER2 status, the false-negative and false-positive rates of local IHC were 14.4% (29/201) and 7.1% (54/756). The concordance rate between central IHC and SISH was 98.4%.ConclusionCentral IHC and SISH markedly decreased the interlaboratory variability of HER2 status and the results of the two were highly concordant. The quality control program for HER2 testing must be focused on decreasing both the false negativity and positivity of IHC in local laboratories.

Is there a correlation between the outcome of transurethral resection of prostate and preoperative degree of bladder outlet obstruction?

To compare the impact of transurethral resection of prostate (TURP) on symptom scores and maximal flow rates (Qmax) in patients with equivocal bladder outlet obstruction (BOO) and definite BOO and to assess the relationship between the surgical outcomes and degree of preoperative BOO, we prospectively evaluated men with lower urinary tract symptoms and bladder outlet obstruction index (BOOI) greater than 20, who were refractory to conventional medical treatment and underwent TURP. Urodynamic evaluation, International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual volume (PVR) check and transrectal ultrasound were performed. 20<BOOI<40 was defined as equivocal BOO and BOOI≥40 as definite BOO. Changes of IPSS, Qmax, PVR and correlation analysis was performed between the degree of improvement of Qmax, subdomains of IPSS and BOOI. Fifty-four patients showed equivocal BOO and 80 patients showed definite BOO. Preoperatively equivocal BOO group and definite BOO group showed significant differences in maximal bladder capacity and prevalence of detrusor overactivity, whereas no difference was noted in prostate volume. Postoperatively both groups showed improvements in Qmax, obstructive (IPSSO) and irritative (IPSSI) subdomain of IPSS, but the degree of improvement in Qmax and IPSSI subdomain was statistically significantly greater in definite BOO group. The degree of improvement of Qmax and IPSSI showed weak correlation with preoperative BOOI. As a weak correlation was identified between preoperative degree of BOO and outcome of TURP, other factors other than BOOI such as severity of patients' symptoms should be considered in deciding treatment modality.

Stress perfusion CMR reliably risk stratifies patients with prior exercise treadmill testing

Seventy patients (50% male, age 58.4 years ±11.2; mean ±SD) were identified. Twelve (17%) had a history of previous MI or revascularisation. Seventeen had an objectively positive ETT, of which 7 (41%) had a positive stress CMR. Thirty one had an equivocal ETT, of which 8 (26%) had a positive stress CMR. Twenty two had a negative ETT, of which 3 (14%) had a positive CMR. All positive CMRs had stenoses ≥50% at angiography, except for two patients (11%), both from the equivocal ETT group. A negative CMR, irrespective of ETT status, resulted in a 0% MACE rate at median 23 months (IQR 20-27) follow up. No positive CMRs were seen in negative or equivocal ETTs where ≥ 10 metabolic equivalents (METS) were attained. Conclusions Adenosine stress perfusion CMR can reliably risk stratify patients independent of previous ETT result. A negative CMR is associated with an excellent prognosis at a median of 23 months follow up.

Pitfalls in electrodiagnosis of Guillain–Barré syndrome subtypes

ObjectiveTo electrophysiologically classify an Italian Guillain–Barré syndrome (GBS) population into demyelinating and axonal subtypes, to investigate how serial recordings changed the classification and to underline the pitfalls in electrodiagnosis of...

Relationship between the bladder outlet obstruction and the area under the curve of detrusor during voiding related parameters

Objective To study the relationship between the bladder outlet obstruction(BOO)and the area under the curve of detrusor during voiding related parameters. Methods One hundred and thirty-eight patiens with benign prostate hyperplasia(BPH) underwent clinical evaluation, including physical examination, flow rate and post-void residual volume measurement. Pressure flow studies were performed. Mean patient age was 68 years (range 56 to 82). The AG number and the LinPURR were recorded to classify the patients into 3 groups, namely unobstructed, equivocal obstructed and obstructed, as the traditional classification. Two new parameters including the area under the curve of detrusor pressure during voiding(AUCdet) and the area under the curve of detrusor pressure during voiding adjusted for voided volume(AUCdet/Vol) were calculated and compared with the traditional classification using the Linear discriminant analysis. Results According to the traditional classification, there were 33 unobstructed, 32 equivocal and 44 obstructed cases. The AUCdet and AUCder/Vol of the 3 groups were different(P＜0.001). Linear discriminant analysis showed that of the cases, 90. 9%(30/33), 43.8%(14/32) and 70. 5%(31/44) were identically categorized by the traditional and the AUCdet/Vol classifications in the unobstructed, equivocal and obstructed groups, respectively. Conclusions The area under the curve of detrusor pressure during voiding related parameters appear to be good parameters of the BOO in patients with BPH. Further studies are needed to test the reliability and validity of these new parameters. Key words: Prostatic hyperplasia; Urodynamics; Urinary bladder neck obstruction; Discriminant analysis

A mathematical model to improve on phenotyping for molecular genetic research in malignant hyperthermia

The in-vitro contracture test is the standard test to diagnose malignant hyperthermia (MH) susceptibility. Maximum sensitivity is important for patient safety. For scientific purposes, the reduced specificity of contracture testing is a major drawback, and precise phenotyping is of utmost importance. Our study aimed to improve phenotyping for MH susceptibility to more accurately select patients for molecular genetic research in MH, thus, improving the probability to detect novel MH associated variants. Patients who underwent contracture and molecular genetic testing were selected from the database of two MH investigation centres (Basel and Leipzig). The area under the curve of halothane and caffeine contracture tests was calculated and a logistic regression model was applied to determine the odds of carrying a MH associated genetic variant. This model was subsequently applied to patients without familial MH related genetic variant. Validation of the logistic regression model showed 98% concordance with molecular genetic results. Among patients with unclear in-vitro contracture test diagnosis (MH equivocal), half of the mutation carriers were classified as positive by the model, whereas 86% of those without familial mutation were classified as negative. Excluding the MH equivocal group, the model showed sensitivity of 0.99 (95% confidence interval: 0.95-0.99) and specificity 0.98 (95% confidence interval: 0.94-0.99), respectively, to identify genetically positive MH individuals. Our model is a valuable tool to select patients from MH families for further molecular genetic research. This preselection increases the probability of successful molecular genetic research and is important when available resources are limited.