Frequency Of Abnormal Results Research Articles

Underestimated Cervical Cancer among Women over 65 Years Old: Is It Time to Revise the Screening Target Age Group?

To compare cytological and histological results from women > 64 years old who followed the Brazilian national cervical cancer screening guidelines with those who did not. The present observational retrospective study analyzed 207 abnormal cervical smear results from women > 64 years old in a mid-sized city in Brazil over 14 years. All results were reported according to the Bethesda System. The women were divided into those who followed the screening guidelines and those who did not. Atypical squamous cells of undetermined significance and low-grade squamous intraepithelial lesion cytology results were found in 128 (62.2%) cases. Of these, 112 (87.5%) had repeated cytology with positive results. The other 79 (38.1%) with abnormal results should have been referred to colposcopy and biopsy. Out of 41 (51.9%) biopsied women, 23 (29.1%) had a confirmed diagnosis of neoplasia or precursor lesion. In contrast, among the 78 (37.7%) biopsied patients, 40 (51.3%) followed the guideline recommendations, with 9 (22.5%) positive biopsies. Of the 38 (48.7%) women who did not follow the guidelines, there were 24 (63.1%) positive results. Women who did not follow the guidelines demonstrated higher chances of cancer and precursor lesions (odds ratio [OR]: 5.904; 95% confidence interval [CI]: 2.188-15.932; p = 0.0002). Women > 64 years old who did not follow the national screening protocol showed significant differences in the frequency of abnormal results and severity of diagnosis compared with those who followed the protocol.

Diagnostic Yield of Combined Lumbar Puncture and Brain MRI in Critically Ill Patients With Unexplained Acute Encephalopathy: A Retrospective Cohort Study.

We sought to characterize the yield of combined LP and brain MRI (bMRI) in such patients as determined by both the frequency of abnormal results and the therapeutic efficacy of these investigations, that is, how often results changed management. Retrospective cohort study of medical ICU patients admitted to a tertiary academic center between 2012 and 2018 who had documented diagnoses of "AMS" and/or synonymous terms, no clear etiology of encephalopathy, and had undergone both LP and bMRI. The primary outcome was the frequency of abnormal diagnostic testing results determined objectively for LP using cerebrospinal fluid (CSF) findings and subjectively for bMRI through team agreement on imaging findings deemed significant through retrospective chart review. We subjectively determined the frequency of therapeutic efficacy. Finally, we analyzed the effect of other clinical variables on the likelihood of discovering abnormal CSF and bMRI findings through chi-square tests and multivariate logistic regression. One hundred four patients met inclusion criteria. Fifty patients (48.1%) had an abnormal CSF profile or definitive microbiological or cytological data by LP, 44 patients (42.3%) had bMRI with significant abnormal findings, and 74 patients (71.2%) had abnormal results on at least one of these investigations. Few clinical variables were associated with the abnormal findings in either investigation. We judged 24.0% (25/104) of bMRI and 26.0% (27/104) of LPs to have therapeutic efficacy with moderate interobserver reliability. Determining when to perform combined LP and bMRI in ICU patients with unexplained acute encephalopathy must rely on clinical judgment. These investigations have a reasonable yield in this selected population.

Calcium requests in a primary care; An observational audit of biochemical requests and frequency of abnormal results

Background/AimsThis aim of this audit was to assess the extent of serum calcium testing and the frequency of hypercalcaemia in the primary care setting. We also assessed the appropriateness of subsequent investigations with repeat serum calcium and PTH testing if hypercalcaemia was identified. MethodsAll laboratory requests for adjusted calcium and PTH samples sent from primary care in Glasgow were analysed over a 12 month period. This covered approximately 125 GP practices and a patient population of over 590,000. ResultsThere were 78,845 requests for adjusted calcium and 2053 PTH requests from 62,745 patients aged 16–105 years (median age 57, IQ range 30 years). Of these requests 1423 (2.3%) of patients had biochemical evidence of hypercalcaemia (adjusted calcium ≥ 2.61 mmol/L). Of the 1423 patients with hypercalcaemia, 368 patients (45.8%) had a single raised calcium level that was within the normal range on repeat testing. Of the 400 patients with persistent hypercalcaemia on 2 or more samples, 210 (52.5%) had a PTH measured. Eight patients had a PTH < 2.0 pmol/L, whilst 202 (96.1%) had a PTH ≥ 2.0 pmol/L (range 2.1–106.1 pmol/L). ConclusionsSerum calcium was checked in 10.6% of the population per year within primary care. In the 2.4% with a raised calcium on initial testing, approximately half (45.8%) will normalise on repeat testing. Of those who remained persistently hypercalcaemic, only half (52.5%) had a PTH measured and the majority (96.1%) were in keeping with primary hyperparathyroidism being the most common cause of hypercalcaemia.

Reference intervals for platelet indices in seniors and frequency of abnormal results in a population-based setting: a comparison between directly and indirectly estimated reference intervals

Abstract Objectives Mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) possess diagnostic and prognostic capabilities in a variety of diseases. We aimed to establish reference intervals (RI) for platelet indices (PI) in seniors. Methods We established direct and indirect RI for MPV, PDW, and PCT in selected reference individuals aged 60 years and older. Abnormal PI were assessed in a population-based setting in the Principality of Liechtenstein, where 37.7% of the whole nation’s population aged 60 years and older had PI determined by hematology analyzers from Sysmex (Horgen, Switzerland). Results Among 689 female and 542 male participants, MPV and PDW did not exhibit age- and gender-specific differences, whereas PCT in females also displayed no age-specific differences. Age- and sex-independent RI were 9.3–12.5 fl for MPV and 10.1–16.7% for PDW, whereas the age-independent RI for PCT in women was 0.18–0.37. In males, age-specific RI for PCT were 0.16–0.30 (age 60–69), 0.15–0.33 (age 70–79), and 0.14–0.33 (age 80 and older). The population-based frequency of abnormal PI results was 0.8% (MPV), 1.1% (PDW), and 24.4% (PCT). Conclusions Applying novel RI for PI reveals that only approximately 1% of patients exhibit abnormal MPV and PDW. Abnormal PCT is observed much more frequently.

Multidimensional evaluation is necessary to assess hand function in patients with Charcot-Marie-Tooth disease type 1A.

Charcot-Marie-Tooth (CMT) disease type 1A (CMT1A) is the most common hereditary neuropathy. Several studies have assessed the relation between axonal loss and grip strength; however, the functional impact on dexterity and health-related quality of life (HRQoL) is unknown. We hypothesized that the severity of axonal loss will be correlated with loss of function and HRQoL. The purpose of this study was to evaluate the relation between severity of electroneuromyography impairment and its impact on function and HRQoL in adults with CMT1A. Grip and lateral pinch strength were evaluated with specific dynamometers: the Jamar and the Pinch Gauge. Dexterity was explored with the Sollerman, Jebsen, and Nine-hole Peg tests. The CMT impact on well-being was assessed by the validated Medical Outcomes Study Short Form 36 (SF-36), Beck Depression Inventory, and Fatigue Severity Scale, and disease severity by the CMT neuropathy score and Inflammatory Neuropathy Cause and Treatment sensory sum score. Finally, axonal loss and demyelination process was assessed by electroneuromyography. We included 33 participants with CMT1A (23 females, mean [SD] age 47.0 [4.7] years). We found lack of correlation between severe electroneuromyography impairment (frequency of abnormal results >80%), significant distal amyotrophy (70%) and quality of life (mean [SD] scores for physical and mental SF-36 36.4 [10.0] and 48.4 [11.5]), autonomy for activities of daily living, and hand function that remains relatively preserved. We found a correlation between lateral pinch and dexterity according to the Sollerman test (r=0.52, p<0.05) but a lack of correlation among the other parameters. Electrophysiological follow-up seems to be of little relevance to follow HRQoL in individuals with CMT1A and manual function related to functional objectives for everyday physical medicine and rehabilitation practice. The manual function is complex and requires an overall, quantitative, qualitative and multidisciplinary assessment. Each tool (Pinch Gauge, Jamar, Sollerman, Jebsen, Nine-hole Peg) measures a specific element of manual function and is necessary when performing a grip function analysis.

Preoperative evaluation for gynecologic surgery: a guide to judicious, evidence-based testing.

Preoperative testing is a routine component of surgical planning, however, the majority of literature agree that laboratory and diagnostic studies are over utilized. We aim to summarize the available literature and provide gynecologists performing elective surgery for benign indications guidance to determine when, in whom, and in what time frame preoperative studies should be collected. Current literature supports previous publications indicating routine laboratory and diagnostic testing for elective surgery is unnecessary and continues to be excessive. The frequency of abnormal results is high, whereas the impact on surgical planning and outcomes is negligible. The preoperative evaluation including thorough history and physical examination should be the cornerstones for eliciting underlying disease, which may alter a surgical strategy. Devising a protocol to direct preoperative testing has been shown to decrease unnecessary tests without compromising prediction of perioperative morbidity/mortality or case cancellation and changes. Avoidance of 'routine preoperative testing' and instead, thoughtful risk stratification of individual patients, should be a goal of providing value-based care.

Impact of Prenatal Risk Factors on Congenital Heart Disease in the Current Era

BackgroundThe healthcare burden related to congenital heart disease (CHD) is increasing with improving survival. We assessed changing trends in prenatal risk factors for CHD in the current era in a Canadian cohort.Methods and ResultsCHD patients <18 years old (n=2339) and controls without structural heart disease (n=199) were prospectively enrolled in an Ontario province‐wide biobank registry from 2008–2011. Family history, frequency of extra‐cardiac anomalies (ECAs), and antenatal risk factors were assessed. Temporal trends were analyzed and associations with CHD were measured using linear and logistic regression. Family history of CHD and frequency of major ECAs was higher in cases versus controls (P<0.001). Despite an increase in genetic testing in the recent era, only 9.5% of cases with CHD had a confirmed genetic diagnosis. Yield of genetic testing (ie, frequency of abnormal results) was higher in familial and syndromic cases. There was an increase in parental age at conception, maternal prepregnancy body mass index, maternal urinary tract infections, type 1 diabetes, and exposure to nonfertility medications during pregnancy from 1990–2011. Later year of birth, family history of CHD, presence of major ECAs, maternal smoking during pregnancy, and maternal medication exposure were associated with increased odds of CHD (P<0.05 for all). Advanced parental age was associated with increased odds of CHD caused by genetic abnormalities.ConclusionsThe increase in prenatal risk factors for CHD highlights the need for more rigorous ascertainment of genetic and environmental factors including gene‐environment interactions that contribute to CHD.

Neurodevelopmental outcome following prenatal diagnosis of an isolated anomaly of the corpus callosum

To assess the ability of prenatal ultrasound and magnetic resonance imaging (MRI) to diagnose isolated anomalies of the corpus callosum (ACC) and to further document the long-term prognosis following diagnosis. This was a prospective case-control study carried out between 1999 and 2004. Diagnosis was made by a combination of ultrasound and MRI. All infants were examined by a neuropediatrician and parents consented to answer questionnaires (CDI, Ireton's Child Developmental Inventory) in 22 cases, which were matched with 44 control infants. The CDI was used to assess neurodevelopmental outcome in cases and controls. Mean DQ-CDI (development quotient calculated from CDI) values and frequencies of abnormal results were compared between groups, and a meta-analysis of previous studies was performed. The diagnosis of ACC was made prenatally and confirmed postnatally in 175 cases. The diagnosis was thought to be isolated ACC in 88/175 (50%) cases. Sixty of these 88 cases (68%) underwent termination of pregnancy and one died in utero. Twenty-seven were liveborn, of which 26 were followed up for a median of 50 (range, 30-74) months. Additional anomalies were diagnosed postnatally in four (15%) of these 26 neonates. The control group was significantly better (P < 0.05) compared with the cases diagnosed prenatally with isolated ACC with respect to gross motor, fine motor, language comprehension, numbers and general development, and it was marginally better for letters (P = 0.066). Seven of 26 (27%) (95% CI, 13-46%) infants with ACC over the age of 30 months had neurodevelopmental delay, compared with only one case with borderline developmental delay among the 44 controls (P = 0.006). Prenatal diagnosis of ACC by a combination of ultrasound and MRI is reliable. However, the isolated nature of the anomaly could only be assessed in 85% of our cases. Since counseling is provided at the time of prenatal diagnosis, our population of isolated ACC included the cases that were missed prenatally as being ACC with associated anomalies. A meta-analysis of nine studies suggests that the development of children diagnosed prenatally with isolated ACC is normal in up to 70% (CI 95%, 56-83%) of cases. This means that the prospective risk of neurodevelopmental delay for a fetus with ACC described as isolated prenatally is 27%, compared with 15% for an infant whose diagnosis of isolated ACC is confirmed postnatally.

Reasons for ordering laboratory tests and relationship with frequency of abnormal results

Objective. Laboratory tests are ordered on a daily basis, even though disease probability is often very low. Abnormal results, especially mildly abnormal results, can be difficult to interpret in these circumstances. Further insights into the occurrence of abnormalities can help improve rational test ordering and test interpretation. The objective was therefore to examine the frequency of mildly and markedly abnormal results and their relationship with physicians' reasons for ordering tests. Design. Prospective study. Participants. A total of 87 primary care physicians in the Netherlands collected data on 1775 patients. Main outcome measures. The physicians recorded the reason for ordering the tests, the most probable diagnosis and the pretest probability. The laboratories' reference values and specified “action limits” were used to assess the number of abnormal results and markedly abnormal results, respectively. Results. Laboratory results were received for 1621 patients and 15,603 tests were reported (mean 9.6). The proportion of abnormal test results increased with increasing pretest probability (from 13.9% to 34.7%) and was 13.4% for tests ordered to reassure the patient and 13.3% for psychosocial diagnoses. The proportion of patients with at least one abnormal test result was high: 53.1% for tests ordered to reassure and 57.7% in patients with low pretest probability. Corresponding values for a marked abnormality were 11.1% and 12.4%, respectively. Conclusion. Abnormal laboratory test results were frequent, even when pretest probability was low. Physicians should therefore carefully consider when tests are necessary. Future research could explore physicians' interpretation of test results and its impact on diagnosis and management.

Cardiac autonomic dysfunction in patients with systemic lupus, rheumatoid arthritis and sudden death risk

The manifestations of autonomic nervous system (ANS) dysfunction in autoimmune diseases have been the subject of many studies. However, the published results pertaining to such research are controversial. Sudden cardiac death due to fatal arrhythmias is frequent in patients with systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). To analyse risk predictors of sudden cardiac death related to the degree of autonomic dysfunction. We performed cardiovascular ANS assessment in 90 patients in this case-controlled study, including 52 (6 male, 46 female) patients with SLE, 38 (6 male, 32 female) with RA and 41 (23 male, 17 female) healthy subjects. The methodology included a comprehensive ECG analysis (with Schiller software AT-10) of QTc interval, late potentials, short-term heart rate variability (HRV) and nonlinear HRV (Poincare plot) analysis; 24-hour Holter ECG monitoring with ECG QTc interval analysis, HRV analysis; 24-hour blood pressure monitoring with systolic and diastolic blood pressure variability; cardiovascular autonomic reflex tests (according to Ewing). Vagal dysfunction was established by performing 3 tests: Valsalva maneuver, deep breathing test and heart rate response to standing test. Dysfunction of the sympathetic nervous system was examined by applying 2 tests: blood pressure response to standing and handgrip test. In all cardiovascular reflex tests, the frequencies of abnormal results were significantly higher among the patients than among the healthy subjects. Severe autonomic dysfunction was more common in RA. QTc interval was more prolonged in patients with SLE. Both diseases were associated with depressed heart rate variability compared to controls, the reduction being greater in RA patients. In the patients with SLE, autonomic dysfunction is predominantly with higher sympathetic activity while in RA vagal predominance is evident. SLE and RA are associated with severe autonomic dysfunction and the presence of significant risk predictors related to the onset of sudden cardiac death.

Cardiovascular autonomic dysfunction in systemic lupus, rheumatoid arthritis, primary Sjögren syndrome and other autoimmune diseases

Neurological manifestations are known to occur in patients with autoimmune diseases, often subclinically, but autonomic nervous system (ANS) involvement has rarely been studied, and studies have shown conflicting results. We performed cardiovascular ANS assessment in 125 patients with autoimmune diseases in this case-control study, including 54 patients with systemic lupus erythematosus (SLE), 39 with rheumatoid arthritis (RA), 20 with primary Sjbgren syndrome (pSS), eight patients with polymyalgia rheumatica (PR), four patients with scleroderma (Ssc) and 35 healthy control subjects. The control group was formed to approximately match the mean age of SLE, RA and pSS patients; controls did not differ significantly by gender from the autoimmune pations. All patients with were in stable condition. Autonomic nervous system dysfunction was diagnosed by applying cardiovascular reflex tests according to Ewing, and was considered to exist if at least two tests were positive. Vagal dysfunction was established by applying three tests: Valsalva manoeuvre, deep breathing test, and heart rate response to standing. Sympathetic dysfunction was examined by applying two tests: blood pressure response to standing and handgrip test. In all cardiovascular reflex tests, frequencies of abnormal results were significantly higher among the patients than among the controls (P < 0.05). The difference between the autoimmune patients and the controls was particularly significant in sympathetic and parasympathetic tests, with P < 0.0001. No correlation was found between disease duration, clinical manifestations, cardiovascular risk factors and diseases activity on the one hand, and ANS dysfunction on the other hand. Cardiovascular autonomic dysfunction was revealed in the majority of autoimmune patients.

High Frequency and Early Onset of Bone Mineral Density Loss Following Allogeneic Stem Cell Transplantation.

Bone mineral density (BMD) loss has been recently associated with allogeneic stem cell transplantation (alloSCT). It is not certain whether BMD loss in alloSCT patients (pts) occurs primarily within the first six months, since some reports cite continuing BMD loss up to six years post-transplant. Furthermore, it has been suggested that alloSCT-BMD loss is more likely to manifest in the femoral neck (FN), as opposed to the lumbar spine (LS). There are no studies that have detailed the incidence of alloSCT-BMD loss. We retrospectively reviewed 90 alloSCT pts who underwent a single alloSCT between 7/1/2001 and 2/26/2005 to assess the frequency of DEXA scan use and alloSCT-BMD loss. 7/1/2001 was chosen as the start date since this was when DEXA scans were first available at RPCI. 50 patients did not have DEXA scans following BMT: 15/50 pts died before day 130, 21/50 pts died after day 130 post BMT, and 14/50 pts are alive post day 130 without DEXA scans (median 1.1 yrs, range 0.34–3.0 yrs). Clinical criteria for obtaining DEXA scans were a medically stable condition with a good KPS and alive at day 130. 37 pts met this criteria. The median survival of the non-DEXA scan pts was 180 (7–1296) days and 571 (110–1282) days for the DEXA scan pts. DEXA scan pt characteristics in this sample included: Median age 39 years (range 7–66); AML (n=12), Lymphoma (n=12), CML (n=5), MDS/MPD (n=5), ALL (n=2), or Aplastic Anemia (n=1); Flu+Mel (n=14), Bu+Cy (n=8), Cy+TBI (n=7), non-myeloablative regimen (n=6), or other regimens (n=2); FK+Mt (n=28), FK+/− other (n=4), Mt (n=2), Cs+Mt (n=2), or Cs+FK+Mt (n=1). Approximately half (n=18/37) of alloSCT pts were found to have BMD loss at day 130 post-transplant. Results were stratified by year, and no trends regarding the frequency of DEXA scans in the population or the frequency of abnormal results over time were noted. There were no differences in terms of conditioning regimens or GVHD prophylaxis between the normal and low BMD groups. Contrary to previously published reports, we did not find a marked difference between the LS and FN T scores of the 18 pts with BMD loss at baseline (LS median T score = −1.4, FN median T score = −1.55). Also, BMD improvement following oral bisphosphonates was seen in six pts with available follow-up scans (LS median T score improved from −1.15 to −0.55, FN median T score improved from −1.45 to −1.1). The day 130 incidence of BMD loss in our alloSCT population was higher than we expected. Therefore, we recommend that all future alloSCT pts undergo DEXA scans as part of the day 100 workup. Further study may elucidate risk factors for BDM loss post BMT. Bisphosphonate use may reverse alloSCT BDM loss.

Cardiovascular autonomic dysfunction in primary Sjögren's syndrome.

To assess the occurrence and clinical significance of a cardiovascular autonomic nervous system dysfunction in primary Sjögren's syndrome (pSS). Fifty-one pSS patients participated in this case-control study. Heart rate and blood pressure variability measurements, spontaneous baroreflex sensitivity examinations and cardiovascular reflex tests were performed. The results of the heart rate and blood pressure variability measurements and also the baroreflex sensitivity parameters of the pSS patients peaked in the lowest percentile ranges of a database on 559 healthy control subjects (P < 0.05). In three of the five cardiovascular reflex tests, the frequencies of abnormal results were significantly higher among the patients than among the controls (P < 0.05), and the median autonomic neuropathy score was also elevated (3 vs 0 in the controls; P < 0.0001). Signs of an autonomic nervous system dysfunction involving the cardiovascular system can be discerned in the majority of pSS patients.

Neuropathy is a major contributing factor to diabetic erectile dysfunction

Erectile dysfunction (ED) in diabetes is multifactorial. So far, the impact of neuropathy has not been well determined. This study was performed to assess the frequency of abnormal neurophysiological tests in patients with ED due to diabetes compared to patients with ED due to nondiabetic neuropathies in order to estimate the contribution of neuropathy in diabetic ED. Forty-nine men with ED were studied. We classified ED as 'diabetic', 'neuropathic' or 'ED of other origin'. 26.6% of the men fulfilled the criteria of diabetic ED, 42.9% had neuropathic ED. In every patient history taking, a questionnaire focusing on autonomic symptoms other than ED, clinical examination, nerve conduction studies (NCS), sphincter ani electromyography (EMG), heart rate variability testing (HRV) and quantitative sensory testing (QST) was performed. Vascular function was assessed by the intracavernosal prostaglandin E1 (PGE1) injection test. The frequency of abnormal results in diabetic and neuropathic patients was compared. Vascular function was abnormal in only one patient with diabetic ED and three patients with neuropathic ED. Both groups had similar frequencies of autonomic symptoms other than ED (64% in diabetic vs. 64% in neuropathic patients), abnormal EMG (33% vs. 40%) and abnormal QST (vibratory perception 83% vs. 84%, cold perception 9% vs. 19%, warm perception 42% vs. 43%). Abnormal clinical findings (50% vs. 33%), NCS (75% vs. 50%) and HRV (39% vs. 25%) were slightly, but not significantly more frequent in men with diabetic ED than neuropathic ED. The tests indicating neuropathy showed abnormalities in men with diabetic ED as frequently as in men with neuropathic ED. Some tests even suggested neuropathy more often in diabetic than in neuropathic ED. The findings support the hypothesis that neuropathy contributes significantly to the pathophysiology of ED in diabetes mellitus. [Neurol Res 2001; 23: 651-654]

Blood Pressure Response to Standing in the Diagnosis of Autonomic Neuropathy: The EURODIAB IDDM Complications Study

Autonomic neuropathy is associated with poor prognosis. Cardiovascular reflexes are essential for the diagnosis of autonomic nerve dysfunction. Blood pressure response to standing is the most simple test for the evaluation of sympathetic integrity, however it is still discussed which diagnostic criteria of abnormal response should be considered as optimal. The EURODIAB IDDM Complications Study involved the examination of randomly selected Type 1 diabetic patients from 31 centres in 16 European counties. Data from 3007 patients were available for the present evaluation. Two tests of autonomic function (response of heart rate /R-R ratio/ and blood pressure from lying to standing) just as the frequency of feeling faint on standing up were assessed. R–R ratio was abnormal in 24% of patients. According to different diagnostic criteria of abnormal BP response to standing (>30 mmHg, >20 mmHg, and >10 mmHg fall in systolic BP), the frequency of abnormal results was 5.9%, 18% and 32%, respectively (p < 0.001). The frequency of feeling faint on standing was 18%, thus, it was identical with the prevalence of abnormal blood pressure response to standing when >20 mmHg fall in systolic blood pressure was considered as abnormal. Feeling faint on standing correlated significantly with both autonomic test results (p < 0.001). A fall >20 mmHg in systolic blood pressure after standing up seems to be the most reliable criterion for the assessment of orthostatic hypotension in the diagnosis of autonomic neuropathy in patients with Type 1 diabetes mellitus.

Salmeterol/Fluticasone Combination Inhaler

The efficacy and tolerability of a new combination inhaler containing both salmeterol 50mg and fluticasone 100mg in a single device was compared with the delivery of the two drugs via two separate inhalers in a multicentre, double-blind, double-dummy study. 244 symptomatic asthma patients (age range 12 to 78 years) were randomised to a 12-week treatment period with either salmeterol/fluticasone (50/100mg twice daily) via a single inhaler (combination) and placebo twice daily via another, or salmeterol 50mg twice daily via one inhaler and fluticasone 100mg twice daily via another (concurrent). Morning peak expiratory flow rate (PEFR), symptoms and tolerability were collected throughout the treatment period. Adjusted mean improvements in morning PEFR were 42 and 33 L/min for combination and concurrent therapies, respectively, over the 12-week treatment period. Adjusted mean improvements in forced expiratory volume in 1 second (FEV(1)) from baseline at week 12 were 0.20 and 0.17L for combination and concurrent therapies, respectively. 60% of patients receiving combination inhaler and 64% of those receiving concurrent therapy had a mean daytime symptom score of zero over the treatment period compared with 17 and 15%, respectively, at baseline. Both treatments were well tolerated. Geometric mean morning serum cortisol levels were similar and no differences in the frequency of abnormal results were noted between the two groups. This was the first study reporting the control of asthma by administration of salmeterol and fluticasone in combination via a single inhaler. The new combination inhaler was as effective and well tolerated as the two drugs administered individually and has potential advantages in terms of convenience.

Troponin T, troponin I and creatine kinase-MB mass after elective coronary stenting.

To assess whether and to what extent elective coronary stenting is associated with biochemical evidence of minor myocardial damage (MMD), as defined by the detection of abnormal post-procedural serum levels of one more among the following markers of ischaemic injury: creatine kinase (CK)-MB mass, troponin T (Tn-T) and troponin I (Tn-I). Nineteen elective procedure of coronary stenting were compared with a matched group of 25 conventional percutaneous transluminal coronary angioplasty (PTCA) procedures performed in our laboratory from March to June 1995. Cases with evolving or recent (< 2 weeks) myocardial infarction, chronic total occlusions and dilation of saphenous vein grafts were excluded. By definition, all of the patients had undergone uneventful deployment of a single palmaz-Schatz stent, with no chest pain and no persistent ECG changes after the procedure. Serum levels of CK-MB mass, Tn-T and Tn-I were determined at baseline and 6, 12 and 24 h after the procedure. The frequency of abnormal results was determined for each marker. Baseline and peak post-procedural levels in the two groups were compared and related to procedural variables. Baseline values were normal in all cases. The quantitative analysis showed that post-procedural levels of each marker (including total CK) were significantly higher with respect to baseline in both groups. In the stent group, two patients had positive CK-MB mass, four positive Tn-T and seven positive Tn-I. Absolute changes in Tn-T and Tn-I were closely related to changes in CK-MB mass (r = 0.76, P < 0.0001; r = 0.90, P < 0.0001), respectively). Three of these patients developed clinically silent side-branch occlusion. All of them were positive for troponins and two were positive for CK-MB. No correlation was found between procedural variables and the results of biochemical assays. In the PTCA group, three patients were positive for Tn-I, whereas the CK-MB mass and Tn-T remained constantly normal. No side-branch occlusion was observed. The peak CK-MB mass and Tn-I were significantly higher in the stent group than they were in the PTCA group (3.04 +/- 4.1 versus 1.27 +/- 1.3 ng/ml, P = 0.046; 0.78 +/- 1.17 versus 0.28 +/- 0.3 ng/ml, P = 0.046, respectively). This difference was no longer apparent when patients with side-branch occlusion were excluded. In our series, Tn-I measurement shows the highest ability to detect MMD, being positive in 37% of stent and 14% of PTCA cases. Elective coronary stenting associated with greater release of CK-MB mass and Tn-I than is conventional PTCA. This finding is mainly determined by cases of side branch occlusion, which account for most, but not all, periprocedural MMD in the stent group.

A comparison of frequency of abnormal results in neuropsychological vs. neurodiagnostic procedures.

Compared the frequency of abnormal Impairment Index values and abnormal results on neurodiagnostic procedures in patients (N = 102) classified as Brain-damaged, Normal, or Equivocal on the basis of final medical diagnosis. The Impairment Index called a higher percentage of the Brain-damaged Ss abnormal than did any single neurodiagnostic procedure. Although it called a higher percentage of the other two groups abnormal than did the skull X-ray, the Impairment Index did not differ from computed tomography (CT) or the EEG with respect to abnormality rates in those groups. Thus, in this sample of patients, the Impairment Index was more sensitive to brain damage than any neurodiagnostic measure, yet no more likely to call patients in the other two groups abnormal than were CT or the EEG. Limitations of the study and difficulties in conducting this kind of research are discussed.

Persistence of transaminase abnormalities in former drug addicts.

A large group of ex-addicts in residence in a rehabilitation program were studied to determine their medical history of hepatitis, the frequency of SH/Au antigen, and the prevalence of liver malfunction. Fifty percent of our population had a history of hepatitis while using drugs. Among the whites, 58.4% had had hepatitis, whereas only 26% of the nonwhites had such a history. The frequency of SH/Au antigen by Ouchterlony technique (1.2/100) was consistent with that of previous studies. There was a significant decline in serum glutamic-pyruvic transaminase (SGPT) values as a function of time free of drug and needle use. There was a 40% frequency of abnormal results (> 50 Karmen units/ml) in tests taken soon after entry into the program; in tests taken after 4 months and up to a year there was a 20% frequency of abnormal results. The persistent abnormal SGPT results and liver biopsy findings in several residents with persistently elevated transaminases showed a high frequency of chronic inflammatory liver disease among the population.