Routine Follow-up Of Patients Research Articles

Clinical Usage of Different Guidelines in Routine Management, Therapy and Follow-Up of Patients with Renal Cell Cancer in Germany

Objectives: To evaluate the usage of different guidelines and to estimate the impact of changed recommendation in routine management, therapy and follow-up of patients with renal cell cancer (RCC). Methods: An anonymous questionnaire was sent to 600 urologists in Germany. Twenty-seven percent of them were included in the analysis. The questions were about the practice setting, surgical and medical treatment of RCC, follow-up modalities, knowledge and usage of RCC guidelines. Results were correlated with the recommendations of the EAU-guideline. Results: Sixty-eight percent of the urologists were office based. Sixty percent were located in bigger cities. Ninety-eight percent of the colleagues reported to be knowledgeable about the EAU-guidelines, 62% reported to know the American Urological Association, 59% DGU/AWMF, 19% National Comprehensive Cancer Network, 19% European Society for Medical Oncology, 13% Onkopedia, and 3% British Association of Urological Surgeons-guidelines. Eighty-seven percent reported that partial nephrectomy (Nx) was performed in tumours with diameter <4 cm. Forty-one percent performed a radical Nx for tumours that were 4-7 cm. Follow-up of RCC was done in 99%. Fifty-nine percent underwent an abdominal CT scan after 6 months. Thirty-nine percent got a chest X-ray done. Among those with metastatic RCC, only 84% were offered systemic therapy. First-line therapy was predominantly advocated using sunitinib. Conclusion: Almost all urologists know and use the EAU-guidelines. Other guidelines are rarely used. Follow-up is performed in discordance with the EAU-recommendations. Interestingly, only 84% with metastatic disease are introduced to systemic therapy.

Depression in adult patients with primary immune thrombocytopenia

Depression in adult patients with primary immune thrombocytopenia

Metabolic assessment of Merkel cell carcinoma: the role of 18F-FDG PET/CT.

Merkel cell carcinoma (MCC) is a rare aggressive skin tumor associated with a high mortality rate. The present study evaluated the role of fluorine-18 fluorodeoxyglucose (F-FDG) PET/computed tomography (CT) in subsequent management of patients with MCC. A total of 101 consecutive F-FDG PET/CT studies of 46 patients with MCC (28 men, 68±15.4 years) were retrospectively evaluated and the role in clinical care was documented. There were 40 positive studies (40%) in 28 patients (61%); of these, 33 studies (33%) in 27 patients (59%) showed metastatic disease. Fifty-two PET/CT studies (51%) in 23/46 (50%) patients were negative. Fifty-three studies (52%) were performed for staging or restaging in 41 patients, 29 scans (29%) were performed for routine follow-up in 10 patients, nine studies were carried out for suspected recurrent disease in eight patients, and 10 studies were carried out for assessment of response to therapy in seven patients. On the basis of PET/CT results, there was a change in disease stage in 12 studies in 12 patients (26%) and further change in the management of seven patients (15%). Overall, 2/29 routine follow-up studies were positive with further impact on management in one patient. F-FDG PET-CT altered the stage of one of four patients and changed the management of one of seven MCC patients. In the majority of patients, a negative F-FDG PET-CT study excluded active MCC with a high degree of confidence. PET-CT contributed toward patient management when performed for staging and restaging, monitoring response to treatment, and suspected recurrent disease, but not in the routine follow-up of asymptomatic patients with MCC.

Cardiovascular disease risk in people with spinal cord injury: is there a possible association between reduced lung function and increased risk of diabetes and hypertension?

Retrospective, descriptive study of medical files 253 patients with chronic traumatic spinal cord injury (SCI). To determine the frequency of cardiovascular disease (CVD) risk factors in SCI people, to estimate CVD risk in this population according to the Framingham Risk Score (FRS) and to determine whether reduced lung function parameters are significant predictors of diabetes mellitus (DM) and hypertension. Academic Rehabilitation Hospital. Demographic and clinical records of the patients and lung function parameters were obtained. The FRS could not be calculated in 26 (10.3%) patients because this tool is designed for adults aged 20 years and older. According to the FRS guideline, ~6.7% of the SCI patients had high risk, 5.9% of them had intermediate risk and 77.1% of the study group had low risk for CVD. Regression analysis showed that impaired lung function parameters (FEV1, FVC and MVV) were significant predictors for the future development of hypertension (odds ratio (OR): 0.483 (0.258-0.903 95% confidence interval (CI)), OR: 0.549 (0.319-0.946 95% CI) and OR: 0.981 (0.965-0.998 95% CI), respectively) and DM (OR: 0.335 (0.140-0.801 95% CI), OR: 0.391 (0.183-0.839 95% CI) and OR: 0.970 (0.947-0.993 95% CI), respectively) in the SCI population. This study showed that there might be a significant relationship between reduced lung function and the risk of DM and hypertension in people with SCI. Therefore, systematic measurement of these parameters should be performed in the routine clinical follow-up of SCI patients. Once reduced lung parameters are determined, the higher risk for developing hypertension and DM should be considered.

Imaging characteristics of focal splenic and hepatic lesions in type 1 Gaucher disease

In Gaucher disease (GD) imaging of liver and spleen is part of routine follow-up of GD patients. Focal lesions in both liver and spleen are frequently reported at radiological examinations. These lesions often represent benign accumulations of Gaucher cells, so-called “gaucheroma”, but malignancies, especially hepatocellular carcinoma, are more frequently found in GD as well. We report the imaging characteristics of all focal lesions in liver and spleen in the Dutch GD cohort. Of the 95 GD1 patients, 40% had focal splenic and/or hepatic lesions, associated with more severe GD. Lesions identified as gaucheroma have variable imaging characteristics: hyper- to hypointense on MRI, hyper- or hypoechoic on US and hypodense on computed tomography (CT). Hepatic lesions were classified as simple cysts or haemangioma based upon imaging characteristics. Focal nodular hyperplasia (FNH), gaucheroma and hepatocellular carcinoma (HCC) could not be distinguished by conventional US, CT or MRI. Growth of these lesions and/or characteristics of HCC on dynamic CT or MRI and pathology was used to identify or rule out HCC. We propose a decision-making algorithm including the use of growth and dynamic CT- or MRI-scanning to characterize lesions.

Relapse of AML after hematopoietic stem cell transplantation: methods of monitoring and preventive strategies. A review from the ALWP of the EBMT.

Allogeneic hematopoietic stem cell transplantation (allo-SCT) remains the therapeutic method with the most potent anti-leukemic activity mediated by the graft versus leukemia effect. However, a significant proportion of patients with AML will relapse after allo-SCT. The prognosis for these patients is dismal, with a probability of long-term survival of <20%. Data from previous studies have shown that disease-specific prognostic factors, are in general, the same as those in patients treated with conventional chemotherapy. Minimal residual disease (MRD) and chimerism status monitoring after allo-SCT may be used as predictors of impending relapse and should be part of routine follow-up for AML patients. A significant number of studies have shown that pre-emptive administration of donor lymphocyte infusion (DLI) based on MRD and chimerism monitoring, as well as prophylactic DLI in AML patients at high risk of relapse is effective in preventing relapse. In this review, we discuss strategies for the identification of high-risk patients, review current therapeutic options and provide our recommendations for the management of post-SCT AML.

Biomarker value and pitfalls of serum S100B in the follow-up of high-risk melanoma patients.

Serum levels of S100B are standard in monitoring advanced malignant melanoma patients in order to discriminate progressive from non-progressive disease. False-positive results lead to distress among patients and increase the amount of cost-intensive diagnostics. We therefore analyzed reported comorbid diseases as putative sources of excessive S100B release. Here, we report a single-center experience on serum S100B levels in 2,664 blood samples from 1,113 stage IB to IV melanoma patients (AJCC) who presented for follow-up examinations over a period of 24 months. Overall, 295 (11%) of patients developed disease progression. In patients with a high tumor load, the rate of false-negative results was 30/185 (16%). The rate of false-positive results was 247/2369 (12%). One hundred and six false-positive results (69%) compared to 46 true-positive results (31%) were found in patients with cardiovascular diseases such as arrhythmia (50/32) or previous myocardial infarction (22/14). Moreover, obesity (85/14), liver cirrhosis (31/10), migraine (18/2), chronic kidney disease (13/2), and previous stroke (11/1) were found to be associated with false-positive S100B levels. Serum S100B is a useful quantitative biomarker in routine follow-up of high-risk melanoma patients. While false-negative results are frequent in patients with low tumor load, false-positive results are associated with several comorbid diseases and warrant careful reevaluation.

The Fontan circulation and the liver: A magnetic resonance diffusion-weighted imaging study

BackgroundPatients with a Fontan circulation tend to develop liver fibrosis, liver cirrhosis and even hepatocellular carcinoma. The aim of this study is to use the magnetic resonance technique diffusing-weighted imaging (DWI) for detecting liver fibrosis/cirrhosis in Fontan patients and to establish whether DWI results are associated with functional aspects of the Fontan circulation. MethodsIn a cross-sectional study, 59 Fontan patients were evaluated by liver DWI. The association between apparent diffusion coefficients (ADC) and patient characteristics, laboratory measurements and functional aspects of the Fontan circulation (NYHA class, maximum oxygen uptake during exercise and cardiac index) was assessed. ResultsLiver ADC values were low (0.82×10−3±0.11×10−3mm2/s) compared with literature values for healthy volunteers and correlated negatively with calculated liver fibrosis/cirrhosis scores (Fib-4 score, p=0.019; AST/ALT ratio, p=0.009) and gamma-glutamyl transferase (p=0.001). Furthermore, ADC values correlated negatively with follow-up duration (p<0.001) and positively with cardiac index (p=0.019). No correlation between ADC values and exercise tests was found. In multivariable analysis, the ADC values were independently correlated with follow-up duration after Fontan completion. ConclusionsThe results of the current study suggest that progressive liver damage due to chronic congestion and potential hypoperfusion is reflected in the liver ADC values in Fontan patients. This study highlights that liver damage in the context of the Fontan circulation might be far more common than previously thought, and that the implementation of liver assessment in the routine follow-up of Fontan patients is recommendable.

PTU-034 Autofluorescence imaging in post-operative crohn’s disease colonoscopy differentiates disease recurrence from anastomotic ulceration

Introduction Colonoscopic assessment after post-operative resection and re-anastomosis for Crohn’s disease (CD) is an accepted part of the routine follow-up of such patients. Anastomotic ulcers (figure) are a relatively frequent observation and may be misinterpreted as recurrent CD, thus incurring the need and cost of biopsy examination. Autofluorescence imaging (AFI) technology detects the wavelengths of light emitted by endogenous molecules (fluorophores; such as NAD, FAD), corresponding to their concentration, metabolic state and spatial distribution 1 . In tissue with a high metabolic rate or under oxidative stress (inflammation or dysplasia), AFI generates a purple colouration, compared to green when normal tissue is imaged. We hypothesised that AFI might discriminate between appearances due to anastomotic ulceration and CD recurrence. Method Patients at our Institution undergoing per-protocol colonoscopy as part of routine post-operative evaluation of CD were examined with the AFI colonoscope (Olympus CF-FH260AZL and either 260 or 290 series processor) by three consultant Endoscopists familiar with AFI technology. The Endoscopists’ opinion as to whether the endoscopic appearance was most in keeping with anastomotic ulceration, with mostly fixed purple (AFI+) or green (AFI-) fluorescence was recorded and compared to eventual histology results. As the measurement of faecal calprotectin (FCALP) is also protocolised post-operatively, we were also able to take into account this well-validated marker. Results 10 patients were examined with AFI. 4 were AFI+ and all were confirmed as having histologic evidence of IBD. 5 were AFI- and again all were confirmed by histologic examination. 1 patient had equivocal changes on AFI and biopsies excluded recurrent CD. Faecal calprotectin was 100 in all 4 patients AFI+. Conclusion Although a small cohort, our results indicate that AFI may be highly discriminatory and suggests potential new applications for this technology: combining non-invasive markers and findings on AFI, NBI and magnification might obviate the need for biopsy to exclude disease recurrence; the degree and extent of mucosal inflammation could be assessed; dysplasia could more readily be detected. Further prospective studies are planned to determine and establish the role of AFI in IBD. Use of the 290 series processor with this technology may improve detection and discrimination. Disclosure of interest None Declared. Reference ASGE technology assessment. Gastrointest Endosc 2011; 73 :647–50

Discharge to Primary Care for Survivorship Follow-Up: How Are Patients With Early-Stage Breast Cancer Faring?

Oncology centers in public health systems often transfer routine follow-up of patients with early-stage breast cancer (BC) to primary care physicians because of the increasing numbers of survivors and evidence supporting the safety of this practice. After transfer of care, it is unknown how BC survivors fare with treatment and surveillance goals, and whether they have unmet needs for access to specialist care. This study conducted in a sample of women in Alberta, Canada, examined adherence with follow-up guidelines, symptoms, and need for a telephone-based survivorship clinic. Through the Alberta Cancer Registry, we randomly invited women with stage I-III invasive BC (N=960) to participate. Of those, 272 responded, and 240 consented to a structured telephone interview and chart review. Women adhered well to follow-up guidelines for mammogram, but less so for clinical examination and endocrine therapy (ET). However, most patients reported ongoing bothersome symptoms, which tended to be higher in those not on ET. More than one-third of patients reported ongoing needs (managing weight, side effects, exercise adherence, and psychosocial health). Younger, fatigued or depressed, nonurban women not on ET reported the most need for a telephone clinic. Adherence with follow-up goals (examination, mammography, ET) was better than expected. Despite this, interest in a telephone survivorship clinic was high. Perceived needs included symptom management plus support for lifestyle behavior change. Medical follow-up needs might be well-met by discharge to primary care. However, high levels of ongoing symptoms and psychosocial needs would suggest that telephone-based survivorship clinics, psychosocial and exercise interventions, or transition programs might benefit the survivorship experience of patients with BC.

Clinical Significance of Nonsustained Ventricular Tachycardia on Routine Monitoring of Pacemaker Patients.

Permanent pacemakers (PPMs) are capable of recording tachyarrhythmic events including nonsustained ventricular tachycardia (NSVT), though the clinical significance of NSVT on routine PPM evaluation is unknown. Our goals: assess the prevalence of NSVT on routine PPM follow-up and survival of PPM patients with NSVT, without NSVT, and with ventricular high rate (VHR) episodes of undefined origin. A single-center retrospective, cohort study was performed on patients implanted with PPMs capable of recording NSVT, defined as ≥5 consecutive ventricular beats at ≥170/minutes lasting <30 seconds. Patients were categorized: (1) no NSVT; (2) NSVT; or (3) VHR episodes of uncertain etiology. The primary endpoint was all-cause mortality within 6 months of last follow-up. Note that in 1,125 enrollees (51.8% male, age 74.2 ± 15.5 years, ejection fraction 57.0 ± 9.0%), 742 (66%) had no NSVT, 223 had NSVT (20%), and 160 (14%) had VHR. There were no differences in ejection fraction, diabetes, hypertension, coronary disease, prior myocardial infarction, baseline creatinine, QRS duration, prevalence of left bundle branch block, or β-blocker use among groups. "No NSVT" patients were older (P = 0.013), NSVT patients had more males (P = 0.012); atrial fibrillation and digoxin use were more prevalent in VHR patients (P < 0.01). During median follow-up of 2.8 years there were 93 deaths within 6 months of last follow-up with no differences in survival among groups (log rank P = 0.47). Age, ejection fraction at time of implant, and β-blocker use were independent predictors of survival. NSVT detected on routine PPM follow-up in this patient population with a preserved ejection fraction is not associated with long-term mortality.

Use of Model-Based Iterative Reconstruction (MBIR) in reduced-dose CT for routine follow-up of patients with malignant lymphoma: dose savings, image quality and phantom study.

To evaluate both in vivo and in phantom studies, dose reduction, and image quality of body CT reconstructed with model-based iterative reconstruction (MBIR), performed during patient follow-ups for lymphoma. This study included 40 patients (mean age 49years) with lymphoma. All underwent reduced-dose CT during follow-up, reconstructed using MBIR or 50% advanced statistical iterative reconstruction (ASIR). All had previously undergone a standard dose CT with filtered back projection (FBP) reconstruction. The volume CT dose index (CTDIvol), the density measures in liver, spleen, fat, air, and muscle, and the image quality (noise and signal to noise ratio, SNR) (ANOVA) observed using standard or reduced-dose CT were compared both in patients and a phantom study (Catphan 600) (Kruskal Wallis). The CTDIvol was decreased on reduced-dose body CT (4.06mGy vs. 15.64mGy p < 0.0001). SNR was higher in reduced-dose CT reconstructed with MBIR than in 50% ASIR or than standard dose CT with FBP (patients, p ≤ 0.01; phantoms, p = 0.003). Low contrast detectability and spatial resolution in phantoms were not altered on MBIR-reconstructed CT (p ≥ 0.11). Reduced-dose CT with MBIR reconstruction can decrease radiation dose delivered to patients with lymphoma, while keeping an image quality similar to that obtained on standard-dose CT. • In lymphoma patients, CT dose reduction is a major concern. • Reduced-dose body CT provides a fourfold radiation dose reduction. • Optimized CT reconstruction techniques (MBIR) can maintain image quality.

The effectiveness of tools for monitoring hemophilic arthropathy.

Hemophilic arthropathy is the most important cause of morbidity in patients with hemophilia. The earliest alterations that occur during the development of hemophilic arthropathy can be shown using magnetic resonance imaging (MRI). In addition, various tools have been developed to monitor joint health. : The purpose of this study was to determine the correlation between these tools when used to assess hemophilia patients. This cross-sectional study enrolled 38 hemophilia patients between 2 and 18 years of age. Hemophilia Joint Health Score (HJHS) and radiologic scores (Pettersson and Arnold-Hilgartner) were used to evaluate the joints of the patients (n=236). Magnetic resonance imaging (MRI) was performed on 46 joints that were pathologic according to the HJHS. These joints were imaged bilaterally; therefore, 14 normal joints were imaged. In addition, the Functional Independence Score in Hemophilia (FISH) was used to evaluate the joints of 33 patients. The HJHS scores were correlated with the MRI and FISH scores. The annual bleeding rate was not correlated with any scores; however, the number of painful joints was correlated with the MRI scores. The radiologic scores were correlated weakly with progressive score and HJHS. The agreement between the HJHS scores and the MRI scores suggests that the HJHS may be used safely as a first-line tool. We recommend that the FISH should be used in the routine follow-up of hemophilia patients as a functional evaluation tool. Painful joints may be useful in deciding to apply MRI, whereas the bleeding frequency may not be useful.

El Nurse-led en la Atención Primaria de Salud: una oportuna y prometedora innovación organizativa

At present, the severe economic crisis along with the increasing prevalence of chronic diseases is leading to different countries to consider updating their Primary Health Care (PHC) services in order to make them more efficient and reduce health inequalities. To that end, various initiatives are being carried out, such as the provision of Nurse-led services and interventions. The purpose of this article is to present the available knowledge, controversies and opportunities for Nurse-led initiatives in the setting of PHC. Nurse- led interventions or health services in PHC have proven to be equal or more effective than usual care in disease prevention, the routine follow-up of patients with chronic conditions, and first contact care for people with minor illness. However, as there are only a few health economic evaluation studies published their efficiency is still potential. In conclusion, the Nurse-led care could be an innovative organizational initiative with the potential to provide an adequate response to the contemporary health needs of the population, as well as an opportunity for the nursing profession and for PHC and health systems in general.

Living with chronic neuropathic pain after spinal cord injury: an interpretative phenomenological analysis of community experience

Purpose: This article presents an in-depth, idiographic study examining the lived experience of chronic pain following spinal cord injury (SCI). Neuropathic pain (NP) occurs in a large majority of the SCI population and is particularly intractable to treatment. It can be both psychologically and physically debilitating. This study examines how the experience of NP is mediated by its meaning to the sufferer. Methods: Semi-structured interviews were conducted with eight people with SCI and chronic NP, attending outpatient clinics at a specialist SCI Centre in the UK. Verbatim transcripts were subjected to interpretative phenomenological analysis to further understand the experience. Results: Analysis suggested that NP has powerful consequences upon the sufferer’s physical, psychological and social well-being, in line with a biopsychosocial understanding of pain. Three super-ordinate themes were identified: a perceived gap between treatments received and participants’ views of what they wanted and needed; a fight for life control and acceptance; and feeling understood by others with SCI, but isolated from the non-understanding able-bodied. Conclusions: The results are discussed in terms of the possible application of acceptance-based therapy to NP and the potential for the alleviation of the debilitating consequences of NP.Implications for RehabilitationChronic NP after SCI is often described as worse than the injury itself, often impacting upon the sufferers physical and psychological health.The experiences of persons with SCI-specific NP highlight the impact of pain on their physical, psychological and social health. This indicates that healthcare professionals should incorporate a biopsychosocial approach for managing pain post-SCI.Routine clinical follow-up of SCI patients with chronic NP, as well as comprehensive pain management treatment programmes, could address the three themes evidenced in the current study, by moving routine intervention with NP away from pain relief, towards pain management.Continued education for patients, friends, family members and healthcare professionals may be beneficial in promoting understanding and awareness of NP and its consequences following SCI.

Graves disease following rabbit antithymocyte globulin treatment of severe aplastic anemia in a Korean child.

Antithymocyte globulin (ATG) is used as an immunosuppressive treatment (IST) to deplete clonal suppressor T cells in patients with severe aplastic anemia (SAA). The depletion of suppressor T cells by ATG may affect the activation of B cells, which results in an increased risk for autoimmune conditions. A 12-year-old boy was diagnosed with idiopathic SAA. As he did not have an human leukocyte antigen-matched sibling, he was treated with rabbit ATG (3.5 mg/kg/day for 5 days) and cyclosporine. Five months later, he became transfusion independent. However, 23 months after IST, he complained of mild hand tremors, sweating, weight loss, palpitations, and goiter. Results of thyroid function tests revealed hyperthyroidism (free thyroxine, 3.42 ng/dL; thyroid stimulating hormone [TSH], <0.01 nIU/mL; triiodothyronine, 3.99 ng/mL). Results of tests for autoantibodies were positive for the antimicrosome antibody and TSH-binding inhibitory immunoglobulin, but negative for the antithyroglobulin antibody and antinuclear antibody. He was treated with methimazole, and his symptoms improved. The patient has been disease free for 39 months after IST and 9 months after methimazole treatment. This case report suggests that although rare, rabbit ATG may have implications in the pathogenesis of autoimmune hyperthyroidism. Our findings suggest that thyroid function tests should be incorporated in the routine follow-up of SAA patients treated with ATG.

Changes in first trimester screening test parameters in pregnancies complicated by placenta previa and association with hyperemesis gravidarum.

To assess the possible changes in first trimester screening test parameters in pregnancies complicated with placenta previa and to determine whether there is an association between hyperemesis gravidarum and placenta previa. A total of 131 singleton spontaneously conceived pregnancies that were complicated by placenta previa and delivered between May 2006 and May 2013 were evaluated from birth charts. Ninety patients without placenta previa were selected amongst patients who delivered within the same period of time as the control group. Cases of low lying placenta (n=52) within the study group were assessed as a separate group. The rest of the cases was considered to be in a different group. Beta human chorionic gonadotropin (BhCG) multiples of medians (MoMs) and nuchal translucency (NT) MoMs were significantly higher in the placenta previa group in comparison with the low lying placenta and control groups. Apgar scores at both the 1st and 5th minutes were significantly lower in the placenta previa group. Hyperemesis gravidarum was found to be significantly more frequent in the placenta previa group. The prevalence of hyperemesis gravidarum in the first trimester is higher in pregnancies complicated by placenta previa. Paying more attention to the development of placenta previa in the routine pregnancy follow-up of patients with hyperemesis gravidarum could be considered.

S118 Incidence And Severity Of Chronic Thromboembolic Pulmonary Hypertension Following The Introduction Of A One-stop Clinic For Acute Pulmonary Embolism

Introduction The management and follow-up of pulmonary embolism (PE) is delivered by various specialities resulting in both under and over investigation for suspected chronic thromboembolic pulmonary hypertension (CTEPH). To standardise our approach to long-term PE management a “one-stop” clinic was established in Sheffield in March 2010 to review all patients approximately 3 months after their presentation with acute PE. The aim of this study was to evaluate the incidence and severity of CTEPH identified from a one-stop clinic using an investigative strategy based on careful clinical assessment Methods Consecutive patients attending the one-stop PE clinic following hospital admission with acute PE were identified. During the one-stop consultation a haematologist and respiratory physician reviewed the patient jointly. The need for further investigation was based on clinical assessment. CTEPH was defined as mean pulmonary artery pressure (mPAP) at right heart catheterisation ≥25 mmHg and required multimodality imaging (isotope perfusion scanning, CT pulmonary angiography and MR imaging including MRA and MR perfusion mapping) demonstrating classical features of CTEPH. Results Over a 3-year period between March 2010 and March 2013, 616 patients (mean age 67.7 years, 50% male) attended the one-stop PE clinic approximately 3 months following their acute presentation. 16 patients were diagnosed with CTEPH. An overall diagnostic rate of CTEPH of 2.6% for patients seen at the clinic and an annual incidence of 8.9/million/year was observed based on a referral population of 600,000. This compares to an annual incidence of CTEPH of 4.8/million/year in patients referred to the SPVDU over the same time period, based on a referral population of 15 million. The 16 patients with CTEPH had mPAP 37 ± 11 mmHg, pulmonary vascular resistance (PVR) 362 ± 240 dynes, significantly lower than patients with CTEPH diagnosed at the SPVDU until 2010 (n = 242) mPAP 48 ± 11 mmHg and PVR 735 ± 389 dynes (Hurdman et al Eur Respir J 2012:39(4):945–955). Conclusion Introduction of a one-stop PE clinic for routine follow-up of patients with acute pulmonary embolism identifies patients with higher rates of CTEPH with less severe pulmonary haemodynamic changes.

Lymphopenia predicts preclinical relapse in the routine follow-up of patients with diffuse large B-cell lymphoma

The absolute lymphocyte count (ALC) has been reported to predict relapse in diffuse large B-cell lymphoma (DLBCL). We performed the present study to determine whether the ALC could identify preclinical relapse during routine follow-up. Among all 148 patients analyzed, 39 patients exhibited relapse. Patients without relapse had a higher ALC compared with those with proven relapse at the time of relapse as well as 1 and 3 months before relapse. Low ALC (< 950/μL) at 1 and 3 months before relapse had a positive predictive value of 74.2% and 69.0% and a negative predictive value of 86.3% and 84.0%, respectively, to predict relapse. Low ALC at both 1 and 3 months before relapse was significantly associated with relapse by univariate and multivariate analysis. Our data suggest the potential of lymphopenia to detect preclinical relapse in DLBCL. This may help to identify patients requiring salvage chemotherapy at the time of minimal disease rather than clinically overt relapse.

VOICES: the value of 6-month clinical evaluation in stroke. The protocol for a planned qualitative study to ascertain the value of stroke follow-up to people affected by stroke

IntroductionThe National Clinical Guidelines for Stroke recommend ‘routine follow-up of patients 6 months post discharge’. The Sentinel Stroke National Audit Programme sets a standard of 6 months postadmission follow-up, capturing...