Record Review to Explore the Adequacy of Post-Operative Vital Signs Monitoring Using a Local Modified Early Warning Score (Mews) Chart to Evaluate Outcomes

Objectives

1) To explore the adequacy of: vital signs’ recordings (respiratory and heart rate, oxygen saturation, systolic blood pressure (BP), temperature, level of consciousness and urine output) in the first 8 post-operative hours; responses to clinical deterioration. 2) To identify factors associated with death on the ward between transfer from the theatre recovery suite and the seventh day after operation.

Design

Retrospective review of records of 11 patients who died plus four controls for each case.

Participants

We reviewed clinical records of 55 patients who met inclusion criteria (general anaesthetic, age >13, complete records) from six surgical wards in a teaching hospital between 1 May and 31 July 2009.

Methods

In the absence of guidelines for routine post-operative vital signs’ monitoring, nurses’ standard practice graphical plots of recordings were recoded into MEWS formats (0 = normal, 1–3 upper or lower limit) and their responses to clinical deterioration were interpreted using MEWS reporting algorithms.

Results

No patients’ records contained recordings for all seven parameters displayed on the MEWS. There was no evidence of response to: 22/36 (61.1%) abnormal vital signs for patients who died that would have triggered an escalated MEWS reporting algorithm; 81/87 (93.1%) for controls. Death was associated with age, ≥61 years (OR 14.2, 3.0–68.0); ≥2 pre-existing co-morbidities (OR 75.3, 3.7–1527.4); high/low systolic BP on admission (OR 7.2, 1.5–34.2); tachycardia (≥111–129 bpm) (OR 6.6, 1.4–30.0) and low systolic BP (≤81–100 mmHg), as defined by the MEWS (OR 8.0, 1.9–33.1).

Conclusions

Guidelines for post-operative vital signs’ monitoring and reporting need to be established. The MEWS provides a useful scoring system for interpreting clinical deterioration and guiding intervention. Exploration of the ability of the Cape Town MEWS chart plus reporting algorithm to expedite recognition of signs of clinical and physiological deterioration and securing more skilled assistance is essential.     

T2-Signal of Ulnar Nerve Branches at the Wrist in Guyon’s Canal Syndrome

Objective

To evaluate T2-signal of high-resolution MRI in distal ulnar nerve branches at the wrist as diagnostic sign of guyon’s-canal-syndrome (GCS).

Materials and Methods

11 GCS patients confirmed by clinical/electrophysiological findings, and 20 wrists from 11 asymptomatic volunteers were prospectively included to undergo the following protocol: axial T2-weighted-fat-suppressed and T1-weighted-turbo-spin-echo-sequences (3T-MR-scanner, Magnetom/Verio/Siemens). Patients were examined in prone position with the arm extended and wrist placed in an 8-channel surface-array-coil. Nerve T2-signal was evaluated as contrast-to-noise-ratios (CNR) from proximal-to-distal in ulnar nerve trunk, its superficial/sensory and deep/motor branch. Distal motor-nerve-conduction (distal-motor-latency (dml)) to first dorsal-interosseus (IOD I) and abductor digiti minimi muscles was correlated with T2-signal. Approval by the institutional review-board and written informed consent was given by all participants.

Results

In GCS, mean nerve T2-signal was strongly increased within the deep/motor branch (11.7±4.8 vs.controls:−5.3±2.4;p = 0.001) but clearly less and not significantly increased in ulnar nerve trunk (6.8±6.4vs.−7.4±2.5;p = 0.07) and superficial/sensory branch (−2.1±4.9vs.−9.7±2.9;p = 0.08). Median nerve T2-signal did not differ between patients and controls (−9.8±2.5vs.−6.7±4.2;p = 0.45). T2-signal of deep/motor branch correlated strongly with motor-conduction-velocity to IOD I in non-linear fashion (R² = −0.8;p<0.001). ROC-analysis revealed increased nerve T2-signal of the deep/motor branch to be a sign of excellent diagnostic performance (area-under-the-curve 0.94, 95% CI: 0.85–1.00; specificity 90%, sensitivity 89.5%).

Conclusions

Nerve T2-signal increase of distal ulnar nerve branches and in particular of the deep/motor branch is highly accurate for the diagnostic determination of GCS. Furthermore, for the first time it was found in nerve entrapment injury that T2-signal strongly correlates with electrical-conduction-velocity.     

Glycemic Control and Radiographic Manifestations of Tuberculosis in Diabetic Patients

Background

Radiographic manifestations of pulmonary tuberculosis (TB) in patients with diabetes mellitus (DM) have previously been reported, with inconsistent results. We conducted a study to investigate whether glycemic control has an impact on radiographic manifestations of pulmonary TB.

Methods

Consecutive patients with culture-positive pulmonary TB who had DM in three tertiary care hospitals from 2005–2010 were selected for review and compared with a similar number without DM. Glycemic control was assessed by glycated haemoglobin A1C (HbA1C). A pre-treatment chest radiograph was read independently by two qualified pulmonologists blinded to patients’ diabetic status. Films with any discordant reading were read by a third reader.

Results

1209 culture positive pulmonary TB patients (581 with DM and 628 without DM) were enrolled. Compared with those without DM, TB patients with DM were significantly more likely to have opacity over lower lung fields, extensive parenchymal lesions, any cavity, multiple cavities and large cavities (>3 cm). The relative risk of lower lung field opacities was 0.80 (95% CI 0.46–1.42) for those with DM with A1C<7%, 2.32 (95% CI 1.36 - 3.98) for A1C 7%–9%, and 1.62 (95% CI 1.12–2.36) for A1C>9%; and that of any cavity over no cavity was 0.87 (95% CI 0.46–1.62) for patients with DM with A1C<7%, 1.84 (95% CI 1.20–2.84) for A1C 7%–9%, and 3.71 (95% CI 2.64–5.22) for A1C>9%, relative to patients without DM.

Conclusions

Glycemic control significantly influenced radiographic manifestations of pulmonary TB in patients with DM.     

Scapular Winging Secondary to Apparent Long Thoracic Nerve Palsy in a Young Female Swimmer

Background

 In neurological diseases, winging of the scapula occurs because of serratus anterior muscle dysfunction due to long thoracic nerve palsy, or trapezius muscle dysfunction due to accessory nerve palsy. Several sports can cause long thoracic nerve palsy, including archery and tennis. To our knowledge, this is the first report of long thoracic nerve palsy in an aquatic sport.

Objective

 The present study is a rare case of winging of the scapula that occurred during synchronized swimming practice.

Methods

 The patient''s history with the present illness, examination findings, rehabilitation progress, and related medical literature are presented.

Results

 A 14-year-old female synchronized swimmer had chief complaints of muscle weakness, pain, and paresthesia in the right scapula. Upon examination, marked winging of the scapula appeared during anterior arm elevation, as did floating of the superior angle. After 1 year of therapy, right shoulder girdle pain and paresthesia had disappeared; however, winging of the scapula remained.

Conclusions

 Based on this observation and the severe pain in the vicinity of the second dorsal rib, we believe the cause was damage to the nerve proximal to the branch arising from the upper nerve trunk that innervates the serratus anterior.     

MR Neurography in Ulnar Neuropathy as Surrogate Parameter for the Presence of Disseminated Neuropathy

Purpose

Patients with ulnar neuropathy of unclear etiology occasionally present with lesion extension from elbow to upper arm level on MRI. This study investigated whether MRI thereby distinguishes multifocal neuropathy from focal-compressive neuropathy at the elbow.

Methods

This prospective study was approved by the institutional ethics committee and written informed consent was obtained from all participants. 122 patients with ulnar mononeuropathy of undetermined localization and etiology by clinical and electrophysiological examination were assessed by MRI at upper arm and elbow level using T2-weighted fat-saturated sequences at 3T. Twenty-one patients were identified with proximal ulnar nerve lesions and evaluated for findings suggestive of disseminated neuropathy (i) subclinical lesions in other nerves, (ii) unfavorable outcome after previous decompressive elbow surgery, and (iii) subsequent diagnosis of inflammatory or other disseminated neuropathy. Two groups served as controls for quantitative analysis of nerve-to-muscle signal intensity ratios: 20 subjects with typical focal ulnar neuropathy at the elbow and 20 healthy subjects.

Results

In the group of 21 patients with proximal ulnar nerve lesion extension, T2-w ulnar nerve signal was significantly (p<0.001) higher at upper arm level than in both control groups. A cut-off value of 1.92 for maximum nerve-to-muscle signal intensity ratio was found to be sensitive (86%) and specific (100%) to discriminate this group. Ten patients (48%) exhibited additional T2-w lesions in the median and/or radial nerve. Another ten (48%) had previously undergone elbow surgery without satisfying outcome. Clinical follow-up was available in 15 (71%) and revealed definitive diagnoses of multifocal neuropathy of various etiologies in four patients. In another eight, diagnoses could not yet be considered definitive but were consistent with multifocal neuropathy.

Conclusion

Proximal ulnar nerve T2 lesions at upper arm level are detected by MRI and indicate the presence of a non-focal disseminated neuropathy instead of a focal compressive neuropathy.     

Long-Term Results after Proximal Thoracic Aortic Redo Surgery

Objective

To evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery.

Methods

We analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed.

Results

In hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome- (ROC 0.786, 95%CI 0.64–0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78–0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43–34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4–14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51–38.79) but not advanced age (OR 2.46, 95%CI 0.48–12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1–52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%.

Conclusions

Despite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.     

Strong Impact of TGF-β1 Gene Polymorphisms on Breast Cancer Risk in Indian Women: A Case-Control and Population-Based Study

Introduction

TGF-β1 is a multi-functional cytokine that plays an important role in breast carcinogenesis. Critical role of TGF-β1 signaling in breast cancer progression is well documented. Some TGF-β1 polymorphisms influence its expression; however, their impact on breast cancer risk is not clear.

Methods

We analyzed 1222 samples in a candidate gene-based genetic association study on two distantly located and ethnically divergent case-control groups of Indian women, followed by a population-based genetic epidemiology study analyzing these polymorphisms in other Indian populations. The c.29C>T (Pro10Leu, rs1982073 or rs1800470) and c.74G>C (Arg25Pro, rs1800471) polymorphisms in the TGF-β1 gene were analyzed using direct DNA sequencing, and peripheral level of TGF-β1 were measured by ELISA.

Results

c.29C>T substitution increased breast cancer risk, irrespective of ethnicity and menopausal status. On the other hand, c.74G>C substitution reduced breast cancer risk significantly in the north Indian group (p = 0.0005) and only in the pre-menopausal women. The protective effect of c.74G>C polymorphism may be ethnicity-specific, as no association was seen in south Indian group. The polymorphic status of c.29C>T was comparable among Indo-Europeans, Dravidians, and Tibeto-Burmans. Interestingly, we found that Tibeto-Burmans lack polymorphism at c.74G>C locus as true for the Chinese populations. However, the Brahmins of Nepal (Indo-Europeans) showed polymorphism in 2.08% of alleles. Mean TGF-β1 was significantly elevated in patients in comparison to controls (p<0.001).

Conclusion

c.29C>T and c.74G>C polymorphisms in the TGF-β1 gene significantly affect breast cancer risk, which correlates with elevated TGF-β1 level in the patients. The c.29C>T locus is polymorphic across ethnically different populations, but c.74G>C locus is monomorphic in Tibeto-Burmans and polymorphic in other Indian populations.     

Incorporation of Chitosan Microspheres into Collagen-Chitosan Scaffolds for the Controlled Release of Nerve Growth Factor

Background

Artifical nerve scaffold can be used as a promising alternative to autologous nerve grafts to enhance the repair of peripheral nerve defects. However, current nerve scaffolds lack efficient microstructure and neurotrophic support.

Methods

Microsphere–Scaffold composite was developed by incorporating chitosan microspheres loaded with nerve growth factor (NGF–CMSs) into collagen-chitosan scaffolds (CCH) with longitudinally oriented microchannels (NGF–CMSs/CCH). The morphological characterizations, in vitro release kinetics study, neurite outgrowth assay, and bioactivity assay were evaluated. After that, a 15-mm-long sciatic nerve gap in rats was bridged by the NGF–CMSs/CCH, CCH physically absorbed NGF (NGF/CCH), CCH or nerve autograft. 16 weeks after implantation, electrophysiology, fluoro-gold retrograde tracing, and nerve morphometry were performed.

Results

The NGF–CMSs were evenly distributed throughout the longitudinally oriented microchannels of the scaffold. The NGF–CMSs/CCH was capable of sustained release of bioactive NGF within 28 days as compared with others in vitro. In vivo animal study demonstrated that the outcomes of NGF–CMSs/CCH were better than those of NGF/CCH or CCH.

Conclusion

Our findings suggest that incorporation of NGF–CMSs into the CCH may be a promising tool in the repair of peripheral nerve defects.     

CBCT Evaluation of the Upper Airway Morphological Changes in Growing Patients of Class II Division 1 Malocclusion with Mandibular Retrusion Using Twin Block Appliance: A Comparative Research

Objective

The purpose of this study was to evaluate the morphological changes of upper airway after Twin Block (TB) treatment in growing patients with Class II division 1 malocclusion and mandibular retrusion compared with untreated Class II patients by cone beam computed tomography (CBCT).

Materials and Methods

Thirty growing patients who have completed TB treatment were recruited into TB group. The control group (n = 30) was selected from the patients with the same diagnosis and without TB treatment. CBCT scans of the pre-treatment (T1) and post-treatment (T2) data of TB group and control data were collected. After three-dimensional (3D) reconstruction and registration of T1 and T2 data, the morphological changes of upper airway during TB treatment were measured. The statistical differences between T1 and T2 data of TB group as well as T2 and control data were accessed by t-test.

Results

During the TB treatment, the mandible moved advanced by 3.52±2.14 mm in the horizontal direction and 3.77±2.10 mm in the vertical direction. The hyoid bone was in a more forward and inferior place. The upper airway showed a significant enlargement in nasopharynx, oropharynx and hypopharynx. In addition, the nasopharynx turned more circular, and the oropharynx became more elliptic in transverse shape. However, the transverse shape of the hypopharynx showed no significant difference. After comparison between T2 and control data, only the horizontal movement of the hyoid bone, the volumetric expansion of the oropharynx and hypopharynx, and changes of the oropharyngeal transverse shape showed significant difference.

Conclusion

Compared to the untreated Class II patients, the upper airway of growing patients with Class II division 1 malocclusion and mandibular retrusion showed a significant enlargement in the oropharynx and hypopharynx as well as a more elliptic transverse shape in the oropharynx, and the hyoid bone moved to an anterior position after TB treatment.     

Low Frequency Variants in the Exons Only Encoding Isoform A of HNF1A Do Not Contribute to Susceptibility to Type 2 Diabetes

Background

There is considerable interest in the hypothesis that low frequency, intermediate penetrance variants contribute to the proportion of Type 2 Diabetes (T2D) susceptibility not attributable to the common variants uncovered through genome-wide association approaches. Genes previously implicated in monogenic and multifactorial forms of diabetes are obvious candidates in this respect. In this study, we focussed on exons 8–10 of the HNF1A gene since rare, penetrant mutations in these exons (which are only transcribed in selected HNF1A isoforms) are associated with a later age of diagnosis of Maturity onset diabetes of the young (MODY) than mutations in exons 1–7. The age of diagnosis in the subgroup of HNF1A-MODY individuals with exon 8–10 mutations overlaps with that of early multifactorial T2D, and we set out to test the hypothesis that these exons might also harbour low-frequency coding variants of intermediate penetrance that contribute to risk of multifactorial T2D.

Methodology and Principal Findings

We performed targeted capillary resequencing of HNF1A exons 8–10 in 591 European T2D subjects enriched for genetic aetiology on the basis of an early age of diagnosis (≤45 years) and/or family history of T2D (≥1 affected sibling). PCR products were sequenced and compared to the published HNF1A sequence. We identified several variants (rs735396 [IVS9−24T>C], rs1169304 [IVS8+29T>C], c.1768+44C>T [IVS9+44C>T] and rs61953349 [c.1545G>A, p.T515T] but no novel non-synonymous coding variants were detected.

Conclusions and Significance

We conclude that low frequency, nonsynonymous coding variants in the terminal exons of HNF1A are unlikely to contribute to T2D-susceptibility in European samples. Nevertheless, the rationale for seeking low-frequency causal variants in genes known to contain rare, penetrant mutations remains strong and should motivate efforts to screen other genes in a similar fashion.     

HbA1C Variability and the Risk of Renal Status Progression in Diabetes Mellitus: A Meta-Analysis

Objective

To explore the association between glycated hemoglobin (A1C) variability and renal disease progression in patients with diabetes mellitus.

Methods

A comprehensive search was performed using the PubMed and Embase databases (up to April 26, 2014). The hazard ratio (HR) was pooled per unit increase in the standard deviation of A1C (A1C-SD) to evaluate the dose-response relationship between A1C-SD and the risk of nephropathy.

Results

Eight studies with a total of 17,758 subjects provided the HR for A1C-SD and were included in the final meta-analysis. The pooled HR results demonstrated that A1C-SD was significantly associated with the progression of renal status (HR for both T1DM and T2DM 1.43, 95% confidence interval [CI] 1.24–1.64; HR for T1DM 1.70, 95%CI 1.41–2.05; HR for T2DM 1.20, 95%CI 1.12–1.28). A1C-SD was significantly correlated with new-onset microalbuminuria (HR for T1DM 1.63, 95%CI 1.28–2.07; HR for T2DM 1.23, 95%CI 1.08–1.39). These outcomes were also supported in subgroup analyses. Furthermore, sensitivity analyses demonstrated that the results were robust.

Conclusions

A1C variability is independently associated with the development of microalbuminuria and the progression of renal status in both type 1 and 2 diabetes patients. A standard method for measuring A1C variability is essential for further and deeper analyses. In addition, future studies should assess the effect of reducing A1C variability on nephropathy complication.     

A Single Nucleotide Polymorphism in cBIM Is Associated with a Slower Achievement of Major Molecular Response in Chronic Myeloid Leukaemia Treated with Imatinib

Purpose

BIM is essential for the response to tyrosine-kinase inhibitors (TKI) in chronic myeloid leukaemia (CML) patients. Recently, a deletion polymorphism in intron 2 of the BIM gene was demonstrated to confer an intrinsic TKI resistance in Asian patients. The present study aimed at identifying mutations in the BIM sequence that could lead to imatinib resistance independently of BCR-ABL mutations.

Experimental Design

BIM coding sequence analysis was performed in 72 imatinib-treated CML patients from a French population of our centre and in 29 healthy controls (reference population) as a case-control study. Real-time quantitative PCR (RT qPCR) was performed to assess Bim expression in our reference population.

Results

No mutation with amino-acid change was found in the BIM coding sequence. However, we observed a silent single nucleotide polymorphism (SNP) c465C>T (rs724710). A strong statistical link was found between the presence of the T allele and the high Sokal risk group (p = 0.0065). T allele frequency was higher in non responsive patients than in the reference population (p = 0.0049). Similarly, this T allele was associated with the mutation frequency on the tyrosine kinase domain of BCR-ABL (p<0.001) and the presence of the T allele significantly lengthened the time to achieve a major molecular response (MMR). Finally, the presence of the T allele was related to a decreased basal expression of the Bim mRNA in the circulating mononuclear cells of healthy controls.

Conclusion

These results suggest that the analysis of the c465C>T SNP of BIM could be useful for predicting the outcome of imatinib-treated CML patients.     

Minor Hypospadias: The “Tip of the Iceberg” of the Partial Androgen Insensitivity Syndrome

Background

Androgens are critical in male external genital development. Alterations in the androgen sensitivity pathway have been identified in severely undermasculinized boys, and mutations of the androgen receptor gene (AR) are usually found in partial or complete androgen insensitivity syndrome (AIS).

Objective

The aim of this study was to determine whether even the most minor forms of isolated hypospadias are associated with AR mutations and thus whether all types of hypospadias warrant molecular analysis of the AR.

Materials and Methods

Two hundred and ninety-two Caucasian children presenting with isolated hypospadias without micropenis or cryptorchidism and 345 controls were included prospectively. Mutational analysis of the AR through direct sequencing (exons 1–8) was performed. In silico and luciferase functional assays were performed for unreported variants.

Results

Five missense mutations of the AR were identified in 9 patients with glandular or penile anterior (n = 5), penile midshaft (n = 2) and penile posterior (n = 2) hypospadias, i.e., 3%: p.Q58L (c.173A>T), 4 cases of p.P392S (c.1174C>T), 2 cases of p.A475V (c.1424C>T), p.D551H (c.1651G>C) and p.Q799E (c.2395C>G). None of these mutations was present in the control group. One mutation has never been reported to date (p.D551H). It was predicted to be damaging based on 6 in silico models, and in vitro functional studies confirmed the lowered transactivation function of the mutated protein. Three mutations have never been reported in patients with genital malformation but only in isolated infertility: p.Q58L, p.P392S, and p.A475V. It is notable that micropenis, a cardinal sign of AIS, was not present in any patient.

Conclusion

AR mutations may play a role in the cause of isolated hypospadias, even in the most minor forms. Identification of this underlying genetic alteration may be important for proper diagnosis and longer follow-up is necessary to find out if the mutations cause differences in sexual function and fertility later in life.     

Nerve Transfer in Delayed Obstetrical Palsy Repair

Objective

 When root avulsions are detected in children suffering from obstetrical brachial plexus palsy (OBPP), neurotization procedures of different nerve trunks are commonly applied in primary brachial plexus repair, to connect distally the nerves of the upper limbs using healthy nerve structures. This article aims to outline our experience of neurotization procedures in OBPP, which involves nerve transfers in the event of delayed repair, when a primary repair has not occurred or has failed. In addition, we propose the opportunity for late repair, focusing on extending the time limit for nerve surgery beyond that which is usually recommended. Although, according to different authors, the time limit is still unclear, it is generally estimated that nerve repair should take place within the first months of life. In fact, microsurgical repair of OBPP is the technique of choice for young children with the condition who would otherwise have an unfavorable outcome. However, in certain cases the recovery process is not clearly defined so not all the patients are direct candidates for primary nerve surgery.

Methods

 In the period spanning January 2005 through January 2011, among a group of 105 patients suffering from OBPP, ranging from 1 month to 7 years of age, the authors have identified a group of 32 partially recovered patients. All these patients underwent selective neurotization surgery, which was performed in a period ranging from 5 months to 6.6 years of age.

Results

 Late neurotization of muscular groups achieved considerable functional recovery in these patients, who presented with reduced motor function during early childhood. The said patients, with the exception of five, would initially have avoided surgery because they had not met the criteria for nerve surgery.

Conclusion

 We have concluded that the execution of late nerve surgical procedures can be effective in children affected by OBPP.     

Four Common Vascular Endothelial Growth Factor Polymorphisms (?2578C>A, ?460C>T, +936C>T,and +405G>C) in Susceptibility to Lung Cancer: A Meta-Analysis

Background and Objective

Vascular endothelial growth factor (VEGF) is one of the key initiators and regulators of angiogenesis and it plays a vital role in the onset and development of malignancy. The association between VEGF gene polymorphisms and lung cancer risk has been extensively studied in recent years, but currently available results remain controversial or ambiguous. The aim of this meta-analysis is to investigate the associations between four common VEGF polymorphisms (i.e., −2578C>A, −460C>T, +936C>T and +405C>G) and lung cancer risk.

Methods

A comprehensive search was conducted to identify all eligible studies to estimate the association between VEGF polymorphisms and lung cancer risk. Crude odds ratios (ORs) with 95% confidence intervals (CIs) were used to evaluate the strength of this association.

Results

A total of 14 published case-control studies with 4,664 cases and 4,571 control subjects were identified. Our meta-analysis provides strong evidence that VEGF −2578C>A polymorphism is capable of increasing lung cancer susceptibility, especially among smokers and lung squamous cell carcinoma (SCC) patients. Additionally, for +936C>T polymorphism, increased lung cancer susceptibility was only observed among lung adenocarcinoma patients. In contrast, VEGF −460C>T polymorphism may be a protective factor among nonsmokers and SCC patients. Nevertheless, we did not find any association between +405C>G polymorphism and lung cancer risk, even when the groups were stratified by ethnicity, smoking status or histological type.

Conclusion

This meta-analysis recommends more investigations into the relationship between −2578C>A and −460C>T lung cancer risks. More detailed and well-designed studies should be conducted to identify the causal variants and the underlying mechanisms of the possible associations.     

Eight Functional Polymorphisms in the Estrogen Receptor 1 Gene and Endometrial Cancer Risk: A Meta-Analysis

Background and Objective

Emerging evidence indicates that common functional polymorphisms in the estrogen receptor 1 (ESR1) gene may have an impact on an individual’s susceptibility to endometrial cancer, but individually published results are inconclusive. The aim of this meta-analysis is to derive a more precise estimation of the associations between eight polymorphisms in the ESR1 gene and endometrial cancer risk.

Methods

A literature search of PubMed, Embase, Web of Science and China Biology Medicine (CBM) databases was conducted on publications published before November 1^st, 2012. Crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Statistical analyses were performed using the STATA 12.0 software.

Results

Thirteen case-control studies were included with a total of 7,649 endometrial cancer cases and 16,855 healthy controls. When all the eligible studies were pooled into the meta-analysis, the results indicated that PvuII (C>T) polymorphism was associated with an increased risk of endometrial cancer, especially among Caucasian populations. There were also significant associations between rs3020314 (C>T) polymorphism and an increased risk of endometrial cancer. Furthermore, rs2234670 (S/L) polymorphism may decrease the risk of endometrial cancer. However, no statistically significant associations were found in XbaI (A>G), Codon 325 (C>G), Codon 243 (C>T), VNTR (S/L) and rs2046210 (G>A) polymorphisms.

Conclusion

The current meta-analysis suggests that PvuII (C>T) and rs3020314 (C>T) polymorphisms may be risk factors for endometrial cancer, especially among Caucasian populations.     

Is There a Benefit in Receiving Concurrent Chemoradiotherapy for Elderly Patients with Inoperable Thoracic Esophageal Squamous Cell Carcinoma?

Background and purpose

The benefit of concurrent chemoradiotherapy (CCRT) in elderly patients with inoperable esophageal squamous cell carcinoma (SCC) is controversial. This study aimed to assess the efficiency and safety of CCRT in elderly thoracic esophageal cancer patients.

Methods and materials

Between January 2002 and December 2011, 128 patients aged 65 years or older treated with CCRT or radiotherapy (RT) alone for inoperable thoracic esophageal SCC were analyzed retrospectively (RT alone, n = 55; CCRT, n = 73).

Results

No treatment-related deaths occurred and no patients experienced any acute grade 4 non-hematologic toxicities. Patients treated with CCRT developed more severe acute toxicities than patients who received RT alone. The 3-year overall survival (OS) rate was 36.1% for CCRT compared with 28.5% following RT alone (p = 0.008). Multivariate analysis identified T stage and treatment modality as independent prognostic factors for survival. Further analysis revealed that survival was significantly better in the CCRT group than in the RT alone group for patients ≤ 72 years. Nevertheless, the CCRT group had a similar OS to the RT group for patients > 72 years.

Conclusion

Our results suggest that elderly patients with inoperable thoracic esophageal SCC could benefit from CCRT, without major toxicities. However, for patients older than 72 years, CCRT is not superior to RT alone in terms of survival benefit.     

“How Much Will I Get Charged for This?” Patient Charges for Top Ten Diagnoses in the Emergency Department

Objectives

We examined the charges, their variability, and respective payer group for diagnosis and treatment of the ten most common outpatient conditions presenting to the Emergency department (ED).

Methods

We conducted a cross-sectional study of the 2006–2008 Medical Expenditure Panel Survey. Analysis was limited to outpatient visits with non-elderly, adult (years 18–64) patients with a single discharge diagnosis.

Results

We studied 8,303 ED encounters, representing 76.6 million visits. Median charges ranged from $740 (95% CI $651–$817) for an upper respiratory infection to $3437 (95% CI $2917–$3877) for a kidney stone. The median charge for all ten outpatient conditions in the ED was $1233 (95% CI $1199– $1268), with a high degree of charge variability. All diagnoses had an interquartile range (IQR) greater than $800 with 60% of IQRs greater than $1550.

Conclusion

Emergency department charges for common conditions are expensive with high charge variability. Greater acute care charge transparency will at least allow patients and providers to be aware of the emergency department charges patients may face in the current health care system.