Value of risk scores in the decision to palliate patients with ruptured abdominal aortic aneurysm

Background: The aim of this study was to develop a 48-h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C-statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48-h mortality in the IMPROVE data was reasonable (C-statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C-statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life-saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non-intervention rates, while respecting the wishes of the patient and family

Use of monoclonal antibody E48 in diagnosing transitional cell carcinoma of urinary bladder.

AIMS: To investigate the localisation of the E48 epitope and to determine the use of monoclonal antibody E48 for the identification of transitional cell carcinomas (TCC); and to determine if antigenic expression was affected by different standard fixation methods. METHODS: Biopsy specimens were labelled with E48 for immunoelectron microscopy. One hundred and nineteen tissue samples from 47 bladder carcinomas were tested for reactivity with E48, using fresh frozen, sublimate formalin, and formalin fixed tissue. Thirteen undifferentiated bladder tumours and 10 undifferentiated prostatic carcinomas were incubated with E48 and prostate specific antigen. RESULTS: Reactivity to E48 was found in all grade 1 and 2 carcinomas and most (83%) grade 3 tumours. At the ultrastructural level, expression was mainly associated with desmosomes and the cytoplasmic membrane. The reactivity of E48 was generally strong in fresh frozen tissue samples and remained preserved in fixed tissue samples. Ten of the 13 bladder carcinomas expressed E48; all prostatic tumours were totally negative. CONCLUSIONS: E48 is a sensitive marker for transitional cell carcinoma and suitable for differentiation between urothelial and prostatic undifferentiated carcinoma. It can be used in routinely processed, formalin fixed, biopsy specimens

The pattern of recovery after severe head injury

The pattern of recovery after head injury was studied on the basis of clinical data on 200 patients. An unmistakable pattern was found in which it was possible to distinguish between symptoms of only short duration (due to the unfavourable prognosis, among other things), symptoms which showed a fairly quick recovery such as the E score and the oculovestibular response, and symptoms characterized by a longer interval between the accident and their recovery. A clear difference was found between the pattern recovery of E scores and oculovestibular response on the one hand, and recovery of M and V scores on the other. The implications of the pattern of recovery thus established, are discussed