Comparisons of oncological and functional outcomes among radical retropubic prostatectomy, high dose rate brachytherapy, cryoablation and high-intensity focused ultrasound for localized prostate cancer: A prospective, controlled, nonrandomized trial

Background: Several clinical decision rules (CDRs) are available to exclude acute pulmonary embolism (PE), but they have not been directly compared. Objective: To directly compare the performance of 4 CDRs (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with D-dimer testing to exclude PE. Design: Prospective cohort study. Setting: 7 hospitals in the Netherlands. Patients: 807 consecutive patients with suspected acute PE. Intervention: The clinical probability of PE was assessed by using a computer program that calculated all CDRs and indicated the next diagnostic step. Results of the CDRs and D-dimer tests guided clinical care. Measurements: Results of the CDRs were compared with the prevalence of PE identified by computed tomography or venous thromboembolism at 3-month follow-up. Results: Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal D-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and D-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal D-dimer result. Limitation: Management was based on a combination of decision rules and D-dimer testing rather than only 1 CDR combined with D-dimer testing. Conclusion: All 4 CDRs show similar performance for exclusion of acute PE in combination with a normal D-dimer result. This prospective validation indicates that the simplified scores may be used in clinical practice. Primary Funding Source: Academic Medical Center, VU University Medical Center, Rijnstate Hospital, Leiden University Medical Center, Maastricht University Medical Center, Erasmus Medical Center, and Maasstad Hospital. © 2011 American College of Physicians

Adrenalectomy for isolated adrenal metastasis after Gamma Knife Surgery for an intracerebral metastasis of non-small-cell lung carcinoma

Only a limited group of patients with non-small-cell lung cancer (NSCLC) is eligible for treatment with a curative intent. Adrenalectomy for a solitary adrenal metastasis of NSCLC may be curative when combined with resection of the primary tumor. It is unclear whether resection of an isolated adrenal metastasis is justified in patients with a second metastasis. We report a case of successful adrenalectomy with adjuvant chemotherapy in a patient who was previously treated with a right lower lobe resection and subsequent Gamma Knife treatment of an intracranial metastasis. At 20-month follow-up, patient was in a good clinical condition without signs of recurrent disease. In selected cases, adrenalectomy with adjuvant chemotherapy for an adrenal metastasis of NSCLC may be performed successfully, with good short-term results, even after earlier treatment of a cerebral metastasis

Adrenalectomy for isolated adrenal metastasis after Gamma Knife Surgery for an intracerebral metastasis of non-small-cell lung carcinoma

Only a limited group of patients with non-small-cell lung cancer (NSCLC) is eligible for treatment with a curative intent. Adrenalectomy for a solitary adrenal metastasis of NSCLC may be curative when combined with resection of the primary tumor. It is unclear whether resection of an isolated adrenal metastasis is justified in patients with a second metastasis. We report a case of successful adrenalectomy with adjuvant chemotherapy in a patient who was previously treated with a right lower lobe resection and subsequent Gamma Knife treatment of an intracranial metastasis. At 20-month follow-up, patient was in a good clinical condition without signs of recurrent disease. In selected cases, adrenalectomy with adjuvant chemotherapy for an adrenal metastasis of NSCLC may be performed successfully, with good short-term results, even after earlier treatment of a cerebral metastasis

Pulmonary Mycobacterium szulgai infection and treatment in a patient receiving anti-tumor necrosis factor therapy.

Contains fulltext : 52929.pdf (publisher's version ) (Open Access)BACKGROUND: A 54-year-old man with a 22-year history of rheumatoid arthritis and an 8-year history of chronic obstructive pulmonary disease presented with dyspnea on exertion, nonproductive cough and fatigue of 1 month's duration. His medication at presentation consisted of etanercept, azathioprine, naproxen and inhaled fluticasone and salbutamol. INVESTIGATIONS: At presentation, the patient underwent physical examination, chest X-ray and high-resolution CT, blood tests, and bronchoalveolar lavage fluid analysis including auramine stains and gene sequence analysis of cultured Mycobacterium szulgai. The patient underwent minithoracotomy after 6 months, and bronchoalveolar lavage fluid analysis, culture and chest X-ray after 18 months. Further chest imaging and culture of sputum samples were performed another year later. DIAGNOSIS: Pulmonary M. szulgai infection. MANAGEMENT: Triple drug therapy with rifampicin, ethambutol hydrochloride and clarithromycin. Anti-tumor necrosis factor treatment was continued

Betrouwbaarheid klinische beslisregels bij diagnostiek van acute longembolie

To directly compare the performance of four clinical decision rules (CDRs) (Wells rule, revised Geneva score, simplified Wells rule and simplified revised Geneva score) in combination with D-dimer testing in excluding acute pulmonary embolism (PE). Prospective cohort study. In patients with suspected PE, the clinical probability of PE was assessed on the basis of the results of the CDRs and D-dimer test results using a computer program which calculated all CDRs and indicated the next diagnostic step. The CDRs results were compared using the outcome measure 'PE' assessed by CT-scanning or by the occurrence of venous thromboembolism or PE during a 3-month follow-up period after excluding PE. A total of 807 consecutive patients with suspected PE were included. PE prevalence was 23%. The number of patients categorised as 'PE unlikely' ranged from 62% (simplified Wells rule) to 72% (Wells rule). This CDR result combined with a normal D-dimer level excluded PE, which was the case in 22-24% of patients. There was no difference between the CDRs in the number of missed PEs (1 missed (0.5-0.6%); upper 95% CI: 2.9-3.1%). Although 30% of the patients had discordant CDR outcomes, PE was missed in none of the patients with discordant CDRs and a normal D-dimer result. All four CDRs show similar performance for exclusion of acute PE in combination with a normal D-dimer level. In addition this prospective study indicates that also the simplified scores can be used in clinical practic

Hestia criteria can discriminate high- from low-risk patients with pulmonary embolism

Thrombosis and Hemostasi

The age-adjusted D-dimer safely excludes a high number of pulmonary embolisms in combination with four different clinical decision rules

Background: Four different clinical decision rules (CDRs) (Wells score, Revised Geneva score (RGS), simplified Wells score and simplified RGS) safely exclude pulmonary embolism (PE), when combined with a normal D-dimer test. Recently, an age adjusted cut-off of the D-dimer (patient's age x 10 ig/L) greatly increased the number of patients in whom PE could safely be excluded. We validated the age-adjusted D-dimer test and assessed its performance in combination with the four CDRs in patients with suspected PE. Methods: Eight hundred and thirty-four consecutive patients with suspected PE were included of whom 414 were > 50 years (50%). The proportion of patients in whom PE could be excluded with an unlikely CDR combined with a normal age-adjusted D-dimer test was calculated and compared with the conventional D-dimer cut-off. We assessed VTE failure rates during 3-months follow-up. Results: Compared to the conventional D-dimer cut-off level, a normal age-adjusted D-dimer level substantially increased the number of patients in whom PE could be safely excluded. All CDRs performed equally well. This difference was nearly fourfold in patients > 70 years, where the Wells rule excluded more patients than the other CDRs. Conclusion: The age-adjusted D-dimer increases the number of older patients in whom PE can be safely excluded, irrespective of the Wells score or RGS, thereby avoiding unnecessary imaging tests

Diagnostic safety of a structured algorithm with use of clinical decision rule, D-dimer and CT scan for clinically suspected recurrent pulmonary embolism

Background: Diagnostic strategies in patients with suspected pulmonary embolism (PE) are well defined but their value in patients presenting with clinically suspected recurrent PE has not been established. The aim of this study was to determine the performance of a simple diagnostic strategy using the Wells clinical decision rule (CDR), quantitative D-dimer testing and computed tomography pulmonary angiography (CTPA) in patients with clinically suspected recurrent PE. Methods: Five hundred and sixteen patients with suspected recurrent PE were included in this multicenter clinical outcome study. An unlikely clinical probability (Wells rule four points or less) in combination with a normal D-dimer (cut-off 500 ng/mL) test result excluded PE and all other patients underwent multislice CTPA. Anticoagulant treatment was started if PE was demonstrated and treatment was withheld in all other patients. Primary outcome was the 3-month venous thromboembolism (VTE) recurrence rate in patients with normal tests, who had not been treated with anticoagulation. Results: An unlikely probability was found in 176 of 516 patients (34%), and the combination of an unlikely CDR-score and normal D-dimer excluded PE in 88 (17%) patients, without recurrent VTE during follow-up (0%; 95% CI 0-3.3%). CTPA excluded PE in 253 patients. During follow-up eight patients had a recurrent VTE (3.2%; 95% CI 1.5-5.9%). All patients had recurrent PE, of which two were fatal. Conclusion: In patients with suspected recurrent PE, the combination of an unlikely Wells CDR score and normal D-dimer safely excludes pulmonary embolism. In patients with a high risk probability or abnormal D-dimer, a CTPA excluding PE, however, is associated with a high rate of recurrent PE. Additional studies using alternative diagnostic algorithms - including performing ultrasonography after normal CT - are urgently needed