A protocol of electronic portal imaging (EPI) registration for the verification of radiation treatment fields has been implemented at our institution. A template is generated using the reference images, which is then registered with the EPI for treatment verification. This study examines interobserver consistency among trained radiation therapists in the registration and verification of external beam radiotherapy (EBRT) for patients with prostate cancer.20 consecutive patients with prostate cancer undergoing EBRT were analyzed. The EPIs from the initial 10 fractions were registered independently by 6 trained radiation therapist observers. For each fraction, an anterior-posterior (AP or PA) and left lateral (Lat) EPIs were generated and registered with the reference images. Two measures of displacement for the AP EPI in the superior-inferior (SI) and right left (RL) directions and two measures of displacement for the Lat EPI in the AP and SI directions were prospectively recorded. A total of 2400 images and 4800 measures were analyzed. Means and standard deviations, as well as systematic and random errors were calculated for each observer. Differences between observers were compared using the chi-square test. Variance components analysis was used to evaluate how much variance is attributed to the observers. Time trends were estimated using repeated measures analysis.Inter-observer variation expressed as the standard deviation of the six observers' measurements within each image were 0.7, 1.0, 1.7 and 1.4 mm for APLR, APSI, LatAP and LatSI respectively. Variance components analysis showed that the variation attributed to the observers was small compared to variation due to the images. On repeated measure analysis, time trends were apparent only for the APLR and LatSI measurements. Their magnitude however was small.No clinically important systematic observer effect or time trends were identified in the registration of EPI by the radiation therapist observers in this study. These findings are useful in the documentation of consistency and reliability in the quality assurance of treatment verification of EBRT for prostate cancer. In the planning and delivery of external beam radiotherapy (EBRT) for prostate cancer, several potential sources of variability have been documented. Prostate organ motion between -17 and dElectronic portal imaging (EPI) enables the verification of treatment fields during a course of EBRT. Several protocols of EPI are currently in use in various institutions and vary mainly in terms of the number, timing, and frequency of images acquired over a treatment course. Other potential sources of variability in the treatment verification process include the type of correction with on-line or off-line protocols which represent in fact two different strategies to reduce variability -7. WhileFew reports from the literature have specifically addressed interobserver variability in portal images verification. In a study of 16 observers of different professional disciplines  using images of various anatomical sites and a 5-point scale to assess conformity between simulator films and portal images, Bissett et al. demonstrated significant inconsistencies between observers . In anotThe protocol for the verification of treatment fields during EBRT for prostate cancer employed at this institution consisted of amorphous silicon EPI acquisition daily during the first 3 days of treatment. These images are then registered to a template generated from the reference images or digitally reconstructed radiographs (DRR). The registration process is based on anatomy matching of the EPI to the reference DRR. On the AP images the key structures are the superior and inferior pubic rami, the pubic symphysis and the obturator foramen. On the Lat images the key structures are the pubic symphysis, the femoral head and the acetabulum. For each fraction, reference images and EPIs are generated for the Anterior-Posterior (AP) and Left Lateral (Lat) beam incidences. The registration process yields 2 measures of displacement of the isocentre for each beam incidence: Superior-Inferior (SI) and Left-Right (LR) directions for the AP images; and SI and Anterior-Posterior (AP) directions for the Lat images. Based on a review of the literature, tolerance of displacements was set at 5 mm. Any single value of displacement greater than twice the tolerance limit (2 × 5 mm = 10 mm), will lead to an off-line correction and a repeat EPI. The values of displacement calculated for the first three fractions are averaged. If this 3-day average exceeds the set tolerance of 5 mm, an off line correction is also applied and the EPI is repeated. For the AP images, directions of displacements are as follows: superior/inferior = +/-; right/left = +/-. For the Lat images: superior/inferior = +/-; anterior/posterior = +/-. To examine possible time trends, EPIs were obtained daily during the first 10 fractions of each course of EBRT. Ten fractions were examined since previous series have suggested that the position of early fractions may not be representative of the overall systematic error as later fractions .Twenty consecutive patients with prostate cancer undergoing radical EBRT over at least 6 weeks were analysed for this study. The AP and Lat EPI of the first ten fractions were registered by 6 trained radiation therapists. Measures of displacements in the SI and LR directions for the AP images and SI and AP directions for the Lat images were independently recorded by the 6 observers, all blinded to each other's results. This yielded a total of 2400 registrations and 4800 values of displacement for the analysis.Mean displacement values and their corresponding standard deviation were calculated for the whole group and the 6 observers individually. Inter-observer variation was assessed by calculating the standard deviation of the six observers' measurements within each image. The sources of variation in measurements of displacement between the observers and the images were compared using variance components analysis. Time trends were estimated using repeated measures analysis. Random and systemic deviations were subsequently calculated for each observer in accordance to previously published definitions Random error was defined as variations between fractions during a treatment series, was determined by calculating the spread (1 SD) of differences around the corresponding mean in each patient and then calculating the average of these SDs for the whole group.Systematic error was defined as deviations between the planned position and the average patient position over the treatment course, were obtained by calculating the mean displacement per patient and then the SD of all patients' means.Descriptive statistics of the measurements are presented in Table An alternate approach to evaluate consistency in measurements is to calculate the individual mean values of the 6 observers and their corresponding standard deviation (SD) for each of the 200 images and the four directions of displacement. These results are presented in Table In order to assess the impact of displacement on previously set tolerance limits, we calculated the proportion of measurements within 3 mm and 5 mm from zero for each observer. Overall proportions are presented in Table To further assess the level of agreement between observers we calculated the standard deviation of the six observers' measured displacement for each image. The results are presented in table The contribution of the observers and the images to the overall variability in measured displacement was estimated using an analysis of variance component. The results are presented in table The presence of time trends was examined using repeated measure analysis. Time was used as a continuous variable in the model and t-test was used to assess statistical significance. The results are presented in Table Table Several protocols of EPI verification have been described in the literature -7.The current study specifically assesses interobserver consistency in the EPI registration within an institutionally-defined EPI protocol.In this protocol, the EPI registration is performed by trained radiation therapists who are responsible to assess treatment accuracy. The analysis was intended to verify that consistency can be achieved among the individuals independently performing the measures.There are few studies available from the literature dealing with interobserver variation in EPI registration. In a study by Dalen et al. investigating the concordance of approval between groups of radiation oncologists and radiation therapists, no statistically significant differences between the two groups was demonstrated . In thisLewis et al.  investigOur center has recently moved toward a fiducial marker protocol for EPI registration in patients receiving EBRT for prostate cancer. The use of gold fiducial markers has been shown to be a feasible and effective method of tracking prostate motion during treatment -17. NedeThis study demonstrated significant consistency among trained radiation therapists in EPI registration for treatment verification of radical prostate cancer EBRT. No significant systematic observer effect and no systematic time trends were identified. These findings may serve as measures of quality assurance of the institutional verification protocol.The author(s) declare that they have no competing interests.EB conceived and designed the study, supervised data acquisition and data analysis, drafted the manuscript. PTT participated in study design, data interpretation, manuscript drafting and revising for intellectual content. SZ participated in study design, data interpretation and manuscript revising for intellectual content. VM performed data analysis, data interpretation, and manuscript review and revision. JR, BB, and DS performed data acquisition, data interpretation, manuscript review and revision for intellectual content. All authors have given final approval of this submitted version.


The most important prognostic factor in the management of head and neck cancer is the presence of cervical nodal metastasis. Once the tumor involves neck nodes, survival drops by almost 50%. Management of cervical metastasis has gone through an evolution since the beginning of the last century. The classic radical neck dissection, where all the neck nodes are removed along with 3 important structures – sternocleidomastoid muscle, internal jugular vein and accessory nerve – was popularized in the landmark article by George Crile. It subsequently became the standard of care in the management of neck nodes for almost 75 years.The major complication from radical neck dissection was very apparent to most clinicians; shoulder dysfunction, which led to modifications in neck dissection techniques. Oswaldo Suarez gets the credit for popularizing functional neck dissection wherein the accessory nerve is carefully preserved to the extent tumor involvement allows. He also popularized the facial envelope and oncologic safety of modified neck dissection, which gained acceptance with the teachings of Itore Bocca, Javier Gavilan, and Richard Jesse. In the 1980's there was a tremendous switch from radical neck dissection to modified neck dissection to maintain patient quality of life and preserve shoulder function. At the same time, the patterns of nodal metastasis were studied in detail. Publications from Lindberg and Shah described the location of metastatic disease in the neck depending upon the primary site, and justified modifications in neck dissection ,3.In the recent modification of the standardization of neck dissection, the Committee on Head and Neck Oncology divided Levels I, II and V into A&B groups . This diThe comprehensive neck dissection removes all lymph nodes in the neck and its modification includes preservation of the sternocleidomastoid muscle, accessory nerve or jugular vein. The selective neck dissection addresses a select group of lymph nodes based on the location of the highest incidence of metastatic disease, thus supraomohyoid neck dissection became very popular as a staging procedure for cancer of the oral cavity . InteresPostoperative radiation therapy in patients with cervical neck node metastasis became the standard practice in the early 1990's. The high incidence of metastatic disease to neck nodes from cancer of the oral tongue was noted at the same time. Supraomohyoid neck dissection became standard practice in patients with cancer of the oral cavity and N0 neck.Clinical evaluation was supplemented with imaging studies, such as computerized tomography (CT) and magnetic resonance imaging (MRI) scanning. Van den Brekel from Amsterdam popularized the role of ultrasound and ultrasound-guided needle biopsy . Even thPostoperative radiation therapy was routinely recommended in patients with large nodal metastasis and extranodal spread. Extranodal spread was considered to indicate grave prognosis in patients with cervical metastasis. These patients had a high incidence of local recurrence and distant metastasis. With this in mind, the EORTC and RTOG conducted randomized prospective trials of the use of postoperative chemo-radiation therapy in patients with cervical nodal metastasis. It is interesting that the two groups reported their results in the same issue of the New England Journal of Medicine.et al, [2 on days 1, 22 and 43. They reported the estimated 2 year rate of local and regional control as 82% in the combined therapy group, as compared with 72% in the radiotherapy alone group. Disease-free survival was significantly longer in the combined therapy group than in the radiotherapy group; however, interestingly the overall survival was not altered by the addition of chemotherapy. The incidence of acute adverse effects of Grade III or greater was reported in 34% of the radiotherapy group and 77% in the combined therapy group. Four patients who received combined therapy died as a direct result of treatment. The authors concluded that among high risk patients in the postoperative setting, concurrent chemo-radiation therapy significantly improves the rates of local and regional control and disease-free survival. However, the combined treatment is associated with a substantial increase in adverse effects.Cooper, et al,  from theet al, [2 on days 1, 22 and 43 of the radiotherapy regimen. They reported a 5 year progression-free survival of 47% compared to 36% with radiation therapy alone. They reported an overall survival rate of 53% in patients who received chemo-radiation therapy compared to 40% with radiation therapy alone. The estimated 5-year cumulative incidence of local or regional relapses was 31% after radiotherapy and 18% after combined therapy. This group also reported severe adverse effects from combined therapy (41%) and radiotherapy alone (21%).In the same issue of the New England Journal of Medicine, Bernier et al,  reportedEven though these two studies are prospective randomized trials, further confirmation needs to be obtained through continued interest in such trials including reduction of adverse effects. The most important complication of combined chemo-radiation therapy that has been noted in organ preservation protocols is severe mucositis and pharyngeal stricture. Pharyngeal stricture is a disastrous complication from this treatment and has a major impact on the quality of life of the patients.It appears that in patients with poor prognostic factors with cervical metastasis there is an increasing interest in treatment with chemo-radiation therapy, rather than radiation alone. Obviously one needs to keep in mind the complications related to chemo-radiation therapy. Such complications are well recognized in patients who undergo an organ preservation protocol for laryngopharyngeal tumors or for oropharyngeal cancers. There is a high incidence of neutropenia, Grade 4 mucositis, and pharyngeal stricture. Development of pharyngeal stricture continues to be a difficult problem to manage in clinical practice and leads to discussion regarding the quality of life. Long term dependency on gastrostomy is extremely frustrating to patients who may have been cured of their neck disease. Since organ preservation and chemo-radiation therapy has become the most prevalent treatment for patients with oropharyngeal and laryngopharyngeal cancers, it has generated controversy about the management of patients with nodal metastasis and their follow-up. The general consensus of opinion is that N1 disease can be easily controlled with chemo-radiation therapy. The problem comes with patients who present with N2 and N3 neck disease. Even though approximately 50% of the patients can be cured with chemo-radiation therapy, the remaining patients may persist with microscopic nodal metastasis. Even though there is no unanimous consensus today about how to manage N2–N3 neck after chemo-radiation therapy, there appears to be a general trend to consider close follow-up of these patients with clinical exam, CT, MRI and PET scan. If there is a residual thickening or presence of nodal disease, neck dissection is routinely recommended. Approximately 40–50% of patients may have viable tumor, which also depends upon the location of the primary tumor.The patients who recur in their neck nodes after previous surgery and radiation therapy are clearly a major challenge to the head and neck surgeon. Every attempt is made to resect the tumor if that is possible, along with (in select patients) additional local radiation therapy or brachytherapy. If brachy catheters are to be used, the carotid artery needs additional protection, preferably with myocutaneous flaps. Carotid resection is considered in very select circumstances where the patient has satisfactory carotid blood flow from the opposite side, and appropriate reconstruction is considered with carotid replacement by either a gortex graft or saphenous vein. There is a high incidence of neurologic complications when the carotid artery is resected. One needs to keep in mind that the carotid artery may not be the only limiting factor in such patients with metastatic disease to the neck. The surrounding structures, such as the vagus nerve, sympathetic trunk, and scalene muscles are also directly involved by the tumor. An appropriate and satisfactory surgical resection should be undertaken only if possible.With increasing interest in sentinel node biopsy in melanoma and breast cancer, some investigators have extended this technology to the squamous carcinoma of the upper aerodigestive tract, especially cancer of the oral cavity . The AmeThe author(s) declare that they have no competing interests.ARS: Conceptualized the editorial prepared the draft and edited it.


The detailed mechanisms which can explain the inherent radiosensitivity of salivary glands remain to be elucidated. Although DNA is the most plausible critical target for the lethal effects of irradiation, interactions with other constituents, such as cell membrane and neuropeptides, have been suggested to cause important physiological changes. Moreover, mast cells seem to be closely linked to radiation-induced pneumonitis. Therefore, in the present study the effects of fractionated irradiation on salivary glands have been assessed with special regard to the appearance of mast cells and its correlation with damage to gland parenchyma. Sprague-Dawley strain rats were unilaterally irradiated to the head and neck with the salivary glands within the radiation field. The irradiation was delivered once daily for 5 days to a total dose of 20, 35 and 45 Gy. The contralateral parotid and submandibular glands served as intra-animal controls and parallel analysis of glands was performed 2, 4, 10 or 180 days following the last radiation treatment. Morphological analysis revealed no obvious changes up to 10 days after the irradiation. At 180 days a radiation dose-dependent loss of gland parenchyma was seen, especially with regard to serious acinar cells in parotid gland and acinar cells and serous CGT (convoluted granular tubule) cells in the submandibular gland. These changes displayed a close correlation with a concomitant dose-dependent enhanced density of mast cells and staining for hyaluronic acid. This cell population seems to conform with the features of the connective tissue mast cell type. The parotid seems to be more sensitive to irradiation than the submandibular gland. Thus, the present results further strengthen the role of and the potential interaction of mast cells with radiation-induced tissue injury and alterations in normal tissue integrity.


For over 30 years, stem cells have been used in the replenishment of blood and immune systems damaged by the cancer cells or during treatment of cancer by chemotherapy or radiotherapy. Apart from their use in the immuno-reconstitution, the stem cells have been reported to contribute in the tissue regeneration and as delivery vehicles in the cancer treatments. The recent concept of 'cancer stem cells' has directed scientific communities towards a different wide new area of research field and possible potential future treatment modalities for the cancer. Aim of this review is primarily focus on the recent developments in the use of the stem cells in the cancer treatments, then to discuss the cancer stem cells, now considered as backbone in the development of the cancer; and their role in carcinogenesis and their implications in the development of possible new cancer treatment options in future. Cancer is the most common cause of mortality and morbidity in U.K. Despite recent advances in the treatments of cancer, the clinical outcome is yet far away from expectation. Use of stem cells in immuno-modulation or reconstitution is one of the methods used for decades in cancer therapy. Stem cells have self-renewal capacity with highly replicative potential in multilineage differentiation capacity .Stem cells can be divided into main three categories: embryonic, germinal, and somatic. Embryonic stem cells (ESCs) originate from the inner cell mass of the blastocyst. ESCs are omnipotent and have indefinite replicative life span, which is attributable to their telomerase expression. Germinain vivo and in vitro into the different mesenchymal cells such as bone, cartilage, fat, muscle, tendon and marrow stroma[Ideally, ESCs would be the source of stem cells for therapeutic purposes due to higher totipotency and indefinite life span compared to ASCs with lower totipotency and restricted life span. However, use of ESCs have ethical constraints  and their use for research and therapeutic purposes are restricted and prohow stroma.ESCs are derived from a 5-day old pre-implantation human embryos, however it posses potential risk of destroying the embryo. ASCs can be obtained from many tissues including bone, synovium, deciduous teeth, adipose tissue, brain, blood vessels, blood and umbilical cord blood-13. Due ex vivo expanded megacaryocyte progenitors[ex vivo expanded peripheral blood stem cells (PBSC)[The stem cells have been used since many years in immuno-reconstitution following cancer development or following cancer treatments. The high dose chemotherapy have the adverse effects on the bone marrow causing myelosupression. Usuallyogenitors and re-ils (PBSC) respectiThe source of stem cells is most commonly either from the bone marrow or the peripheral blood. The procedure of the bone marrow aspiration is invasive and is associated with the potential possible complications including fracture, wound infection and sepsis while the procedure for PBSCs isolation is much less invasive and less morbid. PBSCs have also been shown to induce higher number of CD4 T and NK cells compared to stem cells obtained from the bone marrow . Thus, tThe isolation of stem cells from the allogeneic donor is the most preferable method, however only 30% of candidates are eligible due to the lack of donors and age restrictions. Stem ceThe contamination of the retrieval of stem cells with tumour cells have been major problem which reported by many studies ,53,54, hPurging procedures are used in an attempt to remove these contaminant cancer cells from stem cells. Table in vitro and its potential in vivo use [Apart from long lasting replicative property of stem cells, stem cells from haemopoietic tissues seem to have 'extraordinary' abilities to generate or switch between haematopoietic and non-haematopoietic lineages, exhibiting an unexpected degree of developmental or differentiation potential. On theoretical grounds, this allows HSC to be used to regenerate any non-haematopoietic tissue . This tevivo use . There avivo use -65.in vitro, but has shown restricted effects on human malignancies in vivo [Systematic delivery of drug or gene therapy has promising future but is currently limited by various factors such as immune detection, non-specific accumulation in normal tissues and poor permeation. The effects of many anticancer agents are limited due to either their toxicities or their short half lives such as interferon β, which shows anti-proliferative and pro-apoptotic activities  in vivo -68. One in vivo function of MSC depends partly on signals from the target tissue microenvironment, for example, the tissues such as skin would have high cell turn over where there would be more signals for MSC compared to connective tissues where the high cell turn over is apparent only during healing process[The recent concept of use of stem cells as delivery vehicles came from the fact that the tumours, similar to the wounds, send out chemo-attractants such as the vascular endothelial growth factor (VEGF) to recruit MSC to form the supporting stroma of the tumour, and pericytes for angiogenesis. MSC transduced with an adenoviral expression vector carrying interferon-β gene has been demonstrated to increase the production of interferon-β at the local site. Howeverg process. Likewisg process. The neug process. Similarg process. It may in vitro without any neoplastic changes[The major limiting factor in the use of stem cells in clinical area is the life span of the stem cells. Theoretically, the embryonic stem cells are best from this perspective due to their indefinitive replicative life span attributed to their telomerase expression. Howeverc changes. If it bWhy a tumour does not respond to treatment? Why tumours recur? Why cancer cells develop resistance to treatment? These and many other raised questions may be answered by the new concept of "Cancer Stem Cells".Cancer stem cells can be defined as cells in the tumour growth with a tumour initiating potential. Normal stem cells are characterised by three properties: 1 Capability of self-renewal; 2 Strict control on stem cell numbers; 3 Ability to divide and differentiate to generate all functional elements of that particular tissue . CompareIt has been well-known that in order to induce a tumour in an animal model, hundreds of thousands of cancer cells need to be injected . This ha+CD38- from patients' samples [A fundamental problem in the cancer is the identification of the cell type capable of sustaining the neoplastic growth. There is evidence that the majority of the cancers are clones and that the cancer cells represent the progeny of one cell, however it is not clear which cells possess the tumour-initiating cell (TIC) function (cancer stem cells) and how to recognise them . Though  samples . DespiteRecently, the cancer stem cells were also shown in the solid tumours such as breast cancer and brain tumours ,87. The The cancer stem cells may be able to answer some of the questions related to a cancer growth, however origin of the cancer stem cells is yet to be defined. To recognise the origin of the cancer stem cells, two important factors need to be considered; 1 a number of mutations are required for a cell to be cancerous and 2 a The hypothesis that cancer stem cells are derived from normal stem cells rather than more committed progenitor cells have been addressed in the cases of AML where leukaemia initiating cells (LIC) from various subtypes of AML with different stages of differentiation have been shown to share the same cell-surface markers with normal haematopoietic stem cells ,94. HoweAt present, the cancer treatment is targeted at its proliferation potential and its ability to metastasise, and hence the majority of treatments are targeted at rapidly dividing cells and at molecular targets that represent the bulk of the tumour. This may explain the failure of treatments to eradicate the disease or the recurrence of the cancer . AlthougPTEN[Bmi1 [Although the idea of the therapies focused on the cancer stem cells may look exciting, targeting the cancer stem cells may not be easy. The cancer stem cells are relatively quiescent compared to other cancer cells and do not appear to have the hyper-proliferation signals activated such as tyrosine kinase. These make the cancer stem cells resistant to the toxicity of the anti-cancer drugs, which traditionally target the rapidly dividing cells. In addition, the tumour suppressor gene PTEN, polycomTEN[Bmi1  and the TEN[Bmi1 . These dTEN[Bmi1 ,109.® in chronic myeloid leukaemia that targets the ATP-binding domain of the Abl kinase. Most patients in this study experienced the complete cytogenetic responses[Much of the research is now focused on targeting the essential genes or pathways crucial for the cancer development through the cancer stem cells, with any possible therapies targeted against TICs. One such example is the use of Gleevecresponses,111. altresponses. A comparesponses inhibitsresponses. Thus, tPresently, cancer therapy has entered in to an exciting new era, with traditional therapies such as chemotherapy, radiotherapy and surgery on one side while the stem cells on the other hand. Apart from their well-known role in immuno-reconstitution, the stem cells have attracted much attention especially with the new gene technologies such as the gene incorporation into the eukaryotic cells allowing more focused delivery of the anti-cancer agents. Now the cancer may be considered as a cancer stem cell disorder rather than that of rapidly growing cells. Although the origin of the cancer stem cells is yet to be defined, the concept of the cancer stem cells may allow new treatment options in the possible cure of the cancer. However, further research is required to identify and separate the cancer stem cells in various cancers from normal stem cells and other cancer cells. Further work is also required to differentiate the genes and signalling pathways in the process of the carcinogenesis from cancer stem cells for development of new therapies, with the eventual goal of eliminating the residual disease and recurrence.


Degenerative aortic valve stenosis includes a range of disorder severity from mild leaflet thickening without valve obstruction, "aortic sclerosis", to severe calcified aortic stenosis. It is a slowly progressive active process of valve modification similar to atherosclerosis for cardiovascular risk factors, lipoprotein deposition, chronic inflammation, and calcification. Systemic signs of inflammation, as wall and serum C-reactive protein, similar to those found in atherosclerosis, are present in patients with degenerative aortic valve stenosis and may be expression of a common disease, useful in monitoring of stenosis progression. Degenerative aortic stenosis (AS) is at present time the most frequent valvulopaty in developed countries, and as life expectancy increases, the incidence and prevalence of AS will also rise fundamentally at the expense of the degenerative form.The scientific interest of this valvar disorder was parked for many years, as the image tools necessary to quantify it are at our disposal and we have a certain agreement of the clinical moment for indicating the valve replacement. Nevertheless, in the past years different studies have demonstrated a common pathogenic mechanism between degenerative AS and atherosclerosis -3. This C-reactive protein (CRP) is the marker of inflammation most widely studied in patients with coronary artery disease and hence has become the marker of reference for any other inflammatory-based disease . On thisThe first study showing increased CRP levels in patients with degenerative AS was published by Galante et al, in 2001 . They coFurther studies have confirmed  and expaOne of the principal characteristics of AS is the important degree of valvar calcification that takes place along the different stages of the disease. Thus, investigating whether CRP could be related to the mechanism of calcification appears very atractive. The role of serum CRP in the tissue calcification process has been investigated in a recently elegant study by Warrier et al,. When aortic wall was exposed to an excess amount of CRP in an in vitro simulating model, the calcification rate of aortic wall increased as the concentration of CRP. The results of this work could reveal the role of CRP present in physiological fluid in aortic valvar calcification . Data prRecently, Skowasch et al, have observed localization of CRP in valve tissue of degenerative AS and degenerative aortic valve bioprostheses . FurtherWe have assessed whether serum CRP levels could predict rapid AS progression. We measured serum high sensitivity CRP in 43 asymptomatic subjects with AS at baseline and six months later. Plasma CRP concentration was significantly higher in patients with rapid AS progression (5.1 [2.3 to 11.3] mg/L) compared to patients with slow AS progression . The rate of progression was higher in patients who had a cutpoint level above the median CRP concentration (3 mg/L) than those who had levels ≤3 mg/L  and enhanced inflammation , and not as a result of the effects of valvar heart disease per se .The presence of higher serum CRP levels and the tissue location of CRP in patients with AS have raised the important question of whether medical therapies with agents such as statins and ACE inhibitors, which have already been shown to delay the progression of atherosclerosis may also affect the progression of AS.Preclinical studies have shown that experimental hypercholesterolemia provide evidence of a proliferative atherosclerosis-like process in the aortic valve that is inhibited by statins -24; ie, Although recent retrospective clinical studies suggest that statins also may slow the hemodynamic progression of AS -29, the The main limitations of all the studies that have evaluated the association between CRP and AS are similar to the previous experience in the atherosclerosis setting: variability and laboratory methodology in CRP determination ,33; cardMoving forward, we must learn more about the pathogenic mechanisms of AS. We must integrate the atherosclerotic background of inflammatory biomarkers in our future research, and finally we must focus on the development of prospective, randomised trials using CRP to monitor the individual's response to treatments.Angiotensin Converting ezyme (ACE)Aortic stenosis (AS)C-reactive protein (CRP)Hazard Ration (HR)The author(s) declare that they have no competing interests.Both authors contributed equally to the review.


Robust Hedgehog (Hh) signaling has been implicated as a common feature of human prostate cancer and an important stimulus of tumor growth. The role of Hh signaling has been studied in several xenograft tumor models, however, the role of Hh in tumor development in a transgenic prostate cancer model has never been examined.We analyzed expression of Hh pathway components and conserved Hh target genes along with progenitor cell markers and selected markers of epithelial differentiation during tumor development in the LADY transgenic mouse model. Tumor development was associated with a selective increase in Ihh expression. In contrast Shh expression was decreased. Expression of the Hh target Patched (Ptc) was significantly decreased while Gli1 expression was not significantly altered. A survey of other relevant genes revealed significant increases in expression of Notch-1 and Nestin together with decreased expression of HNF3a/FoxA1, NPDC-1 and probasin.Our study shows no evidence for a generalized increase in Hh signaling during tumor development in the LADY mouse. It does reveal a selective increase in Ihh expression that is associated with increased expression of progenitor cell markers and decreased expression of terminal differentiation markers. These data suggest that Ihh expression may be a feature of a progenitor cell population that is involved in tumor development. Sonic hedgehog (Shh) is one of three mammalian hedgehog (Hh) genes . Each of the Hh genes encodes a secreted signaling peptide that binds to a membrane bound receptor (Ptc). Binding of Hh ligand to the Ptc receptor on the target cell initiates an intracellular signal transduction cascade that ultimately activates expression of Hh target genes through the activity of a family of Gli transcription factors  and their interaction. This was done separately for each of the proteins . The tenability of the assumptions of ANOVA was assessed with residual plots. If the assumptions of ANOVA seemed to be violated, transformations of the response were considered. If a term in the model was statistically significant, pair-wise comparisons were obtained and examined for significance; this corresponds to Fisher's protected Least Significant Difference (LSD) procedure. P < 0.05 was the criterion for statistical significance. The analyses were performed with Proc GLM, SAS v.9.1 statistical software . Results: The natural logarithms of the expression levels were log-transformed prior to ANOVA in order to homogenize the variances and better meet the assumptions of ANOVA.The author(s) declare that they have no competing interests.JG was responsible for the gene expression studies and participated in the preparation of this manuscript. GG and SK carried out the IHC staining and interpretation of data. CC was involved in discussions of these studies and drafted the manuscript. WB conceived the study, participated in its design and coordinated the final draft.


High-risk surgical patients are at increased risk of fungal infections and candidaemia. Evidence from observational and small randomised controlled studies suggests that prophylactic fluconazole may be effective in reducing fungal infection and mortality. We evaluated the effects of prophylactic fluconazole on the incidence of candidaemia and hospital mortality in immunocompetent high-risk surgical patients.Randomised controlled studies involving the use of fluconazole in immunocompetent high-risk surgical patients from the Cochrane Controlled Trial Register  and from the EMBASE and MEDLINE databases (1966–30 April 2005), without any language restriction, were included. Two reviewers reviewed the quality of the studies and performed data extraction independently.P = 0.01; I2 = 0%) and fungal infections other than lower urinary tract infection , but was associated with only a trend towards a reduction in hospital mortality . The proportion of patients requiring systemic amphotericin B as a rescue therapy for systemic fungal infection was lower after prophylactic use of fluconazole . The proportion of patients colonised with or infected with fluconazole-resistant fungi was not significantly different between the fluconazole group and the placebo group .Seven randomised controlled studies with a total of 814 immunocompetent high-risk surgical patients were considered. The use of prophylactic fluconazole was associated with a reduction in the proportion of patients with candidaemia (relative risk [RR] = 0.21, 95% confidence interval [CI] = 0.06–0.72, The use of prophylactic fluconazole in immunocompetent high-risk surgical patients is associated with a reduced incidence of candidaemia but with only a trend towards a reduction in hospital mortality. Candida spp. remain the commonest type of fungal infections in the ICUs and candidaemia accounts for 15% of all nosocomial bloodstream infections in the United States [Fungi are an increasingly important cause of nosocomial infections in intensive care units (ICUs) ,2. Systed States .The use of prophylactic antifungal therapy in ICU is controversial, although evidence from observational studies suggests that antifungal prophylaxis is associated with a reduced risk of candidaemia . The risin vitro [An antifungal agent selected for prophylaxis should have an appropriate spectrum of activity, should be easily delivered, and should have few adverse events . Fluconain vitro . It has in vitro . We condThe literature search was performed on the Cochrane Controlled Trials Register  and the EMBASE and MEDLINE databases (1966–30 April 2005). Only randomised control clinical trials involving immunocompetent critically ill or high-risk surgical adult patients were included. For studies involving a mixture of surgical and non-surgical patients, only data from the surgical subgroup of patients were retrieved if possible. Studies involving the use of fluconazole antifungal prophylaxis for liver transplantation or for neutropenic cancer patients were excluded because they included immunosuppressed patients.During the electronic database search, the following exploded MeSH terms were used: 'fluconazole' or 'antifungal' with 'critically ill', 'intensive care', 'trauma' or 'burns'. The reference lists of related reviews and identified original articles were searched for relevant trials. Finally, to ensure all suitable studies were included, the websites of the International Network of Agencies of Health Technology Assessment and the International Society of Technology Assessment in Health Care were searched and the company manufacturing fluconazole  was contacted. If necessary, the authors of the identified trials were contacted to obtain additional information and unpublished data that were important in the analysis. No studies published in languages other than English were found in the literature search.Two independent reviewers examined the titles and the abstracts of all identified trials to confirm they fulfilled the inclusion criteria. They examined and recorded the trial characteristics and outcomes independently, using a predesigned data abstraction form. This abstraction form was used to record information regarding the quality of the trial such as allocation concealment, the randomisation method, blinding of treatment, and the inclusion and exclusion criteria. The grading of allocation concealment was based on the Cochrane approach (i.e. adequate or uncertain or clearly inadequate). Any disagreements between the two independent reviewers were resolved by consensus. Any duplicated publications were combined to represent one single trial. Data were checked and entered into the Review Manager  database for further analyses.The hospital mortality and the proportion of patients with candidaemia were chosen as the main outcomes of this meta-analysis because they are the most specific clinically relevant outcomes of invasive fungal infections. There were no missing data for these two main outcomes in the included studies. The other outcomes assessed in this study included the proportion of patients colonised with or infected with fluconazole-resistant fungi, the proportion of patients requiring rescue therapy by systemic amphotericin B treatment, the proportion of patients with an adverse effect requiring cessation of the study drug, the proportion of patients with fungal infections other than urinary tract infection, and the total length of hospital stay. Urinary fungal infection is difficult to distinguish from colonisation, and for this reason these infections were excluded from further analyses in the present study. The definition of prophylaxis failure requiring amphotericin B treatment varied between different studies, but the common definition involved clinical deterioration with positive fungal culture from blood, deep tissue, or sputum.I2 statistics [The differences in categorical outcomes between the treatment group and the placebo group were reported as the relative risk (RR) with the 95% confidence interval (CI), using a random effect model. The difference in the total length of hospital stay between the fluconazole group and the placebo group was reported as weight mean difference in days, using a random effect model. The presence of heterogeneity between trials was assessed by chi-square statistics and the extent of inconsistency was assessed by atistics . SensitiWe identified 16 potentially eligible studies, of which seven studies ,15-20 fuP = 0.01; I2 = 0%) and fungal infections other than lower urinary tract infection , but was associated with no significant difference in hospital mortality  . The proportion of patients colonised with or infected with fluconazole-resistant fungi   were not different between the fluconazole group and the placebo group. The total length of hospital stay was no different between the fluconazole group and the placebo group .There was a good overall consistency in the results, without significant heterogeneity. The use of prophylactic fluconazole was associated with a reduction in the proportion of patients with candidaemia  and other candidal infections (RR = 0.4), with less requirement for systemic amphotericin B as a rescue therapy, and with a very safe adverse event profile, and is not associated with a significant increase in fluconazole-resistant fungi. However, we could only observe a trend towards a modest reduction in hospital mortality.The candidaemia rate of 4.5% in the placebo arm of this meta-analysis is consistent with the estimated risk of candidaemia in patients with at least one risk factor for candidaemia. The risk factors include total parenteral nutrition, acute renal failure, central venous catheter, broad-spectrum antibiotics, immunosuppression, and prior surgery . The benAlthough prophylactic fluconazole is effective in reducing candidaemia, our results did not demonstrate a statistical significant reduction in hospital mortality. However, the candidaemia rate in the placebo arm of this meta-analysis is 4.5% and the expected absolute risk reduction in hospital mortality is about 2.25% if we assume that the attributable mortality of candidaemia is 50% . If the A pharmacoeconomic or cost-effectiveness analysis was not performed in the studies included in this meta-analysis. Based on the baseline risk of candidaemia of 4.5% in the placebo arm of this meta-analysis, the number of patients needed to treat is about 25 to prevent one episode of candidaemia. The cost of 200 mg fluconazole is about US$35 per day in Australia and Switzerland  and a 2-Emergence of resistant fungi with widespread use of a prophylactic antifungal agent is a concern even if the drug is cost-effective. Our results did not demonstrate an increase in the risk of colonisation with or infection with fluconazole-resistant fungi within the time frame of the clinical trials . Whether prophylactic fluconazole will select or induce emergence of fluconazole-resistant fungi in the longer term is still controversial and remains a major consideration before it can be recommended -37.Meta-analyses are prone to bias. The quality of trials can affect the direction and magnitude of the treatment effect in meta-analyses. After excluding one study with unclear allocation concealment or double blinding, the direction and magnitude of the results of this meta-analysis remained unchanged. A funnel plot Figure  showed tSecond, although the results of this meta-analysis were fairly consistent across the included studies, there were significant differences in the diagnoses of the patients and the study protocols, especially in the doses of fluconazole used. The optimal dose and route of administration of fluconazole as a prophylactic agent cannot be evaluated from these pooled studies ,38.In immunocompetent high-risk surgical patients, the use of prophylactic fluconazole is associated with a reduced incidence of candidaemia but with only a trend towards reduction in hospital mortality. A large randomised controlled trial would be needed to assess the cost-effectiveness and the risk of inducing fluconazole-resistant fungi before prophylactic fluconazole can be recommended in immunocompetent high-risk surgical patients.• 	Prophylactic fluconazole was effective in reducing candidaemia in high-risk surgical patients and was associated with a trend towards a reduction in hospital mortality.• 	Prophylactic fluconazole was not associated with a significant increase in adverse events or the proportion of patients colonised with or infected with fluconazole-resistant fungi within the time frame of the included studies.CI = confidence interval; ICU = intensive care unit; RR = relative riskNo financial support was received for this study from pharmaceutical companies or other private companies in the form of grants and awards. All authors declare that they have no competing interests in relation to this study.KMH performed the data collection and analyses, and drafted the manuscript. JL and GJD helped with the interpretation of data and drafting the manuscript. SARW performed the data collection, and helped with the interpretation of data and drafting the manuscript.


Medical and technological progress has led to increased numbers of diagnostic tests, some of them inducing high financial costs. In Germany, high-cost diagnostic imaging is performed by a medical specialist after referral by a general practitioner (GP) or specialist in primary care. The aim of this study was to evaluate the physicians' perceived usefulness of high-cost diagnostic imaging in patients with different clinical conditions.Thirty-four GPs, one neurologist and one orthopaedic specialist in ambulatory care from a Medical Quality Network documented 234 referrals concerning 97 MRIs, 96 CTs-scan and 41 intracardiac catheters in a three month period. After having received the test results, they indicated if these were useful for diagnosis and treatment of the patient.The physicians' perceived usefulness of tests was lowest in suspected cerebral disease (40% of test results were seen as useful), cervical spine problems (64%) and unexplained abdominal complaints (67%). The perceived usefulness was highest in musculoskeletal symptoms (94%) and second best in cardiological diseases (82%).The perceived usefulness of high-cost diagnostic imaging was lower in unexplained complaints than in specific diseases. Interventions to improve the effectiveness and efficiency of test ordering should focus on clinical decision making in conditions where GPs perceived low usefulness. The continuous medical and technological progress has led to a rising use of high tech diagnostic tests which are often expensive. For that reason many efforts have been undertaken to enhance the effectiveness and efficiency of referrals for diagnostic tests. Studies have pointed out a wide range of reasons for referrals including patients demand for extensive diagnostics. For instance, referral patterns were related to the physicians' attitudes to their role  and to tConcerning expensive diagnostic procedures, Robling et al. found that the referral for diagnosis with MRI had biomedical, personal and contextual reasons . ParticuIn general, there is no formal gatekeeping role for the GP in the German health care system and ambulatory care comprises almost all specialties . HoweverThis prospective observational study examined referrals for test ordering with respect to the physicians' perceived usefulness of high-cost diagnostic imaging for diagnosis and treatment in general practice. Our aim was to identify clinical conditions where GPs and specialists in ambulatory care perceived limited relevance of the tests so that targeted strategies could be planned to support medical decision making in these conditions. Because of the impact on the financial resources the study focused on high-cost imaging, including MRI scan, CT-scan and intracardiac catheter.The project was designed as a prospective observational study. 34 general practitioners of a medical network, one neurologist and one orthopaedic specialist in ambulatory care and one hospital of the region participated between January and March 2000. In this time period all referrals concerning MRI scan, CT-scan or intracardiac catheter from a total of 234 patients were documented by the physicians. The participating physicians were members of the Medical Quality Network Ried in the southern region of Hessia, Germany. The overall aim of this network is the implementation of continuous quality improvement in primary care. For instance, previous activities focused on the introduction of a patient-held medical record .The participating physicians were instructed to document each referral for MRI, CT-scan or intracardiac catheter. The documentation included reason for referral, clinical symptoms and previously established diagnoses of each patient.The main outcome measure was the assessment by the physician if the result of the diagnostic procedure represents an important contribution to the diagnostic process. This could be a confirmation or negotiation of the estimated diagnoses for providing optimal treatment respectively to reassure that there is no dangerous health problem. To clarify this concept, a workshop with the participating physicians at the start of the study was done, in which the physicians were instructed to use this operationalization. The statement could be given as "useful" or "not useful" after receiving the test result. The estimation of the usefulness was usually made on the same day, when the physician received the referral letter. In Germany, the specialist who performed the diagnostics is obliged to send such a letter to the referring physician where the test results are listed in detail. For every documentation of the referral process and estimation of its usefulness, the physicians received a small financial incentive.Every reason for a diagnostic referral was documented in a free text. The clinical symptoms were clustered into six different subgroups after analysis of the whole spectrum of referrals: cervical and lumbar spine, internal diseases (without cardiac problems), nervous system, musculoskeletal system, cardiac system and others. Baseline data were compared descriptively. The Chi-Square-Test was used for testing the relation between gender of patients and perceived usefulness statistically. The t-test was performed to calculate the relation between perceived usefulness (as independent variable) and age (as dependent variable). Statistical procedures and analysis of the data were done with SPSS 11.0.Referrals for test ordering from 132 women and 100 men were documented . In opposite to that, both the GPs and specialists perceived MRI and CT-scan as useful for lumbar spine problems in about 88–100%. Problems with the knees, shoulder, elbows and foot ankles had the best result regarding usefulness of test ordering (in sum 94 %).In cases of abdominal complaints, where also cancer was suspected as a reason, 67% of the diagnostic referrals were perceived as useful. "Unexplained abdominal symptom" was the most frequent reason for ordering an abdominal CT-scan (seven out of 15 cases). The usefulness of tests for pulmonary diseases, mostly for suspected carcinoma, was higher, but the absolute number of cases was limited. The group of "other tumours" included two cases of breast cancer and one case of oesophageal cancer. In cases of cardiac problems most tests referred to suspected coronary artery disease (CAD), using intracardiac catheters. One MRI was done because of a suspected pericardial effusion. In sum, the cardiological diagnostics were perceived as useful in 82%.The aim of our study was to examine to what extent MRI, CT-Scan or intracardial catheter were perceived as useful for making diagnoses and treatment decisions from the point of view of the physicians. The usefulness was most limited in problems related to cervical spine, unclear cerebral symptoms and abdominal pain.In general, there is a limited usefulness of MRI and CT-scan for diagnostics in cervical spine problems ,11. The In opposite to that, the diagnostic procedures in low back pain were perceived as useful in most cases. However, clinical research showed little correlation between morphology and complaints in low back pain . The valThe comparatively low usefulness of CT-scans in abdominal complaints may express the complexity of diagnostics in these cases. Many patients with unexplained abdominal symptoms show a high psychological co-morbidity , which cThe results concerning the tests for cardiac diseases and problems with the musculoskeletal seem to be more informative. Intracardiac catheter, MRI or CT-scan led in most of these cases to an effective medical decision making, so it was regarded as helpful and appropriate by the referring GP.A limitation of our study was that we investigated a subjective estimation of the physicians for the usefulness of the diagnostic referral but not the appropriateness judged by an external observer. For example, in the field of cardiology the managing of coronary artery disease in Germany has been criticised . This inNevertheless, our study suggests that quality improvement should focus on patients with unexplained complaints to avoid expensive, unnecessary or dangerous diagnostic investigations. A starting point for dealing with these problems could be an analysis together with the network of physicians and a subsequent implementation of evidence based guidelines, accompanied by training in risk communication with difficult patients. This implementation of change should be done in a multifaceted strategy using guidelines, feedback and social interaction ,21.The perceived usefulness of high-cost diagnostic imaging was lower in unexplained complaints than in specific diseases. Interventions to improve the effectiveness and efficiency of test ordering should focus on clinical decision making in conditions where GPS perceived low usefulness. Further research is necessary to identify patient factors underlying unexplained symptoms and to find methods to improve decision making regarding test ordering.The author(s) declare that they have no competing interests.AS performed the statistical analysis and wrote the manuscript. TR supported in writing the manuscript. MW supported in statistics and writing. JS designed and supervised the study. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Systematic reviews (SRs) must be of high quality. The purpose of our research was to compare the methodological and reporting quality of original versus updated Cochrane SRs to determine whether updating had improved these two quality dimensions.We identifed updated Cochrane SRs published in issue 4, 2002 of the Cochrane Library. We assessed the updated and original versions of the SRs using two instruments: the 10 item enhanced Overview Quality Assessment Questionnaire (OQAQ), and an 18-item reporting quality checklist and flow chart based upon the Quality of Reporting of Meta-analyses (QUOROM) statement. At least two reviewers extracted data and assessed quality. We calculated the percentage  of 'yes' answers to each question. We calculated mean differences in percentage, 95% confidence intervals and p-values for each of the individual items and the overall methodological quality score of the updated and pre-updated versions using OQAQ.We assessed 53 SRs. There was no significant improvement in the global quality score of the OQAQ ). Updated reviews showed a significant improvement of 18.9  on the OQAQ item assessing whether the conclusions drawn by the author(s) were supported by the data and/or analysis presented in the SR. The QUOROM statement showed that the quality of reporting of Cochrane reviews improved in some areas with updating. Improvements were seen on the items relating to data sources reported in the abstract, with a significant difference of 17.0 , review methods, reported in the abstract 35 , searching methods 18.9 , and data abstraction 18.9 .The overall quality of Cochrane SRs is fair-to-good. Although reporting quality improved on certain individual items there was no overall improvement seen with updating and methodological quality remained unchanged. Further improvement of quality of reporting is possible. There is room for improvement of methodological quality as well. Authors updating reviews should address identified methodological or reporting weaknesses. We recommend to give full attention to both quality domains when updating SRs. A number of papers have been published on the methodological and reporting quality of reviews. A review of 86 English language meta-analyses published between 1950 and 1986 by Sacks . Shea 33 compareThe Cochrane Collaboration  is an inStudies of the quality of systematic reviews can focus on methodological or reporting quality. Methodological quality is concerned with how well a systematic review was designed and conducted . Reporting quality considers how well systematic reviewers have reported their methodology and findings.The purpose of our study was to compare the methodological and reporting quality of Cochrane systematic reviews with that of their updated versions in order to determine whether updating contributed significantly to the improvement of their quality in these two dimensions.We selected all updated Cochrane systematic reviews from the Cochrane Database of Systematic Reviews 2002 , and theBased on a previously published study , two insThe OQAQ was selected because it has strong face validity, provided data on several essential elements of its development, and had a published assessment of its construct validity available . In addiThe QUOROM statement was chosen for assessing reporting quality. Although, this checklist has not yet been fully validated, extensive work has been conducted and reported . The QUOFor each included Cochrane systematic review, we calculated the percentage  of 'yes' answers to each item of OQAQ and QUOROM. Individual Cochrane systematic reviews were then compared to their updated versions with respect to the percentage of 'yes' ratings received. A percentage difference  of 'yes' answers was calculated for each individual question. In addition, a mean difference  was calculated for the overall quality score (OQAQ) of the updated and pre-updated versions.Assessments of all individual reviews were conducted independently by at least two assessors. One of these assessors (CH) had been involved with the Cochrane Collaboration for six years. The other assessor (BS) had been involved with the Cochrane Collaboration for ten years, and had carried out a number of systematic reviews. A third assessor (DF) was available to assist in the resolution of assessment discrepancies.In total, 53 reviews were included. The mean period between the publication of the original and updated versions of the reviews was 2.7 years (range four months to five years). Complete results for both instruments applied to the reviews are provided in Tables Table There were improvements on seven individual items, although only one item showed a significant improvement (item 9 – Were the conclusions made by the author(s) supported by the data and/or analysis reported in the overview?)  percentage updated reviews complying with item 94%  difference 18.9% ).Table Three questions, item (10) -3.7% , item (14) -3.7%  and item (16), -5.7%  had lower mean scores on updated reviews than on original reviews, but these differences were not statistically significant.In assessing the quality of the sample of 53 systematic reviews of the Cochrane Collaboration, two assessment tools were used. The larger improvement on the QUOROM checklist than on the OQAQ suggests that although the quality of reporting has improved slightly, the quality of design and conduct has not changed. For example, the items in reporting of selection criteria and searching are improved on QUOROM, but the equivalent items on OQAQ, which relate to how well these were carried out have not changed.The significant improvements for the OQAQ item assessing whether the conclusions drawn by the author(s) were supported by the data and/or analysis reported in the overview is also worthy of note. This could suggest that authors are paying more attention to state their conclusion in relation to the data provided. This item has been reported by other methodologists in the context of asessing quality ,17.Improvement in the quality of reporting of the abstract, as assessed by the QUOROM instrument, might also suggest that authors are paying more attention to the details. For example, authors might be more aware of better access to the Cochrane abstracts through electronic systems such as Medline. Also, reporting of literature searches improved. However, the literature searches themselves did not improve. This should be further explored.Assessors expressed that they found the two instruments used in the study to have associated practical weaknesses. Their combined length (28 items) made their use somewhat cumbersome and inefficient. Another problem encountered was the lack of adequate published guidance on the application of the OQAQ question, assessing the overall methodological quality. The QUOROM checklist had the advantage of coming with fairly detailed user instructions. However, it proved very time-consuming to apply . AnotherThe methodological and reporting quality of Cochrane reviews was fair-to-good, but further improvement is obviously needed in both areas. This was also concluded in a recent study by Moja . In addiThe Cochrane Collaboration endeavours to improve the quality of its systematic reviews through the application of a continuous peer review process during their development. The effectiveness of the peer-review process could probably be improved by increased attention to areas of reporting and/or methodological weaknesses. Reviewers should adhere more faithfully to the guidelines provided in the Cochrane handbook  in orderThe overall quality of Cochrane reviews is fair-to-good. Although quality of reporting improved on certain individual items there was no overall improvement seen with updating and methodological quality remained unchanged. Further improvement of quality of reporting is possible. There is room for improvement of methodological quality as well. Authors updating reviews should address identified methodological or reporting weaknesses. We recommend to give full attention to both quality domains when updating SRs.The author(s) declare that they have no competing interests.BS designed the protocol and the study, abstracted the data, conducted the analysis, and wrote the paper; MB designed the protocol and the study, and assisted with writing the paper; JMG provided intellectual input into the design and conduct of the study, and assisted with writing the paper; CH carried out the data abstraction, quality assessment and assisted with the analysis; LMB provided intellectual input into the design and conduct of the study, and assisted with writing the paper.The pre-publication history for this paper can be accessed here:The enhanced version of the overview quality assessment questionnaire (OQAQ).Click here for fileQuality of reporting of meta-analyses (QUOROM) for randomized controlled trials.Click here for file


In a previous study of 131 breast carcinomas with medullary features, we evaluated the diagnostic inter- and intraobserver variation and its prognostic implications using the criteria of typical (TMC) and atypical (AMC) medullary carcinoma of the breast put forward by Ridolfi et al. (1977). We found a considerable interobserver variation as well as intraobserver variation, with significant implication on prognosis, and concluded that the histopathological definition of MC must be sharpened and simplified in order to increase the diagnostic reproducibility. In the present study of the same population of 131 patients with breast carcinomas with medullary features we have examined inter- and intraobserver variation concerning 11 histopathological characteristics. Furthermore, we have analysed the prognostic importance of these 11 histopathological features, and the prognostic implications of the observed inter- and intraobserver variation. Based on the observations, we have eliminated criteria with poor inter-/intraobserver agreement as well as those implying no or minimal impact on the prognosis. We propose a new simplified histopathological definition of medullary carcinoma of the breast (MC), retaining reproducible, prognostically significant criteria . The prognosis of MC, based on this definition, is significantly better than those of infiltrating ductal carcinomas grade II + III.


Cholera Ryu-ko Kiji (Cholera Epidemic Report), published by the prefectural government in 1882 and 1895, provide valuable records for analyzing and modelling diffusion. Text descriptions and numerical evidence culled from the reports were incorporated into a temporal-spatial study framework using geographic information system (GIS) and geo-statistical techniques.Disease diffusion patterns can provide clues for understanding geographical change. Fukushima, a rural prefecture in northeast Japan, was chosen for a case study of the late nineteenth century cholera epidemic that occurred in that country. Two volumes of Changes in diffusion patterns between 1882 and 1895 reflect improvements in the Fukushima transportation system and growth in social-economic networks. The data reveal different diffusion systems in separate regions in which residents of Fukushima and neighboring prefectures interacted. Our model also shows that an area in the prefecture's northern interior was dominated by a mix of diffusion processes , that the southern coastal region was affected by a contagious process, and that other infected areas experienced relocation diffusion.In addition to enhancing our understanding of epidemics, the spatial-temporal patterns of cholera diffusion offer opportunities for studying regional change in modern Japan. By highlighting the dynamics of regional reorganization, our findings can be used to better understand the formation of an urban hierarchy in late nineteenth century Japan. In medical geography, studies of the geographical structures of disease emphasize diffusion and analyses of individual disease factors ).After introducing the data found in the two cholera reports and features of the Fukushima epidemic outbreaks, we describe how GIS-based methodology was used to model and analyze disease diffusion. Our results are presented as visual representations of disease patterns and identified diffusion systems prior to modelling diffusion processes. We present three major findings regarding regional transitions before offering our conclusion.Cholera Ryu-co Ki-ji (Cholera Epidemic Reports) following each outbreak. These documents are now being used to analyze specific epidemic outbreaks and changes in Japan's social-economic structure. Fukushima prefecture released two sets of Cholera Ryu-co Ki-ji, the first published by the police department in 1882 and the second by the prefecture's sanitary agency in 1895. Each report contains data on the number of patients, gender, occupation, age, symptoms, treatment, and how disease prevention laws were applied. The 1895 report is considered more accurate and complete, in part due to progress made in establishing disease recording and reporting systems over the preceding decade.Following the Meiji Restoration, Japan endured a series of cholera outbreaks every 3–5 years from the 1870s to 1895. As part of a modern medical regulatory system established in 1876, several prefectural governments published The contents of the Fukushima cholera reports can be divided into two categories. The first consists of numerical evidence such as the number of cases reported in infected villages. The beginning and ending dates of outbreaks in each village were clearly noted in these reports. The second category consists of textual accounts of diffusion routes, morbidity, and mortality. Also recorded were possible factors for the diffusion of cholera and measures taken to combat its spread.Ryu-co Ki-ji, there were substantial time lags between national and Fukushima outbreaks – it was one of the very last prefectures to feel the effects of the initial national diffusion. The reports also indicate that cholera entered the prefecture via a different route during each outbreak, that it suffered fewer cases than most prefectures, and that it rarely exported the disease.Established in 1876, Fukushima prefecture was at the time Japan's third largest prefecture in terms of area. Its position along the coast in northeast Japan made it an important link between the cities of Tokyo and Sendai  was used for georeferencing. Data for the locations of infected villages and disease attributes were manually digitized and used to create two geodatabases. The 1882 version contains a time-space matrix of epidemic diffusion among 42 infected villages; the 1895 matrix covers 96. The two databases were employed to make comparisons of disease patterns and diffusion systems between 1882 and 1895. Due to improvements in sanitary systems, the 1895 report contains more detailed information  and was therefore used for diffusion modelling.A variety of GIS-based methods were used to digitize and align the data. All processing was performed using ARCGIS (version 9.2) software from ESRI. In order to trace the historical locations mentioned in the two reports, a digital image of the 1898 relocation diffusions or expansion diffusions, with the three main expansion processes being contagious, hierarchical, and mixed [Mechanisms that influence the spread and spatial patterns of a disease or other phenomenon are at the core of diffusion studies . Accountnd mixed . We hypoHi is the number of households in an infected village, Di the direct distance (in kilometers) from the location of origin to the village where the fist cholera cases were reported, and ui a random disturbance; β1 is a constant. The data distribution clearly indicates the presence of outliers among Hi, Di, and Ti, necessitating a transformation step to create a standard distribution. The logarithmic transformation sections of equation (1) served this purpose.where Hi and Di display a double-logarithmic relationship with Ti that makes it possible to represent a mix of two diffusion processes – contagious and hierarchical. Hi represents the hierarchical component of the spreading process and Di the contagious component. Accordingly, statistical significance for Hi is an indicator of hierarchical diffusion, and statistical significance for Di an indicator of contagious diffusion. Since a mixed diffusion requires statistically significant results for both Hi and Di, t-test results and r coefficients were used to assess correlation levels between independent variables.In this model, the independent variables The combination of GIS-based techniques and diffusion modelling allowed us to identify cholera diffusion routes and to visualize outbreak dynamics. To analyze diffusion processes we will present our results in two parts: disease pattern visualization followed by diffusion system identification.An overlay map of cholera case locations and traffic networks is shown in Figure 1. Geographical barriers had a greater effect on 1882 diffusion patterns than those of 1895. Village accessibility and geographical conditions may have limited the spread of cholera during the earlier outbreak.2. Diffusion patterns seem to have been affected by boundary reforms that occurred between 1882 and 1895. Specifically, the weakened diffusion in the mountainous western region in 1895 may be attributed to the breaking up of a western county and placing part of it under the jurisdiction of Niigata prefecture.3. Disease patterns for both outbreaks were clustered in transportation hubs, but the 1895 clusters expanded in the north-inland, south-inland, and southeast coastal areas.To identify diffusion system boundaries, we applied an inverse distance weighted (IDW) interpolation technique  to map their temporal features. Specifically, outbreak dates of index cases in each county were used to create temporal diffusion contours for 1882 and 1895. Temporal diffusion degrees were visualized as color gradations for predicting system boundaries Figs.  and 4d. Fukushima faces the Pacific Ocean and shares boundaries with six other prefectures – two factors leading to increased complexity in terms of disease introduction. As shown in Figures Once a diffusion system was identified, a geostatistical analysis was performed to determine diffusion process type. Due to integrity limitations for the 1882 data, the analysis was only applied to the 1895 diffusion. Prior to modelling each process, we compared three factors for each infected village to identify temporal and spatial diffusion dynamics: number of households, date of first case, and total number of cases. The number of households in infected villages described as susceptible represents urban diffusion systems; increases or decreases in daily accounts of cholera cases represent epidemic waves. Data for each factor were systematically compared with the temporal axes of various diffusion systems identified for the 1895 outbreak. The graphs in Figures The Ibaraki system along the coast lasted the longest (140 days) during the 1895 outbreak Figs.  and 5d. A temporal investigation summary of infected villages/cholera cases, diffusion time period, peak of epidemic wave, date of arrival in larger towns, and type of accumulation curve is presented as Table LogTi(Time) and both the LogHi(Household) and LogDi(Distance) variables, indicating a mixed diffusion process (Table LogTi(Time) and LogDi(Distance), but not between LogTi(Time) and LogHi(Household), indicating a distance-dominated or purely contagious diffusion. No statistically significant associations were identified in the Tochigi system, meaning that it cannot be explained in terms of expansion diffusion.The data were integrated into a multiple regression model for quantitative evaluation. Models of dynamic relationships between the diffusion curves and their geographic locations were individually applied for the Miyagi, Ibaraki, and Tochigi systems. In the Miyagi system, statistically significant relationships were identified between ss Table . In the The cholera outbreaks that are the focus of this study occurred during a period in which sanitation concepts and initial sanitation guidelines were being promoted by the Meiji government. It is a well-studied topic, resulting in a large literature that not only focuses on the disease but also uses it as a frame for understanding societal change . Data accuracy issues and uncertain boundaries often limit efforts to model historical disease diffusions. Our analysis was facilitated by rich data sources (two cholera epidemic reports) and GIS-based techniques that allowed us to digitize the locations of infected villages in order to identify regional patterns. The GIS tools also facilitated reconstructions of temporal-spatial patterns of cholera diffusion to perform comparisons in terms of geographic terrain and traffic networks.We made three primary observations concerning the spatial characteristics of geographic structures. First, the division of Fukushima into a coastal area, inland valley, and western highlands clearly affected diffusion patterns during the 1882 outbreak. Changes in those patterns between 1882 and 1895 reflect increased accessibility to inland and coastal villages. Second, disease patterns that followed main roads or clustered around certain traffic nodes serve as indicators of population distributions and as references for analyzing economic activity in late nineteenth century Fukushima. Third, identified origin locations and diffusion routes from neighbouring prefectures can be used as evidence for determining the movement of people and goods between prefectures.Whereas interactions between infected hosts and a socio-ecological environment are critical for understanding how and where infectious diseases spread, diffusion patterns provide clues to understanding regional interactions. Our results strongly support the notion that cholera diffusions in late nineteenth century Fukushima were dominated by different systems in separate regions. Accordingly, changes in the visualized boundaries of each system may represent interaction dynamics between prefectures.Echigo country; its residents were more closely tied to Niigata prior to the Meiji restoration. The late nineteenth-century reform may have further reduced social and economic exchanges between the two prefectures – changes reflected by a decrease in disease diffusion. In addition, a section of the Tokyo-Sendai railway was opened in 1887; its route through central Fukushima increased interactions with and between neighbouring prefectures to the north and south. Combined with other infrastructure projects, these changes may explain the appearance of clusters of infected villages around traffic hubs in the north inland region and along the southeast coast.A comparison of the 1882 and 1895 cholera outbreaks hint at two important changes in Fukushima. First, the significant decrease in disease diffusion in the western highlands in 1895 may be explained by a change in administrative boundaries that occurred in 1886. Specifically, part of a large county was put under the jurisdiction of Fukushima's western neighbour, Niigata prefecture  was the major centre. Due to increased accessibility and interactions along transport networks, the larger villages and towns in the Miyagi diffusion system may have been hierarchically integrated into a larger urban system shared with its northeast neighbouring prefecture.Differences in diffusion patterns can be explained by specific geographical contexts and regional interactions. In this case study, results from diffusion models shed light on the emergence of an urban system within the identified diffusion systems. Specifically, the distribution of infected villages by size may represent such an emergence during the cholera outbreaks. Our finding that the Miyagi diffusion system consisted of a mix of hierarchical and contagious processes suggests the formation of a small urban system in the northern inland area of Fukushima prefecture. Figure There is no evidence of urban systems developing in Ibaraki or Tochigi prefectures, but our data do reveal other regional features. The diffusion process in the Ibaraki system is representative of a common form of contagious diffusion found in coastal areas where fishing is the main economic activity. The importance of fishing to the Japanese diet may have further facilitated disease diffusion. The data for the Tochigi system do not support a hierarchical or contagious process in the southwest region of Fukushima. Although the Tochigi system affected a larger region than the other systems in terms of land area, only 18 villages reported infections. Due to its comparatively complex landforms Figs. , a relocIn this paper we concentrated on the geographical dynamics of cholera diffusion in modern Japan and described a method for identifying spatial and temporal epidemic diffusion patterns, systems, and processes. Our case study of cholera outbreaks in late nineteenth century Fukushima prefecture reveals changes in geographical structure and in internal and external interactions, as well as the emergence of an urban system. We suggest that our approach can be useful for understanding both the temporal-spatial patterns of infectious diseases and the characteristics of regional change in modern Japan. We will continue to test this framework by investigating various historical diseases across different prefectures.The author(s) declare that they have no competing interests.CLK conceptualized the study, collected and analyzed the data, and produced the original draft. HMF participated in data collection and provided a critical review of the manuscript. All authors read and approved the final manuscript.


Stillbirth rate is an important indicator of access to and quality of antenatal and delivery care. Obtaining overall estimates across various regions of the world is not straightforward due to variation in definitions, data collection methods and reporting.We conducted a systematic review of a range of pregnancy-related conditions including stillbirths and performed meta-analysis of the subset of studies reporting stillbirth rates. We examined variation across rates and used meta-regression techniques to explain observed variation.We identified 389 articles on stillbirth prevalence among the 2580 included in the systematic review. We included 70 providing 80 data sets from 50 countries in the meta-analysis. Pooled prevalence rates show variation across various subgroup categories. Rates per 100 births are higher in studies conducted in less developed country settings as compared to more developed (1.17 versus 0.50), of inadequate quality as compared to adequate (1.12 versus 0.66), using sub-national sample as compared to national (1.38 versus 0.68), reporting all stillbirths as compared to late stillbirths (0.95 versus 0.63), published in non-English as compared to English (0.91 versus 0.59) and as journal articles as compared to non-journal (1.37 versus 0.67). The results of the meta-regression show the significance of two predictor variables – development status of the setting and study quality – on stillbirth prevalence.Stillbirth prevalence at the community level is typically less than 1% in more developed parts of the world and could exceed 3% in less developed regions. Regular reviews of stillbirth rates in appropriately designed and reported studies are useful in monitoring the adequacy of care. Systematic reviews of prevalence studies are helpful in explaining sources of variation across rates. Exploring these methodological issues will lead to improved standards for assessing the burden of reproductive ill-health. The use of perinatal deaths to assess pregnancy outcomes has been a practical approach particularly in settings and circumstances where it is not always easy to distinguish between stillborn and liveborn infants who die shortly after birth. However, due to difficulties in measurement and etiological differences between the two components of perinatal deaths – stillbirths and early neonatal deaths – its value is limited ,2. SeparObtaining reliable estimates of stillbirth rates and making cross-country comparisons has been problematic for several reasons. Routine vital registration information is suggested to be an underestimate of the true picture particularly in developing countries ,7. CommuIn addition to routinely collected data, medical literature includes a range of studies reporting on the prevalence of stillbirths. The results of these studies show variation across and within countries. For example, per 1000 live births, it has been reported as 61 in Zimbabwe, 18 in Turkey and ranging from 3.2 to 7.1 among different ethnic groups in Canada all using the definition involving birth weight of more than 500 g ,16,17.Although there is a wealth of information through routine registration systems and a variety of ad hoc studies, due to the complexities described above, reliable estimates of stillbirth rates do not exist for many settings. Rates vary across and within settings, and summarizing outcomes is not always straightforward. Meta-analytical methods are increasingly being used in comparing and summarizing outcomes for important public health outcomes. They offer valuable tools, particularly for research carried out across different settings, by providing an opportunity to investigate potential sources of variation .We conducted a systematic review and performed meta-analysis of available information from both routine data and other published studies to explore the feasibility of obtaining an overall estimate of the stillbirth rates across various regions of the world and to investigate possible sources of heterogeneity across these rates.This study is the analysis of the stillbirth component of the systematic review of maternal mortality and morbidity undertaken by the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research at the WHO. The objective of the systematic review was to obtain prevalence/incidence data on maternal mortality and a range of conditions including stillbirths. The detailed methodology which followed a pre-defined protocol has been described elsewhere .The search for articles involved bibliographic databases , WHO regional databases , internet, reference lists, contacting experts in the field, and hand-searching of relevant documentation in the WHO Library. We developed specific search strategies for electronic databases according to their structured thesaurus terms or using appropriate keywords in collaboration with two librarians from the WHO and Cochrane Pregnancy and Childbirth Group. Detailed strategies for electronic databases have been previously reported and are available from the authors . The seaTwo reviewers evaluated titles and abstracts of the identified citations for potential inclusion in the review. Prior to this initial evaluation, we assessed inter-observer agreement using the kappa statistics (0.60 95% CI 0.52 to 0.69) which showed moderate to substantial agreement . We discWe developed and used a data extraction instrument including 48 items distributed in five modules three of which were relevant to this analysis. Modules were designed to collect information on (i) study level characteristics , (ii) outcome measures, and (iii) definitions and identification procedures for outcomes. We defined four key criteria for the quality assessment of the articles. These were: sampling schemes conducted as either random or consecutive, adequate description of population characteristics, definition of both the numerator and the denominator of the reported rate, and response rate/completeness of information in the data sets exceeding 75%. We considered the overall quality as adequate if a study fulfilled at least three of the four criteria. We did not exclude studies on the basis of inadequate quality, but accounted for this in the statistical analysis.Prior to the analysis, we developed a protocol that defined inclusion criteria and specified the approach to the analysis. Cross-sectional studies reporting stillbirth rates with representative sampling schemes were eligible for inclusion. For studies reporting information relevant to the same population for more than one year, we included data only from the most recent year. In order to prevent a woman's appearance more than once in a data set, and because the durations of studies extending beyond 12 months were highly variable, we limited analysis to studies with reference periods of 12 months. For studies where no definition for stillbirth was reported we assumed the conventional definition of more than 28 weeks of gestation [We calculated the pooled prevalence estimates for various subgroup categories weighted by the sample size of individual studies. A meta-regression was conducted to identify significant sources of heterogeneity .The independent study-level variables included in the meta-regression were as follows: development status of the country where the study was conducted  for various subgroups of the population-based studies are shown in table Other emerging patterns seen from table R2-value, which is an overall measure of how well the independent variables  together, predict the dependent variable (stillbirth rates), is 52.4%.The results of the meta-regression are presented in table The analysis of the combined study file supports the findings of the population-based meta-regression analysis, showing that three of the predictor variables are significant at the 5% level, namely development status, study quality, and whether or not a study is population-based. Hence, population-based studies have lower prevalence rates on the average than facility-based studies . This is consistent with the relatively large difference in unadjusted overall prevalence rates for the population-based and facility-based studies, given by 0.84 and 2.50 respectively.study quality on stillbirth prevalence rates in more developed regions is different from the effect in less developed regions of the world. In particular, studies of adequate and inadequate quality tend to exhibit smaller differences in prevalence rates in more developed regions than in less developed regions of the world.Tests for interaction effects performed as a secondary analysis revealed a significant interaction between development status and study quality both in the in the population-based file (p = 0.038) and in the combined data file (p = 0.018). This interaction arises because the effect of The results obtained from residual analysis of the final models revealed no evidence of departure from standard underlying assumptions, namely that the residuals are independent, have a common variance with mean 0 and follow a normal distribution.Our results suggest that stillbirth prevalence at the community level is in general less than 1% in more developed parts of the world and could exceed 3% in less developed regions, but we were not able to provide overall estimates of stillbirth prevalence for different regions of the world due to significant heterogeneity across sub-regions. Facility based studies show higher rates, which could be due to referral bias.Meta-regression analysis explained a considerable proportion (52%) of the observed heterogeneity in these data. Not surprisingly, development status of the setting in which the study was conducted was shown to be a strong predictor of stillbirth prevalence. Perhaps less expected was that the quality of a study is another significant predictor, independent of development status, with prevalence rates being lower in studies of higher quality. All other study-level variables we tested for possible influence on stillbirth rates did not show a significant relationship. The remaining variation could be due to other unmeasured variables that could not be investigated in this analysis. For example, with the information available to us, we could not investigate the influence of characteristics such as age and parity, both of which are important predictors of stillbirth -98.Meta-analytical methods including meta-regression has increasingly been used in summarizing outcomes and explaining between-study variability in investigations of treatment effects or associations -101, butThe meta-regression techniques were helpful in explaining a significant portion of the observed variation in stillbirth rates. We believe it is timely to use this approach more widely in the estimation of maternal and perinatal health indicators associated with internationally set goals and targets. The need for global estimates of such indicators is greater than ever in the context of international development goals including the Millennium Development Goals (MDGs) . More emThe empirical evidence we provide regarding the significant influence of the development status of the study setting on stillbirth prevalence has implications for policy and programmatic actions. The significantly higher rates in less developed country settings and the highest rate observed in Western Africa could largely be due to inadequacies in accessing appropriate maternal health care during both antenatal period and delivery. The reported skilled attendance at birth in this region is also very low, corroborating these findings .The independent effect of the quality of primary studies on the rates deserves attention as well. For effect-size studies the perceived quality of a published article is known to be related to its likelihood of being included in a meta-analysis , althougOur study has several limitations. First, our analysis focuses on a subgroup of studies selected from a larger systematic review. The search strategy for the larger review, however comprehensive, did not specifically target stillbirths, and therefore, some relevant studies may have been missed. The trade-off in deciding to limit our investigation to prevalence studies having one-year duration reduced the number of studies included in the analysis. We took this decision because the durations of the remaining studies varied widely and studies of longer duration may have counted multiple pregnancies in the same woman. Since stillbirth may be a recurrent event -110, we The results of this systematic review show significant variation in stillbirth rates in different parts of the world and that, even in the settings with the highest standards of maternal and perinatal care, around five out of 1000 newborns will be stillborns.While these findings do not have direct implications for clinical practice, they highlight the relative frequency of stillbirth as an indicator of the quality of service delivery. Even in developed countries the fact that stillbirths constitute close to 1% of all births should alert policy-makers to initiate audit procedures to identify avoidable cases and take action.We urge epidemiology community to address the methodological standards as well as reporting of prevalence studies. The application of meta-analytical techniques including meta-regression in summarizing prevalence rates needs further research. The standards for data collection and reporting should be addressed through international consensus.LS and AMG had the idea, designed and conducted the systematic review. AD, LS, AMG and GP planned the analysis. AD and MT carried out the analysis. LS wrote and AMG, AD, MT, GP contributed to the manuscript.