Hand eczema is common in the general population and affects women twice as often as men. It is also the most frequent occupational skin disease. The economic consequences are considerable for society and for the affected individuals.To investigate the prevalence and incidence of hand eczema and to evaluate risk factors for development of hand eczema in young adults. Subjects and methods; This is a prospective follow-up study of 2,403 young adults, 16 – 19 years old in 1995 and aged 29 – 32 years, 13 years later, in 2008. They completed a postal questionnaire that included questions regarding one-year prevalence of hand eczema, childhood eczema, asthma, rhino-conjunctivitis and factors considered to affect hand eczema such as hand-washing, washing and cleaning, cooking, taking care of small children and usage of moisturisers. These factors were evaluated with the multinominal logistic regression analysis.The one-year prevalence of hand eczema was 15.8% . The incidence was 11.6 cases per 1000 person-years . Childhood eczema was the most important risk factor for hand eczema. The odds ratios were 13.17 when having hand eczema 1995 and 2008 compared to 5.17 in 2008 (p < 0.001). A high frequency of hand washing was important in predicting hand eczema only when having 1-year prevalence 2008, OR 1.02 (p = 0.038).After 13 years an increased 1-year prevalence of hand eczema was found. The significant risk factors for hand eczema changed over time from endogenous to exogenous factors. Hand eczema is common in the general population. In a recent review of studies in the general population from mostly European countries, the 1-year prevalence rates ranged from 6.5% to 17.5% ,3. SwediOccupation-related hand eczema has many negative consequences. The economic costs are considerable for affected individuals and for society ,9. Hand Several exogenous risk factors for hand eczema have been reported: occupational exposure, use of detergents and wet work at home ,12-14. TThe aim of the present study was to investigate the prevalence and cumulative incidence of hand eczema and to evaluate factors that can influence the development and recurrence of hand eczema in young adults.This is the 13 year prospective follow-up study of a cohort of pupils in upper secondary school, 16–19 years old at the baseline assessment, and consequently they were 29–32 years old at follow-up. In 1995, 2,572 pupils in the four secondary schools in Växjö completed a self-administrated questionnaire regarding hand eczema, the response rate was 98.6%. Växjö is a town in southern Sweden with approximately 70,000 inhabitants ,16. In 1In 1995 the questionnaire was based on the Toulihampi questionnaire . The queTopics surveyed by the questionnaire were: hand eczema, childhood eczema, asthma and rhino-conjunctivitis, household size and family structure, occupation and everyday activities, hand washing and skin care.A self-administrated postal questionnaire and a pre-paid return envelope were distributed in late May 2008. A postcard was sent at the beginning of June as a first reminder. At the end of August, a second reminder was sent which included a copy of the questionnaire, a pencil and a pre-paid return envelope. Finally, a postcard was sent in the middle of September as a third and final reminder.One-year prevalence of hand eczema was estimated from reported hand eczema at present or having had hand eczema some time during the last 12 months ; i.e. the percentage positive agreement in 2008 among the yes-respondents from 1995. The negative predictive value (NPV); i.e. the agreement of no-answers in 1995 and 2008 was also calculated.Potential exogenous risk factors for developing hand eczema such as household size, time required for household work, frequency of hand washing, skin protective habits, working hours outside home and leisure activities were investigated by dividing the cohort into two groups. The respondents who had 1-year prevalence of hand eczema 2008, i.e. the merged groups HX9508 and HX08, denominated the HX group, and the group that reported never having had hand eczema, the NoHX group. Furthermore, hand eczema was also studied in the two hand eczema groups separately regarding these factors.Regarding occupation, the respondents were asked not only to tell their profession, but also to give information about work tasks.The groups HX9508, HX95 and HX08 were compared to the group NoHX using a multinominal logistic regression model. The endogenous factors childhood eczema, asthma and rhino-conjunctivitis as reported in 2008 were used. The response choices in this calculation were Yes/No. Exogenous factors such as hand-washing (times a day), usage of moisturisers , cooking, cleaning/washing laundry, and taking care of children 0–4 years of age (hours a day) were investigated.Categorical data were presented as numbers and/or proportions in groups; quantitative data were presented by mean, median and quartiles. Nominal data were tested with the Chi-squared test. When the number of expected values was insufficient, Fisher’s exact test was used. When comparing groups over time, McNemar’s test was used. Ordinal and interval data were tested with Kruskal-Wallis H test and Mann–Whitney U-test in independent group comparisons. In the multinominal logistic regression analysis odds-ratios, 95% confidence intervals and p-values were given for all the covariates. If data was missing for any covariate, the individual was not included in the analysis. A p-value <0.05 was considered significant in all calculations. All statistical analyses were performed with SPSS 20.0 for Windows.The study was approved by the The Regional Ethical Review Board in Lund, (application no 156/2008).The flow-chart of the cohort is shown in Figure In the first dispatch, 899 (37%) responded, the first postcard reminder yielded 158 (10%) responses. On the second reminder 437 (32%) responded. With the final postcard reminder, 22 (2%) responded, which left 887 non-respondents.The 1-year prevalence of hand eczema in 2008 was 15.8%, Figure In 1995 in total 13.3% (202/1516) reported they had or had had hand eczema, 139 females, (16.2%) and 63 males (9.6%), p < 0.001. In 2008 an additional 198 individuals reported themselves having or having had hand eczema. Thus the cumulative incidence over the 13 years was 15.1% (198/1314), for the females 18.6% and for the males 10.7%, p < 0.001. The incidence rate was estimated as 11.6 cases per 1000 person-years, 14.3 for females and 5.2 for males (p < 0.001).Childhood eczema was reported by 400/1516 (26.4%) of the participants. The proportions of having had childhood eczema, asthma and rhino-conjunctivitis in the four groups in total and by gender for 2008 are shown in Table The question about childhood eczema was answered by 1323 of the 1516 respondents (87.3%) in 2008. In 1995, 297/1323 individuals (22.4%) reported childhood eczema, and 239 of these gave the same answer in 2008. This gives the positive predictive value (PPV) of 80.5% (239/297). The negative predictive value (NPV), i.e. reporting not having had childhood eczema in 1995 as well as in 2008, was 76.7% (610/795). When comparing genders, the PPV for females was 82.3% and the NPV was 77.0%. The PPV for males was 75.6% and the NPV was 76.5%. There were significant differences within three of the four groups between PPV and NPV; HX9508 group: PPV = 90.6% and NPV = 35.0% (p = 0.016); HX95 group: PPV = 76.7% and NPV = 60.7% (p = 0.611); HX08 group: PPV = 94.0% and NPV = 55.3% (p < 0.001); NoHX group: PPV = 73.8% and NPV = 77.6% (p < 0.001).The results regarding potential exogenous risk factors for developing hand eczema are shown in Table Concerning skin care, daily use of moisturisers was reported by 60.5% in the HX group , and by 30.6% in the NoHX group . The differences were significant between the two groups and between the genders within the groups (p < 0.001). Regardless of hand eczema, females used moisturisers significantly more often than males; 52.9% female versus 16.2% male daily users (p < 0.001), However, having hand eczema raised the reported usage of moisturizers by a factor 1.4 for females and 3.3 for males.The exogenous factors were analysed between all four groups, in total as well as between genders  and within genders in all groups, Table with hand eczema used moisturisers as often as women without hand eczema.Among the respondents 487/1323 (36.8%) used moisturisers daily. The HX9508 group used moisturisers significantly more than the other groups, 71.1%, followed by the HX08 group, 54.8%, the HX95group, 45.7% and the NoHX group, 30.6%, (p < 0.001). Among females 52.7% (n = 746), used moisturisers every day; 79% in the HX9508 group, 61.3% in the HX08 group, 56.2% in the HX95 group and 47.4% in the NoHX group (p < 0.001). Among males 16.3% used moisturisers daily: 47.6% in the HX9508 group, 38.6% in the HX08 group, 22.7% in the HX95 group and 12.7% in the NoHX group (p < 0.001). Males The analysis of endogenous and exogenous factors was performed with multinominal logistic regression. The results are shown in Table In this study comprising 1,516 young adults, the 1-year prevalence of hand eczema was more than 15%. One third of these individuals also had 1-year prevalence at the baseline 1995. The 1-year prevalence, and not the point prevalence, was used in all calculations because it better reflects the persistency, the relapsing course and the seasonal variations of the disease ,19. The The estimated incidence of hand eczema in our study was 11.6 cases per 1000 person-years, 14.3 among females and 5.2 among males. Our figures are in the upper amplitude compared to an earlier population based study from Sweden, which showed between 11.4 and 3.7 cases/1000 person-years among 20–29 year-old females and males, respectively . One expThe advantage of a longitudinal cohort study compared with a cross-sectional study is that it enables the estimation of both cumulative incidence and incidence rate. Another advantage of performing a follow-up study is the possibility to compare the development of hand eczema over time in relation to different risk factors.The four groups  were used to investigate the relationship between childhood eczema and the incidence of hand eczema. The assumption was that a smaller proportion of individuals who had hand eczema in 2008 but not in 1995 reported childhood eczema. However, there were no significant differences between the three hand eczema groups concerning childhood eczema. Furthermore, it was found that a higher proportion of individuals who had hand eczema at both occasions reported childhood eczema.Thus, in this cohort childhood eczema was the most important predicting factor regardless of the debut of hand eczema. In 2008, around 30% of our sample reported childhood eczema . In a large population-based Swedish study performed from 2002–2003, among 21–30 years-olds, childhood eczema was reported by 30.1% of females and 20.8% of males, ,28,29. TAnalyses of exogenous factors showed that the individuals with hand eczema only in 2008, reported a significantly higher frequency of hand washing compared to the individuals without hand eczema.Females with hand eczema spent significantly more time doing household activities than men with hand eczema Table . Hand waAn interesting finding was the high odds-ratio in daily use of moisturisers in the two groups with current 1-year prevalence of hand eczema (HX9508 and HX08). This pattern was not seen in the group having had hand eczema in 1995 (HX95).When self-administrated questionnaires are used, it is important for the results to be adjusted based on sensitivity and specificity of validated questions. This is especially important in diseases that are common and affect the general health and well-being of individuals, such as hand eczema. The development of specific instruments like questionnaires implicates problems. In this case the questions regarding childhood and hand eczema were not validated in 1995 but 2,535 of the 2,572 pupils (98.6%) were clinically examined, and the sensitivity of 73% and the specificity of 99% were found . The queThe answers to the open questions on occupation as well as work tasks gave no further information regarding risk factors for developing or maintaining hand eczema. This circumstance seems to be a common problem in questionnaire studies . In a stThis study demonstrated that incidence of hand eczema in early adulthood tends to be associated with factors in everyday life such as frequent hand-washing. Regarding childhood eczema, the odds ratio for having hand eczema was twice as high in the HX9508 group compared to the group HX08, indicating a high vulnerability in this group. Furthermore, early onset of hand eczema seemed to be related to endogenous risk factors such as a history of childhood eczema. The higher frequency of hand eczema among women depended on exogenous factors.The authors declare that they have no competing interests.The authors together designed the study, analysed the data and wrote the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-5945/13/14/prepubQuestions from the questionnaire 2008.Click here for file


Injecting drug users (IDUs) are a major and most important risk factor for rising hepatitis C virus (HCV) prevalence in Iran.The objective of this study was to determine the effectiveness of methadone maintenance treatment (MMT) in prevention of HCV infection transmission among IDUs.A mathematical modeling has been used to estimate number of HCV infections averted. The input parameters used in the model were collected by self-reported method from 259 IDUs before registering and one year after MMT. Nonparametric statistical tests have been used to compare risky injecting and sexual behaviors among IDUs before and after participating in MMT program. Deterministic sensitivity analyses were done to show the effects of parameters’ uncertainty on outcome.Of the 259 participants, 98.4% (255) were men, the mean age ± SD was 33.1 ± 7.58 years and HCV prevalence was 50%. The studied IDUs reported lower rate of risky injecting and sexual behavior after participation in MMT program. The cumulative incidence of HCV per 100 IDUs due to sharing injection and unsafe sexual contact with MMT program were 13.84 (95% CI: 6.17 -21.51), 0.0003 (0.0001 - 0.0005) and without it 36.48 (25.84 - 47.11) and 0.0004 (0.0002-0.0006) respectively.The MMT program is an effective intervention to prevent HCV infection transmission, although it is essential to compare its effectiveness with other interventions before implementing it in nationwide. Chronic infection with hepatitis C virus (HCV) is increasingly recognized as a major global health problem , 2. AlthToday, IDUs are a major and perhaps the most important risk factor for rising prevalence of HCV infection in Iranian population . It has The aim of this study was to determine the effectiveness of MMT program in prevention of HCV infection incidence among IDUs.To estimate number of new infection, a mathematical modeling has been used. This model has been designed by Weinstein and colleagues  that detThe probability of getting infection by investigated injection drug users, (A) through shared injection with other IDUs, (B) is represented by the following equation:BA =1-[PB [(1 - ROT) ni/2] + (1- PB)] mPIn which PB is HCV prevalence among IDUs, ROT is the rate of transmission of HCV, ni is average number of shared injections per week and m is the average number of injecting partners in each session. We assumed that the position of investigated person changes randomly in every injection session, and totally half of them are at risk of infection therefore, all injections were divided by 2 (ni/2).We added all these possibilities and calculated the number of those likely to become infected. After determining the probability of infection, we multiplied it by the number of injecting partners and then multiplied it by the probability of their being negative, so the number of infected people by each individual was calculated. Finally, we subtracted the new estimated HCV infections before and after their arrival to MMT centers.The probability of getting infection through sexual contact is represented by the following equation:BA = 1-[PB [1 - ROTBA (1 - f.e)] ns+ (1-PB)] mP6)  -16 and (6) , 18 resp6) , 20. Fin6) , 10, 21 % -16 and6) , 23 respThe continuous variables were expressed as mean ± standard deviation. After checking data for normality the Wilcoxon signed ranks test were used to compare means. All statistical tests were two-sided and the significance level was set at 0.05. Confidence intervals were calculated using the bias-corrected accelerated (BCA) percentile bootstrapping method. We conducted a deterministic one-way sensitivity analysis to determine the strength of the results. In which each parameter was changed in a sequence to the upper and lower limits at defined range while the other variables were held constant.Before enrolment, the subjects received detailed written and verbal information regarding the aims and protocol of the study and signed informed consent. The study has been approved by the Ethics Committee of the Shiraz University of Medical Sciences.Main characteristics of the subjects are summarized in table 1. Of the 259 participants, 98.4% (255) were men and the mean age ± SD was 33.1 ± 7.58 years. Among all studied IDUs 138 people had HCV certified clinical test, which showed that HCV prevalence was 50%. Our results revealed that the subjects reported higher average number of injection per week (21.28 ± 15.11 vs. 7.74 ± 7.58), sharing injection per week (3.10 ± 5.42 vs. 0.4 ± 0.97) and shared person in each party (2.04 ± 2.76 vs. 0.37 ± 0.80) before, compared to after MMT program, all differences were statistically significant (P < 0.001). We found that the average number of sexual acts per month with partners except spouse has decreased after MMT program  while the average number of sexual acts with spouse per month increased from 0.85 ± 2.29 to 1.03 ± 2.24 (p = 0.007). In addition our results showed that the average numbers of unsafe sexual acts with opposite-sex partner per month before and after MMT program were 0.75 ± 1.54 vs. 0.51 ± 1.44 respectively (P < 0.001). Also after participation in MMT program the subjects reported lower numbers of unsafe homosexual acts per month  . Our results related to number of new infections incidence are summarized in We also investigated how changes in model parameters would affect the total case averted using one-way sensitivity. Our results showed that changes in most of the input parameters had a few effects on the outcome. The total case averted were, especially, high sensitive to HCV transmission rate per injection, HCV prevalence among IDUs, number of shared person in each party and number of sharing injection per week . Illicit injection drug use is an important public health problem around the world, recent global epidemiological data indicating that about 10 million IDUs have been infected with HCV . This stThe estimated cumulative HCV incidence shows that greatest part of the HCV incidence were due to injecting compared to sexual contact. It is partially explained by higher risk of transmission of HCV infection, in high risk injections, compared to unprotected sexual contacts -33, in aWe showed that for every 100 IDUs who participate in MMT program, 22.64 new HCV infections could be averted. In other words relative risk of HCV incidence in IDUs who are on MMT was about 38%. Craine and his colleague in a prospective cohort study showed that relative risk of HCV infection in IDUs who are in opiate substitution treatment was 34%. Protective effects of MMT on incidence of HCV infection have been reported in other studies too, ranged from 18% to 60% . HoweverNonetheless Hagan and his colleague have conducted Meta-analyse to estimate effects of risk-reduction interventions on HCV seroconversion and identify the most effective intervention types. Their results illustrated that MMT was one of the most effective interventions to prevent incidence of HCV among IDUs (estimated RR = 60%) . AlthougAlthough using local high risk behavior data to estimate number of new cases of HCV among IDUs has made our results more applicable in local health policy making. Nonetheless our model has several limitations that merit consideration in interpreting results. First, our data were directly gathered from participants by an interviewer-administered questionnaire. Previous study has demonstrated that IDUs may under-report stigmatized behaviors, such as needle sharing and especially sexual behavior . Second,In conclusion MMT has been used for the treatment of addiction to heroin and other opiates for long time and has proven to be safe even when administered for 15 years or longer . IDUs no


Invasive pneumococcal disease (IPD) continues to occur at high rates among Australian Aboriginal people. The seven-valent pneumococcal conjugate vaccine (7vPCV) was given in a 2-4-6-month schedule from 2001, with a 23-valent pneumococcal polysaccharide vaccine (23vPPV) booster at 18 months, and replaced with 13vPCV in July 2011. Since carriage surveillance can supplement IPD surveillance, we have monitored pneumococcal carriage in western Australia (WA) since 2008 to assess the impact of the 10-year 7vPCV program. We collected 1,500 nasopharyngeal specimens from Aboriginal people living in varied regions of WA from August 2008 until June 2011. Specimens were cultured on selective media. Pneumococcal isolates were serotyped by the quellung reaction. Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis were carried by 71.9%, 63.2% and 63.3% respectively of children <5 years of age, and 34.6%, 22.4% and 27.2% of people ≥5 years. Of 43 pneumococcal serotypes identified, the most common were 19A, 16F and 6C in children <5 years, and 15B, 34 and 22F in older people. 7vPCV serotypes accounted for 14.5% of all serotypeable isolates, 13vPCV for 32.4% and 23vPPV for 49.9%, with little variation across all age groups. Serotypes 1 and 12F were rarely identified, despite causing recent IPD outbreaks in WA. Complete penicillin resistance (MIC ≥2µg/ml) was found in 1.6% of serotype 19A (5.2%), 19F (4.9%) and 16F (3.2%) isolates and reduced penicillin susceptibility (MIC ≥0.125µg/ml) in 24.9% of isolates, particularly 19F (92.7%), 19A (41.3%), 16F (29.0%). Multi-resistance to cotrimoxazole, tetracycline and erythromycin was found in 83.0% of 23F isolates. Among non-serotypeable isolates 76.0% had reduced susceptibility and 4.0% showed complete resistance to penicillin.Ten years after introduction of 7vPCV for Aboriginal Australian children, 7vPCV serotypes account for a small proportion of carried pneumococci. A large proportion of circulating serotypes are not covered by any currently licensed vaccine. Streptococcus pneumoniae, with up to 21% of children in WA having a tympanic membrane perforation before the age of 2 years in remote areas [Invasive pneumococcal disease (IPD), which includes pneumonia, meningitis, and septicaemia, causes an estimated 476,000 deaths in children < 5 years annually, the majority of which occur in the third world . In Westte areas . OM and ®), covering serotypes 4, 6B, 9V, 14, 18C, 19F and 23F, was introduced for Aboriginal Australian children in a 2-4-6-month schedule, with a catch-up schedule for children < 2 years of age, and for children < 5 years of age with predisposing medical conditions. A booster of 23-valent pneumococcal polysaccharide vaccine  was offered at age 18 months to Aboriginal children. In 2005 the 7vPCV program was extended to include all Australian children. On 1 July 2011 13vPCV replaced 7vPCV  in the immunization schedule and a fourth dose of 13vPCV replaced the 23vPPV booster in Aboriginal children. Since the introduction of 7vPCV, the incidence of IPD caused by vaccine serotypes has fallen but IPD due to non-7vPCV serotypes has increased, and almost doubled in WA Aboriginal adults aged 30-49 years [In 2001 the seven-valent pneumococcal conjugate vaccine , and while the incidence of IPD is high, small numbers of cases make it difficult to monitor trends effectively. Given these limitations, surveillance of nasopharyngeal pneumococcal carriage assists in identifying serotypes circulating in the population, helping to predict changes in serotypes causing IPD . CarriagWhile few reports exist on pneumococcal carriage in Aboriginal Australians prior to the introduction of 7vPCV, carriage studies in the Northern Territory indicate that 7vPCV reduced carriage of 7vPCV serotypes, similar to trends observed elsewhere .Haemophilus influenzae, Moraxella catarrhalis and Staphylococcus aureus, in Aboriginal children and adults living in Western Australia. Here we report on carriage rates of bacteria, and serotype distribution and antimicrobial susceptibility of pneumococci in children and adults in WA until the introduction of 13vPCV.Since 2008, we have studied nasopharyngeal carriage of bacterial pathogens in the Aboriginal population in WA. Our aim is to monitor nasopharyngeal carriage of pneumococcal serotypes, as well as the prevalence of other commonly carried pathogens, namely 2, with a range of climates from tropical northern Kimberley to the warm temperate southwest coast, to the inland desert. There is a sparse population of 2.2 million people (population density 0.9 persons/km2) (WA covers an area of 2.5 million kmons/km2) . AborigiFrom August 2008 until June 2011, we visited communities with Aboriginal populations across WA for data collection. Study participants attending health services for routine examination, immunization or illness who identified as Aboriginal were recruited opportunistically. People were also recruited during home visits. Non-Aboriginal people were excluded, as were those with severe congenital abnormalities.After obtaining informed written consent, demographic and environmental data were collected including smoking behaviour of family members and the number of people sharing a home. We recorded information about past and present health status and recent antibiotic use. Where possible, medical records were examined to obtain further details on recently prescribed antibiotics and illness. The Australian Childhood Immunisation Register (ACIR) was later consulted to record the vaccination status of children born from 1998 onwards. ACIR records were accessed using participants’ names and dates of birth. Children were classified as “vaccinated” with 7vPCV if they had received at least two doses of 7vPCV at least 2 weeks prior to specimen collection.Nasopharyngeal swabs (NPS) were collected using a nylon flocked swab . If participants were reluctant to provide a NPS, a nose-blown sample on a clean tissue was swabbed . Swabs wS. pneumoniae by optochin susceptibility, and H. influenzae, M. catarrhalis and S. aureus were confirmed by standard criteria [Primary culture was carried out as described previously . Brieflycriteria . Two pnecriteria .2 test.Since a minimum of two isolates were serotyped for each sample, results were aggregated according to serotype to calculate the proportion of individual serotypes among all isolates. Descriptive analyses were performed using SPSS 15.0 for Windows. Proportions were compared between different groups using the χEthical approval to conduct this study was granted by the Princess Margaret Hospital for Children Ethics Committee, the Western Australian Country Health Service Board Research Ethics Committee and the Western Australian Aboriginal Health Ethics Committee. Approval to approach communities in the Kimberley was also granted by the Kimberley Aboriginal Health Planning Forum. Prior to planning a visit, we consulted local Aboriginal community committees and/or councils to inform them of our study and seek approval to visit at an appropriate time. Written informed consent was obtained from next of kin, caretakers or guardians on behalf of children participants involved in the study, and adults provided written consent for their own participation.We visited 40 communities across WA in the following regions: the Kimberley, Goldfields, Pilbara, Gascoyne, as well as the metropolitan area of Perth and its surroundings . From AuS. pneumoniae, H. influenzae and M. catarrhalis were carried by 71.9%, 63.2% and 63.3% respectively of children < 5 years of age, and 34.6%, 22.4% and 27.2% of people ≥ 5 years. Pneumococcal carriage rates were 74.1% in females and 70.0% in males < 5 years, and 30.6% in females and 40.9% in males ≥ 5 years. More detailed age-specific bacterial carriage rates are shown in S. pneumoniae. The highest rate of pneumococcal carriage was in children aged 6-11 months (S. pneumoniae (not shown). We found no significant difference in pneumococcal carriage in people reporting respiratory symptoms compared to those who were not (p = 0.24).1 months . Of partS. pneumoniae carriage rates for participants < 5 and ≥ 5 years are shown in Region-specific S. pneumoniae, H. influenzae and M. catarrhalis was observed in 40.9 % of children < 5 years. Among adults, M. catarrhalis was most commonly carried in those aged ≥ 50 years, while H. influenzae was rarely carried in adults ≥ 50 years  were non-serotypeable . The ageOverall, we found 14.5% of serotypeable pneumococci were 7vPCV serotypes, equivalent to a prevalence of 7.0%. 13vPCV  would have covered 32.4% of serotypes carried during the study period across all ages. Half (50.1%) of the serotypes found are not included in any currently licensed vaccine . The proResistance to cotrimoxazole was present in 263 (30.6%) of all 857 pneumococcal isolates, while 156 (18.2%), 82 (9.5%), 14 (1.6%), one (0.001%) and one (0.001%) isolates were resistant to erythromycin, tetracycline, penicillin (MIC ≥ 2µg/ml), chloramphenicol and ceftriaxone (MIC ≥ 2µg/ml), respectively . ReducedThis is the first assessment of pneumococcal carriage in Aboriginal people in WA in the PCV era. The PCV program aimed to reduce the burden of invasive pneumococcal disease (IPD) but we also anticipated that it would alter the serotypes that are carried in the nasopharynx. While pneumococcal carriage rates were high, 7vPCV serotypes were rarely carried. Despite a lack of data on carriage serotypes in WA prior to introduction of 7vPCV, it is likely that the vaccination program has contributed to reducing carriage of 7vPCV serotypes. IPD due to 7vPCV serotypes accounted for 40% of IPD in 1997-2001 compared with 12% in 2005-2007 . The high pneumococcal carriage rates found in this study correspond well with studies in the Northern Territory of Australia where prevalence of carriage surpassed 80% in children aged 2-4 years in a cross-sectional study carried out in 2002 and 2004 . PneumocFour of the 12 most common carriage serotypes  are not covered by any currently licensed vaccine . SerotypSerotype 16F has been one of the most common carriage serotypes across Australia since the introduction of 7vPCV and is a predominant cause of OM and tympanic membrane perforation in Australian Aboriginal children . Serotyp 23vPPV serotypes made up half (49.9%) of all serotypes found in this study. 23vPPV was included on the immunization schedule for Aboriginal children at 18 months of age and for Aboriginal adults ≥ 55 years in WA. The relatively high prevalence of 23vPPV serotypes in this study suggests it has little effect on carriage. Outbreaks of IPD caused by serotypes 12F and 19A in 2010 and 2011 indicate 23vPPV may not have been effective in preventing IPD or this may reflect the limited 23vPPV coverage in WA . We rareS. pneumoniae, non-typeable H. influenzae and M. catarrhalis were carried by 41%, 56% and 43% of the rAOM children and 26%, 19%, and 15% of controls [Between 1999 and 2003 carriage rates were almost 50% lower in non-Aboriginal children than in Aboriginal children in the Kalgoorlie-Boulder cohort . During controls . The carPneumococcal antibiotic resistance remains relatively uncommon in this population apart from cotrimoxazole, which is important when considering empiric therapy for common infections such as OM and pneumonia. Reduced susceptibility to penicillin was observed in one-quarter of isolates, but was particularly common in nonserotypeable isolates that were also more likely to be resistant to cotrimoxazole and erythromycin. We compared our antibiotic susceptibility data with resistance rates for 261 isolates  from a cohort of 100 Aboriginal children born in Kalgoorlie-Boulder and followed for 2 years between April 1999 and January 2003 . CotrimoOur study had some limitations. The opportunistic nature of swab collection may not give a representative sample of the population. Sampling in adults was biased towards women: 77% of adults aged over 20 years were female because generally mothers and grandmothers accompanied their children to medical services, where we had the opportunity to ask them if they would like to participate in the study. However, carriage rates were not significantly different in men and women aged ≥ 20 years (p = 0.79). Vaccination data from ACIR could only be accessed for 56.4% of children swabbed, so our findings may not reflect the true number of vaccinated children. The large expanse of land and diverse regions covered by our surveillance could give rise to seasonal or geographical variation in prevalence which we could not ascertain as samples were frequently collected from limited numbers of people living in many different communities visited in different years and seasons. Since July 2011, 13vPCV has replaced 7vPCV in the WA immunization schedule. We therefore anticipate a shift in serotype distribution, with a decrease in circulation of the six additional 13vPCV serotypes now covered in the immunization schedule. Over 30% of our isolates were 13vPCV serotypes. It is essential to closely monitor changes in carriage and IPD  over the coming years to ensure appropriate vaccine policies are in place and to achieve the best outcome for the WA Aboriginal population [


Urothelial bladder carcinoma (UBC) is a very rare condition in patients aged below 50 years. The aim of the study was to answer the question whether the characteristics of cancer in this group of patients differ from general UBC features.Altogether 2160 patients treated with primary transurethral resection due to a bladder tumor were included in the study. The mean age of the cohort was 69.1 years (range 11–100). Patients were divided into three subgroups depending on age: age <41 years (group 1), age 41–50 years (group 2), age >50 years (group 3). Sex ratio, tumor grade, and stage of disease were recorded.P < 0.05). WHO grade 3 tumors were diagnosed in 0%, 8.5%, and 17.2%, respectively (P < 0.05). Non-invasive papillary carcinoma was found in 100.0%, 76.7%, and 62.7%, respectively (P < 0.05). The incidence of muscle-invasive bladder cancer was 0%, 11.0%, and 15.6%, respectively (P < 0.05).Women constituted 18.5%, 19.2%, and 25.8% of the patients in groups 1, 2, and 3, respectively (Pathological characteristics of UBC are dependent on the patients’ age. Being a very rare condition, UBC in young patients is characterized by a relatively good prognosis. Urothelial bladder carcinoma (UBC) belongs to the most common urological malignancies. In a great majority of cases, it affects patients in their sixth or seventh decade of life. According to data from the Polish National Cancer Registry, there were 5820 newly diagnosed bladder cancers in 2008 in Poland. Among them only 48 (0.8%) were found in patients aged below 40 years and 191 (3.3%) in patients aged 40–49 years  of all patients.Pathological records of 2160 consecutive patients with newly diagnosed UBC in the period January 2000 to June 2011 were retrospectively analyzed. The diagnosis was based on microscopic examination of the specimen obtained during primary transurethral resection of the bladder tumor. Mean age of the cohort was 69.1 years (range 11–100) . Women cn = 27), age 41–50 years , age >50 years . For all groups we assessed male-to-female ratio, tumor grade according to WHO 1973 classification, and stage of disease according to the TNM 2009 classification.Patients were divided into three subgroups depending on age: age <41 years . Detailed statistical analysis showed low chi-square values and P values > 0.05 when comparing group 1 to groups 2 and 3, which may depend on the fact that there were just five women in group 1  (r = 0.126)  . We also= 0.126) .P = 0.001). This also meant that there was no muscle-invasive cancer amongst the youngest patients, whereas 11.0% (group 2) and 15.6% (group 3) of the older patients suffered from invasive (T2–T4) bladder carcinoma.Non-muscle-invasive UBC (Tis + Ta + T1) was found in 27 patients (100%) in group 1, in 105 patients (89.0%) in group 2, and in 1603 patients (84.4%) in group 3 . These dWe performed a pathology analysis of UBC features in young patients and compared our results with features of UBC in a typical population, which we defined as individuals of more than 50 years of age. To the best of our knowledge, such an analysis has never been done before based on consecutive and contemporary patients, enrolling in total such significant numbers of patients younger than 50 years.We found that the incidence of UBC in women increased with age. In patients aged <41 years the incidence was 4.5 times higher in men than in women. It was only three times higher in patients aged >50 years. In a previous investigation Shi et al. showed that there was a male-to-female ratio of 4.1 in patients aged <41 years and 2.3 in patients aged >60 years  classifications. This phenomenon is not unique, since many European pathologists (over 42%) still use the primary WHO classification due to its clear criteria and simplicity . It is aThe most important limitation of our study is the relatively small number of patients in study group 1. Even though we analyzed a 10-year-period with over 2100 cases of newly diagnosed UBC, we recruited only 27 cases of patients aged 40 or less and 147 patients aged 50 or less. Because of the changing biology of neoplasms over the past years, we believe it would not be scientifically justified to analyze longer periods of time. The solution of the problem might be a national UBC registry including pathological and clinical data, which we, however, at present lack.Another important limitation of our study is its retrospective character. We did not re-evaluate microscopic slides, and our analysis is based exclusively on archival medical documentation. We are conscious of the fact that microscopic assessment of specimens obtained during transurethral resection of bladder tumors belongs to the most challenging in histopathology, with relatively high staging and grading errors, as well as a relatively high inter- and intra-observer variability . HoweverBased on the results of our study, we conclude that characteristics of urothelial bladder cancer differ depending on the patients’ age. In young patients, compared to patients aged more than 50 years, cancer occurs more frequently in men, more frequently as low-grade tumors, and the disease at the time of diagnosis is more frequently at a low stage, not requiring radical cystectomy. Bladder cancer is a very rare condition in young patients; however, if it occurs, it is characterized by a relatively good prognosis.


Dear Editor,Gasoline burn is one of the major causes of thermal burns even in the developed countries. Lack of understanding on explosive nature of gasoline has resulted into its inappropriate and unsafe use. In order to determine the frequency and outcomes of gasoline burns in our center in Tehran, Iran, we reviewed the hospital records of all acute gasoline burns during the last year. Patient’s age groups and their jobs, the mechanism of burn, Total Body Surface Area (TBSA), total hospitalization days, frequency of inhalation injury and mortality during their hospital admission were determined.One hundred and seventy seven gasoline burned patients were admitted compromising 18% of all acute burn admissions in our center affiliated to Tehran University of Medical Sciences. The Mean TBSA was 46.41%±27.33. The mean hospitalization was 17.77±15.83 days. Eighty six (42.9%) patients had smoke inhalation injuries based upon their history and physical exam. The mean burn percentile was 60.51 ±15.8% in contrast with 33.32±20.18% in those without inhalation injuries (p<0.05).Their mortality rate was 58.1% in contrast with 11% in others. Ninety eight (55.4%) patients were in their third or fourth decade of life and 26.6% were less than 20 years. Distribution of patients by age and TBSA is shown in Flame was responsible for 36.4% of male and 43.6% of female burn injuries in Azerbaijan Province, western Iran. GasolineSurprisingly, no report of burns in relation to carburetor priming was found in our review which was frequently noticed in other studies.6]7] Mo[7] Mo6][ Mo[7] Mo


Introduction. HIV-associated neurocognitive disorder (HAND) remains common despite the availability of antiretroviral therapy. Routine screening will improve early detections. Objective. To compare the performance of the minimental state examination (MMSE) and international HIV dementia scale (IHDS) in assessing neurocognitive function in HIV/AIDS patients on antiretroviral therapy. Methods. A case-control study of 208 HIV-positive and 121 HIV-negative individuals. Baseline demographic data were documented and cognitive function assessed using the two instruments. CD4 cell counts were recorded. Results. Cases comprised 137 females and 71 males. Controls were 86 females and 35 males. Mean MMSE score of cases was 27.7 ± 1.8 compared to 27.8 ± 1.3 in controls (P = 0.54). Mean IHDS score in cases was 8.36 ± 3.1 compared to 10.7 ± 0.9 in controls (P < 0.001). Using the MMSE scale, 6 cases but no controls had HAND (P = 0.09). Using the IHDS, 113 (54.3%) had HAND compared with 10 (8.3%) controls (P < 0.0001). Using IHDS, 56.5% cases with CD4 count > 200 had HAND compared with 92.5% with CD4 count < 200 (P < 0.001). Conclusion. These findings indicate that the IHDS detects higher rates of HAND and may identify HIV/AIDS patients who require further cognitive assessment using more robust assessment batteries. HIV-associated neurocognitive disorder is often encountered in HIV infection despite the use of potent antiretroviral therapy. The spectrum ranges from mild and asymptomatic neurocognitive impairment (ANI), minor neurocognitive disorder (MND), to the more severe HIV-associated dementia (HAD) . ANI is The widespread use of HAART has resulted in a sharp decline in its incidence but the prevalence has actually increased because of prolonged survival –6. SimilScreening for early deficits and careful evaluation of psychomotor function would permit the use of additional treatments –17 to imThe HIV clinic at the Lagos University Teaching Hospital (LUTH) is one of several HIV follow-up and treatment centers in the country funded by the Presidents Emergency Programme for AIDS Relief in Africa (PEPFAR) and is a referral center attending to about 9,000 patients annually. We used a case-control study design involving HIV-positive adults (aged >18 years) as cases and HIV-negative age-matched adults as controls. Approval of the study protocol was obtained from the Health Research and Ethics Committee of the LUTH. Informed consent was obtained from all participants.The HIV-positive cases were recruited consecutively over a 12-month period between June 2007 and May 2008. HIV-negative controls subjects were recruited from the HIV voluntary counseling and testing section of the same hospital. Cases were matched for age and sex with the controls. All cases included had low CD4 cell counts and had been on antiretroviral therapy for at least 6 months. Exclusion criteria were major opportunistic infections of the brain in the past 3 years, any other opportunistic infection not affecting the brain in the past 12 months (very ill patients), major depression according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria, active injection/inhalational recreational drug use , and pregnancy. Baseline demographic parameters, medical history, physical and neurological examination were documented using a standardized proforma. For all HIV-positive cases, latest (within preceding 3 months) CD4 count result was extracted from the clinic electronic database or case records. Face-to-face neuropsychological testing was conducted using both the MMSE  and the The IHDS is a modification of the HIV dementia scale first proposed by Power et al. 1995) [95 [19] at-test, while Pearson Chi-square was used to determine statistical significance of group differences for categorical variables. Level of significance was set at P value < 0.05. Data entry and analysis were achieved using Epi Info (Epi 3.5.1 version) statistical software. Group differences in mean values of numerical data  were compared using Student's P = 0.18 and 0.33 resp.). The mean CD4 count of cases was 251.4 ± 171.4 cells/mm3 (range 4–939 cells/mm3). Data shown in The 208 cases comprised 137 (65.9%) females and 71 (34.1%) males with a mean age ± SD of 36.8 ± 8.3 years (range 19–63 years). The control group  was made up of 86 (71.1%) females and 35 (28.9%) males, with a mean age of 38.0 ± 8.4 years (range 22–66 years). The age and gender differences were not statistically significant (P = 0.54) whilst the mean score of cases using the IHDS scale was 8.36 ± 3.1 compared with 10.7 ± 0.9 in controls (P = 0.0001) . Using the IHDS scale, based on a cut-off score of 10 (<1 SD below mean score of controls of 10.66) to define HAND, 113 HIV-positive cases (54.3%) were found to have HAND compared with 10 (8.3%) among the controls , whereas the MMSE did not detect any significant difference between HIV cases and controls, the IHDS showed a significantly higher frequency of HAND in cases. Furthermore, HAND detection rates within the HIV-positive group were significantly higher using the IHDS  compared to the MMSE  .The mean MMSE scores of HIV-positive cases was 27.7 ± 1.8 compared with 27.8 ± 1.3 for controls (3) was categorized into two to reflect disease severity (defining severe disease as CD4 count ≤200). The study comprised 115 (55.3%) with CD4 count above 200 and 93 (44.7%) ≤ 200. Using the MMSE scale, 1 (0.9%) of cases with CD4 count >200 cells/mm3 had HAND compared with 5 (5.4%) of those with CD4 count ≤200 cells/mm3 (Fisher's exact P = 0.06). Conversely, with the IHDS scale, 44/115 (38.3%) of cases with CD4 count >200 cells/mm3 had HAND compared with 69/93 (74.2%) with CD4 count <200 cells/mm3 .CD4 cell count (mm3 (median 188.0) whilst the mean CD4 count of cases with HAD was 173.4 1226 cells/mm3 (median 150.5) P = 0.0001. A total of 13/25 cases (52%) of ANI/MND had CD4 count <200 compared with 56/88 (63.6%) of cases with HAD P = 0.0001.There was insufficient data to credibly classify the subjects using these criteria (due to absence of data relating to impact on ADL/daily functioning). However with modification of the criteria, ANI and MND were grouped together  and HAD as any with values below 2SD. A total of 25 (12%) of cases had ANI and MND whilst 88 (42.3%) had HAD. The mean CD4 count of cases with ANI/MND was 208.4 99.7 cells/mmThere are few studies corroborating the superiority of the International HIV Dementia Scale over the MiniMental State Examination for assessment of HAND in persons with HIV via direct comparative studies and employing a control group. The main findings from our study are that the IHDS detects a higher proportion of persons with HAND in HIV, affording an advantage for more intensive evaluation and early interventions to improve quality of life. Although extensive neuropsychological testing using a combination of tests is regarded as the “gold standard” for cognitive assessment, the IHDS offers an advantage in the “real-world” clinical setting due to the ease of administration and can thus serve as an indicator of the need for further assessment and also serve as a monitoring tool in routine practice. The MMSE scale was only able to weakly distinguish HIV cases from controls with respect to occurrence of HAND. This reinforces previous observations alluding to its lack of sensitivity to sub-cortical cognitive dysfunction. Skinner et al. compared the performance of the original HIV dementia scale (HDS), IHDS, and MMSE scales against other neuro-cognitive batteries in assessing cognitive dysfunction in HIV patients and also demonstrated the inferiority of MMSE in contrast to the HDS and IHDS. This may be explained by the ability of the IHDS to screen for psychomotor speed , an aspect that is not included in the MMSE scale. Also, literacy level and language comprehension impair the MMSE, thus further limiting its application. The low mean test scores in the control groups may be due to bias as MMSE scores have been shown to be affected by age, sex, lower education level and sociocultural background thereby leading to improper classification of individuals . This study also demonstrated a statistically significantly higher frequency of HAND in relation to disease severity, with higher rates in HIV cases with more severe immune compromise (CD4 cell count below 200). The magnitude of the difference was also higher with the IHDS. This is explicable as CD4-related inflammatory changes in the brains of presymptomatic subjects are known to be mediated by the HIV-associated breakdown of the immune system and consequent lymphocyte dysfunction, allowing brain damage to occur. Also, the evidence for viral replication in the CNS, despite the lack of symptoms, suggests that neurocognitive functioning is likely to be more affected when more systemic immune suppression appears . We noteNjamnshi et al.  reportedOur study has added to the body of evidence encouraging the use of the IHDS as a screening instrument in the real-world clinical scenario of HIV/AIDS management, and we reemphasize that its intrinsic ability to reveal even mild cognitive impairment amenable to earlier intervention more than compensates for the possibility of a lower specificity. Incorporation of variables to determine affectation of activities of daily living into the original design of these instruments may assist in proper classification of patients especially in regions where more robust batteries are unavailable. With the accumulating evidence that standard HAART regimens are unable to fully reverse HAND and the unclear benefits of CNS-penetrant antiretroviral drugs even in the setting of long-term plasma viral suppression, there is a need for randomized prospective trials to explore the role of other adjuvant and neuroprotective therapies.


Patients with prostate cancer face the difficult decision between a wide range of therapeutic options. These men require elaborate information about their individual risk profile and the therapeutic strategies´ risks and benefits to choose the best possible option. In order to detect time trends and quality improvements between an early patient population (2003/2004) and a later reference group (2007/2008) data was analysed with regards to epidemiologic parameters, differences in diagnostics and the type and ranking of the recommended therapies taking into account changes to Gleason Grading System and implementation of new therapeutic strategies, particularly Active surveillance, in 2005.Data from all 496 consecutive patients who received consultation in 2003/2004 (n = 280) and 2007/2008 (n = 216) was retrospectively evaluated. Categorical variables were compared using the Chi-square test. Dependent variables were analysed using the unpaired Students´ t-test and the Mann–Whitney U-test.The cohorts were comparable concerning clinical stage, initial PSA, prostate volume, comorbidities and organ confined disease. Patients in Cohort I were younger  and had a longer life expectancy . 50.9%, 28.2% and 20.9% in Cohort I and 37.2%, 39.6% and 23.2% in Cohort II showed low-, intermediate- and high-risk disease (D´Amico) with a trend towards an increased risk profile in Cohort II (p = .066). The risk-adapted therapy recommended as first option was radical prostatectomy for 91.5% in Cohort I and 69.7% in Cohort II, radiation therapy for 83.7% in Cohort I and 50.7% in Cohort II, and other therapies  for 6.5% in Cohort I and 6.9% in Cohort II (p < .001). Radiation therapy was predominant in both cohorts as second treatment option (p < .001). Time trends showing quality improvement involved an increase in biopsy cores  and an increased recommendation for bilateral nerve sparing (p < .001).In the earlier years, younger patients with a more favourable risk profile presented for interdisciplinary consultation. A unilateral recommendation for radical prostatectomy and radiation therapy was predominant. In the later years, the patient population was considerably older. However, this group may have benefitted from optimised diagnostic possibilities and a wider range of treatment options. At present, about 63.000 new cases of prostate cancer (PCa) are diagnosed every year in Germany . IncreasSince 2001, interdisciplinary consultation then supported by the German Cancer Aid  has been provided to approximately 2500 PCa patients by experienced urologists and radiation therapists at the IPC [Important changes and new complements in prostate cancer therapy around the year 2005 like the revision of the Gleason Grading System , the impData from all 496 consecutive patients who received interdisciplinary consultation in 2003/2004  and 2007/2008  could be analysed. The patients presenting for consultation had to a great extent newly diagnosed, localised prostate cancer. The majority of patients was diagnosed pre-clinically by registered urologists and was then presented to the IPC for interdisciplinary consultation. Also patients with advanced prostate cancers presented for consultation in terms of a second opinion. As the patients presented for a medical consultation with no additional invasive medical procedures  and not within the context of a clinical or experimental study, no special ethical approvement was required . All patients gave their written informed consent for the evaluation and publication of the anonymised data generated within the context of the consultation. Analysis of the data encompassed important epidemiological parameters as far as known at the time of consultation  as well as the type and ranking of the recommended therapies. The recommended therapies were: radical prostatectomy , external 3D-CT-planned external beam radiation therapy (EBRT) with at least 73.8 Gy or IMRT, brachytherapy , Active surveillance , Watchful waiting (WW), high-intensity focused ultrasound , and androgen deprivation (AD). For better presentation and greater clarity, the focus lies on the first two ranks of recommendation. Equally valid recommendations were given the same ranking.Over the years, patients received consultation from a total of 17 urology specialists and 10 radiation oncology specialists. Data was assessed on the basis of medical records and by questionnaires when necessary. Normal distribution was verified by the Kolmogorov-Smirnov test. Data analysis was done using SPSS software version 19.0 . Categorical variables were compared using the Chi-square test. The unpaired Students´ t-test and the Mann–Whitney U-test were used for dependent variables as appropriate. The significance level was set at .05.PCa diagnosis was based on an elevated serum PSA level for 86.8% of the patients in Cohort I and 88.9% of the patients in Cohort II, suspicious palpation findings for 25% of the patients in Cohort I and 13.4% of the patients in Cohort II, histology after transurethral resection of the prostate (TURP) for 2.5% in Cohort I and 4.6% in Cohort II, and PCA-associated symptoms for 7.1% in Cohort I and 10.6% in Cohort II with no measurable group differences (p > .05). Table At the time of interdisciplinary consultation, analysis of the mean age of patients disclosed marked group differences: 66.44 years in Cohort I vs. 69.31 years in Cohort II (p < .001). The mean life expectancy was 17.22 years in Cohort I and 14.75 years in Cohort II (p < .001). 70.9% of the patients in Cohort I and only 40.8% of the patients in Cohort II had a life expectancy of more than 15 years (p < .001).The median PSA value at the time of diagnosis was 7.98 ± 22.59 μg/l (0.4-311) in Cohort I and 7.6 ± 15.66 μg/l (0.88-120) in Cohort II with no group differences (p = .392).Analysis of the number of cores in the diagnostic prostate biopsy showed a significant group difference in favour of Cohort II: 9.95 ± 2.38 (2–20) vs. 8.43 ± 2.29 (2–14) in Cohort I; p < .001. The two cohorts did not differ with regard to the prostate biopsy sites or the mean prostate volume (40.16 ml ± 15.64 in Cohort I and 41.75 ml ± 19.56 (n = 66) in Cohort II; p = .689). The biopsy Gleason score was 6 ± 1.43 in Cohort I and 6.59 ± 0.99 (p < .001) in Cohort II.The clinical stages were distributed as follows: T1a-c 66.1% in Cohort I and 74.4% in Cohort II, T2a-c 28.8% in Cohort I and 22.3% in Cohort II, T3 1.1% in Cohort I 0.5% in Cohort II and T4 0.7% in Cohort I and 0.5% in Cohort II .There were no group differences concerning accompanying diseases measured by the Charlson comorbidity score (CCS): 0.41 (0–6) in Cohort I and 0.39 (0–6) in Cohort II (p = .787).The groups were also comparable in terms of organ-confined disease (T2) according to Partin Tables (2007) . The Kattan nomogram predicted a 5-year biochemical failure free survival of 79.79% in Cohort I and 79.16% in Cohort II (p = .735) after RP and a rate of 79.27% (Cohort I) and 79.77%  after EBRT with no group differences.Patients were stratified by D’Amico classification into low-, intermediate- and high-risk groups as follows: 50.9%, 28.2% and 20.9% in Cohort I; 37.2%, 39.6% and 23.2% in Cohort II, showing a trend towards an increased risk profile in Cohort II (p = .066).In Cohort I, 129/280 patients (46%) underwent preoperative bone scan, which was positive in 17 cases (13.2%). If the current national or international guidelines ,11 had bAt the time of consultation, 143/261 (54.7%) patients in Cohort I and 86/191 (45%) in Cohort II were potent in terms of erections adequate for sexual intercourse (IIEF-5-Score ≥20). In this group of potent patients, the preservation of potency was important to 85.3% in Cohort I and to 87.2% in Cohort II.Table In Cohort I, the D’Amico risk-adapted therapy recommended as the first treatment option was RP for 91.5%, EBRT for 83.7%, BT for 2.4%, and AD for 3.3% (p < .001). The overlap in patients who received the equally valid recommendation for RP and EBRT was 33.9%. Predominant in the second rating of recommendations in Cohort I was EBRT (16%), followed by RP .In Cohort II, the D’Amico risk-adapted therapy recommended as the first treatment option was RP for 69.7%, EBRT for 50.7%, AD for 2.4%, AS for 2.4%, BT for 1.9%, HIFU for 1.4%, and WW for 0.5% (p < .001). The overlap in patients who received the equally valid recommendation for RP and EBRT was 5.7%. Predominant in the second rating of recommendations in Cohort II was again EBRT (49%), followed by RP (30.3%), BT (3.7%), AD (2.4%), AS (1.8%), and HIFU . The rankings of recommendations are shown in Figure Cohort I patients with a recommendation for RP had a mean age of 65.8 (50–78) years, Cohort II patients of 67.46 (48–78) years. No nerve sparing was recommended in 34%, unilateral nerve sparing in 16.5% and bilateral nerve sparing in 46.5%. In this context, there was a group difference in favour of Cohort II patients where no nerve sparing was recommended in 26%, unilateral nerve sparing in 7.4% and bilateral nerve sparing in 65.8%  and 23 in Cohort II (21.7%) were receiving long-term anticoagulant therapy with acetylsalicylic acid, while 4 in Cohort I (10.4%) and 11 in Cohort II (2.1%) were on long-term oral anticoagulation therapy (e. g. phenprocoumon) with a slight trend towards an increased number of recommendations for surgery in patients with anticoagulation therapy in favour of patients in Cohort II .Patients with a recommendation for EBRT had a mean age of 66.43 (50–81) years in Cohort I and 69.43 years (48–85 years) in Cohort II. Of the patients with a recommendation for EBRT, 44 (21%) in Cohort I and 56 (27.8%) in Cohort II were advised to undergo pelvic lymphadenectomy previous to radiation. Neoadjuvant and/or adjuvant AD was recommended for 71 patients (33.9%) in Cohort I and 66 (32.8%) in Cohort II. BT was recommended for 34 (12.1%) patients in Cohort I and 30 (13.9%) in Cohort II without group differences. There was a slight trend towards favouring EBRT for patients over 70 years of age and RP for patients under the age of 70 .AS was not considered an option until 2005 and was therefore only recommended for Cohort II patients. A total of 45 patients 20.8%) received the recommendation for AS as a treatment option in the first and second rank of recommendations. Based on the definition of patients eligible for AS given by Klotz et al. , AS coul% receiveAD alone was recommended for 14 patients (5%) in Cohort I and 13 (6%) in Cohort II. WW was recommended as a treatment option for 2 patients in Cohort I (0.7%) and for 3 patients in Cohort II (1.3%). HIFU was recommended for 27 patients (12.5%) since 2005. A recommendation of combined HIFU with pre-HIFU TURP was given to 11 of these 27 patients (40.7%).This analysis disclosed differences in the age structure of the two cohorts with a corresponding impact on the recommended treatment options. It has confirmed an age shift towards older patients with more widely varying forms of the disease. No significant group differences were found with regard to other epidemiological parameters or comorbidities.Tumor-specific differences between the groups were particularly difficult to analyse, since the revision of the Gleason grading system in 2005  caused aConcerning prostate biopsy, there was a difference in the number of biopsy cores taken in favour of the patients in Cohort II. In this context, the increased number of biopsy cores in the later cohort may be associated with the release of recommendations given by the national ´S3-guidelines on PCa´- working group in 2007  in accorAnother sign of quality improvement in terms of guideline recommendations was the fact, that bilateral nerve sparing was more frequently recommended to patients in Cohort II.Our patient population also showed a distinct trend with regard to the increased recommendation for surgery in patients under anticoagulant therapy in favour of Cohort II patients. Treatment with platelet aggregation inhibitors is particularly common in the age group of patients with PCa. Especially in patients with newly-implanted coronary stents, there seems to be consensus that platelet aggregation inhibition should be continued during RP.As aforementioned there was a measureable difference in the age structure and life expectancy between the two cohorts. Obviously the increased therapeutic options after 2005 may have led to a higher number of patients presenting with more varying forms of the disease or at later stages of the disease. Possibly these patients might have been older than those newly diagnosed with localised stages of the disease. On the other hand, since guidelines have made it easier for registered urologists to advise patients, those patients with clear preferences for one of the treatment options were simply not presented any more for consultation at the IPC. However, as these explanations are speculative, we do not have a sufficient explanation to our observation.In terms of age and therapy recommendations, we found a trend towards favouring RP for patients under 70 years and EBRT for those over 70 years. This trend could have been a result of the hypothesis at that time, that older patients may have a poorer recovery of continence after surgery. However, in their recently published analysis of 1636 patients, Kunz et al. showed that patients over the age of 70 do not face higher surgical risks and that they are not even at higher risk for postoperative incontinence. Instead, surgery-associated morbidity was mainly dependent on the patients’ preexisting comorbidities [Marked group differences were found especially in the first rank of therapy recommendations. In the earlier Cohort I, the standard therapies were predominant. Cohort II showed a marked percentage decrease in recommendations for RP and EBRT as first treatment option. One simple explanation of this observation might be again that fewer patients with a low-risk profile and an obvious preferation for one of the standard therapies presented for consultation. Presumably, the decrease in recommendation for RP or EBRT in the later cohort was due to the above-mentioned shifts in the patients’ age structure and risk profile and because of the introduction of AS and HIFU as new treatment options in 2005. Therefore, the patients in the later cohort II may have benefitted from the greater variety of treatment options.In both cohorts, EBRT was recommended most often in the second rank of recommendations.AS according to the commonly applied specifications of Klotz et al.  was recoAD and WW were a first-rating recommendation in basically only a few cases.An interdisciplinary shared decision making-process as presented here is time-consuming. However, providing a detailed description of all treatment options leads to high levels of patient satisfaction ,18. AparA face to face setting with the patient is ideal to work out the patient´s preferences. Meghani et al. recently showed that men with prostate cancer may be divided into subgroups with some men being likely to trade survival time to prevent potential treatment risks while others may accept treatment risks and are unlikely to trade survival time . The vasA communication mistake can entail overloading patients with too much information . ProvidiDespite the high number of cases and data density, there is a lack of relevant information at the time of consultation, particularly from the earlier years (Cohort I). Missing information includes standardised quality-of-life assessment  and evaluation of micturition (IPSS), erectile function (IIEF) and continence (ICIQ-SF), which are considered standard in the pre- and post-therapeutic situation ,35. ThesIndividualisation of PCa treatment is a reality. Nevertheless, the value of the various treatment options has not yet been prospectively assessed in a multicenter study. A study aimed at clarifying this question for patients in a low-risk situation of the disease is the oncoming ´PREFERE´ trial . ProspecOur analysis disclosed time trends between the two cohorts. In the early years of interdisciplinary prostate cancer consultation, younger patients with a considerably longer life expectancy presented for consultation and a unilateral recommendation for the standard therapies was therefore predominant. In the later years, there was a greater variety of treatment recommendations due to new therapeutic options like AS and HIFU. Patients in the later cohort may have benefitted from these additional treatment options, which, among other influences, may have reduced the number of recommendations for the standard therapies. Quality improvements over the years were seen in the greater number of biopsy cores in accordance with the recommendations of the national and international guidelines and the increased number of recommendations for bilateral nerve sparing prostatectomy in Cohort II. An interdisciplinary consultation for patients with newly diagnosed PCa is the gold standard with regard to comprehensive patient information.PCa: Prostate cancer; IPC: Interdisciplinary Prostate Cancer Center of the Charité-Universitätsmedizin Berlin, Germany; RP: Radical prostatectomy; EBRT: External beam radiation therapy; BT: Brachytherapy; AS: Active surveillance; WW: Watchful waiting; HIFU: High-intensity focussed ultrasound; AD: Androgen deprivation; TURP: Transurethral resection of the prostate; CCS: Charlson comorbidity score; IPSS: International Prostate Symptom Score; IIEF-5: International Index of Erectile Function; ICIQ-SF: International Consultation on Incontinence-Short Form; QLQ-C30: EORTC Quality of Life Questionnaire - Core Questionnaire; QLQ-PR25: EORTC Quality of Life Questionnaire - Prostate Module.The authors declare that they have no competing interests.DB participated in the conception, analysed and interpreted the data, wrote the manuscript and gave final approval to the content. RR and JK acquired the data. AB acquired the data and critically revised the manuscript. CK and US participated in the conception and revised the manuscript. SW analysed and interpreted the data and critically revised the manuscript. LM participated in the conception and acquired the data. MS, SH and TW made substantial contributions to the conception of the consultations´ setting. KM critically revised the manuscript. MSC made substantial contributions to the conception and data analysis and -interpretation and critically revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/13/83/prepub


To describe the cumulative 5 year incidence of visual field loss in adult Chinese in Greater Beijing.The Beijing Eye Study 2006 included 3251 subjects (mean age 60.4±10.1 years) who had participated in the Beijing Eye Study 2001 and returned for re-examination. All participants underwent a comprehensive eye examination, including visual field test by frequency doubling threshold perimetry. An abnormal visual field was defined as reduced sensitivity in at least one test location. Incident visual field loss was defined as a change in visual field from normal at baseline to abnormal at follow-up.P = 0.001), higher intraocular pressure (P<0.001), and higher fasting blood glucose concentration (P = 0.019). Considering only eyes (n = 140) with a detected cause for visual field loss, the most frequent causes were cataract (68 (48.6%) eyes) followed by glaucoma (23 (16.4%) eyes), diabetic retinopathy (13 (9.3%) eyes), age-related macular degeneration (10 (7.1%) eyes), and myopic degenerative retinopathy (9 (6.4%) eyes). For 133 (48.7%) eyes with a visual field loss, the cause for the VFL remained unclear.An incident visual field loss was detected in 273 eyes (4.3±0.5%) /235 subjects (7.3±0.5%). It was significantly associated with higher age (The 5-year incidence of visual field loss was 4.3±0.5% per eye or 7.3±0.5% per subject. It increased significantly with age, intraocular pressure, and fasting blood glucose level. Major causes for the incidence of visual field loss were cataract, glaucoma and diabetic retinopathy. Knowledge about prevalence and reasons of impaired visual acuity and visual field defects is of importance for public health policies and helps to better understand the clinical background of eye diseases. While numerous previous studies have examined the prevalence of impaired visual acuity in many ethnic groups around the globe The Medical Ethics Committee of the Beijing Tongren Hospital approved the study protocol, and all participants gave informed consent, according to the Declaration of Helsinki.The population-based Beijing Eye Study was first performed in the year 2001, and the follow up study was carried out 5 years later in 2006. At baseline, 4439 subjects out of 5324 eligible subjects were included, corresponding to a response rate of 83.4%. The study was divided into a rural part  and an urban part . The mean age was 56.2±10.6 years . At baseline and at the follow-up examination, a comprehensive eye examination was carried out including visual acuity assessment, perimetry, noncontact tonometry , slit-lamp examination of the external eye and anterior segment, and photography of the lens  and ocular fundus . The visual field examinations were performed by frequency-doubling perimetry using the screening program C-20-1  For the determination of the principle cause of incident VFL, the photographs of the lens and fundus taken in 2001 and 2006 were assessed by an experienced ophthalmologist (YXW). If multiple diseases were detected in an eye, the primary cause for visual impairment or blindness was determined by a panel . In a similar manner, if the initial reviewer could not decide on the cause for the VFL or if the cause of VFL was unknown, the panel of 3 ophthalmologists worked together to decide on the etiology.Cataract was considered to be the major reason for visual field loss, if the fundus appeared to be without major abnormality and if the lens photographs in 2006 in contrast to 2001 showed a nuclear lens opacification of grade “3” or higher or if considerable cortical or posterior subcapsular opacifications were present Statistical analysis was performed using a commercially available statistical software package . The frequency of VFL was given as mean±standard error and as 95% confidence intervals (CI). The mean values of all other parameters were given as mean±standard deviation. Multiple logistic regression analysis was used to analyze the factors related to the incidence of VFL.At the baseline examination in the year 2001, frequency doubling perimetry test results were available for 8719 eyes of 4369 subjects. Out of these eyes, the rate of false positive results was higher than 0.33 in 57 (0.7%) eyes which were excluded from further statistical analysis. Out of the whole study population, the rate of fixation loss was higher than 0.33 in 75 (0.9%) eyes. Out of these 75 eyes, 28 (37.3%) eyes had a rate of false positive answers higher than 0.33. For further analysis, all eyes (n = 104) with a rate of false positive answers higher than 0.33 and all eyes with a rate of fixation loss higher than 0.33 were excluded so that the final study population at baseline examination eventually consisted of 4349 patients (8615 eyes). A bilateral examination was available for 4267 subjects, and 83 subjects had unilateral frequency doubling perimetry. There were 1913 (44.0%) subjects from the rural region, and 2436 (56.0%) subjects from the urban region. There were 13 (0.2%) aphakic eyes, and 59 (0.7%) pseudophakic eyes. The details were published previously Among the 4439 subjects who participated in the baseline study in 2001, 3251 (73.2%) returned for the follow-up study in 2006. The remaining subjects had either died during the follow-up , or did not re-participate . From the 4349 subjects (8615 eyes), for whom a reliable visual field examination was available in 2001, 3219 (74.0%) subjects participated in the follow-up examination. In the latter, reliable visual field examinations were available for 6401 eyes of 3211 participants. For 22 eyes out of these 6401 eyes, reliable perimetric examinations for 2001 were not available, so that the study eventually included 6379 eyes (3200 participants) for which reliable visual field examinations were available for both 2001 and for 2006.P<0.001), had higher systolic blood pressure (P = 0.003) and higher fasting blood glucose concentrations (P<0.001), and had a lower visual acuity (P<0.001), a more myopic refractive error (P = 0.003), and higher intraocular pressure (P<0.001)  (P<0.001). The five-year incidence of VFL was 1.2±0.2%  per eyes or 2.0±0.4%  per subjects in the age group of 40 to 49 years, 3.5±0.4%  per eye or 6.1±0.8%  per subject for the age group from 50 to 59 years, 6.9±0.6%  per eye or 11.3±1.0  per subjects for the age group from 60 to 69 years, and 10.6±1.3%  per eye or 19.2±2.3%  per subject for the age group of 70+years, respectively.An incident VFL was found in 273 eyes  or 235 participants ). There were 38 subjects  who showed bilateral incident VFL. The group of subjects with an incident VFL as compared with the group of subjects with normal visual fields in both 2001 and 2006 revealed that subjects with an incident VDL were significantly older  . The assP = 0.001), higher intraocular pressure (P<0.001), and higher fasting blood glucose concentrations (P = 0.019)  .P = 0.01) and had a higher best corrected visual acuity (P<0.001). If the subjects without a detected cause for an incident VFL were compared with the subjects with a normal visual field, they were significantly older  and had a lower visual acuity (P<0.001).The most frequent cause for incident VFL was cataract (68 (24.9%) eyes (or 48.6% of the eyes with a detected cause for VFL)), followed by glaucoma (23 (8.4%) eyes (or 16.4% of the eyes with a detected cause for VFL)), diabetic retinopathy (13 (4.8%) eyes (or 9.3% of the eyes with a detected cause for VFL)), age-related macular degeneration (10 (3.7%) eyes (or 7.1% of the eyes with a detected cause for VFL)), and myopic degenerative retinopathy (9 (3.3%) eyes (or 6.4% of the eyes with a detected cause for VFL)) . StratifP<0.001), more myopic refractive error (P<0.001), higher systolic blood pressure (P = 0.004), higher intraocular pressure (P = 0.044), and higher fasting blood concentration of glucose (P<0.001). a visual field defect was defined as severe loss at any location, incident VFL was found in 34 eyes  or 31 participants . It was associated with age (P<0.001) only.If a visual field defect was defined as moderate loss at any location as proposed by Kogure Few population-based studies have been performed so far focusing on the prevalence of visual field defects, and even fewer investigations addressed the new occurrence of VFL in a repeatedly examined population In all available studies on the incidence of VFL, the incidence and prevalence of VFL increased with age The association between the incidence of VFL and myopic refractive error can be explained by the morphologic changes characterizing myopic degenerative myopia The major causes for incident VFL in our study were cataract, glaucoma and diabetic retinopathy, while age-related macular degeneration and retinal vein occlusion were less frequently responsible for an incident VFL. It reflects the list of disorders which were found to be the major causes for prevalence and incidence of visual impairment and blindness in population-based studies in China The association between the incidence of VFL and fasting blood glucose level agrees with a previous study by Realini and colleagues who found that diabetic patients without retinopathy tended to perform poorly on FDT testing Potential limitations of our study should be mentioned. First, the major concern, and a problem inherent to any epidemiologic study, is non-participation. The Beijing Eye Study 2006 had a reasonable response rate of overall 73%, 3251 of the 4439 subjects participated in the follow-up survey ; however, differences between participants and non-participants could have led to a selection artifact, and may have produced bias in the incidence rates of visual impairment and blindness. Second, 90.9% of the study population was younger than 70 years (40–69), 8.5% of the study population was 70–79 years old, and only 0.6% (19persons) was 80 years and older at baseline. The relatively low participation among the older, especially those older than 80 years, may also have led to an underestimation of the incidence of VFL. Third, another limitation of the present study may be the question how representative the rural regions and the urban regions of Greater Beijing are for the entire area of China. To get data on a purely rural region in China, far away from any major metropolitan region, the recent Handan Study from China may be more appropriate than the Beijing Eye study In conclusion, the 5-year cumulative incidence of visual field loss in adult Chinese in Greater Beijing was 4.3±0.5% in eyes or 7.3±0.5% in subjects. It increased significantly with age, intraocular pressure, and fasting blood glucose concentrations. Major causes for incident VFL were cataract, glaucoma and diabetic retinopathy.


Sir,et al started enrolling patients in August 2005 and ended in March 2009. The first publication on the diagnostic performance of ROMA became available in 2008  values for ROMA, CA125 and HE4 were 0.898 (0.863–0.926), 0.877 (0.840–0.908) and 0.857 (0.819–0.891), respectively, which shows a trend for better performance for ROMA. Approximate 95% confidence intervals (CIs) can be calculated from the data presented in the paper: AUC(ROMA)–AUC(CA125)=0.021 (−0.009 to 0.051), AUC(ROMA)–AUC(HE4)=0.041 (0.017 to 0.065), AUC(CA125)–AUC(HE4)=0.020 (−0.018 to 0.058). Therefore, about 5.1–6.5% AUC gain when using ROMA in place of CA125 or HE4 cannot be excluded with statistical certainty. Van Gorp et al concluded that measurement of HE4 serum levels does not contribute to the diagnosis of ovarian cancer. This conclusion could have relied on comparisons between AUC(CA125) and AUC(CA125 and HE4 combined) or AUC vs AUC(ROMA); however, such comparisons were not described in the paper. The AUC(ROMA)–AUC(CA125) comparison may be considered here, and according to the approximate 95% CI the gain may be as large as 5.1%, less the gain attributable to considering menopausal status. Van Gorp et al stated that even for the pre-menopausal patients, HE4 and ROMA did not perform better than CA125. Indeed, in this study among pre-menopausal patients, CA125 had a higher AUC than either HE4 or ROMA. These were, however, not significant, and the wide CIs did not even exclude the case that ROMA was 6.1% higher than CA125 in terms of AUC. Based on these considerations, a more appropriate conclusion would be the following: In this study ROMA had a higher AUC value discriminating between malignant and benign tumours than CA125 alone by 2.1% this difference was, however, not significant. A rough approximation of the 95% confidence interval of the AUC gain (−0.009 to 0.051) does not exclude a large 5.1% AUC gain when using ROMA in place of CA125 alone, but an AUC loss of 0.9% is also compatible with the data. In the pre-menopausal subgroup ROMA performed worse than CA125 alone, AUC difference −0.010 (rough CI: −0.081 to 0.061); the wide CI allows for both a substantial AUC gain and a substantial AUC loss.In a recent manuscript, vs 53% in the Moore study). There were also differences in the distribution of histological types of tumours. Important differences that could account for the weaker performance of HE4 in the Van Gorp's study include higher proportion of mucinous tumours, LMPs and metastatic tumours of extra-ovarian origin, and lower number of serous tumours. There was also a small difference in Stage I/II vs Stage III/IV distribution, with more early-stage tumours in Van Gorp's study. Moore's study had a higher proportion of serous EOC (64.3 vs 52.2%) and more of the endometrioid type (12.4% vs only 4.3% in Van Gorp's study). These histological types tend to overexpress HE4 and contribute to favourable HE4 performance. Van Gorp's study had more mucinous tumours (13 vs 4.7% in Moore's study). This tumour type tends not to express HE4 and contributes to the lower performance of HE4. Van Gorp's study had a higher proportion of LMPs (23.7% vs 12.3% in Moore's study) and HE4 tends to lack the sensitivity to detect non-invasive LMP.A further important consideration is that the Van Gorp's study had a high cancer incidence (41.4%) rate in comparison with Moore's study (24.3%) (et al stated that combining HE4 and CA125 in ROMA improved HE4 but not CA125 performance. As CA125 is the current standard for comparison, this means neither HE4 nor the ROMA improved the diagnosis of ovarian cancer. This statement is also debatable, as it is not shown what percentage of patients had increased levels of CA125 in this study. If the majority of patients had increased CA125, in the first place no marker alone or marker combination could improve on it. The interpretation of the HE4 thresholds is also arguable: the optimal threshold depends on the characteristics of the population and the consequences of the true and false test outcomes; but in any case HE4 is not intended to be used for screening in a group comparable to the healthy controls, rather among patients with adnexal mass.Van Gorp


The aim of this study was characterize the older injured patient in our setting and identify risk factors that might predict mortality. Trauma is the fifth leading cause of death over the age of 65. In Spain, it has become a major public health problem as a result of the increase of this population. It represents 30% of the trauma admissions to our ICU. Geriatric patients may have comorbidities, limited physiologic reserve, may be taking chronic medication and the injury pattern is different .t/Mann-Whitney tests. Multiple logistic regression analysis was used to predict mortality. P < 0.05 was considered statistically significant.We retrospectively analyzed trauma patients aged 65 years and older admitted to our ICU from January 2000 through December 2010. Three groups were formed on the basis of age: 65 to 70, 71 to 78 and older than 78 years. The Injury Severity Score (ISS) was categorized into three ranges: >12, 12 to 18 and >18. Variables studied include: age, gender, mechanism of injury, anticoagulant therapy (ACT), ISS, Glasgow Coma Scale (GCS) or presence of pupillary abnormalities and need for emergent neurosurgery (ENS) at admission. Primary outcome measures were in-hospital mortality and time to death. The secondary endpoint was to identify the effect of chronic medication on mortality. Categorical variables were compared by chi-squared test and continuous variables by Student's P < 0.05) with a HR of 6.0 (CI 2.5 to 14.6) and 1.01 (CI 1.01 to 1.05) respectively. Furthermore, the time to death was found to be earlier in both of the latter groups (P < 0.05). GCS <4 or bilateral mydriasis was associated with 100% mortality. About 15% of patients with low-energy trauma (LET) underwent ENS compared to 7.8% with high-energy trauma. For the same ISS category, ACT increases the risk with HR 2.7 (CI 1.2 to 6.3) of ENS compared with nonanticoagulated patients.The inclusion criteria were met by 261 patients. Age average was 75.57 years (SD 5.7). Male gender was more prevalent (58.5%) for all age groups. The median ISS was 17. The most frequent trauma mechanism was low-energy type (58.2%). Patients with chronic ACT numbered 41 (15.7%). The mean ICU stay was 12.8 days (SD 2.8). Global mortality was 34.1%. Age >78 years and ISS >18 were predictive of mortality (LET accounted for most of the older trauma patients admitted to our ICU and had increased risk of death, especially with ACT. Although this is not necessarily secondary to alarming mechanisms.


Transanal endoscopic microsurgery as a local therapy option for rectal neoplasms is a tissue-sparing technique that protects the anal sphincter. The present retrospective analysis reports the course of observation after local excision of adenomas and T1 low-risk carcinomas using transanal endoscopic microsurgery.n = 103) or a R0 resection of low-risk T1 carcinomas (n = 41). In this collective, we also examined parameters concerning perioperative management, complications, intraoperative blood loss and duration of hospital stay.In a retrospective analysis we examined data on 279 patients for local recurrence. A total of 144 patients had a rectal adenoma (Patients with adenoma were on average 64.9 (range 37 to 90) years old; 83.5% of the adenomas were located 3 to 11 cm from the anocutaneous line. In adenoma patients the recurrence rate was 2.9% for an observation period of 21.8 months. The postoperative course was without any complications in 98.1% of patients.Patients with T1 low-risk carcinoma were 64.6 (range 30 to 89) years old. In all cases, an R0 resection could be performed. The recurrence rate was 9.8% for an observation period of 34.4 months. In this group the postoperative course was free of complications in 97.6% of patients.The high efficacy of transanal endoscopic microsurgery ensures minimally invasive treatment of adenomas and low-risk T1 carcinomas with low complication rates and a low rate of therapeutic failure. The incidence rate of colorectal cancer in Europe is about 0.00025% a year; 29% of these carcinomas are located in the rectum.en bloc resection and curative rates[Autopsy studies reveal that 34 to 36.9% of men and 28.7 to 32% of women have rectal adenomas. Also, eve rates.The literature reports the recurrence rate for transanal polypectomy using Parks’ method to be between 16 and 20%,15. In 5The literature on treatment of T1 carcinomas with low-risk histology states that when taking account of all relevant factors such as treatment costs, complication rates and mortality, TEM with continuous follow-up examinations is superior to the radical methods,21. An iThe aim of this retrospective analysis is to show that TEM is a safe, minimally invasive technique with a low recurrence rate for the treatment of rectal adenomas and T1 carcinomas with low-risk histology .n = 103) and low-risk T1 carcinoma (n = 41) were retrospectively evaluated for local recurrence. The rest of our collective (n = 135) had advanced stages of rectal carcinomas. These patients were treated by TEM because of multimorbidity, older age or because they avoided a radical surgical procedure. This subgroup is excluded from the present study.Overall 279 patients with rectal neoplasm had a local excision with TEM in our sections in the Olympiapark-Klinik Munich and the Helios-Klinik Müllheim between 1998 and 2006. The patients signed written informed consent forms concerning the potential surgical risks. Out of this group, data for 144 patients with rectal adenoma . The database documented tumor characteristics such as size, pathology and distance from the anocutaneous line. We collected data on the applied excision method, intraoperative blood loss, operation time, perioperative complications and duration of hospital stay.Before surgery, physical examination with digital rectal palpation, rectoscopy and endosonography for the localization and extent of the tumor were performed in all patients. In addition, preoperative histology with biopsy forceps was performed.Patients with adenomas and T1 low–risk histology (pathologic findings (G1 to G2), R0 resection and the absence of microlymphatic or microvascular invasion) were included.All patients underwent surgery using the TEM technique, which was described for the first time by Buess and colleagues,23. SurgThe group of patients with adenoma included 103 patients, 57 patients were female and 46 male. The mean age was 64.9 (range 37 to 90) years, median 65 years. Of the patients, 83.5% preoperatively reported being symptom free, 9.7% consulted a physician because of bloody stools, 4.9% because of bloody mucus, while 1.9% had other symptoms.Digital rectal palpation was classified according to the modified clinical staging of Mason Table11. The rePreoperative histological findings showed in 60% of the study patients a nonhigh-grade adenoma, and in 40% a high-grade adenoma Figure. In the Tumor distance was measured from the lower rim of the tumor to the anocutaneous line. Of the adenomas 83.5% were located 3 to 11 cm from the anocutaneous line, while most (37.9%) of them were at a distance of 6 to 8 cm and 16.5% were situated >11 cm from the anocutaneous line.Full-thickness excision of the intestinal wall was performed in 87.4% of patients, while 12.6% of the patients underwent partial-thickness excision of the intestinal wall to avoid perforation to the abdominal cavity. Intraoperative blood loss averaged 20.6 (range 5 to 100) ml. In the adenoma group we had no severe intraoperative complications such as perforation or uncontrolled bleeding.The postoperative course was without complications in 101 (98.1%) patients. In two cases a rectal stenosis was postoperatively observed by endoscopy; it was overcome with a rectoscope and treated with stool-regulatory measures. Duration of hospital stay after surgery was on average 8.8 (range 1 to 18) days. Twenty-four of 103 patients (23.3%) had a tumor size ≤3 cm. Fifty-four patients (52.4%) had a tumor diameter >3 cm, with a maximum of 5 cm. A tumor diameter >5 cm with a maximum of 7 cm occurred in 17 patients (16.5%). In eight patients the tumor diameter was even larger than 7 cm.After a follow-up period of 21.8 months, 96 (93.2%) patients were free of recurrence with a follow-up rate of 96.1% . The mean age was 64.6 (range 30 to 89) years, median 65 years.Before surgery 62.1% of the patients were symptom free, 23.3% reported bloody stools and 6.8% mucus as the initial symptom, while 7.8% indicated other symptoms such as stool irregularity. The results of digital rectal palpation according to the Clinical Staging of Mason are shown in FigureIn 13 of 41 T1 low-risk carcinoma findings, preoperative histological examination showed adenomas (32.0%). Consistent with preoperative histological findings, 28 (68.0%) patients had a T1 low-risk carcinoma. As in patients with adenoma, 83.3% of T1 carcinomas were located 3 to 11 cm from the anocutaneous line, whereby most (39.8%) of the carcinomas were at a distance of 6 to 8 cm; 16.7% were more than 11 cm from the anocutaneous line.In 89.3% of our cases a full-thickness excision of the intestinal wall was performed, and 10.7% of the study patients were treated with a partial-thickness excision of the intestinal wall.Average intraoperative blood loss was 57.7 ml, median 10  ml. Most of the patients (40 of 41 patients) had no severe intraoperative complications. In one patient, uncontrolled intraoperative bleeding caused delayed hemostasis and blood transfusion was necessary.The postoperative course was without complication in 40 out of 41 patients. In one patient, a suture insufficiency occurred during hospitalization. This was diagnosed by control rectoscopy and treated conservatively. Postoperative hospital stay averaged 10.0 (range 4 to 23) days.In seven out of 41 patients (17.1%) the tumor size was ≤3 cm. Twenty-three of 41 patients (56.1%) had a tumor size >3 cm with a maximum of 5 cm. Eleven patients (26.8%) even had a tumor size larger than 5 cm.Therapy consisted exclusively of local excision by means of TEM. In all 41 patients an R0 resection was performed; 35 of these patients underwent regular follow-up without recurrence or complaints. Histological findings showed T1 low-risk carcinomas  with a follow-up rate of 95.1%. Only two patients were lost to follow-up. Thirty-five (85.4%) patients were recurrence free.Four patients relapsed after 13 to 71 months  of the 103 patients in the adenoma group. Digital rectal palpation classified 52.4% (54/103) of the patients as Clinical Stage 0 and another 35.9% (37/103) as Clinical Stage 1. The biopsy for each patient showed an adenoma.For T1 low-risk carcinomas, digital–rectal palpation showed a Clinical Stage 1 carcinoma in 50.5% of patients. Transrectal ultrasound showed stage uT0/uT1 in 38/41 (92.%) patients. As mentioned, preoperative histology showed a low-risk carcinoma in 68% of patients.Two percent of adenomas and 7% of carcinomas were tagged uT2 at the preoperative endosonographic examination. TEM was offered to these patients as a curative therapeutic option because there is no statistical difference in the 5-year survival rate between TEM and radical surgery for T2 carcinomas.Once more we therefore see that only a combination of examinations can provide the most accurate tumor assessment. This information can be used for surgical planning and for the differentiation between adenomas and T1 low-risk carcinomas. Our study population showed a perioperative mortality rate and a rate of ostomy pouch of 0%. These known advantages of TEM, particularly as compared with the radical surgical procedure, were confirmed by our study. MoreoveThe 103 adenoma patients showed a recurrence rate of 2.9% in an average observation period of 21.8 months. This correlates with data reported to date in the literature, namely recurrence rates of 2.2 to 16% for adenomas following local excision. TEM is therefore described as an appropriate method for treating broad-based rectal adenomas; the resen bloc resection and curative rates compared with the conventional endoscopic mucosal resection[A novel procedure that also enables resection of early rectal neoplasm is ESD. Some comparative studies have shown that ESD offers better short-term clinical outcomes with shorter hospital stay than a local excision approach,31. Neveesection,8. By coThe superiority of TEM versus total mesorectal excision in the treatment of T1 carcinomas is the subject of debate in the literature. Lezoche and colleagues reported that long-term results after local excision using TEM are not inferior to those reported for total mesorectal excision. A compaIn our sample the recurrence rate for patients with T1 low-risk carcinoma was 9.8% for an average observation period of 34.4 months. A limitation of this study is the fact that the depth of submucosal penetration of T1 low-risk carcinoma was not determined in our collective, because it is an important prognostic risk factor for recurrence. DoornebEven though the recurrence rate in our collective is relatively high (9.8%), the rate of failure observed in this collective was 2.4%. This observation implies that 97.6% of the study patients remained recurrence free or were successfully treated after relapse. These data demonstrate that TEM is a curative surgical technique.After relapse the therapeutic trial with TEM was not a disadvantage with regard to the prognosis in three of four cases. Particularly important in this context are continuous follow-up examinations, because 75% of the patients in this study in whom a relapse was diagnosed early were successfully treated. The different approach in therapy after relapse is caused in different wishes of patients and concomitant diseases. Two patients were given radiochemotherapy and re-TEM after relapse. A radical surgical procedure was rejected by the patients because of multimorbidity.Taking these data and the reduced surgical trauma, TEM provides an adequate primary method for treatment in this tumor stage. This finding is consistent with the experiences described by other authors for treatment of early rectal cancer,21. MoreOur results confirm that TEM is an appropriate method for treating broad-based rectal adenomas. For T1 low-risk carcinomas TEM offers a therapeutic option with low complication rates and a low rate of therapeutic failure.ESD: Endoscopic Submucosal Dissection; TEM: Transanal Endoscopic Microsurgery.The authors declare that they have no competing interests.MA, GFB, JB, and AM were responsible for the study concept and design. MA and AM were responsible for data acquisition and conception of the manuscript. MA, AM, and AK were responsible for statistical analysis. All authors were responsible for data analysis and interpretation. MA and AM drafted and designed the manuscript and contributed equally to this work. MA, AM, and AK were responsible for manuscript preparation. All authors reviewed the manuscript. All authors read and approved the final manuscript.