Problems in early diagnosis of bladder cancer in a spinal cord injury patient: report of a case of simultaneous production of granulocyte colony stimulating factor and parathyroid hormone-related protein by squamous cell carcinoma of urinary bladder.
(1/2333)
BACKGROUND: Typical symptoms and signs of a clinical condition may be absent in spinal cord injury (SCI) patients. CASE PRESENTATION: A male with paraplegia was passing urine through penile sheath for 35 years, when he developed urinary infections. There was no history of haematuria. Intravenous urography showed bilateral hydronephrosis. The significance of abnormal outline of bladder was not appreciated. As there was large residual urine, he was advised intermittent catheterisation. Serum urea: 3.5 mmol/L; creatinine: 77 umol/L. A year later, serum urea: 36.8 mmol/l; creatinine: 632 umol/l; white cell count: 22.2; neutrophils: 18.88. Ultrasound: bilateral hydronephrosis. Bilateral nephrostomy was performed. Subsequently, blood tests showed: Urea: 14.2 mmol/l; Creatinine: 251 umol/l; Adjusted Calcium: 3.28 mmol/l; Parathyroid hormone: < 0.7 pmol/l (1.1 - 6.9); Parathyroid hormone-related protein (PTHrP): 2.3 pmol/l (0.7 - 1.8). Ultrasound scan of urinary bladder showed mixed echogenicity, which was diagnosed as debris. CT of pelvis was interpreted as vesical abscess. Urine cytology: Transitional cells showing mild atypia. Bladder biopsy: Inflamed mucosa lined by normal urothelial cells. A repeat ultrasound scan demonstrated a tumour arising from right lateral wall; biopsy revealed squamous cell carcinoma. In view of persistently high white cell count and high calcium level, immunohistochemistry for G-CSF and PTHrP was performed. Dense staining of tumour cells for G-CSF and faintly positive staining for C-terminal PTHrP were observed. This patient expired about five months later. CONCLUSION: This case demonstrates how delay in diagnosis of bladder cancer could occur in a SCI patient due to absence of characteristic symptoms and signs. (+info)
Ultrasound screening for the early detection of ovarian cancer.
(2/2333)
Ovarian cancer screening in the general population has been performed using ultrasound examination of the female pelvis and serum tumor marker determinations. Ultrasound examinations, particularly transvaginal sonography (TVS), have been advocated as potentially useful modalities. Investigators from the University of Kentucky (Lexington, KY) and Hirosaki University (Hirosaki, Japan) have recently published results from ultrasound-based ovarian cancer screening studies. The Kentucky trial screened 14,469 women using TVS on an annual basis. One hundred eighty women underwent surgery, and 17 ovarian cancers were detected, 11 of which were invasive epithelial lesions. The Hirosaki trial reported the results of an ultrasound-based screening study among 51,550 women who were first-time participants. Three hundred twenty-four women underwent surgery, and 22 ovarian cancers were detected. In each of these trials, the positive predictive value of gray-scale sonography was low. Morphologic tumor indexing and Doppler examinations have both been proposed as potential second-line studies, which could increase the positive predictive value of gray-scale ultrasound. A review of these techniques is presented. At present, ovarian cancer screening in the general population using ultrasound examinations is an experimental technique. Further studies are needed to determine whether second-line testing can improve the positive predictive value of gray-scale sonography such that asymptomatic women do not undergo unnecessary surgery for benign masses. (+info)
Status of tumor markers in ovarian cancer screening.
(3/2333)
One of the most promising approaches to management of ovarian cancer is early detection. Stage I ovarian cancer can be cured with currently available therapy in more than 90% of patients. However, fewer than 25% of ovarian cancers are currently detected in stage I. Detection of a greater fraction of cancers at an early stage might improve clinical outcome. Given a prevalence of one patient with ovarian cancer among 2,500 asymptomatic postmenopausal women in the general population, a successful screening strategy must have a sensitivity of more than 75% and a specificity of more than 99.6% to achieve a positive predictive value of 10%. Approaches to screening include transvaginal sonography, serum markers, and two-stage strategies that use alterations in serum markers to prompt sonographic examination. Among the serum markers, CA-125 has been studied most extensively. Isolated values of CA-125 lack adequate sensitivity or specificity, but when monitored over time, serial CA-125 values can achieve a specificity of 99.6%. However, sensitivity is limited and CA-125 may only be expressed by 80% of early-stage cancers. Multiple markers may exhibit greater specificity when studied over time. To combine multiple markers, more sophisticated mathematical analysis will be required. At present, screening women at conventional risk should be restricted to clinical trials. In the future, however, screening for ovarian cancer may reduce the morbidity and mortality of this disease. (+info)
Calculation of the risk of ovarian cancer from serial CA-125 values for preclinical detection in postmenopausal women.
(4/2333)
PURPOSE: Previous studies of CA-125 levels from screening trials for ovarian cancer have indicated that serial CA-125 levels may identify cases better than a fixed CA-125 cutoff. We conducted a study to assess the screening performance of the risk of ovarian cancer calculation based on serial CA-125 levels from prospectively collected serum samples compared with a fixed CA-125 cutoff. PATIENTS AND METHODS: The calculation was applied to data from a prospective trial of screening for ovarian cancer involving 22,000 postmenopausal women older than 45 years. The analysis was performed using 33,621 CA-125 results from 9,233 women for whom two or more serial samples were available. All serum samples from the patients with ovarian cancer were obtained before clinical detection. Sensitivity and specificity levels for preclinical detection of index cancers were calculated for various cutoffs for the risk and a single CA-125 measurement, and receiver operator curves were constructed. RESULTS: The risk calculation significantly improved the area under the curve from 84% to 93% compared with a fixed cutoff for CA-125 (P =.01). For a target specificity of 98%, the risk achieved a sensitivity of 86% for preclinical detection of ovarian cancer, whereas CA-125 achieved a sensitivity of 62%. The estimates of performance are unbiased, because the risk calculation was derived independent of the data from this trial. CONCLUSION: These results provide the first evidence that preclinical detection of ovarian cancer using serial CA-125 levels interpreted with the risk calculation significantly improves screening performance compared with a fixed cutoff for CA-125. The results justify the incorporation of the risk calculation in a prospective, randomized, controlled trial. (+info)
Cervical cancer screening: from the Papanicolaou smear to the vaccine era.
(5/2333)
In the next 20 years, cervical cancer screening will have evolved through four phases. The first was traditional screening, which has been associated with a two-thirds reduction in cancer incidence and death rates in the last 50 years and currently is ending. We are entering a second phase, human papillomavirus (HPV) testing, for managing cytologic abnormalities and possibly for primary screening. A third phase, new in development, proposes the use of host biomarkers (or combinations thereof) as either surrogates of HPV infection or, potentially, indicators to assess cancer risk and concentrate available resources on a subset of women. The fourth and, likely, final phase will be screening in an era of vaccines. If HPV vaccines are successful, the pool of at-risk individuals and the prevalence of papillomaviruses that place them at risk will gradually shrink. In this climate, screening strategies that target HPVs alone (as opposed to cytologic testing) may become more economical. If so, previous strategies may become obsolete as the balance of cervical cancer prevention shifts from traditional screening to primary prevention coupled with HPV testing. (+info)
Sooner or later? Issues in the early diagnosis of dementia in general practice: a qualitative study.
(6/2333)
OBJECTIVE: The aim of this study was to explore the perspectives of primary care practitioners on the early diagnosis of dementia. METHODS: A total of 247 GPs, 146 community nurses, 36 practice nurses, 79 community mental health nurses and others working in a range of hospital, residential and community settings attended 24 one-day workshops in 21 cities and towns in the UK. A nominal group approach was used relating to the early diagnosis of dementia in the community. RESULTS: Groups agreed on the benefits and risks of early diagnosis of dementia; disagreed about screening for dementia, and about professional resistance to making the diagnosis; constructed comprehensive guidelines on diagnosis, but without much reference to resource implications; yet described actual local resource limitations in detail; and avoided dilemmas about dementia care by framing it as a specialist activity. CONCLUSION: Practitioners situate dementia in a family context but do not yet use a disablement model of dementia which might reduce tensions about early diagnosis and the disclosure of the diagnosis. The term diagnosis could usefully be replaced by recognition, to aid this shift in model. Service gaps may emerge or widen if earlier diagnosis of dementia is pursued as a policy objective. (+info)
Women's early warning symptoms of acute myocardial infarction.
(7/2333)
BACKGROUND: Data remain sparse on women's prodromal symptoms before acute myocardial infarction (AMI). This study describes prodromal and AMI symptoms in women. METHODS AND RESULTS: Participants were 515 women diagnosed with AMI from 5 sites. Using the McSweeney Acute and Prodromal Myocardial Infarction Symptom Survey, we surveyed them 4 to 6 months after discharge, asking about symptoms, comorbidities, and demographic characteristics. Women were predominantly white (93%), high school educated (54.8%), and older (mean age, 66+/-12), with 95% (n=489) reporting prodromal symptoms. The most frequent prodromal symptoms experienced more than 1 month before AMI were unusual fatigue (70.7%), sleep disturbance (47.8%), and shortness of breath (42.1%). Only 29.7% reported chest discomfort, a hallmark symptom in men. The most frequent acute symptoms were shortness of breath (57.9%), weakness (54.8%), and fatigue (42.9%). Acute chest pain was absent in 43%. Women had more acute (mean, 7.3+/-4.8; range, 0 to 29) than prodromal (mean, 5.71+/-4.36; range, 0 to 25) symptoms. The average prodromal score, symptom weighted by frequency and intensity, was 58.5+/-52.7, whereas the average acute score, symptom weighted by intensity, was 16.5+/-12.1. These 2 scores were correlated (r=0.61, P<0.001). Women with more prodromal symptoms experienced more acute symptoms. After controlling for risk factors, prodromal scores accounted for 33.2% of acute symptomatology. CONCLUSIONS: Most women have prodromal symptoms before AMI. It remains unknown whether prodromal symptoms are predictive of future events. (+info)
Low fasting serum triglyceride level as a precocious marker of autoimmune disorders.
(8/2333)
The authors recently reported the occurrence of low fasting serum triglyceride (TG) and high free fatty acid (FFA) levels in idiopathic pulmonary fibrosis. TG estimation in diverse groups of patients with autoimmune disease or hyperactive immune response confirmed the occurrence of a similar decrease of TG. In some patients, serum FFA level was also evaluated. TG value in lean and obese patients was compared with that in lean (n = 108) and obese (n = 208) control subjects without autoimmune disease. In patients affected by autoimmune chronic thyroiditis with enhanced concentration of antithyroglobulin antibodies and without thyroidal failure (n = 24), lean and obese patients had reduced TG (-69/%, P < .01 and -52%, P < .0001, respectively). Both lean and obese patients affected by chronic active B or C hepatitis (n = 26), with autoantibodies and without signs of hepatic insufficiency or cirrhosis, presented reduced TG (-57%, P < .01 and -61%, P < .001, respectively). A marked TG decrease (-73%, P < .001) was observed in the lean patients affected by lupus-like syndrome (n = 7). The lean and obese patients with systemic lupus erythematosus or rheumatoid arthritis (n = 11) showed TG decrease (-66%, P < .01 and -55%, P < .05, respectively). In patients affected by anamnestic allergy or atopic dermatitis/asthma (n = 66), both lean and obese, TGs were reduced (-67%, P < .0001 and -62%, P < .001, respectively). In isolated cases of diverse autoimmune diseases (scleroderma, APECED [autoimmune polyendocrinopathy, candidiasis, and ectodermal dystrophy], urticaria or urticarial vasculitis, Reiter or Sjogren syndromes, ulcerative colitis or Crohn's disease, multiple sclerosis or Guillain-Barre syndrome) (n = 14), decreased TG was also observed both in the lean and obese subjects (-59%, P < .01 and -57%, P < .01, respectively). Concerning FFA (n = 69), value in lean patients (n = 22) vs that in lean controls (n = 18) was increased (520 +/- 31 vs 299 +/- 30 mcEq/L, +74%, P < .001), whereas value in obese patients (n = 18) vs that in obese control subjects (n = 11) was decreased (542 +/- 34 vs 774 +/- 62, -30%, P < .01). This opposite behavior of FFA in lean and obese patients needs to be confirmed. Data in this study seem to indicate that low TG value may be a precocious marker of autoimmunity or immune system hyperreactivity. (+info)