Characteristics of breast carcinomas missed by screening radiologists.

PURPOSE: To determine whether breast cancers missed at screening mammography have distinguishing characteristics from those of detected cancers. MATERIALS AND METHODS: The mammograms of 146 women with mammographically identifiable breast cancer were viewed independently by two radiologists who were blinded as to whether the cancer had been missed or detected (group 1 lesions, missed cancers; group 2 lesions, detected cancers) at screening. The mammographic lesions were characterized as to location, size, density, type, and visibility on two views. RESULTS: A significant difference between missed and detected cancers was found for diameter (P = .03), number of views (P < .0017), and density (P = .0007). Stepwise multivariable logistic regression showed that density (P = .01) and the number of views (P = .03) but not diameter (P = .27) were independently significant in distinguishing the groups. No statistically significant difference was found between the two groups for lesion type (P = .32 for reader 1 and P = .27 for reader 2) or location (P = .86 for reader 1 and P > .96 for reader 2). CONCLUSION: Missed cancers were statistically significantly lower in density and more often seen on only one of two views than detected cancers.

Survival in medically treated patients with homozygous beta-thalassemia.

BACKGROUND: The prognosis of patients with homozygous beta-thalassemia (thalassemia major) has been improved by transfusion and iron-chelation therapy. We analyzed outcome and prognostic factors among patients receiving transfusions and chelation therapy who had reached the age at which iron-induced cardiac disease, the most common cause of death, usually occurs. METHODS: Using the duration of life without the need for either inotropic or antiarrhythmic drugs as a measure of survival without cardiac disease, we studied 97 patients born before 1976 who were treated with regular transfusions and chelation therapy. We used Cox proportional-hazards analysis to assess the effect of prognostic factors and life-table analysis to estimate freedom from cardiac disease over time. RESULTS: Of the 97 patients, 59 (61 percent) had no cardiac disease; 36 (37 percent) had cardiac disease, and 18 of them had died. Univariate analysis demonstrated that factors affecting cardiac disease-free survival were age at the start of chelation therapy (P < 0.001), the natural log of the serum ferritin concentration before chelation therapy began (P = 0.01), the mean ferritin concentration (P < 0.001), and the proportion of ferritin measurements exceeding 2500 ng per milliliter (P < 0.001). With stepwise Cox modeling, only the proportion of ferritin measurements exceeding 2500 ng per milliliter affected cardiac disease-free survival (P < 0.001). Patients in whom less than 33 percent of the serum ferritin values exceeded 2500 ng per milliliter had estimated rates of survival without cardiac disease of 100 percent after 10 years of chelation therapy and 91 percent after 15 years. CONCLUSIONS: The prognosis for survival without cardiac disease is excellent for patients with thalassemia major who receive regular transfusions and whose serum ferritin concentrations remain below 2500 ng per milliliter with chelation therapy.

Primary prevention of child sexual abuse: a critical review. Part II.

This paper (Part II) and the previous paper (Part I) provide an overview of the primary prevention of child maltreatment. Part II focuses on the effectiveness of interventions aimed at the primary prevention of child sexual abuse. It includes prospective controlled trials published between January 1979 and May 1993. These studies were systematically identified and the quality of each trial was determined using criteria which assessed methodological rigor. Interventions aimed at the prevention of sexual abuse were classified into eight main categories based on the method of intervention. All programs had education as the primary focus. There is evidence that educational programs can improve safety skills and knowledge of children about sexual abuse but no study has produced data that education actually reduces the occurrence of sexual abuse.

Primary prevention of child physical abuse and neglect: a critical review. Part I.

This paper (Part I) and its companion paper (Part II) provide an overview of the primary prevention of child maltreatment. Part I reviews the effectiveness of interventions aimed at the primary prevention of child physical abuse and neglect. Prospective controlled trials published between January 1979 and May 1993 were systematically identified. The quality of each study was determined using criteria which assessed methodological rigor. Interventions aimed at the prevention of physical abuse and neglect were classified into six main categories within the broad group of perinatal and early childhood programs. While many of these programs did not show a reduction in physical abuse or neglect, there is evidence that extended home visitation can prevent physical abuse and neglect among disadvantaged families.

Growth and clinical course of children with Crohn's disease.

Growth impairment is a common complication of childhood Crohn's disease, but longitudinal data and follow up studies into adulthood are sparse. This study reviewed the records of 100 Tanner stages 1 and 2 children (66 males, 34 females) consecutively diagnosed with Crohn's disease at this hospital between January 1980 and June 1988. The influence of sex, anatomical location of disease, severity of symptoms, corticosteroids, and surgical intervention on growth were analysed by univariate and multivariate regression analysis. At diagnosis mean standard deviation score (SDS) for height was -1.11 (1.28) (males -1.14 (1.26), females -1.05 (1.33)). Twenty one children were below the third centile for height. During years one and two height velocity (cm/y) was 4.4 (2.3) and 5.1 (2.7), but 40% of children in year one and 33% of children in year two grew less than expected (< 4 cm). Forty nine children grew < 4 cm/y during two or more of the 4.9 (1.8) years of follow up. Severity of gastrointestinal symptoms was the major factor influencing linear growth velocity (p < 0.01 for years one and two). Despite the high prevalence of growth impairment, the subset of children who had reached maturity by the time of the study (n = 67) nevertheless maintained their height centile. The SDS for height at ultimate follow up was -0.82 (1.1). Compared with diagnosis, change in SDS was +0.35 (1.08). Growth increments were comparable for surgically treated patients v patients only treated medically and among patients stratified by location of disease. Females (n = 25) achieved greater catch up growth than males (n = 42). Ultimate SDS for height for females was -0.48 (0.91) v -1.02 (1.19) for males. Change in SDS for height was +0.66 (1.27) for females v +0.16 (0.90) for males (p=0.02). These data confirm the frequency of growth impairment in childhood Crohn's disease. After diagnosis, however, the prognosis for ultimate linear growth is good.

Detection of silent coronary artery disease in adolescents and young adults with familial hypercholesterolemia by single-photon emission computed tomography thallium-201 scanning.

Familial hypercholesterolemia (FH), a genetic disease characterized by increased levels of total and low-density lipoprotein cholesterol in the blood, results in a markedly increased incidence of atherosclerosis and coronary artery disease in homozygotes and to a lesser extent in heterozygotes. The purpose of this study was to detect the presence of myocardial ischemia, particularly in heterozygotes, with stress single-photon emission computed tomography thallium-201 scanning and to determine if there were any differentiating variables between heterozygotes with normal and abnormal thallium-201 scans. Fifty-four patients (mean age 16 years; range 8 to 24) with FH were analyzed (4 homozygotes and 50 heterozygotes). Eleven heterozygotes and 3 homozygotes had abnormal thallium-201 scans. Family history, lipid profile, age and sex of heterozygotes with FH did not predict the presence of myocardial ischemia. The mean total cholesterol level in heterozygotes with normal thallium-201 scans was 7.68 +/- 2.29 mmol/liter (297 mg/dl), which was not significantly different from that in heterozygotes with abnormal scans (7.63 +/- 1.07 mmol/liter [295 mg/dl]; p = 0.91). The coronary angiography of 1 homozygote who had an abnormal thallium-201 scan demonstrated a 50% stenosis of the left anterior descending artery. Aggressive, repetitive plasma exchange was then instituted. The 11 heterozygotes with abnormal thallium-201 scans underwent more rigorous dietary and drug therapy. It is concluded that myocardial ischemia with stress in heterozygotes with FH can occur at a young age and that thallium-201 scanning should be performed early as a screening test and to guide patient management.

Clinical factors affecting mortality in children with malrotation of the intestine.

In children with symptoms secondary to malrotation of the intestine, a retrospective statistical study was undertaken to identify factors associated with an increased risk of mortality. Between 1964 and 1989, laparatomy was performed on 182 children. For study purposes, the children were divided into three groups. Group I included 71 patients with an obstruction only in the duodenum. The remaining 111 children, all of whom had midgut volvulus, were further divided; those without gut necrosis (79) into group II, and those with necrosis (32) into group III. One child each died in groups I and II, and 15 in group III. In all children we evaluated the relationship between mortality and age at presentation, presence of associated serious abnormalities, time from onset of symptoms to surgery, and the presence of necrotic bowel. For group III, we considered the influence of percentage of bowel resected on mortality. In these 182 children the factors associated with an increased risk of mortality were presence of necrosis (P < .0001), presence of other abnormalities (P = .0008), and younger age (P = .0084). Time from onset of symptoms to surgery was not associated with statistically increased risk of mortality. The 1% mortality noted in children without intestinal necrosis (group I and II) was related to associated abnormality. For group III the estimated probability of survival ranged from .999 for patients with 10% of intestinal necrosis to .351 for whose with 75% of intestinal necrosis, assuming the best prognostic conditions (patient older than 3 months with no associated serious abnormalities).

The peritoneal equilibration test in children.

The peritoneal equilibration test (PET) has been recommended in adults as a standardized means of estimating solute transport. Based on results of the PET, adult peritoneal permeability has been classified as high, high average, low average, and low. We performed a PET on 32 children aged 0.8 to 17.8 years (mean 9.3) using a dwell volume of 32 +/- 5 ml/kg of 2.5% dialysate. Dialysate to plasma (D/P) ratios for creatinine, urea, and sodium were calculated at two and four hours as were the ratios of dialysate glucose at two and four hours to the dialysate glucose at time 0 (D/Do). Stepwise logistic regression identified only the patients' age and D/Do glucose values at two hours as significant predictors of ultrafiltration. Net ultrafiltration after a four hour dwell could be predicted for 75% of children above 9.3 years, or whose D/Do glucose value at two hours was greater than 0.45. The mean and standard deviation values for D/Do glucose and D/P creatinine at four hours were 0.31 +/- 0.17 and 0.71 +/- 0.12, respectively. When children are characterized according to adult standards, at least 70% fall into the high or high average permeability categories.