Validation of an algorithm to identify incident interstitial lung disease in patients with rheumatoid arthritis.

BACKGROUND/PURPOSE: Interstitial lung disease (ILD) is an important problem for patients with rheumatoid arthritis (RA). However, current approaches to ILD case finding in real-world data have been evaluated only in limited settings and identify only prevalent ILD and not new-onset disease. Our objective was to develop, refine, and validate a claims-based algorithm to identify both prevalent and incident ILD in RA patients compared to the gold standard of medical record review. METHODS: We used administrative claims data 2006-2015 from Medicare to derive a cohort of RA patients. We then identified suspected ILD using variations of ILD algorithms to classify both prevalent and incident ILD based on features of the data that included hospitalization vs. outpatient setting, physician specialty, pulmonary-related diagnosis codes, and exclusions for potentially mimicking pulmonary conditions. Positive predictive values (PPV) of several ILD algorithm variants for both prevalent and incident ILD were evaluated. RESULTS: We identified 234 linkable RA patients with sufficient data to evaluate for ILD. Overall, 108 (46.2%) of suspected cases were confirmed as ILD. Most cases (64%) were diagnosed in the outpatient setting. The best performing algorithm for prevalent ILD had a PPV of 77% (95% CI 67-84%) and for incident ILD was 96% (95% CI 85-100%). CONCLUSION: Case finding in administrative data for both prevalent and incident interstitial lung disease in RA patients is feasible and has reasonable accuracy to support population-based research and real-world evidence generation.

Exploring dairy producer and veterinarian perceptions of barriers and motivators to adopting on-farm management practices for Johne's disease control in Ontario, Canada.

Motivating uptake of management change recommendations requires knowledge of the barriers and motivators influencing producer behavior. This study investigated dairy producers' and veterinarians' perceptions of the barriers and motivators influencing the adoption of Johne's disease (JD) control recommendations in Ontario, Canada. Eight focus groups, 6 with dairy producers and 2 with veterinarians, were conducted and thematically analyzed. Both producer and veterinarian groups identified physical resources (i.e., time, money, infrastructure) and producer mindset (i.e., perceived priority of JD, perceived practicality of JD control recommendations) as key barriers to adoption. Producers tended to prioritize JD control on their farm based on their lived experiences with JD and their view of the public's concern about JD. Many agreed that JD recommendations should focus on biosecurity more holistically and emphasize the broader health benefits of limiting calf exposure to many fecal-orally transmitted diseases. Producers also highlighted that some recommendations for on-farm change (i.e., keeping a closed herd, buying from low-risk herds) were unrealistic or too difficult to perform and often disrupted their habits or routine. In contrast, veterinarians suggested that most recommendations were practical and are routinely recommended. Participants suggested both extrinsic (i.e., incentives, premiums, penalties and regulations, and extension and communication) and intrinsic (i.e., pride and responsibility) methods for motivating producers. This study highlights the importance of producer mindset in on-farm change and offers insights into the attitudes and perceived barriers influencing on-farm change.

Survey of Equine Referring Veterinarians' Satisfaction with Their Most Recent Equine Referral Experience.

BACKGROUND: Little is known about the veterinary referral process and factors that contribute to positive outcomes. OBJECTIVE: To investigate equine referring veterinarians' (rDVMs') satisfaction with their most recent referral experience and compare rDVM and specialist perspectives. SAMPLE: 187 rDVMs and 92 specialists (referral care providers). METHODS: Cross-sectional observational study. An online survey was administered to both rDVMs and specialists. Referring veterinarian satisfaction with their most recent referral experience was evaluated. Both rDVMs and specialists were asked to identify factors influencing a rDVM's decision where to refer, and the top 3 factors they perceive are barriers to referral care. RESULTS: Median rDVM satisfaction with their most recent referral care experience was 80 of 100 (mean, 75; range, 8-100). Referring veterinarians provided the lowest satisfaction score for the item asking about "The competition the referral hospital poses to your practice" (mean, 56.96; median, 62; range, 0-100). The top factor rDVMs identified as influencing their decision where to refer was "quality of care," whereas specialists identified "quality of communication and updates from the clinician." Referring veterinarians' top barrier to referral care was "high cost of referral care," and for specialists was "poor service provided to the client by the referral hospital." CONCLUSIONS AND CLINICAL IMPORTANCE: Referring veterinarians generally were satisfied with referral care, but areas exist where rDVMs and specialists differ in what they view as important to the referral process. Exploring opportunities to overcome these differences is likely to support high quality care.

Group B streptococcal PCR testing in comparison to culture for diagnosis of late onset bacteraemia and meningitis in infants aged 7-90 days: a multi-centre diagnostic accuracy study.

The aim of this study was to compare an in-house real-time PCR assay, with bacterial culture as the reference, for the diagnosis of late onset group B Streptococcal (GBS) disease. This was a retrospective review. All children aged 7-90 days presenting to four paediatric centres that had a blood or CSF sample tested by GBS PCR were included. Of 7,686 blood and 2,495 cerebrospinal fluid (CSF) samples from patients of all ages received for PCR testing, 893 and 859 samples were eligible for the study, respectively. When compared to culture, the sensitivity of blood PCR was 65% (13/20) in comparison to the CSF PCR test which was 100% (5/5). Ten of 23 PCR-positive blood samples and 17 of 22 PCR-positive CSF samples were culture negative. The median threshold Ct values for culture-positive/PCR-positive CSF samples was lower than that of culture-negative/PCR-positive CSF samples (p = 0.08). Clinical details of 17 available cases that were culture negative/PCR positive were reviewed; seven were deemed to be definite cases, eight were probable and two were possible. The results showed that detection of GBS by PCR is useful for CSF samples from infants aged 7-90 days with suspected meningitis; however, analysis of blood samples by PCR is of limited value as a routine screening test for late onset GBS sepsis and should not replace bacterial culture.

Real-time polymerase chain reaction and culture in the diagnosis of invasive group B streptococcal disease in infants: a retrospective study.

Group B streptococcus (GBS) is a leading cause of invasive disease in infants. Accurate and rapid diagnosis is crucial to reduce morbidity and mortality. Real-time polymerase chain reaction (PCR) targeting the dltR gene was utilised for the direct detection of GBS DNA in blood and cerebrospinal fluid (CSF) from infants at an Irish maternity hospital. A retrospective review of laboratory and patient records during the period 2011-2013 was performed in order to evaluate PCR and culture for the diagnosis of invasive GBS disease. A total of 3570 blood and 189 CSF samples from 3510 infants had corresponding culture and PCR results. Culture and PCR exhibited concordance in 3526 GBS-negative samples and 13 (25%) GBS-positive samples (n = 53). Six (11%) and 34 (64%) GBS-positive samples were positive only in culture or PCR, respectively. Culture and PCR identified more GBS-positive infants (n = 47) than PCR (n = 43) or culture (n = 16) alone. Using culture as the reference standard, the sensitivity, specificity, and positive and negative predictive values for PCR on blood samples were 71.4%, 99.2%, 25% and 99.9%, and for CSF samples, they were 60%, 97.8%, 42.9% and 98.9%, respectively. The sensitivity and positive predictive values were improved (blood: 84.6% and 55%; CSF: 77.8% and 100%, respectively) when maternal risk factors and other laboratory test results were considered. The findings in this study recommend the use of direct GBS real-time PCR for the diagnosis of GBS infection in infants with a clinical suspicion of invasive disease and as a complement to culture, but should be interpreted in the light of other laboratory and clinical findings.

Evaluating the effect of Focus Farms on Ontario dairy producers' knowledge, attitudes, and behavior toward control of Johne's disease.

This study evaluated a participatory-based, experiential learning program, Ontario Focus Farms (FF), which aimed to change dairy producer behavior to control Johne's disease (JD) in Ontario, Canada. The goals were to (1) assess the effect of FF on participating dairy producers' knowledge, attitudes, and behavior with regard to JD control; (2) compare changes in these factors among FF participants to changes among a group of nonparticipating dairy producers; and (3) describe the characteristics of producers who made at least one on-farm management change. Pre- and post-FF intervention questionnaires collected data on respondents' knowledge, attitudes, behavior, herd production, and demographic information; before and after JD-risk assessments were used to assess respondents' on-farm risk of JD transmission. Overall, 176 dairy producers participated in the FF process; 39.8% (70/176) of FF and 14.6% (52/357) of control participants responded to both the pre- and postintervention questionnaires. Upon comparison, FF respondents were more likely to be younger, have larger herds, and have higher management scores. The proportion of FF participants who reported making at least one on-farm change (81%) was significantly higher than that of control respondents (38%). Overall, FF respondents significantly changed their risk score in 4 out of 5 risk areas and had an average reduction of 13 points in their overall risk score between before and after risk assessments. Control respondents' risk assessment scores did not significantly change during the study period. In a JD knowledge assessment, FF and control respondents exhibited a moderate knowledge score before the intervention period, with median scores of 75.9% (22/29) in each group. The FF respondents significantly increased their score at the postintervention assessment, with a median of 82.8% (24/29); control-respondent scores did not significantly change. Both FF and control respondents held strong positive attitudes toward JD control and felt a moderate amount of social pressure from veterinarians and industry organizations to make on-farm changes. However, they questioned their ability to effectively control JD on the farm. Last, participating in FF, having a moderate herd management score, having a positive perception about the practicality of on-farm recommendations, and having a singular learning preference were associated with increased odds of making an on-farm change. Overall, the FF process appears to be effective at influencing producer behavior toward implementing on-farm management practices for JD control. Future JD control programs should consider implementing peer-learning extension processes, such as FF, in combination with other extension approaches, to influence producer behavior.

Increased incidence of invasive group A streptococcal disease in Ireland, 2012 to 2013.

Invasive group A streptococcal (iGAS) infections have been notifiable in Ireland since 2004. Incidence rates (2004-2011) have ranged from 0.8 to 1.65 per 100,000. In 2012, the iGAS rate rose to 2.66 per 100,000 and was associated with a high proportion of emm1 isolates. A further increase in January to June 2013 has been associated with increased prevalence of emm3. Public health departments and clinicians have been alerted to this increase.

MicroRNA-204 increases sensitivity of neuroblastoma cells to cisplatin and is associated with a favourable clinical outcome.

BACKGROUND: Neuroblastoma remains a major cause of cancer-linked mortality in children. miR-204 has been used in microRNA expression signatures predictive of neuroblastoma patient survival. The aim of this study was to explore the independent association of miR-204 with survival in a neuroblastoma cohort, and to investigate the phenotypic effects mediated by miR-204 expression in neuroblastoma. METHODS: Neuroblastoma cell lines were transiently transfected with miR-204 mimics and assessed for cell viability using MTS assays. Apoptosis levels in cell lines were evaluated by FACS analysis of Annexin V-/propidium iodide-stained cells transfected with miR-204 mimics and treated with chemotherapy drug or vehicle control. Potential targets of miR-204 were validated using luciferase reporter assays. RESULTS: miR-204 expression in primary neuroblastoma tumours was predictive of patient event-free and overall survival, independent of established known risk factors. Ectopic miR-204 expression significantly increased sensitivity to cisplatin and etoposide in vitro. miR-204 direct targeting of the 3' UTR of BCL2 and NTRK2 (TrkB) was confirmed. CONCLUSION: miR-204 is a novel predictor of outcome in neuroblastoma, functioning, at least in part, through increasing sensitivity to cisplatin by direct targeting and downregulation of anti-apoptotic BCL2. miR-204 also targets full-length NTRK2, a potent oncogene involved with chemotherapy drug resistance in neuroblastoma.

Three-dimensional simulation and prediction of craniofacial surgery.

The treatment of patients with complex facial deformities is one of the most challenging multidisciplinary tasks in plastic surgery. Due to advancements in medical technology and surgical techniques in the last 20 years correction of severe malformations has become possible and is performed by highly specialized teams frequently in a single operation. Recent developments in three-dimensional (3-D) imaging techniques have already greatly facilitated diagnosis of complex craniofacial deformities. Computer-based simulation methods for surgical procedures that are based on imaging data have the potential to improve surgical treatment by providing the ability to perform 'virtual surgery' preoperatively and thus reduce patient risk and morbidity intraoperatively. A method is presented for interactive computer-assisted craniofacial plastic surgery planning and visualization, especially simulation of soft tissue changes using an experimental Craniofacial Surgery Planner. The system computes non-linear soft-tissue deformation because of bone realignment. It is capable of simulating bone cutting and bone realignment with integrated interactive collision detection. Furthermore, soft-tissue deformation and cutting due to surgical instruments can be visualized. Simulation processes are based on an individual patient's preoperative 3-D computed tomography and on a 3-D, photo-realistic model of the patient's preoperative appearance obtained by a laser range scanner. Very fast and robust prediction of non-linear soft-tissue deformation is computed by optimizing a non-linear cost function.

International differences in ageing and spinal cord injury.

DESIGN: The present study is part of a programme of longitudinal research on ageing and spinal cord injury involving three populations - American, British and Canadian. The design was multivariate. OBJECTIVE: To identify international differences in outcomes associated with ageing and spinal cord injury. SETTING: A sample of 352 participants was assembled from five large, well-established databases. The Canadian sample was derived from the member database of the Canadian Paraplegic Association (Ontario and Manitoba divisions). The British sample was recruited from Southport Hospital's Northwest Regional Spinal Injuries Centre and Stoke-Mandeville Hospital's National Spinal Injuries Centre. The American sample has been recruited through Craig Hospital in Denver, Colorado. METHODS: The sample included individuals who had incurred a spinal cord injury at least 20 years previously; were admitted to rehabilitation within 1 year of injury; were between age 15 and 55 at the time of injury. Data were collected using a combination of self-completed questionnaires and interviews. Data included medical information, general health, hospitalisations, and changes in bladder and bowel management, equipment, pain, spasticity, the need for assistance, and other health issues. RESULTS: Clear international differences existed between the three samples in the three different countries. After controlling for sampling differences (ie, differences in age, level of lesion, duration of disability, etc.), the following differences were seen: (1) American participants had a better psychological profile and fewer health and disability-related problems; (2) British participants had less joint pain and less likelihood of perceiving they were ageing more quickly; (3) Canadians had more health and disability-related complications (particularly bowel, pain and fatigue problems). CONCLUSION: These differences are discussed in terms of socio-political, health care system and cultural factors that might be used to explain them, and to generate hypotheses for future research.

The fibrinogen-binding protein (FgBP) of Streptococcus equi subsp. equi additionally binds IgG and contributes to virulence in a mouse model.

The major cell-wall-associated protein of the equine pathogen Streptococcus equi subsp. equi is an M-like fibrinogen-binding protein (FgBP) which binds equine fibrinogen (Fg) avidly, through residues located at the extreme N-terminus of the molecule. In this study, it is shown that FgBP additionally binds equine IgG-Fc. When tested against polyclonal IgG from ten other animal species, it was found that FgBP binds human, rabbit, pig and cat IgG, but does not bind mouse, rat, goat, sheep, cow or chicken IgG. Through the use of a panel of recombinant FgBP truncates containing defined deletions of sequence, it was shown that residues in the central regions of FgBP are important in IgG binding. An fbp knockout mutant which does not express FgBP on the cell surface was also constructed. Mutant cells failed to autoaggregate, bound no detectable equine Fg or IgG-Fc, were rapidly killed in horse blood, and showed greatly decreased virulence in a mouse model. Results suggest that FgBP is the major surface structure responsible for binding either Fg or IgG, that the molecule has pronounced antiphagocytic properties, and that it is a likely factor contributing to the virulence of wild-type S. equi subsp. equi.

Randomized trial of presumptive sexually transmitted disease therapy during pregnancy in Rakai, Uganda.

OBJECTIVE: The purpose of this study was to assess presumptive sexually transmitted disease treatment on pregnancy outcome and HIV transmission. STUDY DESIGN: In a randomized trial in Rakai District, Uganda, 2070 pregnant women received presumptive sexually transmitted disease treatment 1 time during pregnancy at varying gestations, and 1963 control mothers received iron/folate and referral for syphilis. Maternal-infant sexually transmitted disease/HIV and infant outcomes were assessed. Intent-to-treat analyses estimated adjusted rate ratios and 95% confidence intervals. RESULTS: Sexually transmitted diseases were reduced: Trichomonas vaginalis (rate ratio, 0.28; 95% CI, 0.18%-0.49%), bacterial vaginosis (rate ratio, 0.78; 95% CI, 0.69-0.87), Neisseria gonorrhoeae /Chlamydia trachomatis (rate ratio, 0.43; 95% CI, 0.27-0.68), and infant ophthalmia (rate ratio, 0.37; 95% CI, 0.20-0.70). There were reduced rates of neonatal death (rate ratio, 0.83; 95% CI, 0.71-0.97), low birth weight (rate ratio, 0.68; 95% CI, 0.53-0.86), and preterm delivery (rate ratio, 0.77; 95% CI, 0.56-1.05); but there were no effects on maternal HIV acquisition or perinatal HIV transmission. CONCLUSION: Reductions of maternal sexually transmitted disease improved pregnancy outcome but not maternal HIV acquisition or perinatal HIV transmission.

Evaluation of the chemotherapy patient monitor: an interactive tool for facilitating communication between patients and oncologists during the cancer consultation.

Effective communication between oncologists and patients with cancer is of paramount importance. The Chemotherapy Patient Monitor (CPM) is a novel tool designed to assist doctor-patient communication regarding patient concerns and side-effects. Initially, the CPM was assessed in a primary evaluation study of its use during consultations with 26 patients with advanced colorectal cancer (one consultation without, followed by two with, the CPM per patient). This led to a further dissemination/audit of 34 patients attending oncology centres in the UK, who had completed the survey prior to three consultations. The CPM contains a checklist of common side-effects of chemotherapy regimens used in advanced colorectal cancer, and other common concerns of patients with advanced colorectal cancer. The CPM records the presence of side-effects/concerns, the distress caused, whether patients wish to discuss them further, and actions taken as a result. Questionnaires explored the views of patients and oncologists in the UK and Spain regarding the effectiveness of consultations during a baseline visit conducted without the CPM, and then with the CPM in subsequent visits. These data were then complemented by the dissemination/audit study of the CPM across nine centres in the UK. All patients understood the CPM. The CPM was rated as useful by oncologists in 83% of consultations, and did not lengthen 82% of visits. Patients felt it had improved the visit in 95% of cases. Responses from patients (100%) and oncologists (84%) indicated willingness to use the CPM for at least some consultations in the future. The results of the dissemination/audit study supported these conclusions. We conclude that the CPM appears to be a useful new tool for improving patient-doctor communication during cancer consultations.

Male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team.

BACKGROUND: Male circumcision is associated with reduced HIV acquisition. METHODS: HIV acquisition was determined in a cohort of 5507 HIV-negative Ugandan men, and in 187 HIV-negative men in discordant relationships. Transmission was determined in 223 HIV-positive men with HIV-negative partners. HIV incidence per 100 person years (py) and adjusted rate ratios (RR) and 95% confidence intervals (CI) were estimated by Poisson regression. HIV-1 serum viral load was determined for the seropositive partners in HIV-discordant couples. RESULTS: The prevalence of circumcision was 16.5% for all men; 99.1% in Muslims and 3.7% in non-Muslims. Circumcision was significantly associated with reduced HIV acquisition in the cohort as a whole (RR 0.53, CI 0.33-0.87), but not among non-Muslim men. Prepubertal circumcision significantly reduced HIV acquisition (RR 0.49, CI 0.26-0.82), but postpubertal circumcision did not. In discordant couples with HIV-negative men, no serconversions occurred in 50 circumcised men, whereas HIV acquisition was 16.7 per 100 py in uncircumcised men (P = 0.004). In couples with HIV-positive men, HIV transmission was significantly reduced in circumcised men with HIV viral loads less than 50000 copies/ml (P = 0.02). INTERPRETATION: Prepubertal circumcision may reduce male HIV acquisition in a general population, but the protective effects are confounded by cultural and behavioral factors in Muslims. In discordant couples, circumcision reduces HIV acquisition and transmission. The assessment of circumcision for HIV prevention is complex and requires randomized trials.

Mortality associated with HIV infection in rural Rakai District, Uganda.

OBJECTIVE: To assess mortality impact of HIV in rural Uganda. METHODS: An open cohort of 19983 adults aged 15-59 years, in Rakai district was followed at 10 month intervals for four surveys. Sociodemographic characteristics and symptomatology/disease conditions were assessed by interview. Deaths among residents and out-migrants were identified household census. Mortality rates were computed per 1000 person years (py) and the rate ratio (RR) of death in HIV-positive/HIV-negative subjects, and the population attributable fraction (PAF) of death were estimated according to sociodemographic characteristics. Mortality associated with potential AIDS defining symptoms and signs was assessed. RESULTS: HIV prevalence was 16.1%. Mortality was 132.6 per 1000 py in HIV-infected versus 6.7 per 1000 py in uninfected subjects, and 73.5% of adult deaths were attributable to HIV infection. Mortality increased with age, but the highest attributable risk of HIV associated deaths were observed in persons aged 20-39 years (PAF > 80%) and in women. HIV associated mortality was highest in the better educated (PAF > or = 75%) and among government employees (PAF > or = 82%). Of the HIV-positive subjects 40.5% reported no illness < 10 months preceding death, symptoms were poor predictors of death (sensitivity 1.6-38.8%), and only 9.1% met the World Health Organization clinical definition of AIDS. Infant mortality rates in babies of HIV-infected and uninfected mothers were 209.4 and 97.7 per 1000, respectively. CONCLUSION: HIV is taking substantial toll in this population, particularly among the younger better educated adults, and infants. Symptomatology or the World Health Organization definition of AIDS are poor predictors of death.

Whole-body FDG positron emission tomographic imaging for staging esophageal cancer comparison with computed tomography.

PURPOSE: The aim of the authors in this study was to critically evaluate the role of whole-body positron emission tomographic (PET) imaging with fluorine-18 fluorodeoxyglucose (FDG) in staging esophageal cancer, and further to compare this method with conventional imaging with computed tomography (CT). MATERIALS AND METHODS: The authors performed independent, blinded retrospective evaluations of FDG PET images obtained in 47 patients referred for the initial staging of esophageal cancer before minimally invasive surgical staging. Twenty PET studies from patients with nonesophageal thoracic cancers were randomly selected for inclusion in the PET readings. In a subset of 37 of 47 cases, the PET findings were compared with independent readings of CT studies acquired within the same 6-week interval. The utility of the imaging findings was evaluated using a high-sensitivity interpretation (i.e., assigning equivocal findings as positive) and a low-sensitivity interpretation (i.e., assigning equivocal findings as negative). RESULTS: PET was less sensitive (41% in high-sensitivity mode, 35% in low-sensitivity mode) than CT (63% to 87%) for diagnosing tumor involvement in locoregional lymph nodes, which was identified by surgical assessment in 72% of patients. Notable, however, was the greater specificity of PET-determined nodal sites (to approximately 90%) compared with CT (14% to 43%). In detecting histologically proved distant metastases (n = 10), PET performed considerably better when applied in the high-sensitivity mode, with a sensitivity rate of approximately 70% and a specificity rate of more than 90% in the total group and in the subset of patients with correlative CT data. In the low-sensitivity mode, CT identified only two of seven metastatic sites, whereas the high-sensitivity mode resulted in an unacceptably high rate of false-positive readings (positive predictive value, 29%). PET correctly identified one additional site of metastasis that was not detected by CT. CONCLUSIONS: The relatively low sensitivity of PET for identifying locoregional lesions precludes its replacement of conventional CT staging. However, the primary advantage of PET imaging is its superior specificity for tumor detection and improved diagnostic value for distant metastatic sites, features that may substantially affect patient management decisions. In conclusion, PET imaging is useful in the initial staging of esophageal cancer and provides additional and complementary information to that obtained by CT imaging.

Neither the A- nor B-repeat regions of the fibrinogen-binding protein of Streptococcus equi subsp. equi are essential for fibrinogen binding.

The major cell wall-associated protein (FgBP) of Streptococcus equi subsp. equi possesses two internal blocks of repeated sequence (A and B) and binds horse fibrinogen (Fg) avidly through residues located in the N-terminal half of the molecule. In the present study, we investigated the roles of the two repeats blocks in Fg binding through construction of recombinant FgBP proteins containing defined internal deletions of sequence. Ligand binding experiments clearly showed that neither repeat is essential for Fg binding. However, residues within the B repeats seem to play a major role in the aberrant mobility observed for FgBP following sodium dodecyl sulfate polyacrylamide gel electrophoresis.

Minimally invasive surgical staging for esophageal cancer.

BACKGROUND: The incidence of esophageal adenocarcinoma is increasing in the United States, and the 5-year survival rate is dismal. Preliminary data suggest that conventional imaging is inaccurate in staging esophageal cancer and could limit accurate assessment of new treatments. The objective of this study was to compare minimally invasive surgical staging (MIS) with conventional imaging for staging esophageal cancer. METHODS: Patients with potentially resectable esophageal cancer were eligible. Staging by conventional methods used computed tomography (CT) scan of the chest and abdomen, and endoscopic ultrasound (EUS), whereas MIS used laparoscopy and videothoracoscopy. Conventional staging results were compared to those from MIS. RESULTS: In 53 patients, the following stages were assigned by CT scan and EUS: carcinoma in situ (CIS; n = 1), I (n = 1), II (n = 23), III (n = 20), IV (n = 8). In 17 patients (32.1%), MIS demonstrated inaccuracies in the conventional imaging, reassigning a lower stage in 10 patients and a more advanced stage in 7 patients. CONCLUSIONS: In 32.1% of patients with esophageal cancer, MIS changed the stage originally assigned by CT scan and EUS. Therefore, MIS should be applied to evaluate the accuracy of new noninvasive imaging methods and to assess new therapies for esophageal cancer.

Beyond the pressure ulcer blame game: reflections for the future.

The concept of skin wounds caused primarily as a result of external physical forces has been the focus of many healthcare professionals for decades. Unfortunately, some of the choices made regarding the definition, description, and topical management of pressure ulcers hampers the appreciation of the complexity of issues that generally accompany the occurrence of these wounds. As the healthcare industry increasingly focuses on quality and accountability, industry watchdogs continue to develop metrics to evaluate quality of care while legal professionals demand more accountability for healthcare interventions. The management of pressure ulcers is often scrutinized and many healthcare providers are often unfairly accused of neglect. The occurrence of pressure ulcers, when viewed as a failure of the healthcare system, prevents the comprehensive and constructive attention this topic deserves. Therefore, as wound care providers, we must change the image of pressure ulcers and provide a more balanced portrayal of the influences, treatments, and likely outcomes of these wounds. We must separate fact from fiction and reality from the psychological reaction that pressure ulcers evoke. It is now time to recreate a dialogue for pressure ulcers that is productive, realistic, and likely to result in the advancement of care.