[Phosphorus MR spectroscopy and 18F-FDG PET/CT in the study of energy metabolism of glial tumors]. / Fosfornaya MR-spektroskopiya i PET/KT s 18F-FDG v izuchenii energeticheskogo metabolizma glial'nykh opukholei.

OBJECTIVE: To study energy metabolism in glial tumors using dynamic MR spectroscopy and 18F-FDG PET/CT. MATERIAL AND METHODS: The study included 19 patients (9 women and 10 men) with newly diagnosed supratentorial glial tumors WHO Grade I-IV (diffuse astrocytoma - 4 cases, oligodendroglioma - 4 cases, anaplastic astrocytoma - 5 cases, glioblastoma - 6 cases). All patients underwent examination and surgical treatment at the Burdenko Neurosurgery Center. Dynamic MR spectroscopy and 18F-FDG PET/CT were applied in each patient. RESULTS: We found multiple correlations between the ratio of bioorganic phosphate peaks and parameters of glucose uptake by tumor tissue. These relationships were more significant in patients with high-grade tumors: positive significant correlation between SUVtumor and PME/PCr ratio (RS=0.75, p=0.01), T/Nmix and ßATP/Pi ratio (Rs=0.76, p=0.02), SUVpeaktumor and aATP/Pi ratio (RS=0.77, p=0.008). Moreover, there were negative correlations between SUVtumor and PCr/bATP ratio (RS= -0.66, p=0.05), T/Nmix and PDE/bATP ratio (RS= -0.83, p=0.006), SUVpeaktumor and PDE/aATP ratio (RS= -0.76, p=0.009). CONCLUSION: High-grade gliomas were characterized by higher glucose consumption, ATP release (intensification of energy metabolism) and faster cell membrane synthesis. These processes indicate enhanced proliferation of tumor cells (intensification of plastic metabolism).

Fertility-related knowledge and reproductive goals in childhood cancer survivors: short communication.

STUDY QUESTION: Do young adult survivors of childhood cancer know their fertility status, in the context of their parenthood goals and screening for gonadal functioning? SUMMARY ANSWER: While 80% of survivors (who were without children) wanted children in the future, most did not know their fertility status, and screening for gonadal functioning was underutilized. WHAT IS KNOWN ALREADY: Survivors of childhood cancer are at risk for infertility, but fertility counseling and assessment are underutilized. Separate studies indicated that survivors' fertility-related knowledge is poor and that they often wanted to have children. Yet, studies have not investigated the intersection of both issues, as well as potential distress if parenthood goals are not met. STUDY DESIGN, SIZE, DURATION: Young adult male and female survivors of childhood cancer (N = 149) completed cross-sectional surveys, and data for those without children (n = 105, 70.5%) are presented here. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants were 20-40 years old (M = 26.5), diagnosed 5-33 years prior to study participation, and completed questionnaires online. Knowledge of fertility status, parenthood goals, and potential distress if survivors were unable to have children were assessed. Medical records were reviewed for hormone levels as indicators of screening for gonadal functioning. MAIN RESULTS AND THE ROLE OF CHANCE: Most survivors (n = 81; 77.1%) did not know their fertility status, while over 80% (n = 89) wanted children (neither aspect varied by socio-demographic/cancer-specific factors). Two-thirds of survivors indicated they would be distressed if parenthood goals remained unfulfilled; especially female (versus male, t = 2.64; P = 0.01) or partnered (versus single, t = -3.45; P < 0.001) survivors. Forty survivors (38.1%) had documented assessments of gonadal functioning, of which 33 (82.5%) reported not knowing their fertility status. LIMITATIONS, REASONS FOR CAUTION: Relevant risk factors may have not been identified owing to limited sample size and missing treatment information. The underutilization of screening for gonadal functioning needs further exploration in other pediatric centers. WIDER IMPLICATIONS OF THE FINDINGS: Most adult childhood cancer survivors want to become parents, but do not know their fertility status, which could cause significant psychological distress. Healthcare providers should continuously address fertility among survivors, but more research is needed on how to implement routine fertility counseling and/or testing. STUDY FUNDING/COMPETING INTEREST(S): This study was funded by the Research Institute at Nationwide Children's Hospital (V.L.) and Dutch Cancer Society (RUG2009-4442, M.A.T.). All authors have no conflict of interest to declare.

[Assessment of optic nerve decompression efficiency in resection of sellar region meningiomas via intradural subfrontal approach].

In this article we analyze results of the different variants of the optic nerve transcranial decompression in cases with different chiasmal region tumors. We operate 70 patient with different type meningioma (tuberculum sella, shenoid wings, anterior clinoid, optic canal), pituitary adenoma and one case with tuberculoma (we operate it thinking on meningioma, but histology was unexpected). Groups of the patients. Group1. 20 patients with pituitary adenoma with cavernous sinus invasion. It was our "pre-endoscopic" period when we frequently operated adenomas by transcranial approach. In this 20 patients we used intra-extradural Dolenc approach to cavernous sinus. In that cases we removed anterior clinoid process and decompressed optic canal. Here we use the results of surgery in this group for showing the possibility of using high speed drill for the optic canal decompression - for showing it safety. On our opinion this type of optic canal decompression is radical and safe but superfluous for the optic canal invasion by the meningioma. Group 2. 19 patients with meningioma. In that cases we partially unroofed optic canal by Kerrison and additionally we cut the falciform ligament. Group 3. 31 patients with meningioma. It's our "main" group. Here we made intradural wide unroofing the optic canal by high speed drill. Additionaly we cut the falciform ligament and open the dural sheet of the optic nerve. We propose this methodic like sufficient, safe and useful. In this cases we frequently saw the tumor spread inside the dural sheet of the optic nerve, without seeing it on the MRI. A lot of cases in this group was a recurrent after previous meningioma removal. Like a control groups we use two. Group 4. 11 cases with meningioma. In that cases we removed tumor from optic canal without any decompression. It was our archive group - we made this type of surgery before starting optic canal decompression. This group shows the risks of any manipulation with fixed optic nerves without optic canal decompression. Group 5. 31 case with meningioma. In this cases we saw the optic canal invasion by the tumor but we didn't try to decompress it. It was our archive group - we made this type of surgery before starting optic canal decompression. We use this group for found out the risks of canal decompression. This group shows the poor perspectives for the vision in optic canal invasion by the tumor without it decompression. We analyze the results of surgery on the day of discharge and on catamnesis - we decide that the optic nerves need time to recovery. We analyzed the results of surgery in patients with 3 types of the visual dysfunction: moderate (1.0-0.5), hard (0.5-0.1), decompensating (0.1-0). For showing the real risks and effectivety of any type of decompression and surgery without decompression we look for results in patients with decompensating of visual functions. For statistical analyses we use Fisher criteria which used in small series. We statistically showed that any attempts of tumor removal form the optic canal is more risky than decompression. Also we found a tendency that wide intradural decompresstion made by high speed drill with additional falciform ligament cutting and the dural sheet opening is more effective and safe than opening the optic canal by Kerrisson. This technique also could be used during the transcranial surgery for the other type of pathology particularly in cases with short optic nerves and prefixed chiasm - it gives the mobility for the nervesand decreased the nerve damaging.

Operational implementation of prospective genotyping for personalized medicine: the design of the Vanderbilt PREDICT project.

The promise of "personalized medicine" guided by an understanding of each individual's genome has been fostered by increasingly powerful and economical methods to acquire clinically relevant information. We describe the operational implementation of prospective genotyping linked to an advanced clinical decision-support system to guide individualized health care in a large academic health center. This approach to personalized medicine entails engagement between patient and health-care provider, identification of relevant genetic variations for implementation, assay reliability, point-of-care decision support, and necessary institutional investments. In one year, approximately 3,000 patients, most of whom were scheduled for cardiac catheterization, were genotyped on a multiplexed platform that included genotyping for CYP2C19 variants that modulate response to the widely used antiplatelet drug clopidogrel. These data are deposited into the electronic medical record (EMR), and point-of-care decision support is deployed when clopidogrel is prescribed for those with variant genotypes. The establishment of programs such as this is a first step toward implementing and evaluating strategies for personalized medicine.

Health-risk-assessment tools used to predict costs in defined populations.

With the Balanced Budget Act of 1997 mandating that the Health Care Financing Administration (HCFA) implement risk-adjusted payment mechanisms for Medicare managed care plans (Medicare + Choice) by January 2000, risk-adjustment tools will play an important role in future capitated reimbursement. This is because there is growing evidence that healthier-than-average beneficiaries select Medicare + Choice. The risk adjustment that HCFA has adopted is initially based on primary inpatient diagnosis from hospitalizations in the previous year. Other payers are likely to adopt similar payment mechanisms. This article reviews nineteen risk-adjustment research papers, including the tool adopted for Medicare + Choice, some of which are likely to form the basis for subsequent HCFA risk-adjustment methods. In general, claims-based models are more powerful in predicting total costs than survey-based or demographics-based models. Survey-based models, although expensive and not as powerful claims-based models, can be used when claims data are unavailable. One of the most popular survey-based tools, SF-36, is likely to become increasingly important because HCFA will be using it to measure quality outcomes from Medicare + Choice plans and will make the results public. All of the models reviewed have limitations, but can be expected to be building blocks for future risk-based capitated reimbursement.

A decision support system for microbiology quality control.

Manual review of antibiotic sensitivity testing results is an essential component of a microbiology laboratory's quality control process. Such review is tedious and prone to human error, however. An expert system is described that remembers which susceptibility patterns are considered typical or atypical by expert reviewers, then uses these to prescreen future isolates. It uses a similarity function to allow matching against this library when two patterns are close, but not identical. Use of this system allows more efficient and reliable review of the laboratory's antibiotic sensitivity testing results.

Multivariate receiver-operating characteristic curve analysis: prostate cancer screening as an example.

The evolution of test performance analysis should include the long-term costs and benefits associated with testing. Evolutionary laboratory techniques to achieve this include introduction of a new methodological technique, a multivariate extension to a current analytical technique, receiver-operating characteristic (ROC) curve analysis (MultiROC analysis). This extension to ROC methodology allows the comparison of composite test rules in a format similar to that of ROC curves. Statistical properties, guidelines for use, and a detailed example are described. MultiROC is used in the outcomes analysis of the value of screening for prostate cancer. The effect of age and different test decision thresholds are examined in an extension of a previously published outcomes analysis. The results indicate that the variations in test performances caused by these components are important in assigning a final cost:benefit ratio of screening for prostate cancer.

Glycosylated serum proteins and glycosylated hemoglobin in the assessment of glycemic control in insulin-dependent and non-insulin-dependent diabetes mellitus.

To evaluate the relative value of glycosylated serum proteins (GSPs) versus glycosylated hemoglobin (HbA1c) in assessing glycemic control in diabetes mellitus, we performed regular monitoring of GSPs and HbA1c in 30 subjects with insulin-dependent diabetes mellitus (IDDM) or non-insulin-dependent diabetes mellitus (NIDDM) who performed frequent self-glucose monitoring. Analysis of the relationship between patterns of glycemic control and GSPs and HbA1c demonstrated that subjects with IDDM and NIDDM appeared similar when the more traditional indicators of glycemic control such as mean blood glucose level (166.9 +/- 20.9 v 177.4 +/- 39.6 mg/dL) or HbA1c (83.57 +/- 12.8 v 80.24 +/- 15.7 mmol hydroxymethyl furfuraldehyde [HMF]/mol hemoglobin [Hgb]) were used. However, when GSP levels or the standard deviation of mean glucose levels (SDMG) were used to assess glycemic control, higher levels were found in subjects with IDDM (52 +/- 10.3 mg/g protein and 28.59 +/- 7.60 mg/dL) versus NIDDM (44.6 +/- 15.2 mg/g protein and 21.6 +/- 15.9 mg/dL). Using multivariate analysis, GSPs were predictive of SDMG (P = .046), whereas HbA1c added no significant further information (P = .27). Our results suggest that GSPs may be more sensitive than HbA1c assay to the greater fluctuations in blood glucose levels generally associated with IDDM.

Improved care of patients with diabetes through telecommunications.

This project tested the importance of enhanced information transfer of home monitoring results to health care providers. The study tested whether computer-assisted communication of medical information between the chronic care patient and the physician can result in health care benefit. The information tools were constructed/adapted as a test of this hypothesis for diabetes mellitus. Patients connected a glucometer to an intelligent modem weekly for six to nine months. Graphical and mathematical tools extracted and emphasized the information content of the home monitoring data arriving at the central site. Data smoothing, trend analysis, and calculation of quality control statistics were incorporated into a graphical time series oriented report that was used by the health care provider during an outpatient visit. The integrated home monitoring system was tested on 20 patients with diabetes in a double cross-over design over a 15-month period. A significant improvement in serum glucose control as measured by glycated hemoglobin was shown in the study group, but not in the control group.

Expert systems and expert behavior.

Iliad 4.0 and QMR 2.03 are computer-based diagnostic knowledge bases that can play many roles in decision support and other areas of medical practice, but neither appears ready to assume the role of an expert diagnostic consultant. In contrast to human experts, these programs have problems related to recognition of their own limitations, interpretation of continuous data, recognition of dependent findings, selection of tests, and description of the impact of certain tests. Suggestions to improve these aspects of knowledge bases are offered.

MailMinder: taming DHCP's mailman interface.

While the Department of Veteran's Affairs Decentralized Hospital Computer Program (DHCP) is one of the most widely disseminated and successful hospital information systems in existence, it currently is accessed through a user interface which is not as mature as the rest of the system. This interface is a VT-100 compatible, character oriented interface using menus accessed by typed commands for feature access. This project demonstrated that a mature graphical user interface (MailMinder) can be successfully used as a "front-end" to DHCP. MailMinder is completely compatible with the existing unmodified DHCP electronic mail program, Mailman. MailMinder allows the user to be more efficient than the current interface and offers additional features over the current mail system. The program has undergone evaluation and limited deployment at five separate sites. The feature set of this program and its operation will be shown at this demonstration. The demonstration has implications for all current hospital information systems.

The pathologist's workstation. Issues and an early prototype.

The role of a pathologist demands the efficient collection, processing and communication of information. Although computerization has been readily adopted in the laboratory to help with specimen processing, educational programs and technological tools for the pathologist's own information handling are at the inception stage. Many pathologists feel their role as a consultant would be enhanced by easy-to-use microcomputer information tools linked to their laboratory databases. This article provides an overview of emerging computer science trends and reviews areas in which a workstation is likely to be useful to the pathologist. A currently operational project embodying some of these concepts is described.

Significant efficiency findings while controlling for the frequent confounders of CAI research in the PlanAlyzer project's computer-based, self-paced, case-based programs in anemia and chest pain diagnosis.

Richard E. Clark in his widely published comprehensive studies and meta-analyses of the literature on computer assisted instruction (CAI) has decried the lack of carefully controlled research, challenging almost every study which shows the computer-based intervention to result in significant post-test proficiency gains over a non-computer-based intervention. We report on a randomized study in a medical school setting where the usual confounders found by Clark to plague most research, were carefully controlled. PlanAlyzer is a microcomputer-based, self-paced, case-based, event-driven system for medical education which was developed and used in carefully controlled trials in a second year medical school curriculum to test the hypothesis that students with access to the interactive programs could integrate their didactic knowledge more effectively and/or efficiently than with access only to traditional textual "nonintelligent" materials. PlanAlyzer presents cases, elicits and critiques a student's approach to the diagnosis of two common medical disorders: anemias and chest pain. PlanAlyzer uses text, hypertext, images and critiquing theory. Students were randomized, one half becoming the experimental group who received the interactive PlanAlyzer cases in anemia, the other half becoming the controls who received the exact same content material in a text format. Later in each year there was a crossover, the controls becoming the experimentals for a similar intervention with the cardiology PlanAlyzer cases. Preliminary results at the end of the first two full trials shows that the programs have achieved most of the proposed instructional objectives, plus some significant efficiency and economy gains. 96 faculty hours of classroom time were saved by using PlanAlyzer in their place, while maintaining high student achievement. In terms of student proficiency and efficiency, the 328 students in the trials over two years were able to accomplish the project's instructional objectives, and the experimentals accomplished this in 43% less time than the controls, achieving the same level of mastery. However, in spite of these significant efficiency findings, there have been no significant proficiency differences (as measured by current factual and higher order multiple choice post-tests) between the experimental and control groups. Very careful controls were used to avoid what Clark has found to be the most common confounders of CAI research. Accordingly, this research proved Clark's rival hypothesis, that the computer, in itself, does not appear to contribute to proficiency gains, at least as measured by our limited post-testing. Clark's position is that the computer is primarily a vehicle--as is either a pill or a hypodermic needle for delivering a drug.(ABSTRACT TRUNCATED AT 400 WORDS)

Providing integrated information resources to physicians' offices.

Pathologists have been and remain the first major providers of clinical data processed by information tools. The need simply to "get out the numbers" has been superseded by the need to transfer information efficiently. Computerized tools extract trends and convey image information.

Improved diabetic prognosis following telecommunication and graphical processing of diabetic data.

The thesis that an integrated telecommunications/reporting system would affect diabetic prognosis was tested. Over fifteen months a double crossover study compared traditional diaries versus graphical display of telecommunicated blood glucose data. Significant drops in glycohemoglobin were observed in both groups during the telecommunications period, while no significant drops were observed in the groups while diaries were employed.

Findings from an evaluation of PlanAlyzer's double cross-over trials of computer-based, self-paced, case-based programs in anemia and chest pain diagnosis.

We report on three years of research trials of the PlanAlyzer I Project--a carefully controlled research study using a microcomputer-based, self-paced, case-based, event-driven system for medical education. PlanAlyzer presents cases, elicits and critiques a second year student's approach to the diagnosis of anemias and chest pain. PlanAlyzer uses text, hypertext, images and critiquing theory. Students were randomized, one half becoming the experimental group who received the interactive PlanAlyzer cases in anemia, the other half becoming the controls who received the exact same content material in a text format. Later in each year there was a crossover, the controls becoming the experimentals for a similar intervention with the cardiology PlanAlyzer cases. Results at the end of the first two years of trials show that the programs have achieved some significant efficiency and economy gains. 96 faculty hours of classroom time were saved by using PlanAlyzer in their place, with no loss in student achievement. In terms of student proficiency and efficiency, combining the anemia and cardiology trials, the 328 students in the two years of full scale trials were able to accomplish the project's instructional objectives. The experimentals accomplished this in 43% less time than the controls. On the average, for both the anemia and chest pain programs, this amounted to students spending 7.5 hours longer on the 30 text cases than on the same 30 computer cases to achieve the same level of mastery. There have been no significant proficiency differences (as measured by current post-tests) between the experimental and control groups.(ABSTRACT TRUNCATED AT 250 WORDS)