Classifying batted ball outcomes from Division I collegiate baseball players.

Modern technology challenges anecdotal beliefs on baseball performance. The study's purpose examines these beliefs by classifying batted ball outcomes. Three categories of independent variables (anthropometry, in-game situation, technique-based), from 1,922 batted ball outcomes produced by 230 players, were used to classify the likelihood of hits during 2021 college baseball games. Anthropometry included player's heights and weights. In-game situation entailed batter side, same side, ahead count, and pitch type. Technique-based variables measured by TrackMan radar included exit speed (ExSp), launch angle (LA), batted ball distance (BBD), and hang time (HT). Binary logistic regression analysis was performed with batted ball outcome as the dependent variable. Independent variables provided a good fit (χ2 (10) = 522.358, p < 0.01) and correctly classified nearly three-fourths of outcomes. Height (ß = 0.030, p < 0.05), ExSp (ß = 0.023, p < 0.05), LA (ß = 0.028, p < 0.01), and BBD (ß = 0.067, p < 0.01) each had significant positive associations, yet HT (ß = -1.661, p < 0.01) had a significant negative association, with batted ball outcomes. TrackMan provided four significant independent variables. Anthropometry's contribution to batting outcome was modest, while in-game situation's impact was non-significant; results contradict anecdotal beliefs of their importance.

Two cases of differentiation syndrome with ocular manifestations in patients with acute promyelocytic leukaemia treated with all-trans retinoic acid and arsenic trioxide.

PURPOSE: To describe two cases of differentiation syndrome presenting with ocular manifestations including bilateral chorioretinopathy in patients with acute promyelocytic leukaemia treated with all-trans retinoic acid and arsenic trioxide differentiation therapy. OBSERVATIONS: This observational case series identifies two patients at a single tertiary institution diagnosed with differentiation syndrome with associated ophthalmic involvement. Both patients reported bilateral reduction in visual acuity at days fourteen and ten respectively following initiation of differentiation therapy in addition to developing other systemic manifestations of differentiation syndrome. Both patients received the same chemotherapeutic regimen including both all-trans retinoic acid and arsenic trioxide as well as ten days of routine differentiation syndrome prophylaxis with oral prednisolone. Case 1 presented with bilateral pale yellow sub-retinal lesions concentrated at the posterior poles with ocular coherence tomography (OCT) evidence of bilateral multifocal areas of focal RPE elevation and adhesion to the thickened outer retina with interspersed sub-retinal fluid. Fluorescein angiography revealed areas of early hyperflouresence corresponding to the yellow chorioretinal lesions with late diffuse leakage of fluid into the subretinal space. Case 2 presented with a similar characteristic retinal findings on fundoscopy and optical coherence tomography. Both patients experienced rapid improvement in the visual symptoms and marked resolution of the sub-retinal fluid within seven to fourteen days of onset with excellent long-term visual outcome. Both patients achieved molecular remission after induction and received standard consolidation and maintenance therapy without visual disturbance. CONCLUSION AND IMPORTANCE: Ocular manifestations of differentiation syndrome have been only recently recognised. We present a case series of two patients with differentiation syndrome with ocular involvement. Common to both presentations was the presence of bilateral reduction in visual acuity with multifocal serous retinal detachment secondary to chorioretinopathy. The visual outcome from both presentations was excellent with rapid normalisation of visual acuity and resolution of the sub-retinal fluid with only the first case having their differentiation therapy temporarily withheld during the acute phase of illness.

When should iron chelation therapy be considered in patients with myelodysplasia and other bone marrow failure syndromes with iron overload?

Despite the absence of a robust evidence base, there is growing consensus that effective treatment of iron overload leads to decreased morbidity and premature mortality in patients with good prognosis myelodysplastic syndromes (MDSs). Furthermore, new treatment modalities, including disease-modifying therapies (lenalidamide and azacytidine) and reduced intensity conditioning therapies for allogeneic blood stem cell transplants, are offering the prospect of longer survival for patients with traditionally less favourable prognosis MDS, who might also benefit from iron chelation. This article proposes assessment of patients with MDS and related bone marrow failure syndromes to determine suitability for iron chelation. Iron chelation therapy options and monitoring are discussed.

Diagnostic and prognostic utility of the serum free light chain assay in patients with AL amyloidosis.

BACKGROUND: Organ dysfunction in AL amyloidosis is related to the production and deposition of amyloidogenic monoclonal light chains. These pathological light chains can now be quantified using the recently developed serum free light chain assay. METHODS: We retrospectively reviewed 31 patients with AL amyloidosis to determine the frequency of abnormal free light chain assay results at diagnosis and whether changes in the serum free light chain assay predict outcome after therapy. RESULTS: An abnormal free light chain assay was found in 30 of 31 patients (97%) at the time of diagnosis. In the subset of our patients who received treatment for AL amyloidosis, a >50% reduction of the pathological free light chain following treatment was shown to predict improved overall survival. In our series of analyses, achievement of greater magnitudes of reduction of the free light chain result did not appear to provide additional prognostic information, nor did the baseline free light chain result predict outcome. CONCLUSION: Our findings support the use of the free light chain assay in the diagnostic work-up of patients with suspected AL amyloidosis, and also as a sensitive biomarker of response to therapy.

Systematic reviews of clinical decision tools for acute abdominal pain.

OBJECTIVES: To review for acute abdominal pain (AAP), the diagnostic accuracies of combining decision tools (DTs) and doctors aided by DTs compared with those of unaided doctors. Also to evaluate the impact of providing doctors with an AAP DT on patient outcomes, clinical decisions and actions, what factors are likely to determine the usage rates and usability of a DT and the associated costs and likely cost-effectiveness of these DTs in routine use in the UK. DESIGN: Electronic databases were searched up to 1 July 2003. REVIEW METHODS: Data from each eligible study were extracted. Potential sources of heterogeneity were extracted for both questions. For the accuracy review, meta-analysis was conducted. Among studies comparing diagnostic accuracies of DTs with unaided doctors, error rate ratios provided estimates of the differences between the false-negative and false-positive rates of the DT and unaided doctors' performance. Pooled error rate ratios and 95% confidence intervals (CIs) for false-negative rates and false-positive rates were computed. Metaregression was used to explore heterogeneity. RESULTS: Thirty-two studies from 27 articles, all based in secondary care, were eligible for the review of DT accuracies, while two were eligible for the review of the accuracy of hospital doctors aided by DTs. Sensitivities and specificities for DTs ranged from 53 to 99% and from 30 to 99%, respectively. Those for unaided doctors ranged from 64 to 93% and from 39 to 91%, respectively. Thirteen studies reported false-positive and false-negative rates for both DTs and unaided doctors, enabling a direct comparison of their performance. In random effects meta-analyses, DTs had significantly lower false-positive rates (error rate ratio 0.62, 95% CI 0.46 to 0.83) than unaided doctors. DTs may have higher false-negative rates than unaided doctors (error rate ratio 1.34, 95% CI 0.93 to 1.93). Significant heterogeneity was present. Two studies compared the diagnostic accuracies of doctors aided by DTs to unaided doctors. In a multiarm cluster randomised controlled trial (n = 5193), the diagnostic accuracy of doctors not given access to DTs was not significantly worse (sensitivity 28.4% and specificity 96.0%) than that of three groups of aided doctors (sensitivities of 42.4-47.9%, and specificities of 95.5-96.5%, respectively). In an uncontrolled before-and-after study (n = 1484), the sensitivities and specificities of aided and unaided doctors were 95.5% and 91.5% (p = 0.24) and 78.1% and 86.4% (p < 0.001), respectively. The metaregression of DTs showed that prospective test-set validation at the site of the tool's development was associated with considerably higher diagnostic accuracy than prospective test-set validation at an independent centre [relative diagnostic odds ratio (RDOR) 8.2; 95% CI 3.1 to 14.7]. It also showed that the earlier in the year the study was performed the higher the performance (RDOR 0.88, 0.83 to 0.92), that when developers evaluated their own DT there was better performance than when independent evaluators carried out the study (RDOR = 3.0, 1.3 to 6.8), and that there was no evidence of association between other quality indicators and DT accuracy. The one eligible study of the impact study review, a four-arm cluster randomised trial (n = 5193), showed that hospital admission rates of patients by doctors not allocated to a DT (42.8%) were significantly higher than those by doctors allocated to three combinations of decision support (34.2-38.5%) (p < 0.001). There was no evidence of a difference between perforation rates (p = 0.19) and negative laparotomy rates in the four trial arms (p = 0.46). Usage rates of DTs by doctors in accident and emergency departments ranged from 10 to 77% in the six studies that reported them. Possible determinants of usability include the reasoning method used, the number of items used and the output format. A deterministic cost-effectiveness comparison demonstrated that a paper checklist is likely to be 100-900 times more cost-effective than a computer-based DT, under stated assumptions. CONCLUSIONS: With their significantly greater specificity and lower false-positive rates than doctors, DTs are potentially useful in confirming a diagnosis of acute appendicitis, but not in ruling it out. The clinical use of well-designed, condition-specific paper or computer-based structured checklists is promising as a way to improve impact on patient outcomes, subject to further research.

Measurement of free fatty acids in cerebrospinal fluid from patients with hemorrhagic and ischemic stroke.

Free fatty acid (FFA) concentrations in cerebrospinal fluid (CSF) from patients with ischemic and hemorrhagic stroke (n=25) and in contemporary controls (n=73) were examined using HPLC. Concentrations of CSF FFAs from ischemic and hemorrhagic stroke patients obtained within 48 h of the insult were significantly greater than in control patients. Higher concentrations of polyunsaturated fatty acids (PUFAs) in CSF obtained within 48 h of insult were associated with significantly lower (P<0.05) admission Glasgow Coma Scale scores and worse outcome at the time of hospital discharge, using the Glasgow Outcome Scale (P<0.01).

Craniocerebral missile injuries.

Gun shot wounds to the brain are among the most devastating causes of morbidity and mortality in the civilian population. The majority of the victims will not survive and for a great number of survivors life becomes an uphill battle with permanent deficits and complications. While the fundamental surgical care of these patients is essentially unchanged, our scientific understanding of the pathophysiological changes and the post-injury care of the victims has been evolving. The purpose of this article is to provide an overview of the current clinical and laboratory advances in understanding and treating gun shot injuries to the brain.

Angioedema in the emergency department: a presentation of lymphoma.

A 58-year-old woman presented to emergency departments on several occasions with episodic angioedema. Lymphoplasmacytic lymphoma with an IgM paraprotein (Waldenstrom's macroglobulinemia) was eventually diagnosed 14 months later in association with acquired C1 esterase inhibitor deficiency. Resolution of the angioedema and C1 esterase inhibitor deficiency was achieved with danazol and treatment of the underlying lymphoma.

Quantification of free fatty acids in human cerebrospinal fluid.

Free fatty acids (FFA) in cerebrospinal fluid (CSF) are well-recognized markers of brain damage in animal studies. Information is limited regarding human CSF in both normal and pathological conditions. Samples of CSF from 73 patients, who had undergone lumbar puncture for medically indicated reasons, came from a core laboratory upon completion of ordered tests. Using high performance liquid chromatography, mean FFA concentrations (microg/L +/- SEM) were: arachidonic 26.14 +/- 3.44; docosahexaenoic 60.74 +/- 5.70; linoleic 105.07 +/- 10.98; myristic 160.38 +/- 16.17; oleic 127.91 +/- 10.13; and palmitic 638.34 +/- 37.27. No differences in FFA concentrations were seen with gender, race, age, and/or indication for lumbar puncture. This is the first study to document normal human CSF FFA concentrations in a large series. Further characterization of FFA in pathological conditions may provide markers for evaluating clinical treatments and assisting in prognostication of neurological disease.

Simultaneous breast cancer in non-identical Ashkenazi Jewish twins: management dilemmas when genetic testing is negative.

We present the case histories of Ashkenazi Jewish twins of opposite sex who developed breast cancer simultaneously, in whom testing for the anticipated BRCA2 mutations was unexpectedly negative. Their management and the implications of this difficult situation are discussed.

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost.

OBJECTIVE: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN: A randomised controlled trial of 403 patients with inguinal hernias. SETTING: Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS: 400 patients with a diagnosis of groin hernia, 200 in each group. MAIN OUTCOME MEASURES: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.

Bile duct injury during laparoscopic cholecystectomy without operative cholangiography.

BACKGROUND: The role of operative cholangiography in the prevention of bile duct injuries is controversial. A prospective audit of biliary injury is presented. METHODS: Laparoscopic cholecystectomy without operative cholangiography was undertaken in a consecutive series of 1200 patients. All biliary injuries were recorded. RESULTS: Meticulous dissection proved to be a reliable safeguard against injury to the right hepatic, common hepatic and common bile ducts. However, four accessory ducts were sacrificed and localized injury to the common hepatic or common bile duct occurred in three patients. These injuries would not have been prevented by operative cholangiography. CONCLUSION: Operative cholangiography is not a prerequisite for the safe performance of laparoscopic cholecystectomy and cannot be relied upon to prevent all biliary injuries.

Laparoscopic cholecystectomy without operative cholangiogram: 2038 cases over a 5-year period in two district general hospitals.

The place of cholangiography in laparoscopic cholecystectomy is debatable. This retrospective study reviews the outcome of 2061 patients operated upon for symptomatic gallstones in two district general hospitals. Intraoperative cholangiography was not used because all patients were submitted to a policy of selective preoperative investigation of the extrahepatic ducts. The conversion rate to open cholecystectomy was 3.1% and 88% of patients were discharged home within 48 h of surgery. No major duct injuries occurred and only 12 patients have presented with a proven retained stone after operation (0.7%). This policy of preoperative investigation and treatment for extrahepatic bile duct stones without intraoperative cholangiography has been employed in over 2000 patients and is at least as safe as published results using routine intraoperative cholangiography.

The training implications of day-case surgery.

The marked increase in the use of day surgery has major implications for the provision of surgical training. It is essential that day surgery units be used effectively for surgical training. We identify current constraints on such training and suggest methods for improvement.

Laparoscopic versus open inguinal hernia repair: randomised prospective trial.

Laparoscopic surgery benefits patients because it reduces pain and enables earlier mobilisation. There is concern that laparoscopic hernia repair may enter surgical practice without proper evaluation. We have done a randomised, prospective study comparing laparoscopic and open inguinal hernia repair performed under day-case general anaesthesia. 150 patients were randomised to have laparoscopic (group L) or open (group O) herniorrhaphy. Group L underwent transabdominal stapling of preperitoneal Prolene mesh. Group O underwent open repair, with a tension-free nylon darn. Postoperatively patients completed pain analogue scales eight times over 7 days, and use of analgesia was recorded. Time of return to normal domestic activity and to work was assessed. The groups were similar in age, sex, and body surface area. Self-administered co-proxamol was a median of 18 tablets (1 tablet = 325 mg) in group O (n = 75) and 6 in group L (n = 75, p < 0.001). Overall mean pain analogue score was 3.1 (SD 1.8, n = 70) in group O and 1.8 (SD 1.1, n = 71) in group L (p < 0.0001). Return to normal domestic activity was a median of 7 days in group O (n = 72) and 3 days in group L (n = 73) (p < 0.001). Return to work was a median of 28 days in group O (n = 39) and 14 days in group L (n = 40) (p < 0.002). These data suggest that laparoscopic hernia repair induces less pain than open hernia repair, and enables patients to return to normal activity and work more quickly.