Multidetector Computed Tomography and Magnetic Resonance Imaging Evaluation of Craniovertebral junction Abnormalities.

BACKGROUND: Craniovertebral junction (CVJ) abnormalities constitute an important group of treatable neurological disorders with diagnostic dilemma. Their precise diagnosis, identification of probable etiology, and pretreatment evaluation significantly affects prognosis and quality of life of patients. AIMS: The study was to classify various craniovertebral junction disorders according to their etiology and to define the importance of precise diagnosis for pretreatment evaluation with multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI). MATERIALS AND METHODS: This is a prospective observational study of 62 patients referred to our department between October 2012 and September 2014. All patients suspected to have a craniovertebral junction disorder were included in the study, from all age groups and both genders. Detailed clinical history was taken. Radiographs of cervical spine were collected if available. All patients were subjected to MDCT and/or MRI. RESULTS: In our study of 62 patients; 39 were males and 23 were females, with male to female ratio of 1.6:1. Most common age group was 2(nd) -3(rd) decade (19 patients, 30.64%). Developmental anomalies (33 patients, 53.22%) were the most common etiology group followed by traumatic (10 patients, 16.12%), degenerative (eight patients, 12.90%), infective (four patients, 6.45%), inflammatory and neoplastic (three patients each, 4.8%), and no cause found in one patient. CONCLUSIONS: CVJ abnormalities constitute an important group of treatable neurological disorders, especially in certain ethnic groups and are approached with much caution by clinicians. Thus, it is essential that radiologists should be able to make a precise diagnosis of craniovertebral junction abnormalities, classify them into etiological group, and rule out important mimickers on MDCT and/or MRI, as this information ultimately helps determine the management of such abnormalities, prognosis, and quality of life of patients.

Minidose (1 mg) warfarin as prophylaxis for central vein catheter thrombosis.

BACKGROUND: Central vein catheters, which are used in the treatment of cancer patients, are prone to thrombotic complications of the catheter or adjacent vein. Previous studies suggest that 1 mg warfarin daily (minidose) can significantly reduce that risk. AIMS: This, study aims to establish whether minidose warfarin could reduce catheter-related thrombosis in adult patients with haematological malignancies. METHODS: Patients were randomly selected to receive warfarin or not. The end-points studied were: (i) occlusion by thrombus, (ii) removal of catheter for other reasons or (iii) 90 days free of thrombus. RESULTS: There was no significant difference in the incidence of catheter thrombosis or venous thrombosis and no significant variation in catheter survival between the study and control groups. CONCLUSIONS: This study found no benefit of the routine use of minidose warfarin for prophylaxis of central vein' catheter thrombosis in patients with haematological malignancies and therefore does not support the routine use of minidose warfarin for prophylaxis in such patients.

The use of warfarin in Christchurch for the treatment of venous thromboembolism.

AIMS: To identify the actual duration of warfarin therapy received by patients being treated for venous thromboembolism (VTE) compared to that initially intended. To determine the incidence of major haemorrhage during therapy. METHODS: The subjects were 505 consecutive medical inpatients who were referred for a lung scan because of suspected pulmonary embolism. Three years following the discharge of the last patient, hospital notes, local and national computer databases were searched for subsequent relevant events. Surviving subjects were also contacted by telephone or letter. RESULTS: 115/505 (23%) received warfarin therapy for VTE. Direct personal contact was made with 314/352 (89%) surviving patients, including 79/82 (98%) surviving patients who were on warfarin. The intended duration of therapy was specified initially in 60/115 treated cases (52%), and these patients were less likely to be still receiving warfarin 3-4 years later (p<0.001). Indefinite therapy was initially recommended in 11/115 cases (10%), but 26/79 surviving subjects (32%) were known to be still receiving warfarin 3-4 years later. Seven treated subjects had a diagnosed recurrence of VTE. There were no clear indications for prolonged therapy in the remainder. Major haemorrhage occurred eighteen times among 115 treated patients (16%), and in two of these warfarin associated bleeding was considered to be the cause of death. None of these events was reported to the Centre for Adverse Reactions Monitoring. CONCLUSIONS: The intended duration of therapy was often unclear and warfarin was generally continued for much longer than is currently considered necessary. Haemorrhagic events were relatively common and were not reported.

Cost comparison of antibacterial therapies for serious infections. A New Zealand 3-hospital study.

OBJECTIVE: The first aim was to identify and determine the economic costs of the regimens currently used in 3 New Zealand hospitals in the treatment of bacterial infections in haematology patients with febrile neutropenia and in intensive care patients with severe infections. The second was to develop a spreadsheet-based decision analytic model for use by hospital decision-makers as an aid in evaluating the comparative cost of drug regimens. DESIGN AND SETTING: The research utilised time and motion and microcosting techniques. The analytical perspective adopted for the study was that of a hospital administrator or clinical manager. PATIENTS AND INTERVENTIONS: Patients were eligible for inclusion in the study if either they were treated with the imipenem/cilastatin monotherapy, or could have been treated with this regimen. The final analysis considered 360 patient-treatment days and 8 antibacterials. MAIN OUTCOME MEASURES AND RESULTS: Drug acquisition cost ranged from 4.52 New Zealand dollars ($NZ; 1997 values) per patient-treatment day for gentamicin to $NZ104.81 for imipenem. The cost per patient-treatment day (when other cost components such as fluid additives, giving sets and needles were added) ranged from $NZ8.75 for gentamicin to $NZ129.12 for tazobactam. Drug acquisition cost, as a percentage of total drug preparation and administration cost, ranged from 52% for gentamicin to 93% for piperacillin. Giving sets and intravenous (i.v.) fluids were found to be important cost items when they were required specifically for the treatment regimen. There was a mean monitoring rate of 0.40 at a cost of $NZ6.41 per patient-treatment day for gentamicin. It was estimated that nephrotoxicity could add between $NZ23 and $NZ43 per day to the cost of aminoglycoside treatment. CONCLUSIONS: Although the small sample sizes of the study mean that results should be regarded as indicative rather than conclusive, there were sufficient information to construct a working model and show how the total cost of an antibacterial regimen could be evaluated in practical terms. The important cost drivers were found to be drug cost, the use of fluids and giving sets, and monitoring.

Invasive aspergillosis in severely neutropenic patients over 18 years: impact of intranasal amphotericin B and HEPA filtration.

The impact of intranasal amphotericin B and high-efficiency particulate air (HEPA) filtration on the incidence of invasive aspergillosis was reviewed in patients from 1977 to 1994 undergoing intensive chemotherapy. Overall, the incidence of proven invasive aspergillosis was reduced from 24.4% (1977-1984) to 7.1% (1985-1991) (P < 0.001) following the introduction of intranasal prophylaxis, but when probable cases of aspergillosis were included and lymphoma cases excluded, there was no change in incidence. Following the introduction of HEPA filtration, patient exposure to aspergillus spores as measured by air sampling was markedly reduced and there were no new cases of invasive aspergillosis. HEPA filtration proved effective in reducing invasive aspergillosis and has allowed increasingly aggressive treatment regimens to be introduced.

High dose therapy and autologous bone marrow versus blood cell rescue. South Island Bone Marrow Transplant Unit.

AIMS: To compare haematological recovery and supportive care requirements for patients receiving high dose therapy (HDT) supported by rescue with either autologous cytokine mobilised blood cells (BC) or autologous bone marrow (BM). To identify stem cell harvest criteria predictive of rapid haematological recovery after rescue with BC. METHODS: Single arm, open study in four groups of 69 consecutive patients undergoing HDT in a single institution from 1986-95. Group 1 contained patients with solid tumours or myeloma rescued with BC alone (n = 14); group 2 patients with solid tumours rescued with BM (n = 31); group 3 patients with acute leukaemia rescued with BM (n = 21); and group 4 patients with solid tumours rescued with both BC and BM (n = 3). RESULTS: Haemopoietic recovery was most rapid for group 1 where, in comparison with the BM group transplanted for similar disease (group 2), highly significant reductions were observed for median days to 1) neutrophil s >/= 0.5 x 10(9)L (12 v 22; p 0.0001); 2) neutrophils >/= 1.0 x 10(9)/L (14 v 27 ; p = 0.0001); platelets >/= 20 x 10(9) /L (11 v 20; p = 0.0005); and 4) platelets >/= 50 x 10(9)/L (15 v 27; p = 0.001). Similar significant reductions for the BC group over group 2 were also observed for median, (1) inpatient days (22 v 30; p = 0.0001); (2) red cell transfusions (2 v 5; p = 0.01) ; (3) platelet transfusions (2 v 6; p = 0.0001); (4) days of fever (2 v 8; p = 0.001); and (5) days on IV antibiotics (8 v 14; p = 0.02). Group 3 patients yielded data either similar to or less advantageous to that in group 2 and group 4 patients yielded data intermediate between groups 1 and 2. Data from BC harvests suggested that yields of CD34+ cells of > 2.0 x 10(6)/kg and/or of colony forming units-granulocyte-macrophage (CFU-GM) of > 6.0 x 10(4)/kg were predictive of rapid haemopoietic recovery. CONCLUSION: For haemopoietic rescue following single HDT for solid tumours BC has considerable advantages over BM.

The costs and benefits of bone marrow transplantation.

The average direct costs of performing a bone marrow transplant (BMT), including the subsequent year, was found to be NZ$27,074 for 43 consecutive transplants. In 29 BMTs a full two year period of follow up was available and a quality of life analysis was carried out on these patients. It was calculated that 59 quality adjusted life years (QALYs) had been gained by the BMT procedure at the time of analysis. By combining these two analyses the cost of each QALY gained by BMT is NZ$13,272. The relatively low cost of BMT is partly due to the extremely low annual costs in second and subsequent years post BMT. In our patients this cost amounted to $195 per year. The costs and benefits of BMT compare very favourably with other complex medical procedures.