Fatal outcome in untreated adolescent ulcerative colitis: an unusual case of child neglect.
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Adolescent↗
Biomedical subjects
K J Carter
Publications and source records attributed to K J Carter.
The cellular basis of metastatic bone disease in patients with lung cancer.
Histologic patterns of tumor-bone interaction were systematically evaluated in 80 cases of metastatic lung cancer involving bone. Patterns of tumor-bone interaction varied with the histologic type of lung cancer, reflecting the biochemical and biologic differences among the different types of lung cancer. Evidence presented here suggests that destruction of bone by metastatic lung cancer is mediated neither by direct contact of tumor cells with bone matrix nor by release of diffusible substances that lyse bone matrix. Among indirect mechanisms, the most prevalent and important was the activation of bone-lining cells by metastatic tumor. Epidermoid carcinomas in particular were associated with histologic patterns of classical bone remodelling, including osteoblastic, osteoclastic, and osteocytic activity. Adenocarcinomas showed a particularly high association with microfractures and manifested a stromal pattern consistent with release of prostaglandins. Ischemic necrosis of bone due to compression of vessels by expanding tumor mass is also a common and important mechanism. Correlation of histologic patterns with reported data on the frequency of metastases and syndromes of ectopic hormone production provides insight into the mechanism(s) of paraneoplastic hypercalcemia in patients with lung cancer.
Adenocarcinoma↗
Lowering of plasma cholesterol levels in free-living adolescent males; use of natural and synthetic polyunsaturated foods to provide balanced fat diets.
Two hundred and twenty-nine adolescent male pupils, attending two boarding schools, participated in a study, under free-living dietary conditions, designed to assess the effects on plasma lipids of altering only the type and not the amount of dietary fat. The students were monitored for 6 weeks on three different diets. During the first study period, dietary changes comprised substituting a polyunsaturated dried "filled" milk and products derived therefrom for conventional dairy products (diet A). The second dietary phase involved replacing all meat and dairy products with equivalent polyunsaturated ruminant fat products (diet B). The third period consisted of a control diet of conventional dairy and meat products. During both polyunsaturated diets a 14% reduction in plasma cholesterol was achieved compared with control levels. Low-density lipoprotein cholesterol was similarly suppressed. A greater decrease in plasma cholesterol of 19-21% was recorded in those pupils with initial cholesterol levels greater than 230 mg/dl. There was no significant difference in plasma triglycerides between diet A and the control diet whereas the triglyceride levels were 16.5% lower during diet B. The fall in plasma cholesterol coincided with an increase in plasma triglyceride linoleate from 8% to 19% of total triglyceride fatty acids. Dietary analysis of the pupils' diet indicated an increase in the ratio of polyunsaturates to saturates from 0.27 during the control period to 1.08 on the dried filled milk and 0.90 on the polyunsaturated ruminant fat products. A palatability survey showed that both the dried filled milk and the polyunsaturated ruminant fat products were as well accepted by the pupils as the conventional products. The results suggest that such products could, if introduced to the general population, play an important part in plasma cholesterol suppression in the hope that this would significantly reduce the incidence of coronary artery disease.
Adolescent↗
Quality assurance in anatomic pathology: automated SNOMED coding.
This case study details the set-up and implementation of the PathNet autocoder (Cerner Corporation) in a busy anatomic pathology laboratory. After initial start-up, procedures were developed to improve the system's performance. Four classes of software coding errors were identified, and an index was developed to measure the number of cases between errors (CBE). Through modifications in the program, the CBE increased sharply by the end of the six-month study period. During the last three months of the study, the efficiency of case retrieval was tested by comparing manual and electronic methods on the same reference cases. This demonstrated significant time saving and removed the variability of manual coding. The technique employed in this study may assist other institutions seeking to implement such a coding system within their respective environments.
Clinical Laboratory Information Systems↗
Optimal interval for triple-lumen catheter changes: a decision analysis.
A survey of 53 university and community hospitals revealed that 73% of the institutions had no standard policy for the replacement of triple-lumen catheters (TLCs). Since the maintenance of a TLC in place for a prolonged period may lead to infectious complications, it appeared warranted that standards of management be developed. A decision-tree model was constructed for evaluating the optimal time for changing a TLC that would minimize infection. Cost estimates and health effects at three-, five-, and ten-day change intervals were considered for catheter insertion and complications resulting from such insertion. The results suggested that prophylactic catheter changes should occur no later than every five days, provided that there are no signs of infection. However, sensitivity analysis of several variables suggested that individual institutions should establish policy timing changes based upon careful interpretation of their own data. A model was developed to assist in determining the optimal time to change a TLC based upon such data.
Catheterization, Central Venous↗
Sequential test selection in the analysis of abdominal pain.
Numerous decision-making tools exist to assist physicians in diagnosis management. However, the accuracy of available clinical information is often ambiguous or unknown and current analytical models do not explicitly incorporate judgementally defined information. A model encompassing both physician judgment and probability analysis was developed to accommodate such data. A problem requiring sequential diagnostic testing was structured utilizing the analytic hierarchy process (AHP). The case presented involved a patient complaining of upper abdominal pain who, after initial evaluation, did not need immediate surgery. Physicians were faced with identifying the optimal sequence of diagnostic testing. The criteria used for test selection included minimizing risk, patient discomfort, and cost of testing and maximizing diagnostic capability. Although at the onset the "best" test choice was unknown, the clinical picture indicated four test alternatives: upper gastrointestinal series (GI), abdominal ultrasonography (US), abdominal computed tomography (CT), and upper gastrointestinal endoscopy (END). Based upon the relative preferences of the criteria utilized, the AHP analysis indicated that upper GI series was the optimal first test. Given a negative test, posterior probabilities were calculated using Bayes' theorem, resulting in a new estimate of diagnostic capability. The AHP analysis was reiterated, identifying abdominal ultrasonography as the optimal second test. This analysis may be repeated as many times as necessary. Sensitivity analysis demonstrated that changing criteria preferences may alter the choice of tests and/or their sequence.
Abdominal Pain↗
Treatment of early-stage breast cancer in the elderly: a health-outcome-based approach.
PURPOSE: To evaluate the post-lumpectomy treatment of a nonpalpable, stage I, T1b tumor, mammographically detected, in a 74-year-old woman without comorbidities. METHODS: A Markov process, through 120 monthly cycles, was used to model patient progression through a treatment program, employing literature data and a health-outcome utility. Treatments considered were: observation; radiation totaling 5,000 cGy over six weeks; tamoxifen, 20 mg/day, for five years; simple mastectomy; and radiation therapy plus tamoxifen. Health states included absence of disease (NED), loco-regional recurrence, distant metastasis, age-sex-race (ASR)-adjusted death, cancer mortality, treatment complications, and post-mastectomy death. Transition probabilities were established from the literature. Health-state utilities were determined from the responses of health care professionals to a basic reference gamble. RESULTS: Quality-adjusted life years (QALYs) were determined to be 8.19 for radiation plus tamoxifen, decreasing to 8.04 for mastectomy, a difference of only a 0.15 years (1.8 months). Sensitivity analysis, however, showed relative stability in the ranking among treatment options. CONCLUSION: Although the model showed little difference between QALYs with the treatments, the combination of radiation and tamoxifen provides the optimal therapy for this case.
Aged↗
Analysis of three decision-making methods: a breast cancer patient as a model.
PURPOSE: To compare three decision making techniques using a common clinical problem. METHODS: Two recently developed methods, the analytic hierarchy process (AHP) and the analytic network process (ANP), were compared with a Markov process in the evaluation of the optimal post-lumpectomy treatment strategy for an elderly woman with a mammographically detected, nonpalpable early-stage breast cancer. The following treatment alternatives were considered: observation, radiation, tamoxifen, combination radiation and tamoxifen, and simple mastectomy. All three decision methods incorporated patient preferences. RESULTS: The models agreed on the ranking of the preferred treatment, radiation and tamoxifen, but there were variations in the rankings of the other treatment choices. Individual differences between the three models were uncovered. The Markov process provided estimates of quality-adjusted life expectancy and distribution of health events. Both AHP and ANP required less development time than the Markov process. CONCLUSION: All three methods may be useful tools to the clinician in analyzing complex medical problems. The Markov is the most labor-intensive method but provides detailed results, whereas the AHP and the ANP give only rank orders of the alternatives. The most important considerations in choosing between these methods are time to project completion and the detail of information sought.
Antineoplastic Agents↗