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Journal Article A Colorimetric Method for the Determination of Serum Glutamic Oxalacetic and Glutamic Pyruvic Transaminases Get access Stanley Reitman, M.D., Stanley Reitman, M.D. Medical and Laboratory Sections, Research Institute, The Jewish Hospital of St. Louis, St. Louis, Missouri Search for other works by this author on: Oxford Academic Google Scholar Sam Frankel, Ph.D. Sam Frankel, Ph.D. Medical and Laboratory Sections, Research Institute, The Jewish Hospital of St. Louis, St. Louis, Missouri Search for other works by this author on: Oxford Academic Google Scholar American Journal of Clinical Pathology, Volume 28, Issue 1, 1 July 1957, Pages 56–63, https://doi.org/10.1093/ajcp/28.1.56 Published: 01 July 1957 Article history Received: 31 December 1956 Revision received: 11 March 1957 Accepted: 01 April 1957 Published: 01 July 1957

PURPOSE: Promising results from new approaches such as radiosurgery or stereotactic surgery of brain metastases have recently been reported. Are these results due to the therapy alone or can the results be attributed in part to patient selection? An analysis of tumor/patient characteristics and treatment variables in previous Radiation Therapy Oncology Group (RTOG) brain metastases studies was considered necessary to fully evaluate the benefit of these new interventions. METHODS AND MATERIALS: The database included 1200 patients from three consecutive RTOG trials conducted between 1979 and 1993, which tested several different dose fractionation schemes and radiation sensitizers. Using recursive partitioning analysis (RPA), a statistical methodology which creates a regression tree according to prognostic significance, eighteen pretreatment characteristics and three treatment-related variables were analyzed. RESULTS: According to the RPA tree the best survival (median: 7.1 months) was observed in patients < 65 years of age with a Karnofsky Performance Status (KPS) of at least 70, and a controlled primary tumor with the brain the only site of metastases. The worst survival (median: 2.3 months) was seen in patients with a KPS less than 70. All other patients had relatively minor differences in observed survival, with a median of 4.2 months. CONCLUSIONS: Based on this analysis, we suggest the following three classes: Class 1: patients with KPS > or = 70, < 65 years of age with controlled primary and no extracranial metastases; Class 3: KPS < 70; Class 2- all others. Using these classes or stages, new treatment techniques can be tested on homogeneous patient groups.

Gastroesophageal reflux disease (GERD) is arguably the most common disease encountered by the gastroenterologist. It is equally likely that the primary care providers will find that complaints related to reflux disease constitute a large proportion of their practice. The following guideline will provide an overview of GERD and its presentation, and recommendations for the approach to diagnosis and management of this common and important disease. The document will review the presentations of any risk factors for GERD, the diagnostic modalities and their recommendation for use and recommendations for medical, surgical and endoscopic management including comparative effectiveness of different treatments. Extraesophageal symptoms and complications will be addressed as will the evaluation and management of "refractory" GERD. The document will conclude with the potential risks and side effects of the main treatments for GERD and their implications for patient management. Each section of the document will present the key recommendations related to the section topic and a subsequent summary of the evidence supporting those recommendations. An overall summary of the key recommendations is presented in Table 1. A search of OVID Medline, Pubmed and ISI Web of Science was conducted for the years from 1960–2011 using the following major search terms and subheadings including "heartburn", "acid regurgitation", "GERD", "lifestyle interventions", "proton pump inhibitor (PPI)", "endoscopic surgery," "extraesophageal symptoms," "Nissen fundoplication," and "GERD complications." We used systematic reviews and meta-analyses for each topic when available followed by a review of clinical trials.Table 1: Summary and strength of recommendationsTable 1: (continued)The GRADE system was used to evaluate the strength of the recommendations and the overall level of evidence (1,2). The level of evidence could range from "high" (implying that further research was unlikely to change the authors' confidence in the estimate of the effect) to "moderate" (further research would be likely to have an impact on the confidence in the estimate of effect) or "low" (further research would be expected to have an important impact on the confidence in the estimate of the effect and would be likely to change the estimate). The strength of a recommendation was graded as "strong" when the desirable effects of an intervention clearly outweigh the undesirable effects and as "conditional" when there is uncertainty about the trade-offs. It is important to be aware that GERD is defined by consensus and as such is a disease comprising symptoms, end-organ effects and complications related to the reflux of gastric contents into the esophagus, oral cavity, and/or the lung. Taking into account the multiple consensus definitions previously published (3,4,5), the authors have used the following working definition to define the disease: GERD should be defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung. GERD can be further classified as the presence of symptoms without erosions on endoscopic examination (non-erosive disease or NERD) or GERD symptoms with erosions present (ERD). SYMPTOMS AND EPIDEMIOLOGY Epidemiologic estimates of the prevalence of GERD are based primarily on the typical symptoms of heartburn and regurgitation. A systematic review found the prevalence of GERD to be 10–20% of the Western world with a lower prevalence in Asia (6). Clinically troublesome heartburn is seen in about 6% of the population (7). Regurgitation was reported in 16% in the systematic review noted above. Chest pain may be a symptom of GERD, even the presenting symptom (2,3). Distinguishing cardiac from non-cardiac chest pain is required before considering GERD as a cause of chest pain. Although the symptom of dysphagia can be associated with uncomplicated GERD, its presence warrants investigation for a potential complication including an underlying motility disorder, stricture, ring, or malignancy (8). Chronic cough, asthma, chronic laryngitis, other airway symptoms and so-called extraesophageal symptoms are discussed in a subsequent section. Atypical symptoms including dyspepsia, epigastric pain, nausea, bloating, and belching may be indicative of GERD but overlap with other conditions. A systematic review found that ∼38% of the general population complained of dyspepsia. Dyspepsia was more frequent in GERD patients than those without. These patients were at risk for a new diagnosis of GERD. Epigastric pain, early satiety, belching and bloating were more likely to respond to a PPI therapy compared with nausea. Overall, these symptoms can be considered to be associated with GERD if they respond to a PPI trial (9). A recent systematic review on the burden of GERD on quality of life (QOL) included 19 studies. Patients with disruptive GERD (daily or >weekly symptoms) had an increase in time off work and decrease in work productivity. Low scores on sleep scales were seen compared with patients with less frequent symptoms. A decrease in physical functioning was also seen (10). Nocturnal GERD has a greater impact on QOL compared with daytime symptoms. Both nocturnal symptoms and sleep disturbances are critical to elucidate when evaluating the GERD patient (11). The balance of evidence suggests that symptom frequency does not change as we age, however, the intensity of symptoms may decrease after the age of 50 (12). Aging increases the prevalence of erosive esophagitis, Los Angeles (LA) grades C and D (13). Barrett's esophagus increases in prevalence after age 50, especially in Caucasian males (14). There are little data addressing the features of GERD in women distinct from men. Patients with erosive esophagitis are more likely to be men, and women are more likely to have NERD. Barrett's esophagus is more frequent in men compared with women (15). The gender ratio for esophageal adenocarcinoma is estimated to be 8:1 male to female (14). There is a definite relationship between GERD and obesity. Several meta-analysis suggest an association between body mass index (BMI), waist circumference, weight gain and the presence of symptoms and complications of GERD including ERD and Barrett's esophagus (16,17). The ProGERD study, likely the largest of its kind (>5,000 patients) used logistic regression analysis to identify several independent risk factors for ERD. The odds for higher degrees of ERD increased as BMI rose (18). It is of greatest concern that there has been a well-documented association between BMI and carcinoma of the esophagus and gastric cardia (19). Establishing the diagnosis of GERDFigure: No Caption available.The diagnosis of GERD is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy. (Table 2) The symptoms of heartburn and regurgitation are the most reliable for making a presumptive diagnosis based on history alone; however, these are not as sensitive as most believe. A systematic review of seven studies found the sensitivity of heartburn and regurgitation for the presence of erosive esophagitis to be 30–76% and the specificity from 62–96% (20). Empiric PPI therapy (a PPI trial) is a reasonable approach to confirm GERD when it is suspected in patients with typical symptoms. A response to therapy would ideally confirm the diagnosis; however, a well done meta-analysis suggested some limitations of this approach with a sensitivity of 78% and specificity of 54% (21). Therefore, empiric therapy (or a so called PPI trial) has some limitations.Table 2: Diagnostic testing for GERD and utility of testsNon-cardiac chest pain has often been associated with the presence of GERD, and can be the presenting symptom. A meta-analysis found a high probability that non-cardiac chest pain responds to aggressive acid suppression (22). This study supported earlier work suggesting the efficacy and cost effectiveness of a PPI trial (PPI twice daily in variable doses) in patients with chest pain in whom a cardiac cause had been excluded. However, a more recent systematic review suggested that the response of non-cardiac chest pain to a PPI trial was significantly higher than placebo in patients with objective evidence of GERD (ERD on endoscopy and/or abnormal pH monitoring) (23). The response to PPIs compared with placebo was almost non-existent in the absence of objective documentation of GERD. As such, a diagnostic evaluation with endoscopy and pH monitoring should be considered before a PPI trial (24). The presence of heartburn in conjunction with chest pain was not predictive of PPI response of the chest pain component. Dysphagia has historically been an alarm symptom or warning sign and an indication for early endoscopy to rule out a GERD complication. Respiratory symptoms have been associated with GERD, based on retrospective case–control studies. In addition, dental erosions, erosion of dental enamel, sinusitis, chronic laryngitis and voice disturbance have similarly been associated with GERD. These are discussed later in the article. Overall, heartburn and regurgitation remain reliable symptoms of GERD as does non-cardiac chest pain. Other symptoms, while associated with GERD, are not as reliable. The causal relationship between GERD and the so-called atypical and extraesophageal manifestations remains difficult with only a history. Barium radiographs have been historically considered part of the potential diagnostic armamentarium in the patient with esophageal symptoms, including GERD. Although well-performed barium esophagrams with double contrast can detect signs of esophagitis, the overall sensitivity of this test is extremely low (25). The finding of barium reflux above the thoracic inlet with or without provocative maneuvers including the water siphon test does increase the sensitivity of the barium test; however, not sufficiently to be recommended as a diagnostic test without dysphagia (26). The endoscope has long been the primary tool used to evaluate the esophageal mucosa in patients with symptoms suspected due to GERD. Findings of GERD include erosive esophagitis, strictures, and a columnar lined esophagus ultimately confirmed to be Barrett's esophagus. As such, endoscopy has excellent specificity for the diagnosis of GERD especially when erosive esophagitis is seen and the LA classification is used (27). However, the vast majority of patients with heartburn and regurgitation will not have erosions (or Barrett's) limiting upper endoscopy as an initial diagnostic test in patients with suspected GERD (28). Endoscopy allows for biopsy of rings and strictures and screening for Barrett's. Although epidemiologic risk factors for Barrett's esophagus have been well-defined (age over 50, symptoms for>5–10 years, obesity, male sex) the sensitivity and specificity of these symptoms for abnormal endoscopy makes the utility of screening for Barrett's a controversial topic. Recent data indicate that it may be reasonable to perform endoscopy for screening in certain high-risk groups in particular overweight white males over the age of 50 with chronic GERD symptoms (12). The finding of any Barrett's esophagus segment has been associated with pathologic GERD and generally obviates the need for pH testing (29). In a 2009 study, 90% of short-segment BE patients were found to have abnormal pH-impedance testing (30). The addition of esophageal biopsies as an adjunct to an endoscopic examination has been re-emphasized because of the increased prevalence of eosinophilic esophagitis (EoE). Many clinicians routinely biopsy the esophagus in patients with reflux-type symptoms to look for EoE in the setting of an endoscopy that does not reveal erosive changes. Unfortunately, differentiating GERD from EoE using only biopsy is difficult and risks making a diagnosis and instituting treatment without supportive data. Low eosinophil counts in the distal esophagus while suggestive of GERD are not specific. In addition, a high eosinophil count may be seen with GERD and respond to PPIs (PPI responsive eosinophilia) (31). The sensitivity of the other histologic findings; basal cell hyperplasia, elongation of the rete pegs, papillary elongation, and even neutrophils, are of limited clinical usefulness (32,33). There are no studies examining the efficacy of PPIs based on microscopic findings alone. The use of routine biopsy of the esophagus to diagnose GERD cannot be recommended in a patient with heartburn and a normal endoscopy based on current literature. In addition, the practice of obtaining mucosal biopsies from a normal appearing esophagogastric junction has not been demonstrated to be useful in GERD patients (34). Esophageal manometry is of limited value in the primary diagnosis of GERD. Neither a decreased lower esophageal sphincter pressure, nor the presence of a motility abnormality is specific enough to make a diagnosis of GERD. Manometry should be used to aid in placement of transnasal pH-impedance probes and is recommended before consideration of antireflux surgery primarily to rule out achalasia or severe hypomotility (scleroderma-like esophagus), conditions that would be contraindications to Nissen fundoplication, but not to tailor the operation. Ambulatory reflux monitoring (pH or impedance-pH) is the only test that allows for determining the presence of abnormal esophageal acid exposure, reflux frequency, and symptom association with reflux episodes. Performed with either a telemetry capsule (usually 48 h) or transnasal catheter (24 h), pH monitoring has excellent sensitivity (77–100%) and specificity (85–100%) in patients with erosive esophagitis; however, the sensitivity is lower in those with endoscopy-negative reflux symptoms (<71%) when a diagnostic test is more likely to be needed (24). A consensus statement (35) suggested that impedance added to pH monitoring increased the sensitivity of reflux monitoring to close to 90%. Telemetry capsule pH monitoring offers increased patient tolerability and the option to extend the monitoring period to 48 or perhaps to 96 h. The additional monitoring period allows for combining and on and off therapy study in selected situations and offers additional opportunity to correlate symptoms with acid reflux. Catheter-based monitoring allows for the addition of impedance and detection of weakly acidic or non-acid reflux. Optimal use of these two options is certainly debated as is whether to test on or off therapy. As a true diagnostic test (is abnormal acid exposure present) and for evaluation before considering surgery in a patient with NERD an off therapy test is recommended. The use of on and off therapy monitoring in refractory GERD is discussed subsequently. When symptom correlation is required, the decision is more difficult. The two symptom association measures most often used are symptom index (SI) and symptom association probability (SAP). Both have methodological shortcomings that have been reviewed elsewhere (36) and prospective data to validate the ability of these symptom association measures to predict response to treatment is scarce. Both the SI and SAP have been validated when pH monitoring is performed off therapy in a patient with heartburn. A positive test on therapy, coupled with a symptom relationship, theoretically suggests GERD as a cause for symptoms but outcome studies are lacking for any symptom other than heartburn. For patient management, a strongly positive SI or SAP may suggest the need for a therapeutic intervention and a negative result supports the notion that the patient's symptoms are unlikely to be due to reflux. However, these indices should not be used in isolation and other reflux monitoring parameters as well the patient's presentation have to be taken into account. The relationship between H. pylori infection and GERD is controversial. As such, a full discussion is beyond the scope of this article. One issue most often discussed is whether treatment of H. pylori should be altered because of an exacerbation of GERD and if patients on long-term PPIs require screening and subsequent eradication of the bug to prevent the possibility of increasing risk of gastric cancer. A meta-analysis of 12 studies found no increase in GERD (erosive esophagitis) in patients with dyspeptic symptoms who were eradicated compared with those not. This same study found, in subgroup analysis, patients with peptic ulcer disease might experience the new onset of GERD symptoms after H. pylori eradication (37). Concern for the use of long-term PPI therapy in patients with H. pylori infection has been raised because of the potential for development of atrophic gastritis in infected patients on long-term PPI (38). This study prompted a Food and Drug Administration (FDA) review panel that concluded that the evidence was not sufficient to recommend testing of all patients on long-term PPI. The flaws in this study and lack of observational data on negative outcomes lead us to recommend against screening of GERD patients for H. pylori despite the European recommendation in favor of screening (39). GERD is frequent during pregnancy, manifests as heartburn, and may begin in any trimester. One study found onset of 52% in the first trimester, 40% in the second trimester, and 8% in the third trimester (40). Among 607 pregnant women attending an antenatal clinic, 22% experienced heartburn in the first trimester, 39% in the second, and 72% in the third, whereas only 14% of these women reported mild heartburn before their pregnancy (41). Severity also increased throughout pregnancy. Significant predictors of heartburn are increasing gestational age, heartburn before pregnancy, and parity. Maternal age is inversely correlated with heartburn. Race, pre-pregnancy BMI, and weight gain in pregnancy do not correlate with the onset of heartburn. Despite its frequent occurrence during pregnancy, heartburn usually resolves after delivery (42). Pregnancy and amount of weight gain during pregnancy were risk factors for frequent GERD symptoms 1 year post delivery (43). No other GERD symptom has been studied in pregnancy. The diagnosis of GERD during pregnancy should be based on symptoms and treatment symptom-based. Additional diagnostic testing is generally not required for the majority of patients with suspected GERD. In the occasional pregnant patient who does require testing, upper endoscopy is the test of choice, but should be reserved for patients whose symptoms are refractory to medical therapy or who have suspected complications. If possible however, endoscopy should be delayed until after the first trimester. It is uncommon to require ambulatory pH monitoring during pregnancy. Management of GERDFigure: No Caption available.SUMMARY OF THE EVIDENCE Lifestyle interventions are part of therapy for GERD. (Table 3) Counseling is often provided regarding weight loss, head of bed elevation, tobacco and alcohol cessation, avoidance of late-night meals, and cessation of foods that can potentially aggravate reflux symptoms including caffeine, coffee, chocolate, spicy foods, highly acidic foods such as oranges and tomatoes, and foods with high fat content.Table 3: Efficacy of lifestyle interventions for GERDA systematic review (44) evaluated the effect of dietary and other lifestyle modifications on lower esophageal sphincter pressure, esophageal pH, and GERD symptoms. Consumption of tobacco (12 trials), chocolate (2 trials), and carbonated beverages (2 trials) and right lateral decubitus position (3 trials) were shown to lower pressure of the lower esophageal sphincter (LES), whereas consumption of alcohol (16 trials), coffee and caffeine (14 trials), spicy foods (2 trials), citrus (3 trials), and fatty foods trials) had no There was an increase in esophageal acid exposure with tobacco and alcohol consumption in addition to of chocolate and fatty However, tobacco and alcohol cessation trials) were not shown to esophageal pH, or GERD symptoms. In addition, there have been no studies conducted to that have shown clinical in GERD symptoms or complications associated with cessation of coffee, caffeine, chocolate, spicy foods, carbonated fatty foods, or A recent systematic review concluded that there was lack of evidence that consumption of carbonated beverages or GERD gain even in with a normal BMI has been associated with new onset of GERD symptoms studies have demonstrated in GERD symptoms with weight gastric but not has been demonstrated to be in of GERD symptoms A large case–control study based on the demonstrated a 40% in frequent GERD symptoms for women who their BMI by or more compared with of the position has been associated with of esophageal pH and GERD symptoms. have demonstrated in GERD symptoms and esophageal pH with head of bed using or options for patients lifestyle interventions include or PPI therapy. A meta-analysis published in demonstrated that the placebo response in GERD clinical and was lower in patients with erosive esophagitis and PPI compared with with PPI therapy has been associated with and decreased compared with and placebo for patients with erosive esophagitis A meta-analysis demonstrated for all grades of erosive esophagitis using PPI therapy compared with or placebo The overall proportion of or treatment was with PPIs or placebo PPIs a significantly and placebo PPIs provided more heartburn PPIs are associated with a greater of symptom in patients with ERD compared to patients with NERD the symptom For patients with reflux a systematic review demonstrated for PPI therapy compared with and for heartburn the of with over the risk for heartburn primary efficacy in for PPI was confidence for and for In a PPIs were more than and There are seven available PPIs including that can be and are available only by and to in efficacy for symptom between PPIs A meta-analysis published in examining efficacy of PPI therapy for of erosive esophagitis included studies patients) for and there was a increase in the probability of of erosive esophagitis with an risk of and needed to of The by LA of erosive esophagitis were 50, and an 8% increase in the probability of GERD symptom at The clinical of this is of the PPIs with the of and should be before to an has been demonstrated to more nocturnal gastric pH in the first of sleep compared with other PPIs when each is at this effect to any clinical outcomes including symptom further is a delayed PPI in of compared only with demonstrated in esophageal pH in and the of to the any time of the of to in of erosive esophagitis was demonstrated in with in study As it would be expected that of patients with ERD would on PPI therapy and of patients with NERD. of GERD symptoms after a of PPI therapy has been found in of patients and does not in patients PPI or twice The evaluation and management of patients with response are discussed in the refractory GERD section. factors for lack of symptom have included patients with of presence of extraesophageal symptoms, and lack of PPIs are most in pH when taken before a and are generally less when taken at The to this rule to be for the of to have efficacy in pH of and can pH when at is common in practice Although PPI is common in clinical there is limited data to this practice. from trial demonstrated that in GERD patients refractory to patients to therapy daily was as as increasing to twice daily There is no data to PPIs more than in or PPI therapy should be for GERD patients who to have symptoms after PPI is and in patients with complications including erosive esophagitis and Barrett's esophagus. In patients found to have of the patients will off of PPIs over time For patients found to have LA esophagitis, will by In patients found to have any of retrospective studies have suggested a decreased risk for in patients PPI the other studies have demonstrated that patients with NERD and GERD can be with or PPI therapy. In a trial published in of NERD patients to of on were in at compared with of patients on In a systematic review of PPI studies were included in NERD with NERD and mild esophagitis, and studies with The for patients in the were to for patients on PPI therapy and to placebo in patients with but not for patients with ERD. therapy to is option for NERD patients options for GERD patients with response to PPI therapy are The addition of has been recommended for patients with symptoms refractory to PPI. This approach after multiple pH studies demonstrated pH One study suggested potential of pH after a of therapy In of this study and a lack of prospective clinical trial use of a might be most if on as needed in patients with symptoms and patients with objective evidence on pH monitoring of esophageal acid reflux despite PPI therapy with in addition to PPI therapy is option often considered for these has been shown to increase esophageal and gastric data additional of to PPI therapy has not been therapy of with has not been shown to be more compared with or therapy The of has been limited by system side effects including and in of patients in the absence of there is no for in GERD. For the of patients who may from a option is a

PURPOSE: To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS). METHODS: We conducted systematic or structured reviews to identify relevant studies relating to IAH or ACS. Updated consensus definitions and management statements were then derived using a modified Delphi method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. Quality of evidence was graded from high (A) to very low (D) and management statements from strong RECOMMENDATIONS (desirable effects clearly outweigh potential undesirable ones) to weaker SUGGESTIONS (potential risks and benefits of the intervention are less clear). RESULTS: In addition to reviewing the consensus definitions proposed in 2006, the WSACS defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification system. RECOMMENDATIONS included intra-abdominal pressure (IAP) measurement, avoidance of sustained IAH, protocolized IAP monitoring and management, decompressive laparotomy for overt ACS, and negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with an open abdomen. SUGGESTIONS included use of medical therapies and percutaneous catheter drainage for treatment of IAH/ACS, considering the association between body position and IAP, attempts to avoid a positive fluid balance after initial patient resuscitation, use of enhanced ratios of plasma to red blood cells and prophylactic open abdominal strategies, and avoidance of routine early biologic mesh use among patients with open abdominal wounds. NO RECOMMENDATIONS were possible regarding monitoring of abdominal perfusion pressure or the use of diuretics, renal replacement therapies, albumin, or acute component-parts separation. CONCLUSION: Although IAH and ACS are common and frequently associated with poor outcomes, the overall quality of evidence available to guide development of RECOMMENDATIONS was generally low. Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .

BACKGROUND: Despite notable technical advances in therapy for malignant gliomas during the past decade, improved patient survival has not been clearly documented, suggesting that pretreatment prognostic factors influence outcome more than minor modifications in therapy. Age, performance status, and tumor histopathology have been identified as the pretreatment variables most predictive of survival outcome. However, an analysis of the association of survival with both pretreatment characteristics and treatment-related variables is necessary to assure reliable evaluation of new approaches for treatment of malignant glioma. PURPOSE: This study of malignant glioma patients used a non-parametric statistical technique to examine the associations of both pretreatment patient and tumor characteristics and treatment-related variables with survival duration. This technique was used to identify subgroups with survival rates sufficiently different to create improvements in the design and stratification of clinical trials. METHODS: We used a recursive partitioning technique to analyze survival in 1578 patients entered in three Radiation Therapy Oncology Group malignant glioma trials from 1974 to 1989 that used several radiation therapy (RT) regimens with and without chemotherapy or a radiation sensitizer. This approach creates a regression tree according to prognostic variables that classifies patients into homogeneous subsets by survival. Twenty-six pretreatment characteristics and six treatment-related variables were analyzed. RESULTS: The years). Patients younger than 50 years old were categorized by histology (astrocytomas with anaplastic or atypical foci [AAF] versus glioblastoma multiforme [GBM]) and subsequently by normal or abnormal mental status for AAF patients and by performance status for those with GBM. For patients aged 50 years or older, performance status was the most important variable, with normal or abnormal mental status creating the only significant split in the poorer performance status group. Treatment-related variables produced a subgroup showing significant differences only for better performance status GBM patients over age 50 (by extent of surgery and RT dose). Median survival times were 4.7-58.6 months for the 12 subgroups resulting from this analysis, which ranged in size from 32 to 256 patients. CONCLUSIONS: This approach permits examination of the interaction between prognostic variables not possible with other forms of multivariate analysis. IMPLICATIONS: The recursive partitioning technique can be employed to refine the stratification and design of malignant glioma trials.

BACKGROUND: Previous studies have shown that calcium-channel blockers increase morbidity and mortality in patients with chronic heart failure. We studied the effect of a new calcium-channel blocker, amlodipine, in patients with severe chronic heart failure. METHODS: We randomly assigned 1153 patients with severe chronic heart failure and ejection fractions of less than 30 percent to double-blind treatment with either placebo (582 patients) or amlodipine (571 patients) for 6 to 33 months, while their usual therapy was continued. The randomization was stratified on the basis of whether patients had ischemic or nonischemic causes of heart failure. The primary end point of the study was death from any cause and hospitalization for major cardiovascular events. RESULTS: Primary end points were reached in 42 percent of the placebo group and 39 percent of the amlodipine group, representing a 9 percent reduction in the combined risk of fatal and nonfatal events with amlodipine (95 percent confidence interval, 24 percent reduction to 10 percent increase; P=0.31). A total of 38 percent of the patients in the placebo group died, as compared with 33 percent of those in the amlodipine group, representing a 16 percent reduction in the risk of death with amlodipine (95 percent confidence interval, 31 percent reduction to 2 percent increase; P=0.07). Among patients with ischemic heart disease, there was no difference between the amlodipine and placebo groups in the occurrence of either end point. In contrast, among patients with nonischemic cardiomyopathy, amlodipine reduced the combined risk of fatal and nonfatal events by 31 percent (P=0.04) and decreased the risk of death by 46 percent (P<0.001). CONCLUSIONS: Amlodipine did not increase cardiovascular morbidity or mortality in patients with severe heart failure. The possibility that amlodipine prolongs survival in patients with nonischemic dilated cardiomyopathy requires further study.

BACKGROUND AND METHODS: Tamoxifen, a synthetic antiestrogen, increases disease-free and overall survival when used as adjuvant therapy for primary breast cancer. Because it is given for long periods, it is important to know whether tamoxifen affects the skeleton, particularly since it is used extensively in postmenopausal women who are at risk for osteoporosis. Using photon absorptiometry, we studied the effects of tamoxifen on the bone mineral density of the lumbar spine and radius and on biochemical measures of bone metabolism in 140 postmenopausal women with axillary-node-negative breast cancer, in a two-year randomized, double-blind, placebo-controlled trial. RESULTS: In the women given tamoxifen, the mean bone mineral density of the lumbar spine increased by 0.61 percent per year, whereas in those given placebo it decreased by 1.00 percent per year (P less than 0.001). Radial bone mineral density decreased to the same extent in both groups. In a subgroup randomly selected from each group, serum osteocalcin and alkaline phosphatase concentrations decreased significantly in women given tamoxifen (P less than 0.001 for each variable), whereas serum parathyroid hormone and 1,25-dihydroxyvitamin D concentrations did not change significantly in either group. CONCLUSIONS: In postmenopausal women, treatment with tamoxifen is associated with preservation of the bone mineral density of the lumbar spine. Whether this favorable effect on bone mineral density is accompanied by a decrease in the risk of fractures remains to be determined.

This article reports the development of a Sensation Seeking Scale (SSS) designed to quantify the construct: “optimal stimulation level.” Items were written, using the construct as a guide, and given to undergraduates. The items were factor analyzed. A general factor was found and the item-factor cor

BACKGROUND AND OBJECTIVES: Research on children's use of mobile media devices lags behind its adoption. The objective of this study was to examine young children's exposure to and use of mobile media devices. METHODS: Cross-sectional study of 350 children aged 6 months to 4 years seen October to November 2014 at a pediatric clinic in an urban, low-income, minority community. The survey was adapted from Common Sense Media's 2013 nationwide survey. RESULTS: Most households had television (97%), tablets (83%), and smartphones (77%). At age 4, half the children had their own television and three-fourths their own mobile device. Almost all children (96.6%) used mobile devices, and most started using before age 1. Parents gave children devices when doing house chores (70%), to keep them calm (65%), and at bedtime (29%). At age 2, most children used a device daily and spent comparable screen time on television and mobile devices. Most 3- and 4-year-olds used devices without help, and one-third engaged in media multitasking. Content delivery applications such as YouTube and Netflix were popular. Child ownership of device, age at first use, and daily use were not associated with ethnicity or parent education. CONCLUSIONS: Young children in an urban, low-income, minority community had almost universal exposure to mobile devices, and most had their own device by age 4. The patterns of use suggest early adoption, frequent and independent use, and media multitasking. Studies are urgently needed to update recommendations for families and providers on the use of mobile media by young children.

NSAIDs, non-steroidal anti-inflammatory drugs, are one of the most commonly prescribed pain medications. It is a highly effective drug class for pain and inflammation; however, NSAIDs are known for multiple adverse effects, including gastrointestinal bleeding, cardiovascular side effects, and NSAID induced nephrotoxicity. As our society ages, it is crucial to have comprehensive knowledge of this class of medication in the elderly population. Therefore, we reviewed the pharmacodynamics and pharmacokinetics, current guidelines for NSAIDs use, adverse effect profile, and drug interaction of NSAIDs and commonly used medications in the elderly.

The mechanisms by which hepatitis C virus (HCV) induces chronic infection in the vast majority of infected individuals are unknown. Sequences within the HCV E1 and E2 envelope genes were analyzed during the acute phase of hepatitis C in 12 patients with different clinical outcomes. Acute resolving hepatitis was associated with relative evolutionary stasis of the heterogeneous viral population (quasispecies), whereas progressing hepatitis correlated with genetic evolution of HCV. Consistent with the hypothesis of selective pressure by the host immune system, the sequence changes occurred almost exclusively within the hypervariable region 1 of the E2 gene and were temporally correlated with antibody seroconversion. These data indicate that the evolutionary dynamics of the HCV quasispecies during the acute phase of hepatitis C predict whether the infection will resolve or become chronic.

Serum immunoreactive parathyroid hormone (PTH) is increased in obese as compared with nonobese subjects and declines with weight loss. To determine whether alteration of the vitamin D-endocrine system occurs in obesity and whether ensuing secondary hyperparathyroidism is associated with a reduction in urinary calcium, a study was performed in 12 obese white individuals, five men and seven women, and 14 nonobese white subjects, eight men and six women, ranging in age from 20 to 35 yr. Body weight averaged 106 +/- 6 kg in the obese and 68 +/- 2 kg in the nonobese subjects (P less than 0.01). Each of them were hospitalized on a metabolic ward and were given a constant daily diet containing 400 mg of calcium and 900 mg of phosphorus. Whereas mean serum calcium, serum ionized calcium, and serum phosphorus were the same in the two groups, mean serum immunoreactive PTH (518 +/- 48 vs. 243 +/- 33 pg/ml, P less than 0.001), mean serum 1,25-dihydroxyvitamin D [1,25(OH)2D] (37 +/- 2 vs. 29 +/- 2, P less than 0.01), and mean serum Gla protein (33 +/- 2 vs. 24 +/- 2 ng/ml, P less than 0.02) were significantly higher, and mean serum 25-hydroxyvitamin D (25-OHD) (8 +/- 1 vs. 20 +/- 2 ng/ml, P less than 0.001) was significantly lower in the obese than in the nonobese men and women. Mean urinary phosphorus was the same in the two groups, whereas mean urinary calcium (115 +/- 10 vs. 166 +/- 13 mg/d, P less than 0.01) was significantly lower, and mean urinary cyclic AMP (3.18 +/- 0.43 vs. 1.84 +/- 0.25 nM/dl GF, P less than 0.01) and creatinine clearance (216 +/- 13 vs. 173 +/- 6 liter/d, P less than 0.01) were significantly higher in the obese than in the nonobese individuals. There was a significant positive correlation between percentage of ideal body weight and urinary cyclic AMP (r = 0.524, P less than 0.01) and between percentage of ideal body weight and serum immunoreactive PTH (r = 0.717, P less than 0.01) in the two groups. The results provide evidence that alteration of the vitamin D-endocrine system in obese subjects is characterized by secondary hyperparathyroidism which is associated with enhanced renal tubular reabsorption of calcium and increased circulating 1,25(OH)2D. The reduction of serum 25-OHD in them is attributed to feedback inhibition of hepatic synthesis of the precursor by the increased serum 1,25(OH)2D.

BACKGROUND: Salvage radiation therapy is often necessary in men who have undergone radical prostatectomy and have evidence of prostate-cancer recurrence signaled by a persistently or recurrently elevated prostate-specific antigen (PSA) level. Whether antiandrogen therapy with radiation therapy will further improve cancer control and prolong overall survival is unknown. METHODS: In a double-blind, placebo-controlled trial conducted from 1998 through 2003, we assigned 760 eligible patients who had undergone prostatectomy with a lymphadenectomy and had disease, as assessed on pathological testing, with a tumor stage of T2 (confined to the prostate but with a positive surgical margin) or T3 (with histologic extension beyond the prostatic capsule), no nodal involvement, and a detectable PSA level of 0.2 to 4.0 ng per milliliter to undergo radiation therapy and receive either antiandrogen therapy (24 months of bicalutamide at a dose of 150 mg daily) or daily placebo tablets during and after radiation therapy. The primary end point was the rate of overall survival. RESULTS: The median follow-up among the surviving patients was 13 years. The actuarial rate of overall survival at 12 years was 76.3% in the bicalutamide group, as compared with 71.3% in the placebo group (hazard ratio for death, 0.77; 95% confidence interval, 0.59 to 0.99; P=0.04). The 12-year incidence of death from prostate cancer, as assessed by means of central review, was 5.8% in the bicalutamide group, as compared with 13.4% in the placebo group (P<0.001). The cumulative incidence of metastatic prostate cancer at 12 years was 14.5% in the bicalutamide group, as compared with 23.0% in the placebo group (P=0.005). The incidence of late adverse events associated with radiation therapy was similar in the two groups. Gynecomastia was recorded in 69.7% of the patients in the bicalutamide group, as compared with 10.9% of those in the placebo group (P<0.001). CONCLUSIONS: The addition of 24 months of antiandrogen therapy with daily bicalutamide to salvage radiation therapy resulted in significantly higher rates of long-term overall survival and lower incidences of metastatic prostate cancer and death from prostate cancer than radiation therapy plus placebo. (Funded by the National Cancer Institute and AstraZeneca; RTOG 9601 ClinicalTrials.gov number, NCT00002874 .).

The workshop entitled 'Interventions to Slow Aging in Humans: Are We Ready?' was held in Erice, Italy, on October 8-13, 2013, to bring together leading experts in the biology and genetics of aging and obtain a consensus related to the discovery and development of safe interventions to slow aging and increase healthy lifespan in humans. There was consensus that there is sufficient evidence that aging interventions will delay and prevent disease onset for many chronic conditions of adult and old age. Essential pathways have been identified, and behavioral, dietary, and pharmacologic approaches have emerged. Although many gene targets and drugs were discussed and there was not complete consensus about all interventions, the participants selected a subset of the most promising strategies that could be tested in humans for their effects on healthspan. These were: (i) dietary interventions mimicking chronic dietary restriction (periodic fasting mimicking diets, protein restriction, etc.); (ii) drugs that inhibit the growth hormone/IGF-I axis; (iii) drugs that inhibit the mTOR-S6K pathway; or (iv) drugs that activate AMPK or specific sirtuins. These choices were based in part on consistent evidence for the pro-longevity effects and ability of these interventions to prevent or delay multiple age-related diseases and improve healthspan in simple model organisms and rodents and their potential to be safe and effective in extending human healthspan. The authors of this manuscript were speakers and discussants invited to the workshop. The following summary highlights the major points addressed and the conclusions of the meeting.

BACKGROUND: The Migraine Disability Assessment (MIDAS) score is used to quantify headache-related disability. In a previous study, we showed that the MIDAS score was highly reliable in population-based samples of migraine headache sufferers in two countries. OBJECTIVES: To examine the test-retest reliability and internal consistency of the five items comprising the MIDAS score and the overall MIDAS score in a population-based sample of both migraine and nonmigraine headache sufferers. METHODS: Using a clinically validated telephone interview, a population-based sample of migraine and nonmigraine headache sufferers was identified in Baltimore, Maryland, USA. A total of 97 migraine cases and 80 nonmigraine subjects completed the MIDAS questionnaire on two occasions an average of 3 weeks apart. The MIDAS score is derived from five questions about missed time from work (or school) and household work (one question each about missed days and days with at least 50% reduced productivity) and missed days of nonwork activities. RESULTS: Among all headache sufferers the test-retest Spearman's correlations of individual MIDAS questions ranged from 0.67 to 0.73. The Spearman's correlation for the MIDAS score (i.e., sum of lost days and reduced effectiveness days in each domain) was 0.84. Cronbach's alpha, a measure of internal consistency, was 0.83. Mean and median item values and the overall MIDAS scores differed between migraine and nonmigraine cases. Even after adjusting for differences in headache frequency, the mean MIDAS scores differed substantially (i.e., 10.3 points) between migraine cases and nonmigraine cases. CONCLUSIONS: The reliability and internal consistency of the MIDAS score are high, as tested in a population-based sample of headache sufferers. MIDAS scores are substantially higher in migraine cases than in non-migraine cases, supporting the validity of the measure.

BACKGROUND: For women with ductal carcinoma in situ (DCIS) of the breast, the risk of developing an ipsilateral breast event (IBE; defined as local recurrence of DCIS or invasive carcinoma) after surgical excision without radiation is not well defined by clinical and pathologic characteristics. METHODS: The Oncotype DX breast cancer assay was performed for patients with DCIS treated with surgical excision without radiation in the Eastern Cooperative Oncology Group (ECOG) E5194 study. The association of the prospectively defined DCIS Score (calculated from seven cancer-related genes and five reference genes) with the risk of developing an IBE was analyzed using Cox regression. All statistical tests were two-sided. RESULTS: There were 327 patients with adequate tissue for analysis. The continuous DCIS Score was statistically significantly associated with the risk of developing an IBE (hazard ratio [HR] = 2.31, 95% confidence interval [CI] = 1.15 to 4.49; P = .02) when adjusted for tamoxifen use (prespecified primary analysis) and with invasive IBE (unadjusted HR = 3.68, 95% CI = 1.34 to 9.62; P = .01). For the prespecified DCIS risk groups of low, intermediate, and high, the 10-year risks of developing an IBE were 10.6%, 26.7%, and 25.9%, respectively, and for an invasive IBE, 3.7%, 12.3%, and 19.2%, respectively (both log rank P ≤ .006). In multivariable analyses, factors associated with IBE risk were DCIS Score, tumor size, and menopausal status (all P ≤ .02). CONCLUSIONS: The DCIS Score quantifies IBE risk and invasive IBE risk, complements traditional clinical and pathologic factors, and provides a new clinical tool to improve selecting individualized treatment for women with DCIS who meet the ECOG E5194 criteria.

To test the hypothesis that adult respiratory-distress syndrome (ARDS) is related to increased activity of the proteolytic enzyme elastase released from neutrophils in the lung, we determined the differential white-cell count, the elastolytic activity, the source of elastase, and the concentration and activity of the endogenous protease inhibitor alpha-1-antiprotease (alpha-1-AP) in bronchoalveolar lavage fluid from 23 patients with ARDS and from 55 patients without this syndrome. Neutrophil predominance (> 80 per cent) was observed in 18 of 23 patients with ARDS. High elastolytic activity of neutrophil origin was found in 12 of 23 patients with ARDS (52 per cent), in none of 16 normal nonsmokers (P < 0.01), in two of 17 normal smokers, and in three of 22 patients with chronic obstructive pulmonary disease. Although there were no significant differences in alpha-1-AP concentrations, its activity was reduced in eight of nine patients with ARDS and high elastolytic activity. We conclude that in many patients with ARDS, high levels of neutrophil elastolytic activity in the lungs are associated with reduced alpha-1-AP function.

The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system is designed to provide consistent interpretations, to decrease or eliminate ambiguity in US reports resulting in a higher probability of accuracy in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. It was developed by an international multidisciplinary committee sponsored by the American College of Radiology and applies the standardized reporting tool for US based on the 2018 published lexicon of the O-RADS US working group. For risk stratification, the O-RADS US system recommends six categories (O-RADS 0-5), incorporating the range of normal to high risk of malignancy. This unique system represents a collaboration between the pattern-based approach commonly used in North America and the widely used, European-based, algorithmic-style International Ovarian Tumor Analysis (IOTA) Assessment of Different Neoplasias in the Adnexa model system, a risk prediction model that has undergone successful prospective and external validation. The pattern approach relies on a subgroup of the most predictive descriptors in the lexicon based on a retrospective review of evidence prospectively obtained in the IOTA phase 1-3 prospective studies and other supporting studies that assist in differentiating management schemes in a variety of almost certainly benign lesions. With O-RADS US working group consensus, guidelines for management in the different risk categories are proposed. Both systems have been stratified to reach the same risk categories and management strategies regardless of which is initially used. At this time, O-RADS US is the only lexicon and classification system that encompasses all risk categories with their associated management schemes.

Background While artificial intelligence (AI) offers possibilities of advanced clinical prediction and decision-making in healthcare, models trained on relatively homogeneous datasets, and populations poorly-representative of underlying diversity, limits generalisability and risks biased AI-based decisions. Here, we describe the landscape of AI in clinical medicine to delineate population and data-source disparities. Methods We performed a scoping review of clinical papers published in PubMed in 2019 using AI techniques. We assessed differences in dataset country source, clinical specialty, and author nationality, sex, and expertise. A manually tagged subsample of PubMed articles was used to train a model, leveraging transfer-learning techniques (building upon an existing BioBERT model) to predict eligibility for inclusion (original, human, clinical AI literature). Of all eligible articles, database country source and clinical specialty were manually labelled. A BioBERT-based model predicted first/last author expertise. Author nationality was determined using corresponding affiliated institution information using Entrez Direct. And first/last author sex was evaluated using the Gendarize.io API. Results Our search yielded 30,576 articles, of which 7,314 (23.9%) were eligible for further analysis. Most databases came from the US (40.8%) and China (13.7%). Radiology was the most represented clinical specialty (40.4%), followed by pathology (9.1%). Authors were primarily from either China (24.0%) or the US (18.4%). First and last authors were predominately data experts (i.e., statisticians) (59.6% and 53.9% respectively) rather than clinicians. And the majority of first/last authors were male (74.1%). Interpretation U.S. and Chinese datasets and authors were disproportionately overrepresented in clinical AI, and almost all of the top 10 databases and author nationalities were from high income countries (HICs). AI techniques were most commonly employed for image-rich specialties, and authors were predominantly male, with non-clinical backgrounds. Development of technological infrastructure in data-poor regions, and diligence in external validation and model re-calibration prior to clinical implementation in the short-term, are crucial in ensuring clinical AI is meaningful for broader populations, and to avoid perpetuating global health inequity.