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Randomized Clinical Trial of Intramuscular vs Oral Methylprednisolone: Patients

Patients fulfilling the entry criteria were approached by treating physicians or trained research associates for enrollment into the trial. Written, informed consent was obtained from all participants. A data collection instrument was completed by trained research associates. All eligible patients received nebulized P-agonist agents and an IV injection of 1 mg/kg methyl-prednisolone as standard ED treatment.

Randomized Clinical Trial of Intramuscular vs Oral Methylprednisolone: Study Setting and Population

Patients were enrolled from the EDs of two hospitals with a combined adult ED census of 130,000 patients. Patients were considered to be eligible for study entry if they were 18 to 45 years of age and were expected to be discharged from the ED following treatment for an acute asthma exacerbation. This diagnosis was based on the American Thoracic Society Guidelines for the evaluation of impairment/disability in patients with asthma, and included both clinical symptoms and physical examination findings. Eligibility criteria also required a peak expiratory flow rate (PEFR) of < 70% predicted during the ED visit, and a minimum PEFR of > 40% predicted. PEFR entry criteria were included to define an appropriate study population that was ill enough to merit corticosteroid therapy, but was well enough to be managed as outpatients. Predicted values were calculated in the standard fashion, based on age and height. Patients who had other chronic lung diseases, who had known or suspected bacterial pneumonia, who had received systemic corticosteroid therapy in the past month, who currently used theophylline, mast cell stabilizers, or inhaled anticholinergic agents, who had a current illness precluding use of corticosteroids, or who had an allergy to methylprednisolone were excluded from the study.

Randomized Clinical Trial of Intramuscular vs Oral Methylprednisolone

Asthma is a common disorder accounting for 1.5 million emergency department (ED) visits per year in the United States. There is sound evidence from a meta-analysis2 to support the administration of corticosteroids to patients who have been discharged from EDs following treatment for asthma exacerbations. Despite the proven benefit of therapy with steroids, the relapse rates for asthmatic patients remain high. A single IM dose of a long-acting corticosteroid offers the advantage of a sustained drug level, eliminating the need for a pharmacy visit, and may reduce nonadherence.

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node Metastasis: Conclusion

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node Metastasis: ConclusionIn general, metastasis of normal-sized regional lymph nodes is revealed as adenocarcinoma by histologic examination. However, nodal enlargement can be due to reactive hyperplasia or other nonma-lignant conditions in squamous cell cancer. In this study, 12 of 18 cases (66.7%) diagnosed as node positive by CT and as negative by VEGF-C revealed no lymph nodes metastasis pathologically. Ten of these 12 cases were squamous cell carcinoma. Histologic typing of primary tumor should be considered because most of these false-positive cases were reactive hyperplasia. In the beginning, this study was performed for a larger patient group including various histologic types. A predictive value of CT in diagnosing lymph node suffers biases by their histology, so we reanalyzed the data on selected category of patients. A better PPV (80%) could be obtained when limited to patients with adenocarcinoma, compared to all cases (74%). This may be due to the high sensitivity of serum VEGF-C in adenocarcinoma. Among the 21 patients with node-negative CT and node-positive VEGF-C diagnoses, 16 patients (76.2%) received a node-positive pathologic diagnosis. Furthermore, all of these 16 cases were adenocarcinoma.

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node Metastasis: Comment

The involvement of lymph nodes metastasis is a very important prognostic factor in patients with potentially resectable NSCLC. CT of the chest is the most commonly used noninvasive staging method of lymph node metastasis, but it is far from satisfying and less accurate than mediastinoscopy. Regarding the presence or absence of lymph node metastasis, the accuracy of CT was 68.1%. These data were in agreement with the 51.4 to 83.0% reported previously. Surgical techniques like mediastinoscopy are widely regarded as the most useful methods for mediastinal staging. Several reports have described fluorodeoxyglucose positron emission tomography (PET) as advantageous for diagnosing the nodal staging of NSCLC. A noninvasive, accurate and accessible technique for nodal staging is urgently needed because mediastinoscopy is invasive and PET is performed only at limited numbers of facilities. Evaluating serum VEGF-C concentrations would be accessible to hospitals where there is no access to PET scanning; furthermore, it would be a noninvasive and inexpensive examination.

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node Metastasis: Lymph nodes metastasis

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node Metastasis: Lymph nodes metastasisThe median serum VEGF-C concentration gradually increased in correspondence with pathologic T stage categories, but a statistically significant difference could not be detected: T1, 1.453.1 pg/mL (1,098.9 to 2,133.9 pg/mL); T2, 1.780.2 pg/mL (1,255.3 to 2209.4 pg/mL); T3, 1.820.2 pg/mL (1208.3 to 2387.3 pg/mL) [p = 0.337]. Patients with lymph node metastasis revealed higher serum VEGF-C concentrations than those without: 1,465.5 pg/mL (1,110.5 to 1,903.5 pg/mL) vs 2009.2 pg/mL (1,100.5 to 2,987.0 pg/mL) [p = 0.0007; Fig 1].
No statistical difference was found between N1 and N2 category: 1,920.4 pg/mL (1,214.5 to 2350.9 pg/mL) vs 2,041.2 pg/mL (1,675.0 to 2476.5 pg/mL), respectively (p = 0.6143). Serum VEGF-C reached the highest sensitivity and specificity in diagnosing lymph node metastasis when a cut-off value of 1,850.6 pg/mL was applied.

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node Metastasis: Methods

All patients underwent preoperative chest radiography and CT of the thorax. Distant metastasis was ruled out preoperatively by brain MRI, radionuclide bone scan, and abdominal ultrasonography. Native and IV contrast bolus-enhanced CT scans were routine. The mediastinum was scanned at 5- to 8-mm intervals. The nodal stage was determined by CT, and the mediastinal lymph node levels with enlarged nodes were noted. Mediastinal lymph nodes > 1.0 cm at their minimum cross-sectional diameter were considered to be metastatic. The median delay between CT and surgery was 36 days (range, 5 to 97 days). Clinical T and N stages were compared to the final pathologic T and N stages. Blood samples were drawn by venous puncture preoperatively, and divided into tubes without anticoagulant for serum. Within an hour of collection, blood samples were centrifuged at 2,000 revolutions per minute for 10 min, and aliquots were frozen at — 80°C for later analysis. Informed consent was obtained from all of the patients. The VEGF-C was assayed by commercially available sandwich enzyme-linked immunosorbent assay (code No. 17741; IBL; Fujioka; Gunma, Japan). The limits of sensitivity of the VEGF-C assay were 46.9 pg/mL. The coefficient of variation was < 5.0%.

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node Metastasis

Chest CT and Serum Vascular Endothelial Growth Factor-C Level To Diagnose Lymph Node MetastasisLung cancer is a common disease with a dismal prognosis. Even after a complete resection, over two thirds will die of a relapse within 5 years. The first important decision concerns whether or not to operate, in order to avoid surgical risks without benefit. The second question concerns whether or not to provide neoadjuvant therapy. Both questions must be answered relying on preoperative staging, presently based on the TNM classification. The only CT imaging criteria for tumor involvement are morphologic; that is, the criteria rely on the size and shape of the lymph nodes. We have previously reported that vascular endothelial growth factor (VEGF)-C expression in non-small cell lung cancer (NSCLC) was significantly associated with lymph node metastasis, lymphatic vessel invasion and furthermore, nodal microdissemination. In this study, we compared the relative accuracies of CT and serum VEGF-C level for evaluating regional lymph nodes in patients with NSCLC, and evaluated whether circulating VEGF-C could give additional information for discriminating between the absence and presence of lymph node metastasis in patients with lung cancer.

Health-Care Costs and Exercise Capacity: Conclusion

Our study is limited in that we did not have access to detailed data on clinical events during the follow-up period or on costs that may have been incurred outside of the VA system. While it may be assumed that the majority of the patient population was referred for exercise testing due to either known or suspected cardiovascular disease, we are unable at this time to give further information on subsequent diagnostic and therapeutic interventions that may have occurred. It should be noted, however, that exercise capacity was shown to be a more important predictor of cost in our model than even an abnormal exercise test result, which presumably would have been a major driver of subsequent cardiovascular diagnostic and therapeutic interventions. Also, since the model is adjusted for baseline disease status, it appears that fitness is associated with lower costs independent of comorbid disease.

Health-Care Costs and Exercise Capacity: VA system

Health-Care Costs and Exercise Capacity: VA systemWhile the above models provide useful and interesting data, few analyses have utilized actual population and cost data. Pratt et al performed a cross-sectional stratified analysis of the 1987 National Medical Expenditures Survey. For those without physical limitations, the average annual direct medical costs were $1,019 for those who were regularly physically active and $1,349 for those who reported being inactive. Medical care use was also lower for physically active people than for inactive people. The mean net annual benefit of physical activity was $330 per person. The authors estimated that increasing participation in regular physical activity among the > 88 million inactive Americans over the age of15 years could reduce annual national medical costs by as much as $77 billion. Similarly, Luepker et al reported an analysis of 5-year Medicare costs in 3,393 women and 2,495 men aged > 65 years who were categorized as to activity level based on the National Heart, Lung, and Blood Institute Cardiovascular Health Study. When placed in quar-tiles based on the number of kilocalories expended per week, healthy nonsedentary seniors in the two least active quartiles averaged $4,300 less in 5-year costs than did healthy sedentary seniors. Savings were improved to $6,180 in the most active quartile. These studies were based on a questionnaire of exercise habits rather than on the results of an exercise test.