Balch CM, et al.
Prognostic factors analysis of 17,600 melanoma patients: validation of the
American Joint Committee on Cancer melanoma staging system.
J Clin Oncol. 2001 Aug 15;19(16):3622-34.
PMID: 11504744
"Factors predicting melanoma-specific survival rates were analyzed using the Cox proportional hazards regression model. Follow-up survival data for 5 years or longer were available for 73% of the patients." (from the abstract). Includes analysis of prognosis for stage III by tumor burden, ulceration, and nodal involvement.
Sasse AD, Sasse EC, Clark LG, Ulloa L, Clark OA.
Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma.
Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005413. Review.
PMID: 17253556
Sytematic review of 18 (out of 28 identified) studies on the use of chemotherapy v. chemotherapy plus immunotherapy in the treatment of metastatic melanoma.
The Atzpodien and Danson studies were the only ones to include patients with brain metastases.
To see summary of results for each study, go to the Analyses Section. Clicking on the links under Outcome Title for each table will show statistics for each study regarding that outcome.
4/21/08
Which test for iron deficiency anemia has the most diagnostic value?
Guyatt GH, Patterson C, Ali M, Singer J, Levine M, Turpie I, Meyer R.
Diagnosis of iron-deficiency anemia in the elderly.
Am J Med. 1990 Mar;88(3):205-9.
PMID: 2178409
Prospective study of 259 patients aged 65+ diagnosed with iron deficiency anemia. Two hematologists interpreted the results. Since data was generated from the same cohort of patients, the authors used correction factor in generating the ROC curves. Serum ferritin was shown to be the most valuable test for confirming or negating iron deficiency anemia.
Diagnosis of iron-deficiency anemia in the elderly.
Am J Med. 1990 Mar;88(3):205-9.
PMID: 2178409
Prospective study of 259 patients aged 65+ diagnosed with iron deficiency anemia. Two hematologists interpreted the results. Since data was generated from the same cohort of patients, the authors used correction factor in generating the ROC curves. Serum ferritin was shown to be the most valuable test for confirming or negating iron deficiency anemia.
4/18/08
What is the diagnostic value of various tests for pheochromocytoma?
Summary of selected likelihood ratios & sensitivity/specificity from the 2 studies
Lenders JW, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002 Mar 20;287(11):1427-34.
PMID: 11903030
Cohort study of patients referred for testing -- 214 confirmed pheochomocytoma & 644 confirmed negative -- Compared plasma free metanephrines, plasma catecholamines, urinary catecholamines, urinary total and fractionated metanephrines, and urinary vanillylmandelic acid.
Unger N, et al. Diagnostic value of various biochemical parameters for the diagnosis of pheochromocytoma in patients with adrenal mass. Eur J Endocrinol. 2006 Mar;154(3):409-17.
PMID: 16498054
Prospective study -- 24 confirmed pheochromocytoma, 68 w/other types of adrenal masses, 16 w/essential hypertension & 42 healthy, normotensive volunteers --Compared plasma and urine epinephrine and norepinephrine levels as well as plasma and urinary metanephrine and normetanephrine levels
Lenders JW, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002 Mar 20;287(11):1427-34.
PMID: 11903030
Cohort study of patients referred for testing -- 214 confirmed pheochomocytoma & 644 confirmed negative -- Compared plasma free metanephrines, plasma catecholamines, urinary catecholamines, urinary total and fractionated metanephrines, and urinary vanillylmandelic acid.
Unger N, et al. Diagnostic value of various biochemical parameters for the diagnosis of pheochromocytoma in patients with adrenal mass. Eur J Endocrinol. 2006 Mar;154(3):409-17.
PMID: 16498054
Prospective study -- 24 confirmed pheochromocytoma, 68 w/other types of adrenal masses, 16 w/essential hypertension & 42 healthy, normotensive volunteers --Compared plasma and urine epinephrine and norepinephrine levels as well as plasma and urinary metanephrine and normetanephrine levels
4/15/08
Tips for exporting images from Netter Presenter
Netter Presenter is Emory's newest online resource for images. First, you'll have to register
How to access
Download the program
User's Guide The program is not all that user friendly for first time users. Instead of wasting a lot of time trying to figure out how to export an image you have edited, check the user's guide.
How to access
Download the program
User's Guide The program is not all that user friendly for first time users. Instead of wasting a lot of time trying to figure out how to export an image you have edited, check the user's guide.
4/14/08
What is the diagnostic value of the ADAMTS 13 for TTP?
ADAMTS13 activity in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. Blood. 2003 Jul 1;102(1):60-8. Epub 2003 Mar 13.
PMID: 12637323
Prospective study of 255 patients (w/no family history of TTP or HUS) diagnosed with TTP-HUS in 11 hospitals in one region of the US
PMID: 12637323
Prospective study of 255 patients (w/no family history of TTP or HUS) diagnosed with TTP-HUS in 11 hospitals in one region of the US
What is the sensitivity of the tumor marker CA27.29 for detecting recurrence of breast cancer?
CA 27.29 - Breast Cancer
A search of UptoDate provided a reference to "American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast Cancer" (PMID: 17954709.)
There is not much in the way of prospective studies on CA27.29, probably because it measures the same antigen as CA15-3 (MUC-1). At any rate, as a result of a systematic review of the literature, the ASCO 2007 Update concludes that although some of the studies show some value of these markers in detecting recurrence, there is no data to show "clinical benefit in terms of disease-free survival, overall survival, quality of life, toxicity, or cost-effectiveness."
Nicolini A, Tartarelli G, Carpi A, et al: Intensive post-operative follow-up of breast cancer patients with tumour markers: CEA, TPA or CA15.3 vs MCA and MCA-CA15.3 vs CEA-TPA-CA15.3 panel in the early detection of distant metastases. BMC Cancer 6:269, 2006.
PMID: 17116247
Follow-up study of 268 breast cancer patients in clinical remission at the beginning of the study.
A search of UptoDate provided a reference to "American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast Cancer" (PMID: 17954709.)
There is not much in the way of prospective studies on CA27.29, probably because it measures the same antigen as CA15-3 (MUC-1). At any rate, as a result of a systematic review of the literature, the ASCO 2007 Update concludes that although some of the studies show some value of these markers in detecting recurrence, there is no data to show "clinical benefit in terms of disease-free survival, overall survival, quality of life, toxicity, or cost-effectiveness."
Nicolini A, Tartarelli G, Carpi A, et al: Intensive post-operative follow-up of breast cancer patients with tumour markers: CEA, TPA or CA15.3 vs MCA and MCA-CA15.3 vs CEA-TPA-CA15.3 panel in the early detection of distant metastases. BMC Cancer 6:269, 2006.
PMID: 17116247
Follow-up study of 268 breast cancer patients in clinical remission at the beginning of the study.
4/12/08
What is the sensitivity and specificity of electrocardiography findings in diagnosis of pericarditis.
Searched UptoDate, Cochrane Library, EBM Reviews, Pubmed Clinical Queries
Spodick D. Diagnostic electrocardiographic sequences in acute pericarditis. Significance of PR segment and PR vector changes. Circulation. 1973 Sep;48(3):575-80.
Retrospective study, n=50
Surawicz B. Electrocardiogram in pericarditis. Am J Cardiol. 1970 Nov;26(5):471-4.
Retrospective study, n=31
Ginzton LE. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation. 1982 May;65(5):1004-9.
Retrospective study, n=39 (19 acute pericarditis, 20 normal)
Spodick D. Diagnostic electrocardiographic sequences in acute pericarditis. Significance of PR segment and PR vector changes. Circulation. 1973 Sep;48(3):575-80.
Retrospective study, n=50
Surawicz B. Electrocardiogram in pericarditis. Am J Cardiol. 1970 Nov;26(5):471-4.
Retrospective study, n=31
Ginzton LE. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation. 1982 May;65(5):1004-9.
Retrospective study, n=39 (19 acute pericarditis, 20 normal)
4/10/08
Diagnostic tools for cirrhosis and hemachromatosis
1. In patients with suspected cirrhosis, which imaging tool is more sensitive and/or specific--CT or MRI?
***Source: Pubmed
Identified two systematic reviews of studies comparing imaging tools - both reviews focused on studies evaluating efficacy in diagnosing hepatocellular carcinoma.
Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol. 2006 Mar;101(3):513-23
Review: MRI is more sensitive but less specific than ultrasonography or spiral CT for diagnosis of hepatocellular carcinoma.ACP J Club. 2006 Jul-Aug;145(1):21.
2. In diagnosing hemachromatosis, how do the various tests (ferritin, % saturation, genetics test) compare in terms of sensitivity and specificity. Is there a gold standard?
***Source: UptoDate - searched hemochromatosis
Clinical Guideline for diagnosing hereditary hemochromatosis - from the American Association for the Study of Liver Diseases. Tavill, AS, Hepatology 2001; 33:1321.
***Source: Pubmed
Study/Review - Type of assessment - Sensitivity - Specifity
Baynes (1988) - UIBC - 77% - 95%
Bryant (2008, pooled data from 11 studies) - genetic - 91.8% - NA
Adams (2006, validation study) - serum ferriten and transerrin saturation - means for both were statistically significantly higher in homozygotes than in other genotypes
Liver biopsy is considered the definitive tool for measuring extent of iron overload; however may not be necessary in all cases as documented in the AASLD guideline cited above.
***Source: Pubmed
Identified two systematic reviews of studies comparing imaging tools - both reviews focused on studies evaluating efficacy in diagnosing hepatocellular carcinoma.
Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol. 2006 Mar;101(3):513-23
Review: MRI is more sensitive but less specific than ultrasonography or spiral CT for diagnosis of hepatocellular carcinoma.ACP J Club. 2006 Jul-Aug;145(1):21.
2. In diagnosing hemachromatosis, how do the various tests (ferritin, % saturation, genetics test) compare in terms of sensitivity and specificity. Is there a gold standard?
***Source: UptoDate - searched hemochromatosis
Clinical Guideline for diagnosing hereditary hemochromatosis - from the American Association for the Study of Liver Diseases. Tavill, AS, Hepatology 2001; 33:1321.
***Source: Pubmed
Study/Review - Type of assessment - Sensitivity - Specifity
Baynes (1988) - UIBC - 77% - 95%
Bryant (2008, pooled data from 11 studies) - genetic - 91.8% - NA
Adams (2006, validation study) - serum ferriten and transerrin saturation - means for both were statistically significantly higher in homozygotes than in other genotypes
Liver biopsy is considered the definitive tool for measuring extent of iron overload; however may not be necessary in all cases as documented in the AASLD guideline cited above.
4/7/08
Whole brain radiation therapy (WBRT) for a patient with breast cancer that has metastasized to the brain
Two questions were generated on this topic:
1. What is the survival rate for breast cancer patients with brain metastases versus breast cancer patients with no metastases?
Source: MD Anderson Manual of Medical Oncology. McGraw-Hill. 2006:Chapter 20.
5-year survival rate for metastatic breast cancer is 23%
versus 70% up to > 90% for local disease w/no evidence of axillary involvement
Source: UpToDate
5-year survival rate for metastatic breast cancer is 5-10%
citing older study (1996)
Source: Pubmed Clinical Query
-----------------------
2. What is the functional and/or survival benefit of treating a patient with breast cancer that has metastasized to the brain with WBRT plus chemotherapy versus treating with only chemotherapy?
1. What is the survival rate for breast cancer patients with brain metastases versus breast cancer patients with no metastases?
Source: MD Anderson Manual of Medical Oncology. McGraw-Hill. 2006:Chapter 20.
5-year survival rate for metastatic breast cancer is 23%
versus 70% up to > 90% for local disease w/no evidence of axillary involvement
Source: UpToDate
5-year survival rate for metastatic breast cancer is 5-10%
citing older study (1996)
Source: Pubmed Clinical Query
-----------------------
2. What is the functional and/or survival benefit of treating a patient with breast cancer that has metastasized to the brain with WBRT plus chemotherapy versus treating with only chemotherapy?
Searched Cochrane, EBM Reviews, Pubmed, Embase
Found a few RCTs comparing efficacy of WBRT+chemotherapy v. chemotherapy only. They are discussed in the Cochrane article below. Most RCTs compared WBRT alone or in combination w/systemic chemotherapy, radiosensitizing agents, or radiosurgery
***Source: Cochrane Library (searched: brain metasta* radi* )
Whole brain radiotherapy for the treatment of multiple brain metastases. Cochrane Database of Systematic Reviews 2006, Issue 3. (Should be able to see fulltext on campus)
Reviews RCTs comparing WBRT either alone or w/other treatments in adults with multiple metastases to the brain from any primary cancer. Some trials measured survival, while others also measured cognitive function and quality of life. Check out Authors' Conclusions and Discussion sections.
***Source: Pubmed Clinical Query (therapy, breast cancer AND brain metast* AND (radia* OR radio*))
Found a few RCTs comparing efficacy of WBRT+chemotherapy v. chemotherapy only. They are discussed in the Cochrane article below. Most RCTs compared WBRT alone or in combination w/systemic chemotherapy, radiosensitizing agents, or radiosurgery
***Source: Cochrane Library (searched: brain metasta* radi* )
Whole brain radiotherapy for the treatment of multiple brain metastases. Cochrane Database of Systematic Reviews 2006, Issue 3. (Should be able to see fulltext on campus)
Reviews RCTs comparing WBRT either alone or w/other treatments in adults with multiple metastases to the brain from any primary cancer. Some trials measured survival, while others also measured cognitive function and quality of life. Check out Authors' Conclusions and Discussion sections.
***Source: Pubmed Clinical Query (therapy, breast cancer AND brain metast* AND (radia* OR radio*))
Improved survival, quality of life, and quality-adjusted survival in breast cancer patients treated with efaproxiral (Efaproxyn) plus whole-brain radiation therapy for brain metastases. (This is further work from authors of earlier RCT reviewed in Cochrane Review above. )
This RCT includes only patients with breast cancer that has metastasized to the brain. One group received WBRT and the other received WBRT plus efaproxiral. It does show a statistically significant improvement in median survival time for the group receiving WBRT+efaproxiral, but the difference in the two measures is less than 5 months. Also, the drug can be very toxic. There is a table of hazard ratios for various subgroups in the article (Table
This RCT includes only patients with breast cancer that has metastasized to the brain. One group received WBRT and the other received WBRT plus efaproxiral. It does show a statistically significant improvement in median survival time for the group receiving WBRT+efaproxiral, but the difference in the two measures is less than 5 months. Also, the drug can be very toxic. There is a table of hazard ratios for various subgroups in the article (Table
This RCT explores differences in response to WBRT based on various prognostic factors. Shows useful criteria to consider in contemplating WBRT.
***Source: EMBASE, no information that was different from above
4/4/08
What is the sensitivity of the straight leg raise test in diagnosing disc problems
From PubMed Clinical Queries:
1. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002 May;72(5):630-4
Cross-sectional study of 274 patients with pain radiating into the leg. Analysis showed that the straight leg raise was not predictive.
2. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999 Oct;246(10):899-906.
Systematic review of 37 studies which found that of the various tests used during the physical examination of lower back pain, the straight leg raise was the only test that was reported consistently to be sensitive. However, the sensitivity values varied greatly and the review identified several types of methodological problems with the studies that probably led to overestimating the sensitivity.
Full results from PubMed Clinical Queries
1. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002 May;72(5):630-4
Cross-sectional study of 274 patients with pain radiating into the leg. Analysis showed that the straight leg raise was not predictive.
2. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999 Oct;246(10):899-906.
Systematic review of 37 studies which found that of the various tests used during the physical examination of lower back pain, the straight leg raise was the only test that was reported consistently to be sensitive. However, the sensitivity values varied greatly and the review identified several types of methodological problems with the studies that probably led to overestimating the sensitivity.
Full results from PubMed Clinical Queries
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