Background and Purpose-Hyperperfusion syndrome is a rare but potentially devastating complication after carotid endarterectomy (CEA). The aim of this study was to investigate whether preoperative measurement of cerebral vasoreactivity (CVR) and intraoperative measurement of internal carotid artery (ICA) flow could identify patients at risk for hyperperfusion after CEA. Methods-For 26 patients with unilateral ICA stenosis Ն70%, cerebral blood flow (CBF) and CVR were investigated before and 1 month after CEA, with resting and acetazolamide-challenge single-photon emission CT. CBF on the first postoperative day was also measured. ICA flow was measured before and after reconstruction by electromagnetic flowmeter during surgery. Results-Ipsilateral CBF on the first postoperative day significantly increased relatively (56.6Ϯ53.2%) as well as absolutely (37.9Ϯ8.8 to 57.7Ϯ18.0 mL/100 g per minute) in the reduced CVR group (CVR Ͻ12%) but not in the normal CVR group (CVR Ն12%) (10.3Ϯ15.5% and 40.6Ϯ7.9 to 43.9Ϯ5.7 mL/100 g per minute, respectively). One month later, this difference almost disappeared. Two patients showed ipsilateral CBF increase of Ն100%. A significant association of intracerebral steal with hyperperfusion (CBF increase Ն100%) on the first postoperative day was also observed. ICA flow increase after reconstruction significantly correlated with CBF increase on the first postoperative day in the reduced CVR group but not in the normal CVR group. The threshold of ICA flow increase for hyperperfusion was estimated to be 330 mL/min in the reduced CVR group. Conclusions-Single-photon emission CT with acetazolamide challenge and ICA flow measurement during surgery could identify patients at risk for hyperperfusion after CEA, in whom careful monitoring and control of blood pressure should be initiated even intraoperatively. (Stroke. 2001;32:1567-1573.)

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For the treatment of COPD, LAMA+LABA has fewer exacerbations, a larger improvement of FEV, a lower risk of pneumonia, and more frequent improvement in quality of life as measured by an increase over 4 units or more of the SGRQ. These data were supported by low or moderate quality evidence generated from mainly participants with moderate to severe COPD in heterogeneous trials with an observation period of less than one year. Our findings support the recently updated GOLD guidance.

Topotecan is the most reliable chemotherapy regimen for relapsed small-cell lung carcinoma (SCLC). The efficacy and adverse effects of topotecan as reported by previous studies varied greatly. The inclusion criterion was a prospective study that was able to provide data for 6-month over-all survival (OS) rate, 1-year OS rate, objective responses, and/or adverse effects of single agent topotecan as a second line chemotherapy for SCLC, written in English language as a full article. Any topotecan regimen were allowed. Binary data were meta-analyzed with the random-model generic inverse variance method. We included 14 articles consisted of 1347 patients. Pooled values were estimated as follows. Six-month OS rate: 37% (95% CI: 28–46%). One-year OS rate: 9% (95% CI: 5–13%). Response rate: 5% (95% CI: 1–8%). Six-month OS rate: 57% (95% CI: 50–64%). One-year OS rate: 27% (95% CI: 22–32%). Response rate: 17% (95% CI: 11–23%). Grade III/IV neutropenia 69% (95% CI: 58–80%). Grade III/IV thrombopenia 41% (95% CI: 34–48%). Grade III/IV anemia 24% (95% CI: 17–30%). Non-hematorogical events were rare. Chemotherapy-related death 2% (95% CI: 1–3%). In conclusion, Topotecan provided a possibly promising outcome for sensitive-relapse SCLC and poor outcome for refractory relapse SCLC. Adverse events were mainly hematological.

No abstract

Diagnostic test accuracy of the loop-mediated isothermal amplification (LAMP) assay for culture proven tuberculosis is unclear. We searched electronic databases for both cohort and case-control studies that provided data to calculate sensitivity and specificity. The index test was any LAMP assay including both commercialized kits and in-house assays. Culture-proven M. tuberculosis was considered a positive reference test. We included 26 studies on 9330 sputum samples and one study on 315 extra-pulmonary specimens. For sputum samples, 26 studies yielded the summary estimates of sensitivity of 89.6% (95% CI 85.6–92.6%), specificity of 94.0% (95% CI 91.0–96.1%), and a diagnostic odds ratio of 145 (95% CI 93–226). Nine studies focusing on Loopamp MTBC yielded the summary estimates of sensitivity of 80.9% (95% CI 76.0–85.1%) and specificity of 96.5% (95% CI 94.7–97.7%). Loopamp MTBC had higher sensitivity and lower specificity for smear-positive sputa compared to smear-negative sputa. In-house assays showed higher sensitivity and lower specificity compared to Loopamp MTBC. LAMP promises to be a useful test for the diagnosis of TB, however there is still need to improve the assay to make it simpler, cheaper and more efficient to make it competitive against other PCR methods already available.

Background and Purpose-Hyperperfusion syndrome is a rare but disastrous complication after carotid endarterectomy (CEA). The aim of this study was to investigate the relationship between preoperative cerebral blood flow (CBF) abnormalities and postoperative hyperperfusion through the use of statistical brain mapping analysis. Methods-For 41 patients with unilateral carotid stenosis Ն70%, CBF and cerebral vasoreactivity (CVR) were investigated with resting and acetazolamide-challenge single photon emission CT before CEA. CBF 1 day after CEA was also measured. Three-dimensional stereotactic surface projection (3D-SSP) analysis of CBF changes was performed by use of a control database of 20 subjects. Results-Patients with reduced CVR (CVR Ͻ10%, nϭ15) were categorized into 2 groups based on the severity of CBF reduction relative to the control database by 3D-SSP analysis without normalization: type I (ipsilateral CBF decrease Ͻ20%, nϭ8) and type II (ipsilateral CBF decrease Ն20%, nϭ7). With thalamic normalization, the patients were also categorized into 2 groups: type A (ipsilateral Z score Յ2, nϭ10) and type B (ipsilateral Z score Ͼ2, nϭ5). Severe CBF reduction (Ն20% or Z score Ͼ2) was significantly associated with postoperative hyperperfusion (CBF increase Ն100%). However, 3D-SSP with thalamic normalization (Z score) demonstrated a higher predictive value (80%) and specificity (91%) for hyperperfusion than 3D-SSP without normalization (percent reduction) (57% and 73%, respectively). No patients with normal CVR (CVR Ն10%, nϭ26) demonstrated postoperative hyperperfusion. Conclusions-Objective evaluation of abnormalities of CBF and CVR with 3D-SSP could identify patients at risk for postoperative hyperperfusion.

Diagnostic test accuracy of D-dimer for acute aortic dissection (AAD) has not been evaluated by meta-analysis with the bivariate model methodology. Four databases were electrically searched. We included both case-control and cohort studies that could provide sufficient data concerning both sensitivity and specificity of D-dimer for AAD. Non-English language articles and conference abstract were allowed. Intramural hematoma and penetrating aortic ulcer were regarded as AAD. Based on 22 eligible articles consisting of 1140 AAD subjects and 3860 non-AAD subjects, the diagnostic odds ratio was 28.5 (95% CI 17.6–46.3, I2 = 17.4%) and the area under curve was 0.946 (95% CI 0.903–0.994). Based on 833 AAD subjects and 1994 non-AAD subjects constituting 12 studies that used the cutoff value of 500 ng/ml, the sensitivity was 0.952 (95% CI 0.901–0.978), the specificity was 0.604 (95% CI 0.485–0.712), positive likelihood ratio was 2.4 (95% CI 1.8–3.3), and negative likelihood ratio was 0.079 (95% CI 0.036–0.172). Sensitivity analysis using data of three high-quality studies almost replicated these results. In conclusion, D-dimer has very good overall accuracy. D-dimer <500 ng/ml largely decreases the possibility of AAD. D-dimer >500 ng/ml moderately increases the possibility of AAD.