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Augmented reality: a new tool to improve surgical accuracy during laparoscopic partial nephrectomy? | Use of an augmented reality (AR)-based soft tissue navigation system in urologic laparoscopic surgery is an evolving technique. To evaluate a novel soft tissue navigation system developed to enhance the surgeon's perception and to provide decision-making guidance directly before initiation of kidney resection for laparoscopic partial nephrectomy (LPN). Custom-designed navigation aids, a mobile C-arm capable of cone-beam imaging, and a standard personal computer were used. The feasibility and reproducibility of inside-out tracking principles were evaluated in a porcine model with an artificially created intraparenchymal tumor in vitro. The same algorithm was then incorporated into clinical practice during LPN. Evaluation of a fully automated inside-out tracking system was repeated in exactly the same way for 10 different porcine renal units. Additionally, 10 patients underwent retroperitoneal LPNs under manual AR guidance by one surgeon. The navigation errors and image-acquisition times were determined in vitro. The mean operative time, time to locate the tumor, and positive surgical margin were assessed in vivo. The system was able to navigate and superpose the virtually created images and real-time images with an error margin of only 0.5 mm, and fully automated initial image acquisition took 40 ms. The mean operative time was 165 min (range: 135-195 min), and mean time to locate the tumor was 20 min (range: 13-27 min). None of the cases required conversion to open surgery. Definitive histology revealed tumor-free margins in all 10 cases. | This novel AR tracking system proved to be functional with a reasonable margin of error and image-to-image registration time. Mounting the pre- or intraoperative imaging properties on real-time videoendoscopic images in a real-time manner will simplify and increase the precision of laparoscopic procedures. | closed_qa |
Glycopeptide-resistant enterococci carriage: Are actual isolation and identification techniques sufficient? | The monitoring of infection by glycopeptide-resistant enterococci (GRE) is one of the main elements of hospital hygiene policy. It involves systematic rectal swabs in clinics at risk (asymptomatic carriage).AIM: We compare two GRE screening methods and evaluate a new kit associating multiplex PCR and hybridization (Génotype(®) Enterococcus, Hain Lifescience) on a panel of 448 samples collected over a 4-month period. The first method is based on direct inoculation of the sample; the second one involves a preliminary enrichment phase followed by molecular diagnosis allowing the identification of species of enterococci as well as glycopeptide resistance genes. All the resistant strains were isolated using the enrichment technique. The incidence of GRE (VanA) carriage was 0,55% (two out of 362 patients, two out of 448 isolates) with two Enterococcus faecium VanA. Six Enterococcus gallinarum VanC1 and two Enterococcus casseliflavus VanC2/C3 were also isolated and identified. The main clinics concerned are intensive care and hematology. The two patients with E. faecium VanA had been previously given glycopeptides for 10 days. For three strains, the molecular method allowed to correct prior erroneous results based on rapid identification (RapidID32Strep V2.0). | The method using direct samples inoculation underestimates real incidence of GRE carriage. The performances of Génotype(®) Enterococcus molecular method, evaluated for other parameters using reference strains and DNA sequencing, offer new possibilities applicable to routine laboratory. | closed_qa |
Is combination rituximab with cyclophosphamide better than rituximab alone in the treatment of lupus nephritis? | To assess if combination rituximab and cyclophosphamide is more effective than rituximab monotherapy as an induction therapy for proliferative lupus nephritis. A randomized open-label pilot study in which 9 patients received rituximab alone and 10 patients received two doses rituximab + intravenous cyclophosphamide. The clinical, laboratory and renal histological changes were assessed after 48 weeks of treatment. At week 48, four patients had a complete response, 11 patients achieved partial response, 2 patients remained the same or stable and 2 worsened. There were no statistical differences in the proportion of patients with complete or partial response between the two groups. None of the variables was an independent predictor of response at week 48. Nine patients had significant improvement in activity indices in renal biopsies, but there were no significant differences between the two groups. Overall, 18 out of 19 patients were found to have effective B-cell depletion. The median duration of complete B-cell depletion in all patients was 22 weeks. There were no statistically significant differences in the proportion of patients with complete depletion at weeks 4, 8, 24 and 48 between the two groups except at week 2. | Rituximab monotherapy appears to be effective as induction therapy in lupus nephritis. The addition of cyclophosphamide offers no additional improvement in clinical, laboratory and renal histological assessment or the duration of B-cell depletion at 48 weeks. Large-scale studies with longer duration are needed to confirm these findings. | closed_qa |
Cardiac workup of ischemic stroke: can we improve our diagnostic yield? | Discovering potential cardiac sources of stroke is an important part of the urgent evaluation of the ischemic stroke patient as it often impacts treatment decisions that are essential for determining secondary stroke prevention strategies, yet the optimal approach to the cardiac workup of an ischemic stroke patient is not known. A review of the literature concerning the utility of cardiac rhythm monitoring (ECG, telemetry, Holter monitors, and event recorders) and structural imaging (transthoracic and transesophageal echocardiography) was performed. Data supporting a definitive, optimal, and cost-effective approach are lacking, though some data suggest that appropriate patient selection can improve the diagnostic and therapeutic yield of rhythm monitoring and echocardiography in the evaluation of stroke etiology. | Based on available data, an algorithmic approach for the evaluation of patients with acute ischemic cerebrovascular events that takes into account therapeutic and diagnostic yield as well as cost-efficiency is proposed. | closed_qa |
Are electronic health records ready for genomic medicine? | The goal of this project was to assess genetic/genomic content in electronic health records. Semistructured interviews were conducted with key informants. Questions addressed documentation, organization, display, decision support and security of family history and genetic test information, and challenges and opportunities relating to integrating genetic/genomics content in electronic health records. There were 56 participants: 10 electronic health record specialists, 18 primary care clinicians, 16 medical geneticists, and 12 genetic counselors. Few clinicians felt their electronic record met their current genetic/genomic medicine needs. Barriers to integration were mostly related to problems with family history data collection, documentation, and organization. Lack of demand for genetics content and privacy concerns were also mentioned as challenges. Data elements and functionality requirements that clinicians see include: pedigree drawing; clinical decision support for familial risk assessment and genetic testing indications; a patient portal for patient-entered data; and standards for data elements, terminology, structure, interoperability, and clinical decision support rules. Although most said that there is little impact of genetics/genomics on electronic records today, many stated genetics/genomics would be a driver of content in the next 5-10 years. | Electronic health records have the potential to enable clinical integration of genetic/genomic medicine and improve delivery of personalized health care; however, structured and standardized data elements and functionality requirements are needed. | closed_qa |
HIV-1 superinfection in the antiretroviral therapy era: are seroconcordant sexual partners at risk? | Acquisition of more than one strain of human immunodeficiency virus type 1 (HIV-1) has been reported to occur both during and after primary infection, but the risks and repercussions of dual and superinfection are incompletely understood. In this study, we evaluated a longitudinal cohort of chronically HIV-infected men who were sexual partners to determine if individuals acquired their partners' viral strains. Our cohort of HIV-positive men consisted of 8 couples that identified themselves as long-term sexual partners. Viral sequences were isolated from each subject and analyzed using phylogenetic methods. In addition, strain-specific PCR allowed us to search for partners' viruses present at low levels. Finally, we used computational algorithms to evaluate for recombination between partners' viral strains.PRINCIPAL FINDINGS/ | All couples had at least one factor associated with increased risk for acquisition of new HIV strains during the study, including detectable plasma viral load, sexually transmitted infections, and unprotected sex. One subject was dually HIV-1 infected, but neither strain corresponded to that of his partner. Three couples' sequences formed monophyletic clusters at the entry visit, with phylogenetic analysis suggesting that one member of the couple had acquired an HIV strain from his identified partner or that both had acquired it from the same source outside their partnership. The 5 remaining couples initially displayed no evidence of dual infection, using phylogenetic analysis and strain-specific PCR. However, in 1 of these couples, further analysis revealed recombinant viral strains with segments of viral genomes in one subject that may have derived from the enrolled partner. Thus, chronically HIV-1 infected individuals may become superinfected with additional HIV strains from their seroconcordant sexual partners. In some cases, HIV-1 superinfection may become apparent when recombinant viral strains are detected. | closed_qa |
Is laparoscopic management suitable for solid pseudo-papillary tumors of the pancreas? | Solid pseudo-papillary tumors (SPT) are rare pancreatic neoplasms of low-malignant potential occurring mainly in young women. The purpose of this report is to describe our experience with laparoscopic management of these tumors with 4-year follow-up. Three children with SPT were admitted to two hospitals in Paris, France, between February 2000 and December 2006. Diagnosis or treatment was carried out using laparoscopic techniques (biopsy and resection in one case and biopsy only in two). Long-term follow-up data were collected. All three patients presented recurrences within 3 years after resection, i.e., disseminated peritoneal recurrence in two patients and local recurrence in one. The two patients with peritoneal recurrences were treated by surgical resection and chemotherapy. The patient with local recurrence could not be treated due to contraindicating local factors. All three patients were alive at the time of this writing. | This is the first report describing long-term follow-up after laparoscopic management of SPT. All three patients developed recurrences. These poor results contrast sharply with the low risk of local or disseminated recurrence after open laparotomy without chemotherapy that has been considered as the treatment of choice up to now. Recurrences after laparoscopic management may have been due to diffusion of tumor cells caused by gas insufflation especially during biopsy. Laparoscopic biopsy should not be performed in patients presenting SPT. | closed_qa |
Overlap syndrome: an indication for sleep studies? | The coexistence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary diseases (COPD) is known as overlap syndrome (OS); it occurs in 10-20% of patients with OSA. Patients with OS have a higher risk of pulmonary hypertension and worse nocturnal hypoxemia than those with either disease alone. Differences may be seen according to severity of COPD, anthropometric measures, and polysomnography (PSG) features of patients. Recent studies have suggested that long-term use of continuous positive airway pressure for OSA is associated with worsening of coexistent COPD. This stresses the importance of identifying this subgroup of patients in order to provide adequate therapy. This study aims to describe the presence of OS among subjects at our institution and study its association to daytime hypercapnia, nocturnal hypoxemia, and severity of OSA and of COPD. We reviewed the records of patients who underwent PSG and pulmonary function test (PFT) at our center since 2002. Data gathered from PSG and PFTs included respiratory disturbance index (RDI), apnea index, lowest nocturnal desaturation, forced expiratory volume in 1 s (FEV1), FEV1/forced vital capacity ratio, arterial blood gasses, and anthropometric measures. Five hundred forty-seven records were reviewed, but only 73 met all inclusion criteria for analysis. Thirty-six patients had COPD, 52 had OSA, and 29 had OS. The mean predicted FEV1 percent of all subjects was 80%, and the mean diurnal partial pressure of carbon dioxide (pCO(2)) was 39 mmHg. There were no significant differences in average pCO(2) or RDI between subjects with OSA and OS. In all subjects, hypercapnia significantly correlated with worse RDI (p = 0.01) and with worse nocturnal desaturation (p = 0.01). During rapid eye movement (REM) sleep, those with FEV1 less than 80% predicted had higher RDI than those with higher FEV1 (p = 0.010). | In these preliminary results, the prevalence of OS in our population is similar to that previously reported. Daytime hypercapnia correlated with the more severe sleep-disordered breathing (SDB) and worse nocturnal hypoxemia in all subjects. Severity of obstructive ventilatory impairment is associated with worse SDB during REM sleep. Randomized trials to determine if PSGs are indicated in all patients with severe COPD should be considered. This is an ongoing study. | closed_qa |
Quality of life in MS: does aging enhance perceptions of mental health? | This study was designed to examine the relationship between age and quality of life in middle aged and older adults with MS. Individuals with MS, recruited through a Comprehensive Care Centre and local registries of the National Multiple Sclerosis Society, completed a telephone interview which incorporated several scales of the MS Quality of Life Inventory. Participants were divided into three age groups reflective of developmental transitions in adulthood, from midlife transition to late adulthood. Between group comparisons controlling for physical functioning and duration of MS revealed that the oldest age group (age 65 and above) reported significantly better mental health than the middle age group (age 50-64), but not the youngest age group (age 35-49). Differences between the middle and youngest age group were not significant. | Results suggest that perhaps the process of getting older, or factors related to being older, enhance perceptions of mental health in individuals with MS. Results are discussed within the context of social comparison theory, which might be an adaptive strategy that could underlie response shift in older individuals with MS. | closed_qa |
Changing clinicians' habits: is this the hidden challenge to increasing best practices? | The purpose of this article is to reflect on the concept of habit as an under-explored, but critically important factor that might help explain the lack of uptake of new, scientifically sound practices by rehabilitation clinicians. The complexity relating to being a scholarly practitioner is first presented. The transtheoretical model of behaviour change, developed to better understand behaviour change such as stopping a 'bad' habit or implementing a 'good' one for health improvement purposes, is used to foster reflection on factors involved in uptake of best practices in rehabilitation. To illustrate simply the different scenarios relating to uptake of best practices, such as the use of a standardised tool over a home-grown one, two well known approaches to assessment (use of thermometer versus hand on forehead) that could be used to assess the same construct (body temperature) are contrasted. As rehabilitation clinicians, we are potentially blocked in our uptake of best practices by our habits. Although habits are often comfortable, and change is less so, we need to move away from our comfort zone if we are to adopt best practices. | Given the extensive literature suggesting that there are major gaps between best practice and actual practices, it behoves us to explore the impact of habits to a greater extent. | closed_qa |
Occupational blood exposure among unlicensed home care workers and home care registered nurses: are they protected? | Little is known about the risk of blood exposure among personnel providing care to individual patients residing at home. The objective of this study was to document and compare blood exposure risks among unlicensed home care personal care assistants (PCAs) and home care registered nurses (RNs). PCAs self-completed surveys regarding blood and body fluid (BBF) contact in group settings (n = 980), while RNs completed mailed surveys (n = 794). PCAs experience BBF contact in the course of providing care for home-based clients at a rate approximately 1/3 the rate experienced by RNs providing home care (8.1 and 26.7 per 100 full time equivalent (FTE), respectively), and the majority of PCA contact episodes did not involve direct sharps handling. However, for PCAs who performed work activities such as handling sharps and changing wound dressings, activities much more frequently performed by RNs, PCAs were at increased risk of injury when compared with RNs (OR = 7.4 vs. 1.4) and (OR = 6.3 vs. 2.5), respectively. | Both PCAs and RNs reported exposures to sharps, blood, and body fluids in the home setting at rates that warrant additional training, prevention, and protection. PCAs appear to be at increased risk of injury when performing nursing-related activities for which they are inexperienced and/or lack training. Further efforts are needed to protect home care workers from blood exposure, namely by assuring coverage and enforcement of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard [Occupational Safety and Health Administration. 1993. Frequently Asked Questions Concerning the Bloodborne Pathogens Standard. Available at: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=21010#Scope. Accessed May 30, 2008]. | closed_qa |
Is it an association between body appreciation, self-criticism, oral health status and oral health-related behaviors? | Our aim was to investigate whether body appreciation and self-criticism are associated with self-reported oral health status and oral-health-related behaviors were associated. The present study sample consisted of 178 first year medical students. The questionnaire included information about socio-demographic factors, behavioral variables, self-reported oral health status, self-criticism and body appreciation. Significant differences were found on body appreciation and self-criticism scales according to several variables: gender, anxiety, stress, depression, smoking status, perceived dental health status, current extracted teeth, satisfaction by appearance of own teeth, self-reported gingival condition. When oral health behaviours were analysed we observed that toothbrushing frequency once a day or less was reported mainly in persons with low-levels of body appreciation (P<0.01) and comparative self-criticism (P<0.05). Moreover, individuals who visit their dentist mainly when treatment is needed or when in pain were compared with persons who visit their dentist mainly for check-up or for tooth cleaning and scaling; they showed lower levels of body appreciation (P = 0.005), as well as higher levels of comparative self-criticism (P<0.05), internalized self-criticism (P<0.05) and total self-criticism (P = 0.009). Multiple linear regression analyses revealed that anxiety in everyday life, body appreciation and comparative self-criticism scales were significantly positively associated with oral health status (r2 = 0.144; F = 3.436, P = 0.001), while body appreciation was related also to gingival health-related status (r2 = 0.087; F = 1.943, P = 0.057). When oral health behaviors were evaluated, it was shown that gender and body appreciation scale were positively associated with toothbrushing frequency (P<0.0001). | The results suggest that there is an increased risk for impaired dental health status and behaviour among subjects with low levels of body appreciation and high levels of self-criticism. | closed_qa |
Does a single session of theta-burst transcranial magnetic stimulation of inferior temporal cortex affect tinnitus perception? | Cortical excitability changes as well as imbalances in excitatory and inhibitory circuits play a distinct pathophysiological role in chronic tinnitus. Repetitive transcranial magnetic stimulation (rTMS) over the temporoparietal cortex was recently introduced to modulate tinnitus perception. In the current study, the effect of theta-burst stimulation (TBS), a novel rTMS paradigm was investigated in chronic tinnitus. Twenty patients with chronic tinnitus completed the study. Tinnitus severity and loudness were monitored using a tinnitus questionnaire (TQ) and a visual analogue scale (VAS) before each session. Patients received 600 pulses of continuous TBS (cTBS), intermittent TBS (iTBS) and intermediate TBS (imTBS) over left inferior temporal cortex with an intensity of 80% of the individual active or resting motor threshold. Changes in subjective tinnitus perception were measured with a numerical rating scale (NRS). TBS applied to inferior temporal cortex appeared to be safe. Although half of the patients reported a slight attenuation of tinnitus perception, group analysis resulted in no significant difference when comparing the three specific types of TBS. Converting the NRS into the VAS allowed us to compare the time-course of aftereffects. Only cTBS resulted in a significant short-lasting improvement of the symptoms. In addition there was no significant difference when comparing the responder and non-responder groups regarding their anamnestic and audiological data. The TQ score correlated significantly with the VAS, lower loudness indicating less tinnitus distress. | TBS does not offer a promising outcome for patients with tinnitus in the presented study. | closed_qa |
Systemic absorption of amphotericin B with topical 5% mafenide acetate/amphotericin B solution for grafted burn wounds: is it clinically relevant? | To determine if patients receiving topical amphotericin B in combination with 5% mafenide acetate solution will acquire systemically detectable levels of amphotericin B. A prospective, observational study of consecutive patients from May 2007 to March 2008 who received 5% mafenide acetate/amphotericin B (2 mcg/ml) solution topically every 4h to their excised and grafted burn wounds for at least 5 days. Serum amphotericin B levels were measured every 5 days during treatment. In addition, the percentage of graft take, occurrence of infection, and potential adverse reactions or toxicities were monitored and recorded. A total of 27 patients were enrolled, accumulating 420 treatment days and 72 amphotericin B levels. Sixty-nine of the amphotericin B levels were undetectable, while 3 were detectable at non-therapeutic levels (<0.5 mcg/ml). Of the patients with a detectable serum amphotericin B level, only one experienced adverse reactions that could potentially be attributed to amphotericin B. The mean TBSA burned was 32% (SD+/-14%), with a mean TBSA treated with solution of 21% (SD+/-13%). The median duration of treatment was 8 days (range 5-52 days), and the median number of amphotericin B levels drawn per patient was 1 (range 1-19). The median percentage graft take was 95%, and there were no fungal wound infections. | We conclude that 5% mafenide acetate/amphotericin B (2 mcg/ml) solution, applied to excised and grafted burn wounds, does not produce clinically relevant serum levels of amphotericin B. Based on our observations, this topical regimen is safe. | closed_qa |
Does mental imagery prior to cystoscopy make a difference? | We sought to determine whether mental imagery improves surgical performance of residents novice to cystoscopy. We performed a multicenter randomized controlled trial. Residents who had performed<or = 3 cystoscopies were randomized to preoperative mental imagery sessions or reading a book chapter describing cystoscopy. The primary outcome was comparison of groups' surgical performance scores. Secondary outcomes were measurements of operative times and resident ratings of helpfulness of their preparation. Scores were compared using 2-factor analysis of variance. In all, 68 residents were randomized; 33 to imagery and 35 to control groups. Groups did not differ in age, cystoscopic experience, residency level, or sex. The imagery group's surgical assessment scores were 15.9% higher than controls (P = .03). Operative times did not differ between groups. Imagery residents rated imagery preparation as more helpful than controls (P<.0001). | Residents considered mental imagery to be a more useful preoperative preparation. The mental imagery group's surgical performance was superior to controls. | closed_qa |
Varicocelectomy in men with nonobstructive azoospermia: is it beneficial? | To investigate the effect of open lymph sparing high ligation varicocelectomy in nonobstructive azoospermic men with palpable varicocele and determine predictive parameters of outcome. After a standard diagnostic evaluation, a total number of 83 men with nonobstructive azoospermia (54 men with complete azoospermia and 29 with virtual azoospermia) and palpable varicocele underwent open lymph sparing high ligation varicocelectomy. Testicular core biopsy was also performed perioperatively in all patients. Varicocelectomy was performed bilaterally in 60 patients and unilaterally in 23. The outcome success was assessed in terms of improvement in semen parameters and spontaneous pregnancy. Four patients with recurrent varicocele were excluded from final data analysis. After a mean follow up of 7.4 months, motile sperm in the ejaculate could be identified in 27 (34.2%) nonobstructive azoospermic patients with a mean postoperative sperm count of 3.56+/-4.8 x 106/mL (range 0.3-18.9) and a mean sperm motility of 42.24+/-17.64% (range 24-76). No predictive parameters of postoperative improvement other than testicular histopathology could be concluded. Of these 27 patients, 2 had Sertoli-only-cell pattern, 6 had maturation arrest at spermatid stage pattern, 13 had hypospermatogenesis and 8 had normal spermatogenesis. Spontaneous pregnancy was achieved in 6 (7.7%) patients. Of these 6 patients, 2 had maturation arrest at spermatid stage pattern, 2 had hypospermatogenesis and 2 had normal spermatogenesis. No predictive parameters of spontaneous pregnancy achievement could be concluded. | High ligation varicocelectomy may offer nonobstructive azoospermic men an opportunity to have motile sperm via ejaculate and even the chance of natural conception, instead of the more bothersome assisted reproductive techniques. | closed_qa |
Global measures of quality- and patient safety-related childbirth outcomes: should we monitor adverse or ideal rates? | The objective of the study was to propose a new measure of ideal childbirth outcome, based on the proportion of women delivering without maternal or newborn childbirth morbidity. Using the 2002 California discharge dataset, we calculated rates of childbirth complications among women with singleton, term deliveries, stratified by pregnancy risk status, method of delivery, and parity. An ideal delivery (ID) was defined as a delivery without any complications. The distribution of hospital-level ID rates was calculated for laboring women stratified by parity. Among 382,276 women, the ID rate was 78.5%. Rates, type, and severity of complications varied by risk group (high vs low risk), parity, delivery method, and across hospitals. Complications in childbirth were not rare; approximately 22% of deliveries had at least 1 complication. Women who delivered vaginally and multiparous women were more likely to have an ideal delivery. | The ID rate is a simple hospital-level measure of childbirth outcome that is easy to calculate and interpret. | closed_qa |
Adolescence and depressive symptoms: are group health questionnaires useful in detecting them? | Depressive symptomatology during adolescence can have severe consequences when not treated. Formal health and surveillance programs rarely research its presence. To determine whether it is possible to integrate a depressive symptomatology questionnaire into a standard health survey; to determine whether there are relationships with common variables in such surveys. A cross-sectional analytical study, using both bivariate and multivariate logistic regression. Questionnaires, administered during school hours, included the 21-Beck Depression Inventory (BDI), items from the "Health Habits in the Youth Population of Madrid Surveillance System" and the Youth Risk Behavior Survey (YRBS, Atlanta). Two Health Areas in Vallecas (Madrid). All 798 pupils (13-20 years) attending school filled in the questionnaires. Rate of participation of centers: 100%, of the surveyed groups: 79.2%. pupils who were absent or refused to participate. An association was found between the main variable, depressive symptomatology by BDI, and the following: a) for severe depressive symptomatology: gender (female, odds ratio [OR]=11; 95% confidence interval [95% CI], 4.2-28.8), family relationships (per unit of decrease, OR=3.4; 95% CI, 2.3-5, quantitative variable), risk behaviors (two or three, OR=2.9; 95% CI, 1.3-6.7; four or more, OR=5.3; 95% CI, 2.1-13.4), and b) for moderate depressive symptoms: the previous ones, plus academic achievement (per unit of decrease, OR=1.53; 95% CI, 1.1-2.1, quantitative variable). | it is possible to include depressive symptomatology into health surveys for adolescent populations. These results will allow professionals to assess the presence of depressive symptomatology from relevant surveys which are not usually investigated. There should be discussions on the suitability of current programs. | closed_qa |
The impacted varus (A2.2) proximal humeral fracture in elderly patients: is minimal fixation justified? | The purpose of this retrospective case control study was to assess the outcome of K-wire osteosynthesis of a varus displaced proximal humeral fracture in patients over 65 years old, compared to a control group treated nonoperatively. The patient cohort was taken from our database in the period 2003-2007. After data extraction, the patients were re-examined and scored by the Constant score (CS), modified Constant score (MCS), and the QuickDASH score. The control group was carefully selected and matched to the surgical one for age, type of fracture, and degree of displacement. Minimum follow-up was 12 months, with a mean of 30 months in the surgery group, and 27 months in the nonoperative group. K-wire osteosynthesis in our series yielded consistently good results in older patients who sustained an A2.2 proximal humeral fracture, with an average MCS of 88 points and a QuickDASH score of 15. The surgery group had a statistically significant higher CS and modified Constant score at follow-up than did the conservatively treated group (p = .03). | Operative treatment of varus displaced proximal humerus fractures treated with K-wire osteosynthesis yields good results that are superior to those treated nonoperatively. | closed_qa |
Are starting and continuing breastfeeding related to educational background? | To assess the effect of a woman's educational level on starting and continuing breastfeeding and to assess the role of sociodemographic, lifestyle-related, psychosocial, and birth characteristics in this association. We used the data of 2914 participants in a population-based prospective cohort study. Information on educational level, breastfeeding, sociodemographic (maternal age, single parenthood, parity, job status), lifestyle-related (BMI, smoking, alcohol use), psychosocial (whether the pregnancy was planned, stress), and birth (gestational age, birth weight, cesarean delivery, place and type of delivery) characteristics were obtained between pregnancy and 12 months postpartum. Odds ratios and 95% confidence intervals of starting and continuing breastfeeding for educational level were obtained by logistic regression, adjusted for each group of covariates and for all covariates simultaneously. Of 1031 highest-educated mothers, 985 (95.5%) started breastfeeding; the percentage was 73.1% (255 of 349) in the lowest-educated mothers. At 6 months, 39.3% (405 of 1031) of highest-educated mothers and 15.2% (53 of 349) of lowest-educated mothers were still breastfeeding. Educationally related differences were present in starting breastfeeding and the continuation of breastfeeding until 2 months but not in breastfeeding continuation between 2 and 6 months. Lifestyle-related and birth characteristics attenuated the association between educational level and breastfeeding, but the association was hardly affected by sociodemographic and psychosocial characteristics. | Decisions to breastfeed were underlain by differences in educational background. The underlying pathways require further research. For the time being, interventions on promoting breastfeeding should start early in pregnancy and should increase their focus on low-educated women. | closed_qa |
Screening for postpartum depression at well-child visits: is once enough during the first 6 months of life? | Screening for maternal depression is gaining acceptance as a standard component of well-child care. We tested the feasibility of this policy and determined the prevalence and incidence of maternal depression at well-child visits during the first 6 months of life. Providers in an adolescent-oriented maternity program were cued electronically, when they opened the electronic medical records of 0- to 6-month-old infants to conduct well-child visits, to ask the mothers to complete the Edinburgh Postpartum Depression Scale. Incident cases represented mothers who crossed the referral threshold (score of>or =10) after the first screening. Mothers usually brought their infants to the clinic, and none refused screening. Providers could act on 99% of the 418 screening cues; they administered the Edinburgh Postpartum Depression Scale 98% of the time and always referred mothers with scores of>or =10. Overall, 20% of the mothers scored>or =10. Scores were unstable at<or =3 postpartum weeks (kappa = 0.2). Thereafter, the prevalence and incidence of scores of>or =10 decreased from 16.5% at 2 months to 10.3% and 5.7%, respectively, at 4 months. Prevalence increased to 18.5% at the 6-month visit, and incidence decreased to 1.9%. Repeat screening detected only 2 mothers (5.7%) with scores of>or =10. | Electronic cueing improved compliance with the detection and referral phases of screening for maternal depression at well-child visits. Screening 2 months after delivery detects most mothers who become depressed during the first 6 postpartum months, and screening at the 6-month well-child visit is preferable to screening at the 4-month visit. | closed_qa |
Shielding parenteral nutrition from light: does the available evidence support a randomized, controlled trial? | Exposure of total parenteral nutrition to ambient light induces the generation of peroxides, creating oxidant stress, which potentially compounds complications of prematurity. Photograph protection of total parenteral nutrition reduces the peroxide load and has been shown to be associated with nutritional and biochemical benefits in animals and humans. It is unclear whether this reduction in peroxides from total parenteral nutrition leads to a reduction in the complications of prematurity, such as bronchopulmonary dysplasia. Our hypothesis was that shielding total parenteral nutrition from ambient light is linked to clinical benefits. The purpose of this work was to determine whether photograph protection of total parenteral nutrition (light protected), as compared with no photoprotection (light exposed), reduces the occurrence of bronchopulmonary dysplasia or death in preterm infants. The Canadian Neonatal Network provided data for infants born in 2006 at<28 weeks' gestation admitted to level 3 NICUs in Canada. A retrospective analysis was performed comparing bronchopulmonary dysplasia and death in infants who received light-exposed or light-protected parenteral nutrition. Data were analyzed by using logistic regression models. RESULTS. Thirteen NICUs offered partial light-protected (total parenteral nutrition bag only, intravenous tubing exposed) and 13 offered light-exposed parenteral nutrition; not a single NICU offered complete light-protected parenteral nutrition (total parenteral nutrition bag plus intravenous tubing). The incidence of bronchopulmonary dysplasia or death was 66% with light-protected (n = 428) vs 59% with light-exposed (n = 438) parenteral nutrition. | Partial photograph protection of total parenteral nutrition was not associated with a reduction in bronchopulmonary dysplasia or death as compared with no photograph protection; this relationship is confounded by covariates with strong associations with bronchopulmonary dysplasia. Partial photograph protection of total parenteral nutrition solutions confers no clinical benefit, while consuming valuable resources. A randomized, controlled trial is justified to determine whether there is a true "cause-and-effect" relationship between complete photoprotection of total parenteral nutrition and bronchopulmonary dysplasia or death. | closed_qa |
Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? | Nasogastric tube insertion is a common procedure in children that is very painful and distressing. Although nebulized lidocaine has been shown to be effective in reducing the pain and discomfort of nasogastric tube insertion in adults, there have been no similar studies in children. We set out to investigate the role of nebulized lidocaine in reducing pain and distress of nasogastric tube insertion in young children. We conducted a randomized, double-blind, placebo-controlled trial of nebulized 2% lidocaine at 4 mg/kg versus saline placebo during nasogastric tube insertion at a tertiary urban pediatric emergency department. Patients were eligible if they were aged from 1 to 5 years with no comorbid disease and a clinical indication for a nasogastric tube. Nebulization occurred for 5 minutes, 5 minutes before nasogastric tube insertion. Video recordings before, during, and after the procedure were rated using the Face, Legs, Activity, Cry, and Consolability (FLACC) pain and distress assessment tool (primary outcome measure) and pain and distress visual analog scale scores (secondary outcome measures). Difficulty of insertion and adverse events were also assessed. Eighteen participants were nebulized with 2% lidocaine and 18 participants with normal saline. Nebulization was found to be highly distressing. FLACC scores during nasogastric tube insertion were very high in both groups. There was a trend in the post-nasogastric tube insertion period toward lower FLACC scores in the lidocaine group. Visual analog scale scores for this postinsertion period were significantly lower in the lidocaine arm for pain and distress. There were no significant differences between groups in terms of difficulty of insertion and the number of minor adverse events. The study was terminated early because of the distress and treatment delay associated with nebulization. | Nasogastric tube insertion results in very high FLACC scores irrespective of lidocaine use. Nebulized lidocaine cannot be recommended as pain relief for nasogastric tube insertion in children. The delay and distress of nebulization likely outweigh a possible benefit in the postinsertion period. | closed_qa |
Does picky eating affect weight-for-length measurements in young children? | Picky eating is a major source of parental concern, and children with picky eating habits are potentially at risk for nutritional deficits. This research aimed to determine whether picky eating is related to being underweight in young children. Participants included 34 children with picky eating behavior who were referred to the Pediatric Feeding and Nutrition Clinic for evaluation and 136 healthy controls.Weight and height measurements were obtained, and weight-to-length data were calculated for each child. In all, 7 of 34 children (20.6%) in the picky eaters group and 9 of 136 children (6.6%) in the control group were underweight (P = .02). Underweight was found in 15 children (14.2%) at or under 36 months and in 1 child (1.6%) older than 36 months (P = .002). | Children with picky eating habits, especially those younger than 3 years of age, are at increased risk of being underweight. | closed_qa |
Are DBA/2 mice associated with schizophrenia-like endophenotypes? | Due to its intrinsic deficiency in prepulse inhibition (PPI), the inbred DBA/2 mouse strain has been considered as an animal model for evaluating antipsychotic drugs. However, the PPI impairment observed in DBA/2 mice relative to the common C57BL/6 strain is confounded by a concomitant reduction in baseline startle reactivity. In this study, we examined the robustness of the PPI deficit when this confound is fully taken into account. Male DBA/2 and C57BL/6 mice were compared in a PPI experiment using multiple pulse stimulus intensities, allowing the possible matching of startle reactivity prior to examination of PPI. The known PPI-enhancing effect of the antipsychotic, clozapine, was then evaluated in half of the animals, whilst the other half was subjected to two additional schizophrenia-relevant behavioural tests: latent inhibition (LI) and locomotor reaction to the psychostimulants-amphetamine and phencyclidine. PPI deficiency in DBA/2 relative to C57BL/6 mice was essentially independent of the strain difference in baseline startle reactivity. Yet, there was no evidence that DBA/2 mice were superior in detecting the PPI-facilitating effect of clozapine when startle difference was balanced. Compared with C57BL/6 mice, DBA/2 mice also showed impaired LI and a different temporal profile in their responses to amphetamine and phencyclidine. | Relative to the C57BL/6 strain, DBA/2 mice displayed multiple behavioural traits relevant to schizophrenia psycho- and physiopathology, indicative of both dopaminergic and glutamatergic/N-methyl-D: -aspartic acid receptor dysfunctions. Further examination of their underlying neurobiological differences is therefore warranted in order to enhance the power of this specific inter-strain comparison as a model of schizophrenia. | closed_qa |
Is there any role of resecting the stomach to ameliorate weight loss and sugar control in morbidly obese diabetic patients? | Among the restrictive procedures the role of restrictive vs. resecting the stomach is still ambiguous. This study evaluate which is the role of the stomach with respect to blood glucose levels (BG) and percent excess weight loss (EWL) over the 18 months after restrictive procedures in morbid obese diabetic patients. We retrospectively compared a group of patients who underwent partial gastrectomy (just part of the gastric body) with gastric banding (GBSR; n=27), sleeve gastrectomy (part of gastric body and complete fundus resection; LSG; n=53) to laparoscopic gastric banding (LAGB; n=100). Differences among groups at 3, 6, 12, and 18 months were evaluated by analysis of variance. The three cohorts were diabetic patients similar in BMI, age, and gender. At 12 and 18 months, LSG had higher EWL (P<0.05) and lower BG (P<0.05) than did either LAGB or GBSR. There were no operative deaths. LAGB-two staple-line oozing, two wound infections; LSG-one hemorrhage, two staple-line oozing, two leaks; GBSR-one hemorrhage, two wound infections. All complications were readily treated. | LSG provides better weight loss and glucose control at 1 year and 1.5 years after surgery than does either LAGB or GBSR, suggesting that gastric fundus resection plays an important, not yet well-defined, role. | closed_qa |
Is there a post-PPH syndrome? | Despite early studies reporting significant decreases in postoperative pain and morbidity with the procedure for prolapse and hemorrhoids (PPH) compared to traditional hemorrhoidectomy, certain complications and long-term efficacy remain uncertain. This study was performed to assess the prevalence of usage of PPH and the observed postoperative complaints and complications. A questionnaire was mailed to national and international members of the American Society of Colon and Rectal Surgeons (ASCRS) and the accumulated data were reviewed. The rate of response to the 2,642 questionnaires was 28.5% (n=754). Of the 754 respondents, 531 (70.4%) had performed PPH and 451 (84.9%) continued to perform PPH. The most commonly reported postoperative complaint was delayed postoperative pain. Pain lasting for months was reported by 15.1% of respondents. Persistent bleeding was reported by 34.5%, and 40.9% felt there is a post-PPH syndrome. | Some long-term studies critically examining PPH have come to fruition. A majority of respondents continued to perform PPH. Nearly half of these agreed that there is a "post-PPH syndrome" relating to postoperative morbidities. The most disturbing morbidity was lasting perineal pain of unexplained etiology demanding challenging management. Persistent bleeding from hemorrhoidal disease distal to the staple line requires further management and raises the question as to the use of PPH as a permanent remedial procedure. | closed_qa |
Do improvements in emotional distress correlate with becoming more mindful? | The study aimed (1) to investigate changes in older adults' emotional wellbeing (specifically depression, anxiety and stress levels) and mindful ability following a mindfulness-based cognitive therapy (MBCT) course; (2) to explore correlations between mindfulness (measured as an overall ability and as individual components; observe, describe, act with awareness and accept without judgement) and changes in depression, anxiety and stress levels. Twenty-two participants took an eight-week MBCT course. Levels of depression, anxiety and stress were recorded pre- and post-intervention, as was mindfulness ability (measured both as an overall ability and as individual components). Significant improvements in emotional wellbeing and mindfulness were reported post-MBCT, with large to moderate effect sizes. Increased mindfulness was moderately and significantly associated with improved emotional wellbeing. Increases on all four components of mindfulness were positively associated with greater emotional wellbeing, however only act with awareness and accept without judgement were significantly correlated (with reduced depression). Older adults in our sample reported higher scores on observe and act with awareness than other populations. | This study adds to a growing evidence-base indicating the efficacy of MBCT for depression, anxiety and stress, and extends these finding to older adults. This study found older adults to have elevated levels of certain facets of mindfulness and recommendations are made for researching the possibility that mindfulness may be an extension of the developmental process. | closed_qa |
Does hormone treatment added to radiotherapy improve outcome in locally advanced prostate cancer? | To quantify the magnitude of benefit of the addition of hormone treatment (HT) to exclusive radiotherapy for locally advanced prostate cancer, a literature-based meta-analysis was conducted. Event-based relative risks (RR) with 95% confidence intervals (CIs) were derived through a random-effect model. Differences in primary (biochemical failure and clinical progression-free survival) and secondary outcomes (cancer-specific survival, overall survival [OS], recurrence patterns, and toxicity) were explored. Absolute differences and numbers of patients needed to treat (NNT) were calculated. A heterogeneity test, a metaregression analysis with clinical predictors of outcome, and a correlation analysis for surrogate endpoints were also performed. Seven trials (4387 patients) were gathered. Hormone suppression significantly decreased both biochemical failure (RR, 0.76; 95% CI, 0.70-0.82; P<.0001) and clinical progression-free survival (RR, 0.81; 95% CI 0.71-0.93; P=.002), with absolute differences of 10% and 7.7%, respectively, which translates into 10 and 13 NNT. cancer-specific survival (RR, 0.76; 95% CI, 0.69-0.83; P<.0001) and OS (RR, 0.86; 95% CI, 0.80-0.93; P<.0001) were also significantly improved by the addition of HT, without significant heterogeneity, with absolute differences of 5.5% and 4.9%, respectively, which translates into 18 and 20 NNT. Local and distant relapse were significantly decreased by HT, by 36% and 28%, respectively, and no significant differences in toxicity were found. Primary and secondary efficacy outcomes were significantly correlated. | Hormone suppression plus radiotherapy significantly decreases recurrence and mortality of patients with localized prostate cancer, without affecting toxicity. | closed_qa |
Is hyperglycemia associated with frailty status in older women? | To determine whether hyperglycemia is related to prevalent frailty status in older women. Secondary data analysis of baseline data of a prospective cohort study. Baltimore, Maryland. Five hundred forty-three women aged 70 to 79. Research used baseline data from 543 participants in the Women's Health and Aging Studies I and II aged 70 to 79 who had all variables needed for analyses. The dependent variable was baseline frailty status (not frail, prefrail, frail), measured using an empirically derived model defining frailty according to weight loss, slow walking speed, weakness, exhaustion, and low activity (1-2 characteristics present=prefrail,>OR =3 =frail). Covariates included body mass index (BMI), interleukin-6 (IL-6), age, race, and several chronic diseases. Analyses included descriptive methods and multinomial logistic regression to adjust for key covariates. A hemoglobin A1c (HbA1c) level of 6.5% or greater in older women was significantly associated with higher likelihood of prefrail and frail status (normal HbA1c<6.0% was reference). The association between HbA1C levels of 6.0% to 6.5% and frailty status was not different from that of normal HbA1c, but HbA1c levels of 6.5% to 6.9% had nearly twice the likelihood of frailty (odds ratio (OR)=1.96, 95% confidence interval (CI)=1.47-2.59) as normal HbA1c. A HbA1c level of 9.0% or greater was also strongly associated (OR=2.57, 95% CI=1.99,3.32). Significant associations were also seen between baseline prefrail and frail status and low (18.5-20.0 kg/m2) and high (430.0 kg/m2) body mass index (BMI), interleukin-6, and all chronic diseases evaluated, but controlling for these covariates only minimally attenuated the independent association between HbA1c and frailty status. | Hyperglycemia is associated with greater prevalence of prefrail and frail status; BMI, inflammation, and comorbidities do not explain the association. Longitudinal research and study of alternative pathways are needed. | closed_qa |
Does troponin-I measurement predict low cardiac output syndrome following cardiac surgery in children? | To determine whether serum troponin I (TnI), measured 4 hours after surgery for congenital heart disease, is a predictor of myocardial dysfunction and low cardiac output syndrome (LCOS). Prospective, observational study. Paediatric intensive care unit in a tertiary care academic children's hospital, 1 June 2003 to 12 May 2004. 99 consecutive eligible children who underwent a variety of surgical procedures for congenital heart disease, using cardiopulmonary bypass. All patients were cared for by a consistent perioperative care team. Measurement of TnI preoperatively, and at 0, 4, 8, 12, 24 and 36 hours after ICU admission. Patient demographics and outcome (as median and 25th-75th percentile) were as follows: age, 23.9 (4.6- 65.9) months; cardiopulmonary bypass time, 135 (98-178) minutes; aortic cross-clamp time, 65 (28-85) minutes; preoperative TnI level, 0.02 (0.01-0.03) ng/mL; 4h TnI, 10.6 (3.0-23.4) ng/mL; highest 24 h TnI, 11.7 (3.9-29.5) ng/mL; time to discontinuation of inotropes, 43.9 (18.7-92.9) hours; maximal inotrope score, 10.0 (5.0-16.3); time to extubation, 42.4 (19.8-137.5) hours; and time to ICU discharge 91.8 (45.7-169.7) hours. Twenty-three patients developed LCOS. A 4h TnI level>13 ng/mL predicted LCOS with a sensitivity of 0.78 (95% CI, 0.56-0.93), and a specificity of 0.72 (95% CI, 0.61-0.82). The area under the receiver operating characteristic curve for TnI as a predictor of LCOS was 0.75 (95% CI, 0.63-0.88). TnI was the only predictive variable associated with LCOS in multivariate logistic regression analysis, with an odds ratio of 1.45 (95% CI, 1.05-2.01) for developing LCOS with each 10 ng/mL increase in 4h TnI. Linear regression analysis showed TnI to be significantly correlated with increased time to discontinuation of inotropes, maximal inotrope administration, time to extubation, and time to ICU discharge. | Measurement of early postoperative levels of TnI may aid in the early identification of children who will develop LCOS. | closed_qa |
Is Demodex folliculorum an aetiological factor in seborrhoeic dermatitis? | Seborrhoeic dermatitis (SD) is a common inflammatory skin disease for which no single cause has been found, although many factors have been implicated. The mite Demodex folliculorum (DF) is most commonly seen in the pilosebaceous unit in humans. SD is located in areas that are rich in sebaceous glands, which are also preferred by DF. To compare the number of DF parasites in patients with clinical SD and in healthy controls, and to investigate any possible relationship between the number of DF mites and the presence of SD. The study comprised 38 patients with SD and 38 healthy controls. Standard random and lesion-specific sampling was performed in the group of patients with SD, whereas standard random sampling only was performed for controls. Demodex folliculorum sampling was positive in 19 patients (50%) and 5 controls (13.1%). Mean DF density was 8.16 +/- 10.1/cm(2) (range 0-40) and 1.03 +/- 2.17/cm(2) (1-7) in patient and control groups, respectively. The differences between groups for DF positivity and mean DF density were significant (P = 0.001 for each). DF was found in 13 lesional areas in the patient group, but in only 5 areas in the control group (P = 0.031). | The number of DF mites was significantly higher in both lesional and nonlesional areas of patients with SD. This suggests that, when other aetiological causes are excluded, DF may have either direct or indirect role in the aetiology of SD. | closed_qa |
Is insertion torque correlated to bone-implant contact percentage in the early healing period? | A precise and scientifically established method for the evaluation of the bone quality/primary stability is the measure of the insertion torque (IT). The aim of this study was a comparison between the IT values and the bone-implant contact percentage (BIC) of human implants retrieved after a 4/8-week healing period. Seventeen implants, all with a sandblasted and acid-etched surface, were evaluated in the present study. The implants had been retrieved for different causes, after 4/8 weeks, with a 5 mm trephine bur, and immersed in 10% buffered formalin to be processed for histology. A not statistically significant correlation was found between IT and BIC (P<or=0.892). | In the present study on human-retrieved implants, no statistically significant correlation was found between the IT values and BIC. These results could be due to a lack of relationship between bone structure and IT, or to the fact that primary stability may not only be influenced by bone volumetrical density and/or bone trabecular connectivity but also by the thickness and density of the cortical layer. Moreover, the present knowledge of the bone microstructure is not enough to explain the relationship of bone quality and primary implant stability. | closed_qa |
Surgery for obstructed defaecation: does the use of the Contour device (Trans-STARR) improve results? | Data were collected on all patients undergoing PPH01 or Trans-STARR over a 2 year period. Initially, all were treated using the PPH01 device and during the last 8 months using the Trans-STARR. During the analysis period, 25 consecutive patients were treated with PPH01 and 27 patients were treated with Trans-STARR. The median follow up was 12 months (range 3-12 months) for the PPH01 group and 6 months (range 3-12 months) for the Trans-STARR group. Although the resected specimen was larger in the Trans-STARR group (P<0.001), there was no difference in early adverse events, time to discharge or late complications between the groups. In both groups, postoperative urgency was common (occurring more than occasionally in up to 40% at last review) but the incidence was high preoperatively. ODS and symptom severity scores improved with surgery (P<0.001). However, the degree of improvement was similar with complete resolution of symptoms occurring in 64% of the PPH01 group and 67% of the Trans-STARR group. | Our study shows that both procedures are safe and effective in the surgical treatment of obstructed defaecation but despite a larger resection the Trans-STARR procedure does not offer any additional benefit. A policy of individualizing techniques tailored to the extent of prolapse may be appropriate, but requires further evaluation. | closed_qa |
Is the presence of mitral annular calcification associated with poor left atrial function? | Mitral annular calcification (MAC) is characterized by calcium and lipid deposition in the annular fibrosa of the mitral valve. MAC is associated with cardiovascular events but little is known of its association with left atrial (LA) function. We prospectively obtained 12-lead electrocardiograms (ECGs) and transthoracic echocardiograms (TTE) on patients scheduled for nonemergent echocardiographic assessment at a tertiary care hospital. MAC was graded as 0 = none, 1 = mild, 2 = moderate, 3 = severe. LA linear and volume measurements (stroke volume, LA passive emptying fraction, LA active emptying fraction and LA kinetic energy) were done specifically in addition to commonly measured TTE parameters. From the 124 considered for the study, 72 patients remained (aged 68+/-18 years; 44% male) after excluding those with poor ECG tracings and/or poor TTE images. Eighteen patients had MAC; mild MAC = 14, moderate MAC = 3, severe MAC = 1. When patients with MAC were compared to those without MAC, no significant difference was noted, except for LA linear dimension index (2.1+/-0.4 vs. 1.9+/-0.3 cm/m(2); P = 0.03). For those with mild and moderate MAC, a trend was noted toward lower LA function with increasing MAC severity. In addition, significant differences were noted between those with and without interatrial conduction delay, where those with such delay had significantly impaired LA stroke volume (9.8+/-3 vs. 19.93+/-4 ml; P<0.0001), LA active emptying fraction (18.83+/-8 vs. 65.71+/-9%; P<0.0001) and LA total/reservoir fraction (39.54+/-6 vs. 75.1+/-6%; P<0.0001). | MAC is associated with increase in LA linear dimension on TTE and may be equally represented with lower overall LA function. Further study in a much larger cohort is warranted to delineate these and other potential associations of MAC. | closed_qa |
Dietetic service provision for burn care in the United Kingdom: are nutrition support standards being met? | Catabolism and lean body mass losses in severe burn injury present an extreme challenge to the dietitian. A high level of nutritional intervention is often required, but service levels have not been described in the UK. This study aimed to identify levels of current dietetic services with respect to burns and to assess adequacy against existing nutrition support standards. A postal survey of 34 UK dietetic departments known to provide care to burned adult and paediatric admissions was undertaken. Data were collected on burns settings, hospital service characteristics, staffing and caseload issues, and absence cover. Comparison was made between funding and activity to National Health Service standards for the nutritional care of inpatients. The response rate was 71% and data were analysed for 20 departments Clinical settings were either burn units or plastic surgery wards. Dietetic care was provided to critically ill burned patients in 16 hospitals. Most hospitals had no dietetic funding assigned for burn care. The funding deficit for critical care compared to recommendations was 5.9 full-time equivalents and no individual hospital met funding standards. Thirty-seven percent of dietitians were unable to provide daily follow up for critically ill patients. Absence cover was limited in 60% of cases. Approximately one-third of dietitians were members of a nutrition support team. | Compared to national guidelines for nutrition support, deficiencies of dietetic service provision exist within UK burns settings. This is further reinforced when practice is compared with existing multi-professional burns management standards. | closed_qa |
Assessment of donor steatosis in liver transplantation: is it possible without liver biopsy? | Macrovesicular steatosis of the liver is associated with early dysfunction or poor function of the graft after transplantation; however, it can be quantified accurately only through a liver biopsy that sometimes may not be available and whose result is anyway known when the recipient has already been selected. It would, therefore, be helpful to be able to predict the degree of steatosis, on the basis of non-invasive readily available variables. Data from 374 deceased liver donors from whom a liver biopsy had been taken were analyzed with the receiver operating characteristic area [area under the curve (AUC)] to identify variables that could predict the degree of macrovesicular steatosis classified as: absent to mild (0-30%) and moderate to severe (>30%). Steatosis was associated significantly with donor age, increased body mass index (BMI), presence of type II diabetes, ultrasonographic features, heavy alcohol consumption, transaminases [aspartate-aminotransferase and alanine-aminotransferase (ALT)], gamma-glutamyl-transpeptidase, and glucose blood levels. The combination of BMI, elevation of ALT, presence of type II diabetes, history of heavy alcohol consumption, and ultrasonography signs of steatosis could identify steatosis>30% accurately with an AUC of 0.86 (95% CI = 0.81-0.91). | Fatty infiltration in liver donors can be estimated based on clinical and biochemical parameters. | closed_qa |
Income and oral health relationship in Brazil: is there a threshold? | We explored the relationship between income and two oral health outcomes in Brazil, in order to assess the shape of this relationship. Individual-level data from a national oral health survey were obtained for 22 634 15- to 19-year-old subjects from 330 municipalities. Relationships between income (equivalized household income) and oral health were smoothed using the locally weighted ordinary least squares regression (LOWESS) technique in order to assess the relationship between material circumstances and oral health. We also ranked individuals based on equivalized household income, supplemented by information from total household income, interviewees' earnings, number of cars in the household and years of education, in order to assess the relationship between social position and oral health. The relationship between oral health and equivalized household income showed a threshold and, assuming causality, income levels higher than R$850 per month did not improve oral health further. The relationship between oral health and social position was linear. Correlations of oral health with the ranking variable (social position) were stronger than with equivalized household income, regardless of the income level, and did not decrease after controlling for income. | The relation of oral health in teenagers with equivalized household income (material circumstances) showed a threshold, but the relation with a ranking variable (social position) was linear. Maybe differences in oral health between individuals are influenced by both their material circumstances (up to a certain level of income) and their social position in relation to others, i.e. social status (at any income level). | closed_qa |
Are we teaching what patients need to know? | Heart failure (HF) self-care requires both knowledge and skill, but little attention has been given to identify how to improve skill in HF self-care. The objective was to assess what self-care skills patients with HF perceive that they need and how they developed the skills needed to perform self-care. Data from 85 adults with chronic HF enrolled in 3 prior studies were analyzed using qualitative descriptive meta-analysis techniques. Themes were reexamined using within study and across-study analyses and translated to create a broader and more complete understanding of the development of skill in HF self-care. Tactical and situational skills are needed to perform adequate self-care. Skill in self-care evolves over time and with practice as patients learn how to make self-care practices fit into their daily lives. Proficiency in these skills was acquired primarily through input from family and friends. Health care professionals rarely made significant contributions to the learning of essential skills. | Traditional patient education does not support self-care skill development in patients with HF. New patient teaching strategies are needed that support the development of tactical and situational skills, foster coherence, and use trusted resources. Research testing coaching interventions that target skill-building tactics, such as role-playing in specific situations, are needed. | closed_qa |
Are general surgery residency programs likely to prepare future rural surgeons? | Too few surgeons practice in small rural areas of the United States. Many newly graduating surgeons choose not to practice rurally because they feel unprepared for rural practice. Family medicine residencies have a track record of placing graduates in rural settings. Their experience shows that having a stated interest in training rural physicians, a rural-focused curriculum, and rural practice exposure opportunities are successful elements for graduating physicians who practice rurally. To describe the extent to which general surgery residency training is likely to prepare future rural surgeons using criteria cited in reviews of rural family medicine residency programs. Three criteria were used to assess whether general surgery residency programs are positioned to produce rural surgeons: rural location, rural-focused curriculum, and self-identified interest in rural training. Several search strategies were employed to identify residency programs that meet the criteria. Additionally, data extracted from the American Medical Association's Physician Masterfile was used to determine demographic characteristics of residency programs that have trained surgeons who currently practice rurally. Overall, 25 general surgery residency programs meet at least 1 of the 3 criteria. This finding represents approximately 10% of all residency programs in the United States. Residency programs located in the Midwest and the South have generally been more successful in graduating surgeons who are practicing rurally than those situated in the Northeast and West. | Although a few general surgery residency programs have been successful in graduating surgeons who practice rurally, there has not been a coordinated effort among programs to accomplish this goal. Our findings suggest a need for organization and coordination among those programs committed to training surgeons for rural practice. The creation of a consortium of general surgical residency programs with an interest in training rural surgeons could be a useful first step in this process. | closed_qa |
Increased serum ferritin levels in patients with Crimean-Congo hemorrhagic fever: can it be a new severity criterion? | Serum ferritin is one of the markers indicating hemophagocytosis that may have a role in the pathogenesis of Crimean-Congo hemorrhagic fever (CCHF). This study was designed to determine any correlation between serum ferritin and routine diagnostic laboratory markers of CCHF, and to investigate the relationship between serum ferritin levels and disease severity. Sixty-six patients with CCHF admitted to the hospital during the spring and summer months of 2006 and 2007 were included in the study. Serum ferritin levels were measured in sera obtained during the initial days of hospitalization. Data from 53 patients showing decreasing platelet counts over the first three days were used for further analysis and these patients were divided into two groups according to disease severity: group A included severe cases with lowest platelet counts<or =20x10(9)/l and group B included mild cases with lowest platelet counts>20x10(9)/l. Forty patients (60.6%) were male (mean age 43+/-17 years). Three patients died, thus the fatality rate was 4.5%. Fifty-one patients (77.3%) had abnormal serum ferritin levels, with levels above 500 ng/ml in 62.1%. There was a significant negative correlation between ferritin levels and concordant platelet counts (p<0.001; r=-0.416) and ferritin was also found to be positively correlated with aspartate aminotransferase (p<0.001; r=0.625), alanine aminotransferase (p<0.001; r=0.479), and lactate dehydrogenase (p<0.001; r=0.684). Group A had higher ferritin levels than group B (p<0.001). Receiver operating characteristic analysis revealed that a ferritin level of>or =1862ng/ml had a sensitivity of 87.5% and a specificity of 83.8% in differentiating severe cases from mild ones. | Increased serum ferritin levels may suggest a significant role of hemophagocytosis in the pathogenesis of CCHF and may be a useful marker for diagnosis, disease activity, and prognosis. | closed_qa |
Preparation for pacemaker or implantable cardiac defibrillator implants in patients with high risk of thrombo-embolic events: oral anticoagulation or bridging with intravenous heparin? | Current guidelines recommend stopping oral anticoagulation (OAC) and starting heparin infusion before implanting/replacing a pacemaker/implantable cardioverter-defibrillator (ICD) in patients with high risk for thrombo-embolic events. The aim of this study was to demonstrate that the maintenance of OAC during device implantation/replacement is as safe as bridging to intravenous heparin and shortens in-hospital stay. A cohort of 101 consecutive patients with high risk for embolic events and indication for implant/replacement of a pacemaker/ICD were randomized to two anticoagulant strategies: bridging from OAC to heparin infusion (n = 51) vs. maintenance of OAC to reach an INR = 2 +/- 0.3 at the day of the procedure (n = 50). Haemorrhagic and thrombo-embolic complications were evaluated at discharge, 15 and 45 days after the procedure. A total of 4/51 patients (7.8%) from heparin group and 4/50 (8.0%) from the OAC group developed pocket haematoma following the implant (P = 1.00). One haematoma in each group required evacuation (1.9 vs. 2%, P = 1.00). No other haemorrhagic events or embolic complications developed during the follow-up. Duration of the hospital stay was longer in the heparin group [median of 5 (4-7) vs. 2 (1-4) days; P<0.001]. | Implant of devices maintaining OAC is as safe as bridging to heparin infusion and allows a significant reduction of in-hospital stay. | closed_qa |
Differential expression of metabotropic glutamate receptors 2 and 3 in schizophrenia: a mechanism for antipsychotic drug action? | Preclinical and clinical data implicate the group II metabotropic glutamate receptors mGluR2 and mGluR3 in the pathophysiology of schizophrenia. Moreover, a recent phase II clinical trial demonstrated the antipsychotic efficacy of a mGluR2/mGluR3 agonist. The purpose of the present study was to distinguish the expression of mGluR2 and mGluR3 receptor proteins in schizophrenia and to quantify glutamate carboxypeptidase II (GCP II) in order to explore a role for the metabotropic receptors in schizophrenia therapeutics. GCP II is an enzyme that metabolizes N-acetyl-aspartyl-glutamate (NAAG), which is the only known specific endogenous agonist of mGluR3 in the mammalian brain. The normal expression levels of mGluR2, mGluR3, and GCP II were determined for 10 regions of the postmortem human brain using specific antibodies. Differences in expression levels of each protein were examined in the dorsolateral prefrontal cortex, temporal cortex, and motor cortex in 15 postmortem schizophrenia subjects and 15 postmortem matched normal comparison subjects. Chronic antipsychotic treatment in rodents was conducted to examine the potential effect of antipsychotic drugs on expression of the three proteins. Findings revealed a significant increase in GCP II protein and a reduction in mGluR3 protein in the dorsolateral prefrontal cortex in schizophrenia subjects, with mGluR2 protein levels unchanged. Chronic antipsychotic treatment in rodents did not influence GCP II or mGluR3 levels. | Increased GCP II expression and low mGluR3 expression in the dorsolateral prefrontal cortex suggest that NAAG-mediated signaling is impaired in this brain region in schizophrenia. Further, these data implicate the mGluR3 receptor in the antipsychotic action of mGluR2/mGluR3 agonists. | closed_qa |
Dual-energy CT in patients suspected of having renal masses: can virtual nonenhanced images replace true nonenhanced images? | To qualitatively and quantitatively compare virtual nonenhanced (VNE) data sets derived from dual-energy (DE) computed tomography (CT) with true nonenhanced (TNE) data sets in the same patients and to calculate potential radiation dose reductions for a dual-phase renal multidetector CT compared with a standard triple-phase protocol. This prospective study was approved by the institutional review board; all patients provided written informed consent. Seventy one men (age range, 30-88 years) and 39 women (age range, 22-87 years) underwent preoperative DE CT that included unenhanced, DE nephrographic, and delayed phases. DE CT parameters were 80 and 140 kV, 96 mAs (effective). Collimation was 14 x 1.2 mm. CT numbers were measured in renal parenchyma and tumor, liver, aorta, and psoas muscle. Image noise was measured on TNE and VNE images. Exclusion of relevant anatomy with the 26-cm field of view detector was quantified with a five-point scale (0 = none, 4 =>75%). Image quality and noise (1 = none, 5 = severe) and acceptability for VNE and TNE images were rated. Effective radiation doses for DE CT and TNE images were calculated. Differences were tested with a Student t test for paired samples. Mean CT numbers (+/- standard deviation) on TNE and VNE images, respectively, for renal parenchyma were 30.8 HU +/- 4.0 and 31.6 HU +/- 7.1, P = .29; liver, 55.8 HU +/- 8.6 and 57.8 HU +/- 10.1, P = .11; aorta, 42.1 HU +/- 4.1 and 43.0 HU +/- 8.8, P = .16; psoas, 47.3 HU +/- 5.6 and 48.1 HU +/- 9.3 HU, P = .38. No exclusion of the contralateral kidney was seen in 50 patients, less than 25% was seen in 43, 25%-50% was seen in 13, and 50%-75% was seen in four. Mean image noise was 1.71 +/- 0.71 for VNE and 1.22 +/- 0.45 for TNE (P<.001); image quality was 1.70 HU +/- 0.72 for VNE and 1.15 HU +/- 0.36 for TNE (P<.0001). In all but three patients radiologists accepted VNE images as replacement for TNE images. Mean effective dose for DE CT scans of the abdomen was 5.21 mSv +/- 1.86 and that for nonenhanced scans was 4.97 mSv +/- 1.43. Mean dose reduction by omitting the TNE scan was 35.05%. | In patients with renal masses, DE CT can provide high-quality VNE data sets, which are a reasonable approximation of TNE data sets. Integration of DE scanning into a renal mass protocol will lower radiation exposure by 35%. | closed_qa |
Are there sex-based differences in serum troponin I after cardiac surgery? | To determine whether there are sex-based differences in serum troponin I (TnI) after cardiac surgery with cardiopulmonary bypass. Prospective, observational, cohort study. Tertiary cardiac surgery intensive care unit (ICU) at a university hospital. None. Serum TnI was measured in samples obtained at ICU admission and 6, 12, 24, and 48 hours later. A total of 761 consecutive patients were studied (444 men and 317 women). The characteristics and results of the different sex subgroups were as follows:A) Coronary bypass: 165 men and 38 women. Age, Parsonnet score, Acute Physiology and Chronic Health Evaluation III score, prevalence of renal failure, intra-aortic balloon use, and the lengths of cardiopulmonary bypass, mechanical ventilation, and ICU stay were similar in the two groups. Body mass index, red-cell transfusion needs, and use of noradrenaline were significantly higher in women, whereas dobutamine requirements were higher in men. Mortality: 3 men (1.6%) vs. 0 women (p = not significant).The TnI peak was slightly, but significantly, higher in men (6.2 +/- 4.9 vs. 4.5 +/- 2.6 microg/L. p<0.05).B) Valve surgery: 279 men and 279 women. Some significant differences were found: Women were older than men and had higher Parsonnet score and transfusion needs. The other recorded variables were similar. Mitral prosthesis: 62 men and 125 women (p<0.05). Mitral valvuloplasty: 24 men, 7 women (p<0.05). Aortic prosthesis: 162 men, 103 women (p<0.05). Mitral and aortic prosthesis: 31 men and 44 women (p<0.05). TnI peaks were similar for both sexes in each valve subgroup. Mortality: 3 men (1%) vs. 11 women (3.4%) (p<0.05).The TnI peak did not reach any significant differences between sexes (men 7.9 +/- 6.0 vs. 8.5 +/- 6.5 microg/L in women. p = not significant). | No clinically relevant sex-based differences were found in the TnI peaks after cardiac surgery. | closed_qa |
Does analgesia and condition influence immunity after surgery? | Cellular immunity varies in the perioperative period. We evaluated the effects of fentanyl, clonidine and ketamine at different time points after surgery and in animals in different conditions (young vs. old). Rats undergoing laparotomy under sevoflurane anaesthesia were assigned to receive saline, fentanyl (40 microg kg(-1)), clonidine (10 microg kg(-1)) or ketamine (10 mg kg(-1)) 1 h before surgery. Natural killer (NK) activity was quantified at different time points (immediately or after 18, 24, 48, 72 h and 8 days) in vitro by the lysis of YAC-1 cells. In-vivo assessment included counting the number of lung metastases induced by the MADB-106 cells. During the first 24 h after surgery, a rapid increase in NK activity was noted, followed by a significant depression returning to baseline at 8 days. Analgesics show specific effects: fentanyl depressed NK activity with or without surgery. Clonidine depressed NK activity in nonoperated animals and during the first 24 h after surgery. Ketamine depressed NK activity in nonoperated animals but, after surgery, this activity varied with the same time course as saline. Ketamine and clonidine significantly reduced the number of lung metastases in operated animals. Ketamine significantly reduced the number of metastases in old nonoperated animals. Finally, ageing has a significant negative influence. | Surgery, analgesics and co-existing conditions significantly influence cellular immunity. The importance of these changes varies with time. Fentanyl had a worse influence than clonidine and ketamine, but seemed equally protective against the development of metastases. | closed_qa |
Central pontine myelinolysis after liver transplantation: is sodium the only villain? | Critically ill patients frequently develop neurologic symptoms, which frequently become a clinical challenge. Described approximately 50 years ago, pontine neuronal demyelination is a pathologic change associated with neurologic and psychiatric problems after liver transplantation. The objective of this report was to present a case of central pontine myelinolysis diagnosed after liver transplantation and to discuss its pathophysiology. A 29 years old female patient underwent liver transplantation for fulminant hepatic failure. Postoperatively, she developed neurologic symptoms characteristic of the Locked In Syndrome and the MRI showed changes compatible with central pontine myelinolysis. The patient did not develop dramatic changes in sodium plasma levels, which is frequently incriminated as the causal agent, and improved considerably within a few weeks. | The etiology of central pontine myelinolysis is multifactorial, and special attention should be given to the group of patients at greater risk, such as those with sudden changes in the plasma levels of sodium, liver transplantation, chronic alcoholics, and malnourished. It is important to recognize that osmotic demyelination can develop in patients with low, normal, or elevated plasma levels of sodium, indicating the contribution of other trigger factors. | closed_qa |
Is stapled ileal pouch anal anastomosis a safe option in ulcerative colitis patients with dysplasia or cancer? | The purpose of this study was to investigate the oncological and clinical outcome of ulcerative colitis (UC) patients with coexisting colorectal cancer/dysplasia following stapled ileal pouch-anal anastomosis (IPAA). One hundred eighty-five UC patients who underwent stapled IPAA were followed prospectively in a comprehensive pouch clinic. They were divided into three groups: colorectal cancer, dysplasia, and no cancer/dysplasia. Demographic parameters, clinical data, and oncological and functional outcome of the three groups were compared. Sixteen patients had cancer and 14 had dysplasia. Two of the three cancer patients who developed metastatic disease died. One patient who had rectal cancer was found to have cancer cells in the rectal cuff 10 years after IPAA. All other cancer/dysplasia patients were disease-free at 62 months (median). The 5-year survival rate was 87.5% for the cancer group and 100% for the others (p<0.0001). Chemotherapy (nine patients) did not affect pouch function. Two rectal cancer patients who received radiotherapy did not maintain a functioning pouch. Overall pouch failure rates were 19%, 7%, and 6% for cancer, dysplasia, and no-cancer/dysplasia patients, respectively (p = 0.13). The mean frequency of bowel movements in 24 h was similar between the groups. | Stapled IPAA is a reasonable option for UC patients with cancer/dysplasia. Chemotherapy is safe, but the effect of radiation on pouch outcome is worrisome. Close long-term follow-up for UC patients with cancer/dysplasia is recommended for early detection of possible recurrence. | closed_qa |
Are risk factors for stillbirths in low-income countries associated with sensorineural hearing loss in survivors? | To determine associated risk factors for stillbirths in Lagos, Nigeria and to examine possible relationships between these factors and the risk of sensorineural hearing loss (SNHL). Stillbirths in an inner-city maternity hospital from June 2005 to May 2007 were matched with live-birth controls at ratio 1:2. Risk factors and their associated adjusted odds ratio (OR) at 95% confidence interval (CI) were first determined by multiple logistic regression and then correlated with hearing screening failure among survivors who received a two-stage hearing screening with automated otoacoustic emissions and auditory brainstem response. Of 201 cases examined and matched with 402 live births, 101 (50.2%) were fresh stillbirths and 100 (49.8%) macerated. Multiparity (OR: 1.92; CI: 1.16-3.20), lack of antenatal care (OR: 7.23; CI: 3.94-13.26), hypertensive conditions (OR: 6.48; CI: 2.94-14.29), antepartum haemorrhage (OR:18.84; CI: 6.96-51.00), premature rupture of membrane (OR:3.36; CI: 1.40-8.05), prolonged obstructed labour (OR: 22.25; CI: 10.07-49.16) and prematurity (OR: 2.30; CI: 1.2-4.01) were associated with increased risk of stillbirths whereas caesarean section (OR: 0.24; CI: 0.12-0.48) was associated with lower risk of stillbirths. Infants delivered by mothers with hypertensive conditions during pregnancy were at risk of SNHL (OR: 2.97; CI: 1.15-7.64). | Hypertensive conditions during pregnancy increase the risk of stillbirths and place survivors at greater risk of SNHL. | closed_qa |
Is the non-respect of ethical principles by health professionals during first-trimester sonographic Down syndrome screening damaging to patient autonomy? | To evaluate the understanding of health professionals involved in first-trimester ultrasound screening of the ethical stakes involved by addressing three questions regarding: how much these professionals know about Down syndrome screening by nuchal translucency thickness measurement; their personal opinion with respect to this screening test; and their attitude with respect to their patients, in order to answer the question: 'Are ethical principles respected when women are proposed ultrasound screening during the first trimester of pregnancy?' We studied the medical population in the east part of France by sending a questionnaire to each of 460 medical correspondents. This questionnaire attempted to evaluate the respondent's level of medical knowledge, their personal opinion with respect to first-trimester screening and their attitude towards their patients. We adapted the three-dimensional diagram designed by Marteau et al. to develop a measure of informed choice regarding screening. Only health professionals who were relatively well informed and adopted an autonomy-oriented approach were considered to be in a position to obtain true consent from their patients, respecting ethical principles in terms of competence and the autonomy of patients. We received 276 (60%) responses to the questionnaire. Only 31.9% of health professionals had an approach that facilitated obtaining true consent from their patients and respected the ethical principles of competence and patient autonomy; 46% were in favor of the screening test and adopted an autonomy-oriented approach but were poorly informed; and 15.4% had a directive-authoritarian approach combined with poor knowledge. Regression analysis showed that two independent factors (speciality (P = 0.031) and location of practice (P = 0.034)) affected the level of medical knowledge, and two independent factors (location of practice (P = 0.034) and the type of medical practice i.e. public or private (P<0.05)) affected the opinion of health professionals about the screening test. Two independent factors (speciality (P<0.001) and the age of the health professional (P = 0.02)) affected the attitudes of health professionals towards their patients. | The answer to the question 'Are ethical principles respected when women are proposed ultrasound screening during the first trimester of pregnancy?' is clearly 'No'. Major effort is required to ensure that the decisions made by patients are based on a possibility of true choice. | closed_qa |
Is early laparoscopic cholecystectomy safe after the "safe period"? | Early laparoscopic cholecystectomy (ELC) in acute cholecystitis improves hospital stay and outcome. Operative difficulty is said to increase with delay, and surgery is usually advised within 3 days of presentation. It can be difficult to accommodate all these patients within 3 days; this study evaluates results within and after this "safe period." In total, 137 patients (male:female 45:92) presenting as an emergency due to acute cholecystitis over 45 months from August 1, 2003, who then underwent ELC with an on-table cholangiogram (OTC) or laparoscopic ultrasound were prospectively studied. Outcome was compared between those who underwent surgery within 72 hours (group 1) or after 72 hours (group 2). There were 87 patients in group 1 versus 50 in group 2. There was no significant difference with reference to ASA grading, length of operation (median 90 vs. 90 minutes; P = 1.000), conversion rates (7 vs. 10%; P = 0.523), median postoperative stay (2 vs. 3 days; P = 0.203), or 30-day readmission rates [5/87 [6%] vs. 3/50 [6%]; P = 1.000] between groups, respectively. There was no mortality. One patient had a biliary leak from a duct of Lushka in group 2, which settled after endoscopic stenting. | In experienced hands, ELC is safe even after 72 hours. | closed_qa |
Do neonates with genetic abnormalities have an increased morbidity and mortality following cardiac surgery? | Genetic abnormalities occur in approximately 20% of children with congenital heart disease. The purpose of this study was to evaluate the effect of genetic abnormalities on short-term outcomes following neonatal cardiac surgery. Retrospective review of all neonates (n = 609) undergoing cardiac surgery from January 2003 to December 2006. Genetic abnormalities were identified in 93 neonates (15%). Genetic abnormalities identified were 22q11.2 deletion (23), chromosomal abnormalities including various monosomies, trisomies, deletions, duplications, and inversions (17), dysmorphic undefined syndrome without recognized chromosomal abnormality (27), Down syndrome (9), laterality sequences (9), recognixed syndromes and genetic etiology including Mendelian (i.e. Alagille, CHARGE) (8). Neonates with genetic abnormalities had lower birth weights and were older at time of surgery. There was no difference in operative variables, duration of mechanical ventilation or ICU length of stay between the two groups. There was an increase in total hospital length of stay and postoperative complications in the neonates with genetic abnormalities. Importantly, in hospital mortality was not different. | Neonates with genetic abnormalities have a higher risk of postoperative complications and a longer hospital length of stay. However, there is no increase in hospital mortality. This information may aid in patient management decisions and parental counseling. Longer-term studies are needed for understanding the total impact of genetic abnormalities on neonates with congenital heart disease. | closed_qa |
Does the menstrual cycle influence the motor and phosphene thresholds in migraine? | The excitability of the visual and motor cortical areas is altered in migraineurs. Controversial results of previous studies on cortical excitability may depend on the hormonal status of female subjects. The present study aimed to determine whether the different phases of the menstrual cycle influence the phosphene thresholds (PT) and resting motor thresholds (RMT) in migraineurs. Thirty-two migraine patients participated in this study. Three to six PT and RMT measurements were done in headache-free intervals during the follicular, middle and luteal phases of the female cycle, or in active dosage and withdrawal phases in patients who were taking low dosage oral contraceptives. Generally, PTs showed higher individual variabilities than RMTs. Additionally, we have observed that the RMTs and PTs were significantly independent from hormonal changes. However, patients who were taking a low dosage of oral contraceptives had lower PTs compared with patients who were not taking oral contraceptives. RMTs show the opposite tendency. | The results imply that PTs and RMTs can be reliably measured independently from the menstrual hormone status in female migraineurs. | closed_qa |
Interpersonal processes of care and patient satisfaction: do associations differ by race, ethnicity, and language? | Describe association of patient satisfaction with interpersonal processes of care (IPC) by race/ethnicity.DATA SOURCES/ Interview with 1,664 patients (African Americans, English- and Spanish-speaking Latinos, and non-Latino Whites).STUDY DESIGN/ Cross-sectional study of seven IPC measures (communication, patient-centered decision making, and interpersonal style) and three satisfaction measures (satisfaction with physicians, satisfaction with health care, and willingness to recommend physicians). Regression models explored associations, controlling for patient characteristics. In all groups: patient-centered decision making was positively associated with satisfaction with physicians (B=0.10, p<.0001) and health care (B=0.07, p<.001), and "recommend physicians" (OR=1.23, 95 percent CI 1.06, 1.43); discrimination was negatively associated with satisfaction with physicians (B=0.09, p<.05) and health care (B=0.17, p<.001). Unclear communication was associated with less satisfaction with physicians among Spanish-speaking Latinos. Explaining results was positively associated with all satisfaction outcomes for all groups with one exception (no association with satisfaction with physicians for Latino Spanish-speakers). Compassion/respect was positively associated with all outcomes for all groups with two exceptions (no association with satisfaction with health care among English-speaking Latinos and Whites). | All IPC measures were associated with at least one satisfaction outcome for all groups except for unclear communication. | closed_qa |
Sex differences in the use of absorbent (incontinence) pads in independently living elderly people: do men receive less care? | The subjects participated in a large-scale study about the prevalence of UI. All the independently living patients in nine family practices aged 60 or above with uncomplicated UI, who were willing to participate in the study were interviewed at home. In total, 56 men and 314 women were interviewed. Fifteen per cent of the men and 87% of the women with UI used pads. All men and nine out of 10 women used different kinds of absorbent pads, and half of the men and women used pads specifically made for UI. Only half of the men and two-third of the women felt satisfied with the pads. The reasons for not being satisfied were: leakage, irritation and discomfort. The use of pads, the use at daytime and the type of pads were correlated to the severity of incontinence. | Only one out of nine men with UI uses pads in contrast with four out of five women. Only half of them wear pads specifically made for UI. Men are less satisfied about the pads compared with women. | closed_qa |
Complications of atrial fibrillation ablation in a high-volume center in 1,000 procedures: still cause for concern? | Catheter ablation is potentially curative treatment for atrial fibrillation (AF). However, complications are more frequent and more severe compared with other ablation procedures. We investigated the complication rate in 1,000 AF ablation procedures in a high-volume center and examined possible risk factors. One thousand consecutive circumferential pulmonary vein radiofrequency ablations were performed for symptomatic, drug-refractory AF. Major complications were defined as the ones that were life threatening, caused permanent harm, and required intervention or prolonged hospitalization. Thirty-nine (3.9%) major periprocedural complications were observed. There was no death immediately associated with the procedure. However, there were 2 deaths (0.2%) of unclear cause, 14 days and 4 weeks after ablation. The most common complications were tamponade (1.3%), treated mainly by percutaneous drainage, and vascular complications (1.1%). There were also 4 thromboembolic events (0.4%): 3 nonfatal strokes and one transient ischemic attack. Importantly, 2 cases (0.2%) of atrial-esophageal fistula and 2 cases (0.2%) of endocarditis were observed. Factors associated with an increased complication risk were age>or = 75 years (hazard ratio 3.977, P = 0.022) and congestive heart failure (hazard ratio 5.174, P = 0.001). | AF ablation still has a considerable number of major complications that may be life threatening or may lead to severe residues. Atrial-esophageal fistula is still observed despite continuous systematic methods to prevent it. Stroke, tamponade, and vascular complications are the most frequent major complications. However, in most patients treatment can be conservative and results in complete recovery. Advanced age and congestive heart failure seem to be associated with an increased risk of complications. | closed_qa |
Lack of effect of norfloxacin on hyperdynamic circulation in bile duct-ligated rats despite reduction of endothelial nitric oxide synthase function: result of unchanged vascular Rho-kinase? | In cirrhosis, portal hypertension is maintained by splanchnic vasodilation owing to overproduction of the vasodilator nitric oxide (NO) and defective contractile signalling by Rho-kinase. NO overproduction is partially caused by bacterial translocation from the gut to mesenteric lymph nodes. However, the effects of intestinal bacterial decontamination on hyperdynamic circulation or vascular contractility are unknown. We investigated the haemodynamic and vascular effects of norfloxacin in rats with secondary biliary cirrhosis. Cirrhosis was induced by bile duct ligation (BDL). One group was treated with norfloxacin (20 mg/kg/day, 5 days, orally). Bacterial growth in the lymph nodes was determined on blood agar plates. Invasive haemodynamic measurements were combined with coloured microspheres. Aortic contractility was assessed myographically. Protein expression/phosphorylation was examined by Western blot analysis. Norfloxacin treatment of BDL rats abolished bacterial translocation to mesenteric lymph nodes. BDL rats had hyperdynamic circulation, including portal hypertension and splanchnic vasodilation. None of these parameters was changed by norfloxacin, although norfloxacin reduced endothelial NO synthase expression and phosphorylation. The latter was associated with a diminished activity of protein kinase G (PKG), which mediates NO-induced vasodilation. However, norfloxacin had no effect on aortic contractility to methoxamine or Ca2+, or the aortic expression of RhoA, Rho-kinase and beta-arrestin 2, or the phosphorylation of the Rho-kinase substrate moesin. | Short-term treatment of BDL rats with norfloxacin does not change hyperdynamic circulation or vascular contractility, despite reduction of PKG activity. | closed_qa |
Surgical reintervention in acromegaly: is it still worth trying? | There has not been a formal evaluation of how frequently and to what extent surgical reintervention in patients with persistently active acromegaly may achieve significant, albeit incomplete, reductions in growth hormone (GH) and insulinlike growth factor-I (IGF-I) levels. Of importance, recent studies suggest that the response to radiotherapy and pharmacotherapy is better with lower degrees of hypersomatotropism. The objective of this study was to evaluate the outcome of surgical reintervention in patients with active acromegaly at our institution between 1995 and 2005. We retrospectively evaluated the outcome in 53 patients with active acromegaly (49 with macroadenomas) who underwent a second operation a mean of 24.1 +/- 25.2 months after the first intervention. Basal and postglucose GH as well as IGF-I levels were analyzed at diagnosis and after the first and second pituitary procedures. Basal GH decreased in 38 patients (72%): to<10 ng/mL in 17 and to<2.5 ng/mL in 11. The mean IGF-I index and basal GH decreased significantly after surgical reintervention: 1.7 +/- 0.4 to 1.4 +/- 0.4 (P = .0001) and 13.0 +/- 12.8 to 8.3 +/- 11.3 ng/mL (P = .0001), respectively. Some decrement in IGF-I was observed after surgical reintervention in 30 patients (57%), being greater than 30% in 9 (17%). Only 5 patients (9%) achieved complete biochemical cure (normal IGF-I and a postglucose GH level of<1 ng/mL). Reoperation achieved a significant decline in basal and postglucose GH levels as well as in IGF-I index only in patients with noninvasive macroadenomas. | Pituitary surgical reintervention in patients with acromegaly results in a low percentage of biochemical cure. If a remnant of a noninvasive macroadenoma is visible and accessible, however, such a procedure may significantly reduce GH and IGF-I levels. | closed_qa |
Does age-related change affect the short-term postoperative improvement of physical functions and abilities in compressive cervical myelopathy? | A total of 56 patients with cervical myelopathy who were candidates for surgery (63.1+/-11.5 years; 40 men, 16 women) were investigated. Written consent to participate in this study was obtained from all participants. The following items were assessed before and/or a month postoperatively; six basic characteristics (Hattori's classification, symptom duration, comorbidity, Pavlof ratio, dynamic instability of cervical spine and cervical intramedullary high intensity change); one motor and one sensory function in the lower and upper extremities, respectively; two walking abilities; one manual dexterity. After division into the elderly group (>or =65 years) and non-elderly group (65 years>). basic characteristics, physical functions and abilities were compared between the two groups. The elderly group consisted of 27 participants (72.7+/-5.2 years; 16 men, 11 women) and the non-elderly group consisted of 29 participants (54.1+/-8.1 years; 24 men, 5 women). In the 6 preoperative characteristics, the rate of having comorbidity in the elderly group (63.0%) was significantly greater than the non-elderly group (27.6%). Most comobidities were orthopedic disorders. Preoperative motor function in the lower extremity in the elderly group was significantly inferior to the non-elderly group, whereas the improvement rate based on preoperative finding at a month postoperatively was equal to the non-elderly group. Preoperative walking abilities were significantly inferior to the non-elderly group, although their improvement rates were equal to or significantly greater than the non-elderly group. Moreover, preoperative upper extremity motor function and manual dexterity in the elderly group were equal to those in the non-elderly group, and their improvement rates were also equal. | Preoperative motor function in the lower extremity and walking abilities in elderly cases of compressive cervical myelopathy were significantly inferior to non-elderly cases of cervical myelopathy, although their improvement rates based on preoperation at one month postoperatively were equal to or significantly greater than non-elderly cases of cervical myelopathy; therefore age-related change is not a directly negative factor for short-term postoperative improvement. | closed_qa |
Does the presence of a hiatal hernia affect the efficacy of the reflux inhibitor baclofen during add-on therapy? | Reflux inhibitors, like the gamma-aminobutyric acid type B (GABA(B)) receptor agonist, baclofen, block transient lower esophageal sphincter relaxations (TLESRs) and are proposed as an add-on therapy in patients with proton pump inhibitor (PPI)-resistant gastroesophageal reflux. However, as other mechanisms of reflux become more important in the presence of a hiatal hernia (HH), the efficacy of reflux inhibitors to reduce acid and non-acid exposure may be hampered. Therefore, we compared the effect of baclofen in patients with no HH (-HH) and those with a large HH during PPI treatment. A total of 27 gastroesophageal reflux disease (GERD) patients on PPI were included; 16 had -HH and 11 had a large (>or =3 cm) HH (+HH). During PPI treatment, the effect of baclofen (3 x 20 mg) on acid and non-acid reflux was evaluated in a randomized, double-blind, placebo-controlled cross-over study. Reflux was measured during 24 h using combined esophageal impedance and pH-metry. The majority of reflux events consisted of both gaseous and liquid reflux with a significant increase in non-acid, mixed reflux episodes in +HH patients compared with those in -HH patients. Acid exposure time was in the normal range in both patient groups during both placebo and baclofen. In this study, baclofen significantly reduced the total number of reflux episodes with 36% in -HH patients and 43% in +HH patients, but did not change the number of acid reflux episodes or total acid exposure time. | This study shows that baclofen is also effective in patients with GERD with +HH, further underscoring the potential of reflux inhibitors as treatment of GERD. | closed_qa |
Hepatitis C performance measure on hepatitis A and B vaccination: missed opportunities? | Prevention of hepatitis A virus (HAV) and hepatitis B virus (HBV) infection in patients with chronic hepatitis C (CHC) through vaccination is endorsed by all major professional societies. This study was conducted to determine adherence to the recently adopted physician performance measure on HAV and HBV vaccination. This was a retrospective study. Hepatitis A and B serology data and immunization records between 2000 and 2007 from CHC patients with detectable hepatitis C virus (HCV) RNA were analyzed. A total of 2,968 CHC patients were included in the study. Of these, 2,143 patients (72%) were tested for susceptibility to HAV, of which 53% had immunity. Of the non-immune patients, 746 (74%) were vaccinated as well as an additional 218 without prior testing. For HBV, 2,303 patients (78%) were tested for immunity and 782 (34%) were immune. Of the susceptible patients, 1,086 (71%) were vaccinated as well as an additional 197 patients without prior testing. The overall vaccination performance measure adherence rate was 71% for HAV, 70% for HBV, and 62% for both HAV and HBV. Random review of 176 charts found the major reasons for non-adherence were missed opportunity (41%), change of health care system (31%), and documented vaccination outside our health care system (22%). | Our study found a high and improved adherence to the recommendations, but missed opportunity was still the main reason of non-adherence. This study also supported the strategy of selective vaccination in the veteran population. | closed_qa |
Does the use of trypan blue during phacoemulsification affect the intraocular pressure? | The purpose of the study was to evaluate the effect of trypan blue on intraocular pressure (IOP) after small-incision cataract surgery. Prospective, randomized study. Fifteen patients (30 eyes) with bilateral, dense, age-related cataracts. Patients with glaucoma, ocular hypertension, exfoliation, pigment dispersion syndrome, history of uveitis, recent use of topical or systemic steroids, and previous ocular surgery were excluded. The patients were randomly assigned to receive trypan blue during cataract surgery for enhancing capsulorrhexis in 1 of their eyes, while in the other eye, trypan blue was not used. Cataract surgery was performed in an identical fashion in both eyes, with a sutureless posterior limbal incision, phacoemulsification, and implantation of a foldable intraocular lens. The same viscoelastic (sodium hyaluronate) was used in all cases and was thoroughly aspirated at the end of the procedure. All patients received a single dose of 250 mg acetazolamide 8 hours after surgery. No other antiglaucomatous agent was used during surgery or postoperatively. The intraocular pressure (IOP) was measured preoperatively and at 24 hours, 1 week, 1 month, and 3 months postoperatively. IOP values were similar in both groups at all 4 postoperative measurements. There was no statistically significant difference in postoperative IOP values between the eyes in which trypan blue was used and the control eyes. | The use of trypan blue during small-incision cataract surgery does not have any effect on IOP during the immediate and early postoperative period. | closed_qa |
Medical school curricula: do curricular approaches affect competence in medicine? | US medical school curricula continually undergo reform. The effect of formal curricular approaches (course organization and pedagogical techniques) on competence in medicine as measured by the United States Medical Licensing Examinations (USMLE) Step 1, 2, and 3 is not fully understood. The purpose of this study was to investigate the effects of formal curricular approaches in a latent variable path analysis model of achievement-aptitude-competence in medicine. Using Association of American Medical Colleges (AAMC) and USMLE longitudinal data (1994-2004) for 116 medical schools, structural equation modeling was used to study latent variable path models assessing the impact of curriculum on competence in medicine (n=9,332). A latent variable path model consisting of three latent variables measured by undergraduate grade point average (general achievement), Medical College Admission Test subscores (aptitude for medicine), and USMLE Step 1-3 (competence in medicine) was used to assess the impact of curriculum on competence in medicine. Two models were tested; one resulted in a Comparative Fit Index=.931 with a path coefficient of 0.04 from curriculum to competence in medicine. While there was a good fit of the data to the final model, the type of school curriculum did not significantly influence competence in medicine since it accounted for less than 1% of the variation in student performance on the USMLE. | Various formal curricular approaches have little differential effect on students' performance on the USMLE. | closed_qa |
Midcarpal instability: a diagnostic role for dynamic ultrasound? | The aim of this study was to describe the technique of dynamic ultrasound (US) examination of the triquetral clunk, and to illustrate the range of findings in four patients with midcarpal instability (MCI). Four patients were identified (3 men, 1 woman). The case notes, plain radiographs, MRI and dynamic US for each patient were reviewed. Digital video files recording the dynamic US of the triquetral clunks were analysed for the following features of abnormal triquetral mobility: direction and speed of triquetral snap, amount of anteroposterior translocation, and flexion or extension during the snap. Five different triquetral clunks were recorded in 4 patients. In four out of five cases the clunk occurred during ulnar translocation of the wrist, and in one during radial translocation. Anteroposterior translocation was anterior (3.4 - 4.7 mm) in three of the clunks and posterior (1 - 10 mm) in two. The degree of flexion or extension varied between 1 and 16 degrees . The snapping phase of the clunk lasted between 0.17 and 0.25 seconds. | Dynamic US can be used to confirm the diagnosis of midcarpal instability by identifying a triquetral catch-up clunk. Quantification of carpal mobility with US may lead to further insights into the mechanics of MCI. | closed_qa |
Fetal short time variation during labor: a non-invasive alternative to fetal scalp pH measurements? | To determine whether short time variation (STV) of fetal heart beat correlates with scalp pH measurements during labor. From 1279 deliveries, 197 women had at least one fetal scalp pH measurement. Using the CTG-Player, STVs were calculated from the electronically saved cardiotocography (CTG) traces and related to the fetal scalp pH measurements. There was no correlation between STV and fetal scalp pH measurements (r=-0.0592). | Fetal STV is an important parameter with high sensitivity for antenatal fetal acidosis. This study shows that STV calculations do not correlate with fetal scalp pH measurements during labor, hence are not helpful in identifying fetal acidosis. | closed_qa |
Does lactate level in the first 12 hours of life predict mortality in extremely premature infants? | To determine if high lactate levels within the first 12 h of life independently or in combination with Clinical Risk Index for Babies (CRIB) II can predict mortality in extremely premature babies. A retrospective review of medical charts of babies born between 2001 and 2003 with birthweight<1000 g or gestation<28 weeks was performed. Blood gases and highest umbilical lactate levels in first 12 h of life were noted. Area under the curve (AUC) was calculated for lactate, CRIB and CRIB II as a predictor of mortality. The AUC for lactate and CRIB II were combined using discriminant analysis. Two hundred nineteen infants were included in the study, 41 (18.7%) of whom died. The AUC for lactate was 0.67 (P<0.001), while AUCs for CRIB and CRIB II score were 0.81 (P<0.001) and 0.82 (P<0.001), respectively. The AUC for the combined measure of lactate and CRIB II was 0.82, similar to CRIB II. | Lactate predicts mortality in premature infants, but was found to be inferior to CRIB and CRIB II. Adding lactate level to CRIB II score does not improve its predictive ability. | closed_qa |
Can parents accurately screen children at risk of developmental delay? | One hundred and forty-one term infants born with moderate or severe newborn encephalopathy (NE) and 374 randomly selected comparison infants were administered a Griffiths Mental Development Scales (GMDS) assessment and an IMQ concurrently. Concordance of classifications between measures was compared for agreement, sensitivity, specificity, positive predictive value, negative predictive value, false positives and false negatives. Overall, sensitivity and specificity of the IMQ for infants with NE averaged across all age groups was 87%, positive predictive value 57% and negative predictive value 97%. The IMQ did not perform as well for comparison infants with a sensitivity of 50%, specificity 94%, positive predictive value 15% and negative predictive value 99% averaged across all age groups. Overall under-referral for infants with NE was 13%, compared with 50% for comparison infants. | Use of the IMQ as an accurate screening measure in infants 'at risk' of developmental delay is supported. The low sensitivity of the IMQ for the comparison infants indicates a need for caution when considering its application for general population screening. | closed_qa |
Does left atrial volume and pulmonary venous anatomy predict the outcome of catheter ablation of atrial fibrillation? | Preprocedural factors may be helpful in selecting patients with atrial fibrillation (AF) for treatment with catheter ablation and in making an assumption regarding their prognosis. The aims of this study were to investigate whether left atrial (LA) volume and pulmonary venous (PV) anatomy, evaluated by computed tomography (CT) prior to ablation, will predict AF recurrence following catheter ablation. We included 146 patients (mean age 57 +/- 11 years, 83% male) with symptomatic AF (55% paroxysmal, 18% persistent, 27% long-standing persistent). All patients underwent CT scanning prior to catheter ablation to evaluate LA volume and PV anatomy. Circumferential PV isolation was performed guided by Cartomerge electroanatomical mapping. The outcome was defined as complete success, improvement, or failure. After a mean follow-up of 19 +/-7 months, complete success was achieved in 59 patients (40%), and 38 patients (26%) demonstrated improvement. LA volume was found to be an independent predictor of AF recurrence with an adjusted OR of 1.14 for every 10-mL increase in volume (95% CI 1.00-1.29, P = 0.047). PV variations were equally distributed among the different outcomes of the ablation procedure, and therefore univariate analysis did not identify PV anatomy as a predictor of outcome. | LA volume is an independent predictor of AF recurrence after catheter ablation. Additionally, PV anatomy did not have any effect on the outcome. These findings suggest that an assessment of LA volume may be incorporated into the preprocedural evaluation of patients being considered for AF ablation. | closed_qa |
Does the gender of the standardised patient influence candidate performance in an objective structured clinical examination? | The objective structured clinical examination (OSCE) requires the use of standardised patients (SPs). Recruitment of SPs can be challenging and factors assumed to be neutral may vary between SPs. On stations that are considered gender-neutral, either male or female SPs may be used. This may lead to an increase in measurement error. Prior studies on SP gender have often confounded gender with case. The objective of this study was to assess whether a variation in SP gender on the same case resulted in a systematic difference in student scores. At the University of Ottawa, 140 Year 3 medical students participated in a 10-station OSCE. Two physical examination stations were selected for study because they were perceived to be 'gender-neutral'. One station involved the physical examination of the back and the other of the lymphatic system. On each of the study stations, male and female SPs were randomly allocated. There was no difference in mean scores on the back examination station for students with female (6.96/10.00) versus male (7.04/10.00) SPs (P = 0.713). However, scores on the lymphatic system examination station showed a significant difference, favouring students with female (8.30/10.00) versus male (7.41/10.00) SPs (P<0.001). Results were not dependent on student gender. | The gender of the SP may significantly affect student performance in an undergraduate OSCE in a manner that appears to be unrelated to student gender. It would be prudent to use the same SP gender for the same case, even on seemingly gender-neutral stations. | closed_qa |
It's better on TV: does television set teenagers up for regret following sexual initiation? | Two-thirds of sexually experienced teenagers in the United States say they wish they had waited longer to have intercourse for the first time. Little is known about why such a large proportion of teenagers express disappointment about the timing of their initial experience with sex. Data on television viewing, on regret about the timing of first intercourse and on potentially relevant covariates were obtained from a national, three-year (2001-2004) longitudinal survey of adolescents aged 12-17 at baseline. Logistic regression and path analysis were used to examine the association between exposure to sex on television and the likelihood of regret following sexual initiation, the extent to which shifts in expectations about the positive consequences of sex mediate this association and whether these relationships differ by gender. Sixty-one percent of females and 39% of males who had sex for the first time during the study period reported that they wished they had waited to have sex. Exposure to sexual content on television was positively associated with the likelihood of regret following sexual initiation among males (coefficient, 0.34) but not females. The association among males was partly explained by a downward shift in males' sex-related outcome expectancies following sexual initiation. | Interventions that limit teenagers' exposure to televised sexual content, that provide a more accurate portrayal of sexuality than typically depicted on television or that help adolescents think critically about televised sexual content may help teenagers make more carefully considered decisions about sexual debut. | closed_qa |
Are the predictors of sexual violence the same as those of nonsexual violence? | Violence manifests itself in such multifarious ways as sexual, physical, and psychological abuse. What has hitherto eluded the medical community, however, is whether sexual and nonsexual abuse share the same predictors.AIM: Drawing upon a representative sample of married men and women in the Iranian capital, Tehran, we aimed to determine: (i) the overlap between sexual abuse and physical and psychological violence, and (ii) the predictors that sexual violence victimization share with physical and psychological violence victimization. Victimization through any type of sexual coercion by the husband in the context of the current marital relationship, as determined via the conflict tactic scales-revised (CTS-2). In a cross-sectional survey in Tehran in 2007, 460 married Iranian men and women were selected via a multicluster sampling method from four different randomized regions. Independent variables comprised sociodemographic characteristics, subscores of psychological, and personality characteristics known to be allied with intimate abuse (personal and relationship profile), and dichotomus data on victimization history through all types of violence by the spouse including psychological aggression, physical assault, and sexual coercion (CTS-2). In both genders, the experience of physical or psychological violence increased the likelihood of sexual violence victimization. In both genders, higher conflict was a predictor of sexual and psychological violence victimization. In addition, the common predictors of sexual and physical violence victimization were low self-control and high violent socialization in the men and women, respectively. | Sexual violence victimization shares some factors with the victimization of nonsexual types of marital abuse, but this seems to be partially gender dependent. | closed_qa |
Does improvement in the treatment of those who attempt suicide contribute to a reduction in elderly suicide rates in England? | The reported decline in elderly suicide rates in England may have been, in part, due to prompt and successful resuscitation of those who attempt suicide. This study examines the impact of prompt and successful resuscitation of those who attempt suicide on elderly suicide rates in England. Possible changes in rates of attempted suicides in elderly age-bands over a nine-year period and the correlation between rates of attempted suicide and suicide in elderly age-bands in England were examined using nationally collected data. There was a significant increase in the rates of attempted suicide over the study period in the age-band 60-74 years, but not in the age-band 75+ years. There was a positive correlation between rates of attempted suicide and suicide in the age-band 75+ years, but not in the age-band 60-74 years. | The findings of this study were unable to confirm conclusively that prompt and successful medical resuscitation of those who attempt suicide makes a contribution to the decline in elderly suicide rates and requires further study. Public health initiatives should be designed to reduce not only suicide rates but also rates of attempted suicide; otherwise they are failing in the prevention of mental illness and suicidal behavior, early identification and treatment of those with mental illness and those at risk of suicide, and systematic follow-up of those recovering and recovered from mental illness. | closed_qa |
Is there an advantage in scoring early embryos on more than one day? | This study was undertaken to determine what characteristics should be recorded on which days to build a predictive model for selection of Day 3 embryos. Embryos failing to form a clinical sac or that formed a viable fetus (to>or =12 weeks), and transferred singly (n = 269) or in pairs (n = 1326) were scored for early cleavage and pronuclear status on Day 1, and cell number, fragmentation, and symmetry on Days 2 and 3, with number of nuclei per blastomere also recorded on Day 2. Seven candidate models were identified using a priori clinical knowledge and univariate analyses. Each model was fit on a training-set and evaluated on a test-set with resampling, with discrimination assessed using the area under the ROC curve (AUC) and calibration assessed using the Hosmer-Lemeshow statistics. Models built using Day 1, 2 or 3 scores independently on the 30 resampled data sets showed that Day 1 evaluations provided the poorest predictive value (median AUC = 0.683 versus 0.729 and 0.725, for Day 2 and 3). Combining information from Day 1, 2 and 3 marginally improved discrimination (median AUC = 0.737). Using the final Day 3 model fitted on the whole dataset, the median AUC was 0.732 (95% CI, 0.700-0.764), and 68.6% of embryos would be correctly classified with a cutoff probability equal to 0.3. | Day 2 or Day 3 evaluations alone are sufficient for morphological selection of cleavage stage embryos. The derived regression coefficients can be used prospectively in an algorithm to rank embryos for selection. | closed_qa |
Gender gap, inflammation and acute coronary disease: are women resistant to atheroma growth? | Gender differences that exist in patients with acute coronary disease (ACD) are unexplained. We sought to determine if these differences could be related to differences in the pathologic substrate found in the coronary arteries at the time of death. The hearts of 83 patients (64 men and 19 women) who died of ACD were obtained fresh and uncut at the autopsy table. The coronary arteries were injected with a colored barium gelatin mass. After formalin fixation, the epicardial arteries were dissected intact, decalcified and cut at 2-3 mm intervals, with all segments mounted for histologic study. The severity of luminal stenosis and the frequency of adventitial inflammation, intimal calcification and atheromas were determined microscopically for each segment. Plaque burden was determined histologically by assessing the severity of luminal stenosis for each coronary segment. The number of plaque ruptures (PRs), with and without luminal thrombosis, were tabulated for each heart in the study. These results were compared with 22 control patients who died of noncoronary disease. There are gender similarities as well as significant differences in the pathologic substrate of patients who die of ACD. Active, inflammatory atherosclerosis and associated ACDs develop earlier in life in men than in women, and are associated with death at an earlier age, producing a "gender gap." There were no significant gender differences in the frequency of PRs. The women were significantly older than the men and had more extensive active disease, but had the same overall plaque burden as men, suggesting women may be resistant to plaque growth, particularly atheroma growth. | Gender gap appears to be related to factors peculiar to women who resist atheroma growth, delaying PR and the onset of ACD. | closed_qa |
Does the type of resuscitative fluid affect healing of colonic anastomosis in experimentally induced hemorrhagic shock in rats? | The aim of the study was to investigate the effects of different resuscitative fluids on the healing of intestinal anastomosis in a hemorrhagic-shock rat model. Closed-colony Wistar male rats (n = 40; 8 rats per group) were subjected to volume-controlled hemorrhagic shock, followed by a 30-min shock phase. The animals were then resuscitated with one of the following fluids (which also corresponds to their respective groups): lactated Ringer's solution (LR), hydroxyethyl starch (HES), 7.5% hypertonic saline (HS) and autologous blood (AB). There was also a control group (CL), which did not experience hemorrhagic shock or receive any resuscitative fluids. All rats underwent laparotomy, segmental resection and anastomosis of the left colon. Five days later, a 2nd laparotomy was performed and the anastomotic bursting pressure was measured in vivo. Thereafter, the anastomosed segment was resected to measure the tissue hydroxyproline level and the grade of anastomotic fibrosis. All experimental groups (LR, HES, HS and AB) exhibited lower anastomotic bursting pressures than the CL group; however, no intergroup differences achieved statistical significance. The mean tissue hydroxyproline level and fibrosis grade also were similar across all 5 groups. | In traumatic hemorrhagic shock, anastomosis safety does not appear to be affected by the type of fluid used for resuscitation. Moreover, LR, HES and HS all seemed to reinforce healing as effectively as transfused blood. | closed_qa |
Is obesity associated with a survival advantage in patients starting peritoneal dialysis? | Obesity has been found to be associated with a survival advantage in hemodialysis patients. Results from studies in peritoneal dialysis (PD) patients are inconsistent. The aim of this paper was to study the association between obesity and mortality in the PD population in the Netherlands Co-operative Study on the Adequacy of Dialysis-2 (NECOSAD) cohort and critically discuss the observational data from an epidemiological perspective. Patients starting PD were selected from the Netherlands Co-operative Study on the Adequacy of Dialysis-2 (NECOSAD), a prospective cohort study in incident dialysis patients in The Netherlands and followed for 5 years. Cox regression analysis was used to calculate relative risk of mortality (hazard ratios (HR) with 95% CIs) of baseline and time-dependent BMI, with a BMI of 18.5-25 as the reference. In total, 688 patients with end-stage renal disease starting with PD were included (66% men, age: 53 +/- 15 years, BMI: 24.6 +/- 3.8 kg/m2). At the start of dialysis, 8.4% of the patients were obese (BMI>or =30). Compared with a normal BMI, obesity at the start of PD (BMI>or =30) was associated with a HR of 0.8 (0.5, 1.3). Time-dependently, this was 0.7 (0.4, 1.2). The HR of BMI<18.5 at the start of PD was 1.3 (95% CI: 0.4, 3.2), and time-dependently this was 2.3 (1.0, 5.3). | Observational data suggest that PD patients who are obese at the start of dialysis do not have a worse survival compared with PD patients with a normal BMI. PD patients with a low BMI during dialysis have a twofold increased mortality risk. However, it can be argued to what extent the observed association between BMI and mortality in the dialysis population can be causally interpreted. | closed_qa |
Is Burch or mid-urethral sling better with abdominal sacral colpopexy? | This study aims to compare the post-operative rates of stress urinary incontinence (SUI) after abdominal sacral colpopexy (ASC) with either Burch or mid-urethral sling, tension-free vaginal tape (TVT), or no anti-incontinence procedure. The null hypothesis was there would be no difference in SUI among groups. A cohort of women who had undergone ASC (n = 150) either alone or with an anti-continence procedure were analyzed to determine the rates of post-operative SUI. Statistically significant differences were evaluated with a Student's t-test. A total of 150 subjects were evaluated, with 115 having SUI preoperatively. Post-operatively, 10% (15/150) of all subjects had SUI. Subjects with preoperative SUI who had a Burch were more likely to have post-operative SUI than those who had a TVT (10 versus 0, p = 0.007). | Burch and TVT procedures improve SUI symptoms in patients undergoing ASC. Mid-urethral slings performed with ASC have lower rates of post-operative SUI. | closed_qa |
Does lack of routine postnatal examination on maternity unit increase the risk of hospital admission in the first week of life? | The purpose of this study is to establish whether omitting routine postnatal examination on maternity units increases the risk of hospitalisation in the first week of life of the newborn. Retrospective analysis of maternal and baby details and paediatric admission data spanning 12 months in the setting of two maternity units and children's admission unit (CAU) at the University Hospitals of Leicester NHS Trust, Leicester, UK looking at all live-born babies not admitted to neonatal units (n = 7,058). For babies within first week of life, main outcome measures are: (1) risk of the need to be assessed on CAU and (2) risk of hospitalisation for 48 h. Babies who had routine postnatal examination on maternity unit (n = 3,631) and babies who had no such examination (n = 3,427) had similar risks of the need to be seen on CAU (3% and 2.4%, respectively; p = 0.057) and of hospitalisation for 48 h (0.82% and 0.67%, respectively; p = 0.22). Babies born to first-time mothers and/or premature were more likely to have postnatal examination on the maternity unit and were at a higher risk of hospitalisation in the first week of life. | With prudent selection and extended surveillance of at-risk babies, lack of routine postnatal examination on maternity unit did not increase the risks of hospital review or admission in the first week of life. Worryingly, however, as many as 27% of all babies might not have had routine postnatal examination at all. | closed_qa |
Does defense style or psychological mindedness predict treatement response in major depression? | The aim of this study was to define the impact of defense style and psychological mindedness (PM) on the prognosis of major depressive disorder (MDD) in patients treated with either fluoxetine (FLX) or short-term psychodynamic psychotherapy (STPP) in a randomized comparative study. 50 patients with MDD received either STPP or FLX treatment for 16 weeks. The Hamilton Depression Rating Scale (HDRS) was the outcome measure completed at baseline and in the follow-ups at 4- and 12-months. Patients completed the Psychological Mindedness Scale (PMS) and the Defense Style Questionnaire at the baseline. In the FLX group recovery measured by the decrease in the HDRS during the 4-month follow-up associated with baseline mature defense style (r=-.59, P=.015). There were no correlations between the PMS-scores and the outcome measures in either treatment groups nor defense status and the outcome in the STPP group. | Mature defense style predicts good response to FLX therapy in major depression. This association was not found in the psychotherapy group. The results may imply that patients with immature defenses benefit relatively more from brief psychotherapy than medication. PM measured by the PMS was not useful in predicting recovery in MDD. | closed_qa |
Too much ado about instrumental variable approach: is the cure worse than the disease? | To review the efficacy of instrumental variable (IV) models in addressing a variety of assumption violations to ensure standard ordinary least squares (OLS) estimates are consistent. IV models gained popularity in outcomes research because of their ability to consistently estimate the average causal effects even in the presence of unmeasured confounding. However, in order for this consistent estimation to be achieved, several conditions must hold. In this article, we provide an overview of the IV approach, examine possible tests to check the prerequisite conditions, and illustrate how weak instruments may produce inconsistent and inefficient results. We use two IVs and apply Shea's partial R-square method, the Anderson canonical correlation, and Cragg-Donald tests to check for weak instruments. Hall-Peixe tests are applied to see if any of these instruments are redundant in the analysis. A total of 14,952 asthma patients from the MarketScan Commercial Claims and Encounters Database were examined in this study. Patient health care was provided under a variety of fee-for-service, fully capitated, and partially capitated health plans, including preferred provider organizations, point of service plans, indemnity plans, and health maintenance organizations. We used controller-reliever copay ratio and physician practice/prescribing patterns as an instrument. We demonstrated that the former was a weak and redundant instrument producing inconsistent and inefficient estimates of the effect of treatment. The results were worse than the results from standard regression analysis. | Despite the obvious benefit of IV models, the method should not be used blindly. Several strong conditions are required for these models to work, and each of them should be tested. Otherwise, bias and precision of the results will be statistically worse than the results achieved by simply using standard OLS. | closed_qa |
Are sedatives and hypnotics associated with increased suicide risk of suicide in the elderly? | While antidepressant-induced suicidality is a concern in younger age groups, there is mounting evidence that these drugs may reduce suicidality in the elderly. Regarding a possible association between other types of psychoactive drugs and suicide, results are inconclusive. Sedatives and hypnotics are widely prescribed to elderly persons with symptoms of depression, anxiety, and sleep disturbance. The aim of this case-control study was to determine whether specific types of psychoactive drugs were associated with suicide risk in late life, after controlling for appropriate indications. The study area included the city of Gothenburg and two adjacent counties (total 65+ population 210 703 at the start of the study). A case controlled study of elderly (65+) suicides was performed and close informants for 85 suicide cases (46 men, 39 women mean age 75 years) were interviewed by a psychiatrist. A population based comparison group (n = 153) was created and interviewed face-to-face. Primary care and psychiatric records were reviewed for both suicide cases and comparison subjects. All available information was used to determine past-month mental disorders in accordance with DSM-IV. Antidepressants, antipsychotics, sedatives and hypnotics were associated with increased suicide risk in the crude analysis. After adjustment for affective and anxiety disorders neither antidepressants in general nor SSRIs showed an association with suicide. Antipsychotics had no association with suicide after adjustment for psychotic disorders. Sedative treatment was associated with an almost fourteen-fold increase of suicide risk in the crude analyses and remained an independent risk factor for suicide even after adjustment for any DSM-IV disorder. Having a current prescription for a hypnotic was associated with a four-fold increase in suicide risk in the adjusted model. | Sedatives and hypnotics were both associated with increased risk for suicide after adjustment for appropriate indications. Given the extremely high prescription rates, a careful evaluation of the suicide risk should always precede prescribing a sedative or hypnotic to an elderly individual. | closed_qa |
Alcohol and drug screening of newborns: would women consent? | To examine the conditions under which mothers would consent to alcohol and drug screening of their infants, and to identify predictors of screening consent. A cross-sectional survey was administered in person by trained research assistants on the postpartum units of three hospitals in a large Canadian urban centre over four months. The survey was administered to 1509 mothers (78.4% of those eligible) who were fluent in English and had given birth within the preceding 48 hours. Mothers indicated that they would consent to screening of their newborn (1369/1460, 93.8%), and thought all mothers should consent if infants at risk would be more likely to receive effective treatment (1440/1476, 97.6%). Respondents believed that they would consent to screening if they were provided the following information: what would happen if the infant sample was positive for prenatal exposure (1431/1476, 97%); who would have access to the information (1377/1476, 93.4%); how effective medical care would be for the child (1435/1476, 97.4%); and the likelihood that a baby with a positive screen would have a problem (1444/1476, 98.1%). Self-reported alcohol use did not decrease willingness to consent. In a multivariate model, belief that universal screening would not make women feel discriminated against was a significant predictor of consent (adjusted OR 5.9; 95% CI 3.3-10.6). | Mothers would support a universal newborn alcohol and drug screening program if there was evidence that screening could lead to effective treatment for the mother and baby, and if appropriate resources were available. | closed_qa |
Can acute cholecystitis with gallbladder perforation be detected preoperatively by computed tomography in ED? | The purpose of this study is to determine which computed tomography (CT) findings and clinical data can help to diagnose gallbladder perforation in acute cholecystitis. The medical records and CT findings of patients with surgically proven acute cholecystitis within the last recent 5 years were retrospectively reviewed and compared between 2 groups with and without gallbladder perforation. A total of 75 patients with acute cholecystitis were included in the study, and 16 patients were proven to have gallbladder perforation. Higher mortality rate was found in the perforation group (18.8% vs 1.7%; P = .029). Older age (>70 years; P = .004) and higher percentage of segmented neutrophil (>80%; P = .027) were significant clinical factors for predicting gallbladder perforation in acute cholecystitis. The significant CT signs related to gallbladder perforation included visualized gallbladder wall defect (P = .000), intramural gas (P = .043), intraluminal gas (P = .000), intraluminal membrane (P = .043), pericholecystic abscess or biloma formation (P = .009), intraperitoneal free air (P = .001), and presence of ascites in the absence of hypoalbuminemia or other intraabdominal malignancy (P = .017). In multivariate analysis, visualized gallbladder wall defect was the most significant predicting CT feature for diagnosing gallbladder perforation in acute cholecystitis. | Elderly patients with higher segmented neutrophil and CT signs of gallbladder wall defect associated with acute cholecystitis may have high possibility of gallbladder rupture. | closed_qa |
Are physicians' recommendations to limit life support beneficial or burdensome? | Although there is a growing belief that physicians should routinely provide a recommendation to surrogates during deliberations about withdrawing life support, there is a paucity of empirical data on surrogates' perspectives on this topic. To understand the attitudes of surrogate decision-makers toward receiving a physician's recommendation during deliberations about whether to limit life support for an incapacitated patient. We conducted a prospective, mixed methods study among 169 surrogate decision-makers for critically ill patients. Surrogates sequentially viewed two videos of simulated physician-surrogate discussions about whether to limit life support, which varied only by whether the physician gave a recommendation. The main quantitative outcome was whether surrogates preferred to receive a physicians' recommendation. Surrogates also participated in an in-depth, semistructured interview to explore the reasons for their preference. Fifty-six percent (95/169) of surrogates preferred to receive a recommendation, 42% (70/169) preferred not to receive a recommendation, and 2% (4/169) felt that both approaches were equally acceptable. We identified four main themes that explained surrogates' preferences, including surrogates' perceptions of physicians' appropriate role in life or death decisions and their perceptions of the positive or negative consequences of a recommendation on the physician-surrogate relationship, on the decision-making process, and on long-term regret for the family. | There is no consensus among surrogates about whether physicians should routinely provide a recommendation regarding life support decisions for incapacitated patients. These findings suggest that physicians should ask surrogates whether they wish to receive a recommendation regarding life support decisions and should be flexible in their approach to decision-making. | closed_qa |
Do recorded abstracts from scientific meetings concur with the research presented? | Research abstracts for scientific meetings are usually submitted several months in advance of the meeting. Authors may therefore be tempted to submit an abstract on the basis of the research that is ongoing or not yet fully analysed. This study aims to determine the extent to which submitted abstracts, often disseminated in printed form or online, differ from the research ultimately presented. The risk taken by clinicians considering changes in practice on the basis of presented research who refer back to the printed abstract can be assessed. All posters presented at the Royal College of Ophthalmologists Annual Congress 2007 were compared with abstracts in the 'Final Programme and Abstracts'. Discrepancies were recorded for authorship, title, methodology, number of cases, results and conclusions. A total of 171 posters were examined. The title changed in 21% (36/171) and authorship in 25%. The number of cases differed in 22% (number of cases in the poster ranging from less than one quarter to more than triple the number in the abstract). Differences between abstract and poster were found in the methodology of 4%, the results of 11% and conclusions of 5% of studies. | Scientific meetings provide an opportunity for timely dissemination of new research presented directly to clinicians who may then consider change of practice in response. Caution is advised when referring back to printed records of abstracts, as substantial discrepancies are frequently seen between the published abstract and the final research presented, which, in a minority of cases, may even alter the conclusions of the research. | closed_qa |
Analysis of 18F-FDG PET diffuse bone marrow uptake and splenic uptake in staging of Hodgkin's lymphoma: a reflection of disease infiltration or just inflammation? | (18)F-FDG PET has been successfully evaluated in the management of Hodgkin's lymphoma (HL) and the most recent international guidelines recommended (18)F-FDG PET for initial staging and final therapeutic assessment. However, (18)F-FDG PET diffuse bone marrow uptake (BMU) and splenic uptake (SU) are frequently observed at the initial imaging and remain difficult to analyse. The aim of this retrospective study was to evaluate the significance of (18)F-FDG diffuse BMU and SU in initial staging of HL. A total of 106 patients (median age: 31 years, range: 9-81, 51 female, 55 male) underwent (18)F-FDG PET/CT for initial staging of HL. BMU level was assessed visually according to liver uptake (1 = below liver uptake, 2 = corresponding to liver uptake, 3 = above liver uptake) and semi-quantitatively using the maximum standardized uptake value (SUV(max)) measured in the sacral area. SU was assessed visually according to liver uptake (1 = below liver uptake, 2 = corresponding to liver uptake, 3 = above liver uptake). These data were compared with the patient's characteristics including sex, age, Ann Arbor staging, bulky disease (tumour burden>10 cm), presence of B symptoms, bone foci on PET (n = 106), bone marrow involvement (BMI) on biopsy (n = 75), leukocyte count (n = 74), lactic dehydrogenase (LDH) (n = 87), C-reactive protein (CRP) (n = 83) and fibrinogen (n = 60). Univariate and multivariate analyses were performed. Multivariate analysis found an independent correlation between BMU visual grading and CRP level (p = 0.007). For semi-quantitative BMU evaluation, multivariate analysis found an independent correlation between sacral SUVs and CRP level (p = 0.032) and Ann Arbor stage (p = 0.005). No BMI was found in patients who presented with SUV(max) below 3.4. For splenic evaluation, multivariate analysis found an independent correlation between SU and splenic foci (p = 0.034). No statistical link was found between SU and inflammatory markers. | Our study demonstrates that diffuse BMU at initial staging of HL could be due to bone marrow involvement but more likely to bone marrow inflammatory change and that diffuse SU in contrast is probably more associated with disease involvement than with inflammatory change. | closed_qa |
Reversal of Hartmann's procedure following acute diverticulitis: is timing everything? | Patients who undergo a Hartmann's procedure may not be offered a reversal due to concerns over the morbidity of the second procedure. The aims of this study were to examine the morbidity post reversal of Hartmann's procedure. Patients who underwent a Hartmann's procedure for acute diverticulitis (Hinchey 3 or 4) between 1995 and 2006 were studied. Clinical factors including patient comorbidities were analysed to elucidate what preoperative factors were associated with complications following reversal of Hartmann's procedure. One hundred and ten patients were included. Median age was 70 years and 56% of the cohort were male (n = 61). The mortality and morbidity rate for the acute presentation was 7.3% (n = 8) and 34% (n = 37) respectively. Seventy six patients (69%) underwent a reversal at a median of 7 months (range 3-22 months) post-Hartmann's procedure. The complication rate in the reversal group was 25% (n = 18). A history of current smoking (p = 0.004), increasing time to reversal (p = 0.04) and low preoperative albumin (p = 0.003) were all associated with complications following reversal. | Reversal of Hartmann's procedure can be offered to appropriately selected patients though with a significant (25%) morbidity rate. The identification of potential modifiable factors such as current smoking, prolonged time to reversal and low preoperative albumin may allow optimisation of such patients preoperatively. | closed_qa |
Does emergency medical services transport for pediatric ingestion decrease time to activated charcoal? | Activated charcoal (AC) is a potentially beneficial intervention for some toxic ingestions. When administered within one hour, it can reduce absorption of toxins by up to 75%. This study evaluated whether pediatric emergency department (ED) patients arriving by ambulance receive AC more quickly than patients arriving by alternative modes of transport. This was a retrospective review of AC administration in children in a large, urban pediatric ED from January 2000 until January 2006. Patients aged 0-18 years were identified from pharmacy billing codes and the National Capital Poison Center's database. Charts were reviewed for age, gender, triage acuity, disposition, transportation mode, triage time, and time of AC administration; analysis of variance (ANOVA) controlling for these covariates tested the equality of mean time intervals. Pharmacy billing codes identified 394 cases, and poison center records identified 34 cases. Three hundred fifty-one patients met the inclusion criteria. One hundred thirty-eight (39%) were male; 216 (61%) were female. Two-hundred twenty-one (63%) patients were aged 5 years and under; in this subset, 116 were male and 105 were female. Twenty-one (6%) patients were aged 6-12 years; nine were male and 12 were female. One hundred nine (31%) patients were aged 13-18 years; 13 were male and 96 were female. One hundred eighteen (34%) arrived by emergency medical services (EMS). Time from triage to charcoal administration in patients transported via EMS was a mean of 65 minutes (standard deviation [SD] = 44 minutes). Time for the alternative transport group was a mean of 70 minutes (SD = 40 minutes) (p = 0.59). In the subset of patients triaged as most acute and arriving by EMS, time to charcoal administration was a mean of 42 minutes (SD = 22 minutes); time to AC in the alternative transport group was a mean of 67.8 minutes (SD = 42 minutes) (p = 0.013). | The sickest patients arriving by EMS had a faster time from triage to AC administration. However, when comparing patients of all triage categories, EMS arrival alone did not influence time to AC administration. Furthermore, the interval from triage to charcoal administration was often insufficiently long. This suboptimal timing of charcoal administration demonstrates the need for reevaluation of triage and prehospital practices. | closed_qa |
Is there still a role for autopsy in abdominal surgery in 2008? | Although autopsy has been shown to play an important role in certain surgical disciplines as cardiac surgery, few studies have been performed in digestive surgery. The purpose of the study is to determine if autopsy still has a role to play in abdominal surgery in 2008. Retrospective study for the period 01.01.1996 to 31.12.2005. 8,586 patients underwent abdominal surgery during this period. The average age was 55.2 years and male/female sex ratio was 1.1. Surgery was elective in 82% and emergency in 18% of cases. The surgical approach was laparoscopic in 65% and open surgery in 35% of cases. In-hospital morbidity, reintervention and mortality rates were 9.5%, 0.9% and 2.4% respectively. Among the 210 patients who died, thirty-three with generalized cancer or an extensive mesenteric infarct did not have an indication for autopsy ; 74 of the remaining 177 patients, (42%) had an autopsy. The most frequent causes of death were respiratory complications, sepsis and cardiac complications. In 8% of cases, a surgical complication may have caused death. In 44.5% of cases, the results of autopsy showed either a missed major diagnosis that would have changed the patient's prognosis (Goldman class I: 18.9%), or a missed major diagnosis that would not have changed the patient's prognosis (Goldman class II: 25.6%). | Despite technological progress, autopsy still has an important role to play in the assessment and improvement of the quality of surgical practice. | closed_qa |
Transrectal-HIFU as primary minimally-invasive option for localized prostate cancer. Is spinal anaesthesia cost-effective? | The management of Prostate cancer (PC), since PSA testing has been introduced in the clinical practice, has been significantly spoiled by a "leading-time bias" effect. As a consequence, this has brought to a dramatic diagnosis anticipation at the 4th-5th decade of life in sexually active and otherwise asymptomatic men. Standard options as radical prostatectomy or EBRT are hampered by a significant negative impact on patient's QoL. More recently several alternative minimally-invasive ablative treatment modalities have been proposed with promising results. Among these, TR-HIFU (Trans-Rectal High Intensity Focused Ultrasound) is playing a growing role in the treatment of localized low-intermediate risk PC, although long-term oncologic outcome are still awaited. In order to achieve an optimal result, a specific TR-HIFU's requirement is given by an unchanging target throughout the whole procedure. Therefore, the ideal anaesthesia should be either minimally-invasive and allow to get a motionless target up to 3-4 hours. A retrospective evaluation of efficacy and safety of a spinal anaesthesia in this patient's setting was done. 107 patients with localized prostate cancer treated in our institution from October 2004 to December 2007 with TR-HIFU procedure received a subarachnoidal anaesthesia with combined administration of 0.5% normobaric racemic bupivacaine (15 to 17.5 mg) and sufentanil 5 microg. This technique allowed covering the whole TR-HIFU procedure (analgesia and motor blockade up to 4-5 hours). It was well tolerated by patients who only rarely required additional sedative or analgesics. A low anaesthesia-related side effects rate, as arterial hypotension, nausea and vomiting, and no severe side effects of intrathecal opioids, as deep sedation, bradycardia, myosis, bradypnea and oxygen desaturation, occurred. Intraoperative employment of sedatives and postoperative need of analgesics was low. | Using a low-dose intrathecal sufentanil an effective spinal block either on the sensitive and motor pathways was provided. Patients' tolerance to the procedure was good and the side-effect rate low. No adverse reactions to intrathecal sufentanil 5 microg were observed. In our experience TR-HIFU can be performed with neuraxial block in most of the cases and it's associated to a favorable cost-benefit rate. | closed_qa |
Identifying the metabolic syndrome in obese children and adolescents: do age and definition matter? | To assess the prevalence of the metabolic syndrome (MetS) in overweight/obese children and adolescents of an out-patient clinic, and to compare two definitions of MetS in adolescents. In total, 528 overweight / obese children (3-16 years), of multi-ethnic origin, underwent an oral glucose tolerance test, blood collections and anthropometric measurements. In children<10 years, MetS was assessed according to child-specific cut-off values (MetS-child). In adolescents, MetS-child and MetS-adolescent (the recommendation of the International Diabetes Federation for adolescents) were compared. The prevalence of MetS-child within the cohort (median age 11.3, range 3.1-16.4 yrs) was 18.6% (children<10 years vs. adolescents: 14.1% vs. 20.7%, P=0.073). Insulin resistance was present in 47.7% (children<10 years vs. adolescents: 21.8% vs. 60.1%, P<0.001). MetS-child was highly prevalent, and not statistically significant between age groups. In adolescents, the prevalence of MetS-adolescent was higher than MetS-child (33.2% vs. 20.7%, P<0.001). The agreement between the MetS definitions was moderate (kappa =0.51), with the agreement for the MetS-criteria for abnormal lipid levels being substantial to very good (kappa =0.71 to 0.80). | MetS-child was highly prevalent in overweight/obese children and adolescents. A higher prevalence of MetS according to adolescent- as compared to child-specific criteria was found. | closed_qa |
Does deinstitutionalization increase suicide? | (1) To test whether public psychiatric bed reduction may increase suicide rates; (2) to investigate whether the supply of private hospital psychiatric beds-separately for not-for-profit and for-profit-can substitute for public bed reduction without increasing suicides; and (3) to examine whether the level of community mental health resources moderates the relationship between public bed reduction and suicide rates. We examined state-level variation in suicide rates in relation to psychiatric beds and community mental health spending in the United States for the years 1982-1998. We categorize psychiatric beds separately for public, not-for-profit, and for-profit hospitals. Reduced public psychiatric bed supply was found to increase suicide rates. We found no evidence that not-for-profit or for-profit bed supply compensates for public bed reductions. However, greater community mental health spending buffers the adverse effect of public bed reductions on suicide. We estimate that in 2008, an additional decline in public psychiatric hospital beds would raise suicide rates for almost all states. | Downsizing of public inpatient mental health services may increase suicide rates. Nevertheless, an increase in community mental health funding may be promising. | closed_qa |
T-cell epitope polymorphisms of the Plasmodium falciparum circumsporozoite protein among field isolates from Sierra Leone: age-dependent haplotype distribution? | In the context of the development of a successful malaria vaccine, understanding the polymorphisms exhibited by malaria antigens in natural parasite populations is crucial for proper vaccine design. Recent observations have indicated that sequence polymorphisms in the C-terminal T-cell epitopes of the Plasmodium falciparum circumsporozoite protein (Pfcsp) are rather low and apparently stable in low endemic areas. This study sought to assess the pattern in a malaria endemic setting in Africa, using samples from Freetown, Sierra Leone. Filter-paper blood samples were collected from subjects at a teaching hospital in Freetown during September-October 2006 and in April-May 2007. The C-terminal portion of the Pfcsp gene spanning the Th2R and Th3R epitopes was amplified and directly sequenced; sequences were analysed with subject parameters and polymorphism patterns in Freetown were compared to that in other malaria endemic areas. Overall, the genetic diversity in Freetown was high. From a total of 99 sequences, 42 haplotypes were identified with at least three accounting for 44.4% (44/99): the 3D7-type (19.2%), a novel type, P-01 (17.2%), and E12 (8.1%). Interestingly, all were unique to the African sub-region and there appeared to be predilection for certain haplotypes to distribute in certain age-groups: the 3D7 type was detected mainly in hospitalized children under 15 years of age, while the P-01 type was common in adult antenatal females (Pearson Chi-square = 48.750, degrees of freedom = 34, P = 0.049). In contrast, the single-haplotype predominance (proportion>50%) pattern previously identified in Asia was not detected in Freetown. | Haplotype distribution of the T-cell epitopes of Pfcsp in Freetown appeared to vary with age in the study population, and the polymorphism patterns were similar to that observed in neighbouring Gambia, but differed significantly at the sequence level from that observed in Asia. The findings further emphasize the role of local factors in generating polymorphisms in the T-cell epitopes of the P. falciparum circumsporozoite protein. | closed_qa |
Recurrence of intracranial meningiomas: did better methods of diagnosis and surgical treatment change the outcome in the last 30 years? | Meningiomas are benign intracranial tumors growing from the arachnoid cap cells. Although their behavior is usually benign, they tend to recur even after total removal, and their recurrence is dependent on different aspects. Between 1991 and 2002, 463 patients with an intracranial meningioma were operated in the Department of Neurosurgery, University of Kiel, Kiel, Germany. We compared the outcome of these patients after operation and the different methods of radiation therapy and chemotherapy with the data from Buhl (1994), who analysed 661 patients with intracranial meningioma who were operated on in the Department of Neurosurgery, University of Essen, Essen, Germany, between 1968 and 1988, to find out whether better methods of diagnosis like magnetic resonance imaging scans, magnetic resonance spectroscopy, post-operative radiation therapy and chemotherapy have an influence on the recurrence and outcome after surgical treatment. The patients' mean age in both studies was between 50 and 59 years. Both studies underlined the preponderance of female patients for intracranial meningiomas. In the primary study, there were 506 female and 208 male patients, and in the new study, there were 366 female and 97 male patients. The gender distribution changed from 2.4 : 1 to 3.8 : 1. Complete removal of the tumor was possible in 86.7% in both studies. The recurrence rate in the first study was 11% (73/661), while it was 16% in the second study (73/463). The intracranial localization of the meningiomas was similar to the distribution of the histological subtypes and the rate of recurrence; only the malignant meningiomas showed a higher grade of recurrence in the last study. Indications for post-operative radiation therapy were given earlier in the last study owing to the experience from the primary study. The outcome of the patients after surgical removal was improving in the last years; the 30 day post-operative mortality after a primary operation on an intracranial meningioma decreased from 12.1 to 3%. After removal of a recurrent meningioma, the mortality declined from 20 to 12.5%. | In the last 30 years, nothing important changed at the time of appearance of meningiomas, concerning the gender distribution and localisation as well as histological subtypes. With better operating modalities and additional treatment with radiation and gamma knife, the mortality decreased significantly from 12 to 3% and the outcome of the patients is still improving, so that even elderly patients with intracranial meningioma can undergo surgical treatment with minor risks. | closed_qa |
Rhabdomyolysis in MDMA intoxication: a rapid and underestimated killer. "Clean" Ecstasy, a safe party drug? | Ecstasy is a popular drug among young adults. It is often thought to be safe. The dose of methylenedioxymethamphetamine (MDMA) in a tablet of Ecstasy varies greatly, and there is also a difference in individual response to a dose of MDMA. To increase the awareness of potential mortality in MDMA use. We report the case of a patient with a lethal intoxication after pure MDMA intoxication. The serum toxicology screening showed an elevated level of MDMA (1.5 mg/L) but no other amphetamines or other drugs. | The cause of death was a rapidly evolving hyperkalemia due to rhabdomyolysis. There is still a need to educate the public about the dangers of this so-called "safe" party drug. | closed_qa |
Ecstasy-associated acute severe hyponatremia and cerebral edema: a role for osmotic diuresis? | Ecstasy, or 3,4-methylenedioxymethamphetamine (MDMA), is a drug of abuse with a wide range of toxicity affecting the brain, heart, and liver. Renal toxicity of MDMA is due either to acute kidney injury (e.g., non-traumatic rhabdomyolysis) or to water and electrolyte imbalance (i.e., hyponatremia). Although syndrome of inappropriate secretion of antidiuretic hormone has been recognized as a major mechanism for MDMA-associated hyponatremia, other factors (e.g., MDMA-induced polydipsia) have also been proposed. Hypertonic saline has been used by most authors to treat MDMA-associated acute symptomatic hyponatremia. Our case is the second published report in which mannitol was chosen for management of this pathologic phenomenon. We present a case of MDMA-associated acute severe hyponatremia and cerebral edema in a young female, and analyze the underlying pathophysiology, the therapeutic strategy, and the course of disease. | Based on this observation, coupled with the previous report and the complex pathophysiology of this phenomenon, we suggest that osmotic diuresis be considered a possible therapeutic option for MDMA-associated acute symptomatic hyponatremia. | closed_qa |
The feasibility of a self-management education program for patients with type 2 diabetes mellitus: Do the perceptions of patients and educators match? | To compare the feasibility experienced by patients with type 2 diabetes mellitus in a self-management educational program to the hindrance assessed by the educator of the program. Twenty-five type 2 diabetes patients on maximally tolerated oral hypoglycaemic agents followed a 6-month educational program consisting of five components: background, medication, physical exercise, nutrition and blood glucose self-monitoring. Medication was unchanged during the study. Outcome measures were feasibility encountered by the patient, hindrance observed by the educator and HbA(1c)-level. The feasibility encountered by patients was significantly related to the hindrance assessed by the educators (rho 0.756, p<0.001). Feasibility increased significantly for three components but not for physical exercise and nutritional advice. Mean HbA(1c)-level decreased from 8.2+/-1.1% before onset of the program to 7.2+/-1.3% 6 weeks after termination of the program. | Feasibility experienced by the patients matched the hindrance noticed by the educators. This might have led to an increase in patients' self-efficacy, which in turn gives an improvement in self-management and glycaemic control. | closed_qa |
First impressions: what are preclinical medical students in the US and Canada learning about sexual and reproductive health? | This study evaluates the inclusion of sexual and reproductive health (SRH) topics in preclinical US and Canadian medical education. Between 2002 and 2005, we sent surveys to the student coordinators of active Medical Students for Choice chapters at 122 US and Canadian medical schools. Students reported on the preclinical curricular inclusion of 50 specific SRH topics in the broad categories of pregnancy, contraception, infertility, elective abortion, ethical and social issues, and other topics. We received 77 completed surveys, for an overall response rate of 63%. Coverage of pregnancy physiology and STIs/HIV was uniformly high. In contrast, inclusion of contraceptive methods and elective abortion procedures greatly varied by subtopic and geographic region. Thirty-three percent of respondents reported no coverage of elective abortion-related topics. | Inclusion of contraception and elective abortion in preclinical medical school courses varies widely. As critical components of women's lives and health, we recommend that medical schools work to integrate comprehensive family planning content into their standard curricula. | closed_qa |
Familial exudative vitreoretinopathy and DiGeorge syndrome: a new locus for familial exudative vitreoretinopathy on chromosome 22q11.2? | To describe a patient with DiGeorge syndrome in association with familial exudative vitreoretinopathy (FEVR). Observational case report. A newborn female and her parents. Family members were examined by slit-lamp biomicroscopy and indirect ophthalmoscopy. Deletion mapping was performed by fluorescent in situ hybridization and genotyping. Mutation screening was undertaken by direct sequencing. The presence or absence of a microdeletion on chromosome 22q11.2 in the patient and her parents and mutation screening of FZD4 and LRP5 in the patient. The patient had classical features of DiGeorge syndrome and FEVR. A de novo microdeletion on chromosome 22q11.2 was found in the patient, confirming the diagnosis of DiGeorge syndrome. No mutations were identified in the known FEVR genes. | Patients with DiGeorge syndrome should have a dilated retinal examination to look for signs of FEVR. Chromosome 22q11.2 may represent a novel locus for FEVR. | closed_qa |
Do researcher-derived classifications of youths' smoking behavior correspond with youths' characterizations of their behavior? | To describe the categories employed by researchers to describe adolescents' smoking behavior and to determine how these various categorizations compare with youths' self-defined smoking status. A search of the PubMed and Science Direct databases, limited to articles in the English language, published between January 2002 and November 2007. Employing a mixed methods approach, several categories of youths' smoking status were obtained from a literature review and subsequently reproduced by using responses to detailed questionnaire items. Associations between the researcher-derived smoking categories (from the literature review) and the youths' self-reported smoking status, from survey data, were determined. The categories of smoking status, from the literature review, varied in definition and in the number of categories. The associations between the literature-based categories and the youths' self-reported smoking status were modest. | Researcher-derived categories of youths' smoking status may not adequately encapsulate youths' perceptions of their own smoking behavior. There is a need to better describe adolescents' smoking behavior with special consideration of the ways in which adolescents characterize their own smoking behavior. | closed_qa |
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