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Are suburethral slings less successful in the elderly? | We aimed to evaluate the success of suburethral slings in women ≥70 years of age. This was a retrospective cohort study of women who underwent suburethral sling placement. Subjects were separated into three groups: ≤50 years of age (group 1), 51 to 69 years of age (group 2), and ≥70 years of age (group 3). The primary aim was to evaluate success as defined by ≥ improved on a validated patient improvement satisfaction score and a negative postoperative standardized stress test. There were 1,464 subjects. Mean age was 44.51 ± 4.25 (n = 296) for group 1, 60.5 ± 5.28 (n = 680) for group 2, and 77.68 ± 5.41 (n = 488) for group 3. The median follow-up was 26 (6-498) weeks, 45 (6-498) weeks, and 42 (6-543) weeks, for groups 1, 2, and 3 respectively. Multiple logistic regression analysis demonstrated no difference in sling success according to age stratification. Lower success was associated with having had a previous sling (adjusted OR 0.25, 95 % CI 0.12-0.5), having detrusor overactivity (adjusted OR 0.44, 95 % CI 0.28-0.69), and having a history of urge urinary incontinence (UUI) for ≥ 4 years (adjusted OR 0.54, 95 % CI 0.31-0.95). | There is no difference in sling success between the elderly and younger populations. However, those with previous sling surgery or a long standing history of UUI may be at a higher risk of failure. | closed_qa |
Is retrograde intubation more successful than direct laryngoscopic technique in difficult endotracheal intubation? | Difficult airway intubation is an emergency condition both at the emergency department (ED) and in out-of-hospital situations. Retrograde intubation (RI) is another option for difficult airway management. There are limited data regarding the successful rate of RI compared with direct laryngoscopy (DL) intubation, the commonly used method in the ED. This study was a randomized, controlled trial. Participants were randomly assigned to either the RI or the DL technique to attempt intubation on a difficult airway mannequin (Cormack and Lehane grades 3-4). First, all participants received the training on the RI or DL, and then attempted intubation. After the training, the participants had 2 chances to intubate. The outcomes of this study included numbers of participants who successfully intubated and times of successful intubation. There were 100 participants in this study, with 50 participants in each group (RI and DL). There was no significant difference between the groups in terms of experience at the ED or DL. The successful rate of intubation was significantly higher in the RI group than in the DL group (74% vs 12%; P = .001), as was the rate of successful intubation on the first attempt (34% vs 8%; P = .026). There were no statistical differences between physicians and medical students in any of the 3 outcomes in either the DL or RI group. | The RI technique had a higher success rate in difficult airway intubation than the DL technique, regardless of experience. | closed_qa |
Is inguinal orchidopexy still a current procedure in the treatment of intraabdominal testis in the era of laparoscopic surgery? | To report our experience in surgical management of nonpalpable intraabdominal testis (NPIT) by inguinal orchidopexy without division of the spermatic vessels. We reviewed the records of NPIT patients who underwent orchidopexy between 2012 and 2015. All patients were evaluated ultrasonographically. When the testis was not detected ultrasonographically, a laparoscopic exploration was performed. If the testis was found on laparoscopy, surgery was resumed through an inguinal incision. A follow-up was performed at 1week, 1, 3 and 6months. Twenty-one NPIT patients were treated, mean age 21.0±11.7months. Ultrasound identified 15 cases of NPIT (71%); diagnostic laparoscopy was performed in 6 (29%). All patients underwent an inguinal orchidopexy. At 1week, four testes were in a high scrotal position. At 6months follow-up, one testis was in a high scrotal position and one retracted up to the external inguinal ring. No atrophy was recorded. | Despite several attempts to find a surgical technique without any significant complications, all described procedures failed to meet the target. In our experience, inguinal orchidopexy is a safe, reliable and successful surgical procedure for the management of NPIT. It should be preferred to a technique requiring vascular division, burdened with a higher incidence of atrophy. | closed_qa |
Is the timing of surgery associated with avascular necrosis after unstable slipped capital femoral epiphysis? | An unstable slipped capital femoral epiphysis (SCFE) is associated with a high rate of avascular necrosis (AVN). The etiology of AVN seems to be multifactorial, although it is not thoroughly known. The aims of our study were to determine the rate of AVN after an unstable SCFE and to investigate the risk factors for AVN, specifically evaluating the notion of an "unsafe window", during which medical interventions would increase the risk for AVN. This retrospective multicenter study included 60 patients with an unstable SCFE diagnosed between 1985 and 2014. Timing of surgery was evaluated for three time periods, from acute onset of symptoms to surgery: period I,<24 h; period II, between 24 h and 7 days; and period III,>7 days. Multivariate logistic regression analysis was used to identify risk factors for AVN. Closed reduction and pinning was performed in 43 patients and in situ pinning in 17. Among these cases, 16 patients (27%) developed AVN. The rate of AVN was significantly higher in patients treated by closed reduction and pinning (15/43, 35%) than in those treated by in situ pinning (1/17, 5.9%) (p = 0.022). In patients treated by closed reduction and pinning, the incidence of AVN was 2/11 (18%) in period I, 10/13 (77%) in period II and 3/15 (20%) in period III, showing the significantly higher rate in period II (p = 0.002). The surgery provided in period II was identified as an independent risk factor for the development of AVN. | Our rate of AVN was 27% using two classical treatment methods. Time-to-surgery, between 24 h and 7 days, was independently associated with AVN, supporting the possible existence of an "unsafe window" in patients with unstable SCFE treated by closed reduction and pinning. | closed_qa |
Is the $1000 Genome as Near as We Think? | The substantial technological advancements in next-generation sequencing (NGS), combined with dropping costs, have allowed for a swift diffusion of NGS applications in clinical settings. Although several commercial parties report to have broken the $1000 barrier for sequencing an entire human genome, a valid cost overview for NGS is currently lacking. This study provides a complete, transparent and up-to-date overview of the total costs of different NGS applications. Cost calculations for targeted gene panels (TGP), whole exome sequencing (WES) and whole genome sequencing (WGS) were based on the Illumina NextSeq500, HiSeq4000, and HiSeqX5 platforms, respectively. To anticipate future developments, sensitivity analyses are performed. Per-sample costs were €1669 for WGS, € 792 for WES and €333 for TGP. To reach the coveted $1000 genome, not only is the long-term and efficient use of the sequencing equipment needed, but also large reductions in capital costs and especially consumable costs are also required. | WES and TGP are considerably lower-cost alternatives to WGS. However, this does not imply that these NGS approaches should be preferred in clinical practice, since this should be based on the tradeoff between costs and the expected clinical utility of the approach chosen. The results of the present study contribute to the evaluation of such tradeoffs. | closed_qa |
Do cobalt and chromium levels predict osteolysis in metal-on-metal total hip arthroplasty? | Serum metal ions are part of the regular follow-up routine of patients with metal-on-metal total hip arthroplasties (MoM-THA). Increased cobalt levels have been suggested to indicate implant failure and corrosion. (1) Is there a correlation between the size of the osteolysis measured on a CT scan and metal ion levels? (2) Can metal ion levels predict the presence of osteolysis in MoM-THA? (3) Are cobalt and chromium serum levels or the cobalt-chromium-ratio diagnostic for osteolysis? CT scans of patients (n = 75) with a unilateral MoM-THA (Birmingham Hip System, Smith&Nephew, TN, USA) implanted by a single surgeon were reviewed to determine the presence of osteolysis. Statistical analysis was performed to detect its association with metal ion levels at the time of the imaging exam. The incidence of osteolysis was the same in men and women (35.6 vs 35.7 %). The cobalt-chromium-ratio correlates with the size of the osteolysis on the CT scan and the femoral component size in the overall study population (p = 0.050, p = 0.001) and in men (p = 0.002, p = 0.001) but not in women (p = 0.312, p = 0.344). The AUC for the cobalt-chromium-ratio to detect osteolysis was 0.613 (p = 0.112) for the overall population, 0.710 for men (p = 0.021) and 0.453 (p = 0.684) for women. The data suggest that a cut off level of 1.71 for the cobalt-chromium-ratio has a sensitivity of 62.5 % and specificity of 72.4 % to identify male patients with osteolysis. | The disproportional increase of cobalt over chromium, especially in male patients with large component sizes can not be explained by wear alone and suggests that other processes (corrosion) might contribute to metal ion levels and might be more pronounced in patients with larger component sizes. | closed_qa |
Is There a Right Ear Advantage in Congenital Aural Atresia? | To compare speech/language development and academic progress between children with right versus left congenital aural atresia (CAA). Case control survey and review of audiometric data. Tertiary care academic practice. Children with unilateral CAA. Demographic and audiometric data; rates of grade retention, use of any hearing or learning resource, and behavioral problems. No significant differences in grade retention rate, utilization of amplification, speech language therapy, use of an individualized education program, or frequency modulated system were found between children with right versus left CAA. Children with left CAA were significantly more likely to be enrolled in special education programs (p = 0.026). Differences in reported communication problems approached significance with more difficulty noted in the right ear group (p = 0.059). Left CAA patients were also more likely to have reported behavioral problems (p = 0.0039). | Contrary to the hypothesis that a normal hearing right ear confers a language advantage in patients with unilateral hearing loss, children with left CAA (normal right ear) were statistically more likely to be enrolled in a special education program and have behavioral problems. Reported communication problems were more common in right CAA patients, but this did not reach statistical significance. No differences were found in use of amplification, frequency modulated system, individualized education program, or grade retention. Further investigation of both the clinical implications and underlying psychoacoustics of unilateral hearing loss and the identification and habilitation of "at risk" unilateral hearing loss children is warranted. | closed_qa |
CDH23 Related Hearing Loss: A New Genetic Risk Factor for Semicircular Canal Dehiscence? | To investigate the prevalence and relative risk of semicircular canal dehiscence (SCD) in pediatric patients with CDH23 pathogenic variants (Usher syndrome or non-syndromic deafness) compared with age-matched controls. Retrospective cohort study. Multi-institutional study. Pediatric patients (ages 0-5 years) were compared based on the presence of biallelic pathogenic variants in CDH23 with pediatric controls who underwent computed tomography (CT) temporal bone scan for alternative purposes. Retrospective review of diagnostic high resolution CT temporal bone scans and magnetic resonance imaging (MRI) for evaluation of SCD. Superior and posterior semicircular canals were evaluated by a neuroradiologist for presence of SCD or abnormal development. Forty-two CT scans were reviewed for SCD. Eighty-six percent of the CDH23 variant group had abnormalities in at least one canal compared with only 12% in age-matched controls. In the CDH23 variant group there were four patients with superior SCD (57%, RR = 10.0) and three patients with posterior canal abnormalities (43%, RR = 7.5) compared with two, and two patients, respectively, in the control population. Four CDH23 variant children had bilateral abnormalities. One child had thinning or dehiscence in both the superior and posterior canals. Relative risk of SCD in children with CDH23 pathogenic variants is 7.5 (p < 0.001) compared with the pediatric control population. | Children with a CDH23 pathogenic variants are at significantly increased risk of having SCD and this may be a contributing factor to the vestibular dysfunction in Usher syndrome type 1D patient population. | closed_qa |
Is Administration of Nitric Oxide During Extracorporeal Membrane Oxygenation Associated With Improved Patient Survival? | To evaluate the outcomes associated with the use of inhaled nitric oxide during extracorporeal membrane oxygenation. Post hoc analysis of data from an existing administrative national database, Pediatric Health Information system (2004-2014). Multivariable logistic regression models were fitted to study the effect of inhaled nitric oxide during extracorporeal membrane oxygenation on study outcomes. Forty-two children's hospitals across the United States. Patients in the age group from 1 day through 18 years admitted to an ICU who received extracorporeal membrane oxygenation during their hospital stay were included. None. In total, 6,419 patients qualified for inclusion. Of these, inhaled nitric oxide was used among 3,629 patients during extracorporeal membrane oxygenation run. Approximately one half of the study patients received inhaled nitric oxide at extracorporeal membrane oxygenation initiation. The proportion of patients receiving inhaled nitric oxide during extracorporeal membrane oxygenation decreased with increasing duration of extracorporeal membrane oxygenation. After adjusting for patient characteristics and center variables, use of inhaled nitric oxide was not associated with any survival benefit. However, higher proportion of patients receiving inhaled nitric oxide were associated with prolonged hospital length of stay and prolonged duration of extracorporeal membrane oxygenation. In adjusted models, the hospital charges were higher in the inhaled nitric oxide group. The median hospital costs among patients receiving inhaled nitric oxide were higher by $39,732 (95% CI, $31,074-48,390) as compared to the patients who did not receive inhaled nitric oxide, after adjusting for patient (including hospital length of stay) and center level variables. As the duration of inhaled nitric oxide therapy increased, proportion of patients with prolonged duration of extracorporeal membrane oxygenation and prolonged hospital length of stay increased. | This large observational analysis of use of nitric oxide during extracorporeal membrane oxygenation calls into question the benefits of inhaled nitric oxide among patients receiving extracorporeal membrane oxygenation for pulmonary or cardiac failure. Given our inability to determine type of extracorporeal membrane oxygenation and control for severity of illness, these findings should be interpreted as exploratory. | closed_qa |
Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short Term for Improving Function and Quality of Life After Arthrocentesis? | Although arthrocentesis has been used for the management of patients with temporomandibular joint pain, the benefit of hyaluronic acid (HA) or corticosteroid (CS) remains uncertain. The purpose of this study was to assess the efficacy of HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis for changes in quality of life (QoL), jaw function (Jaw Function Limitation Scale [JFLS] score), and maximum incisal opening (MIO). This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then instillation of HA, CS, or LR. All patients were evaluated clinically at 1 and 3 months. The outcome variables were QoL, JFLS score, and MIO. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant. One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for analysis of data at 1 month. An additional 51 were lost to follow-up at 3 months, leaving 51 patients for data analysis at this time point. There was no difference among groups for QoL Mental Health Composite score at 1 month (P = .70) or 3 months (P = .69). There was no difference among groups for JFLS score at 1 month (P = .71) or 3 months (P = .98). There was no difference among groups for MIO at 1 month (P = .47) or 3 months (P = .31). All groups showed within-group improvements in JFLS score and MIO at 1 and 3 months. | Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in improving jaw function and MIO at 1 and 3 months. QoL is not improved with arthrocentesis alone or in combination with CS or HA. | closed_qa |
Is Hyaluronic Acid or Corticosteroid Superior to Lactated Ringer Solution in the Short-Term Reduction of Temporomandibular Joint Pain After Arthrocentesis? | Arthrocentesis has been used for the management of patients with temporomandibular joint (TMJ) pain, with good success. The additional use of hyaluronic acid (HA) or corticosteroid (CS) remains controversial. The purpose of this study was to compare HA, CS, and lactated Ringer solution (LR; placebo) after arthrocentesis. This was a prospective multicenter double-blinded randomized clinical trial. Consecutive patients presenting to the oral and maxillofacial departments at Emory University, the University of Pennsylvania, the University of California-Los Angeles, the University of Cincinnati, and the Oregon Health Sciences University were enrolled in the study. Patients were randomized to HA, CS, or LR. All patients underwent arthrocentesis and then the instillation of HA, CS, or LR. Patients were evaluated clinically at 1 and 3 months. The primary outcome variable was pain at 1 month (by visual analog scale). Secondary outcome variables were pain at 3 months and analgesic consumption. Univariate, bivariate, and multivariate statistics were computed, with a P value less than .05 considered significant. One hundred two patients were enrolled in the study. Four were lost to follow-up, leaving 98 patients for the final analysis. The mean age of patients in the HA, CS, and LR groups was 39.6, 44.3, and 51.8 years, respectively (P = .02). There was no difference among groups in time to follow-up at 1 month (P = .11). The mean decrease in pain in the CS group was 19% for right-side procedures (P = .12) and 36% for left-side procedures (P = .02). The mean decrease in pain in the HA group was 31% for right-side procedures (P = .01) and 34% for left-side procedures (P = .01). The mean decrease in pain in the LR group was 43% for right-side procedures (P<.01) and 37% for left-side procedures (P<.01). There was no difference in pain decrease among groups (P = .55). There was no difference in the use of narcotic (P = .52) or nonsteroidal anti-inflammatory drugs (P = .71) among groups. | Arthrocentesis alone is as efficacious as arthrocentesis with HA or CS in decreasing TMJ pain. | closed_qa |
Can a Patient's In-Hospital Length of Stay and Mortality Be Explained by Early-Risk Assessments? | To assess whether a patient's in-hospital length of stay (LOS) and mortality can be explained by early objective and/or physicians' subjective-risk assessments.DATA SOURCES/ Analysis of a detailed dataset of 1,021 patients admitted to a large U.S. hospital between January and September 2014. We empirically test the explanatory power of objective and subjective early-risk assessments using various linear and logistic regression models. The objective measures of early warning can only weakly explain LOS and mortality. When controlled for various vital signs and demographics, objective signs lose their explanatory power. LOS and death are more associated with physicians' early subjective risk assessments than the objective measures. | Explaining LOS and mortality require variables beyond patients' initial medical risk measures. LOS and in-hospital mortality are more associated with the way in which the human element of healthcare service (e.g., physicians) perceives and reacts to the risks. | closed_qa |
The Perception and Costs of the Interview Process for Plastic Surgery Residency Programs: Can the Process Be Streamlined? | The purpose of this study was to assess applicant perceptions and costs associated with the interview process for plastic surgery residency positions. This was a cross-sectional survey of applicants to the integrated- and independent-track residencies at the authors' institution. All applicants who were interviewed were invited to complete a Web-based survey on costs and perceptions of various components of the interview process. Descriptive and bivariate statistics were computed to compare applicants to the two program tracks. Fifty-three applicants were interviewed for residency positions; 48 completed a survey (90.5 percent response rate). Thirty-four applicants were candidates for the integrated program; 16 applicants were candidates for the independent program. The program spent $2763 per applicant interviewed; 63 percent of applicants spent more than $5000 on the interview process. More than 70 percent of applicants missed more than 7 days of work to attend interviews. Independent applicants felt less strongly that interviews were critical to the selection process and placed less value on physically visiting the hospital and direct, in-person interaction. Applicants placed little value on program informational talks. Applicants who had experience with virtual interviews felt more positively about the format of a video interview relative to those who did not. | The residency interview process is resource intensive for programs and applicants. Removing informational talks may improve the process. Making physical tours and in-person interviews optional are other alternatives that merit future study. | closed_qa |
Is the Road to Mental Health Paved With Good Incentives? | The use of physician incentives to improve health care, in general, has been extensively studied but its value in mental health care has rarely been demonstrated. In this study the population-level impact of physician incentives on mental health care was estimated using indicators for receipt of counseling/psychotherapy (CP); antidepressant therapy (AT); minimally adequate counseling/psychotherapy; and minimally adequate antidepressant therapy. The incentives' impacts on overall continuity of care and of mental health care were also examined. Monthly cohorts of individuals diagnosed with major depression were identified between January 2005 and December 2012 and their use of mental health services tracked for 12 months following initial diagnosis. Linked health administrative data were used to ascertain cases and measure health service use. Pre-post changes associated with the introduction of physician incentives were estimated using segmented regression analyses, after adjusting for seasonal variation. Physician incentives reversed the downward and upward trends in CP and AT. Five years postintervention, the estimated impacts in percentage points for CP, AT, minimally adequate counseling/psychotherapy, and minimally adequate antidepressant therapy were +3.28 [95% confidence interval (CI), 2.05-4.52], -4.47 (95% CI, -6.06 to -2.87), +1.77 (95% CI, 0.94-2.59), and -2.24 (95% CI, -4.04 to -0.45). Postintervention, the downward trends in continuity of care failed to reverse, but were disrupted, netting estimated impacts of +7.53 (95% CI, 4.54-10.53) and +4.37 (95% CI, 2.64-6.09) for continuity of care and of mental health care. | The impact of physician incentives on mental health care was modest at best. Other policy interventions are needed to close existing gaps in mental health care. | closed_qa |
Does Arterial Flow Rate Affect the Assessment of Flow-Diverter Stent Performance? | Our aim was to assess the performance of flow-diverter stents. The pre- and end-of-treatment angiographies are commonly compared. However, the arterial flow rate may change between acquisitions; therefore, a better understanding of its influence on the local intra-aneurysmal hemodynamics before and after flow-diverter stent use is required. Twenty-five image-based aneurysm models extracted from 3D rotational angiograms were conditioned for computational fluid dynamics simulations. Pulsatile simulations were performed at different arterial flow rates, covering a wide possible range of physiologic flows among 1-5 mL/s. The effect of flow-diverter stents on intra-aneurysmal hemodynamics was numerically simulated with a porous medium model. Spatiotemporal-averaged intra-aneurysmal flow velocity and flow rate were calculated for each case to quantify the hemodynamics after treatment. The short-term flow-diverter stent performance was characterized by the relative velocity reduction inside the aneurysm. Spatiotemporal-averaged intra-aneurysmal flow velocity before and after flow-diverter stent use is linearly proportional to the mean arterial flow rate (minimum R2>0.983 of the linear regression models for untreated and stented models). Relative velocity reduction asymptotically decreases with increasing mean arterial flow rate. When the most probable range of arterial flow rate was considered (3-5 mL/s), instead of the wide possible flow range, the mean SD of relative velocity reduction was reduced from 3.6% to 0.48%. | Both intra-aneurysmal aneurysm velocity and flow-diverter stent performance depend on the arterial flow rate. The performance could be considered independent of the arterial flow rates within the most probable range of physiologic flows. | closed_qa |
Does an association exist between the hierarchical motor components of upper and lower limbs in stroke? | Abnormal synergisitic linkage exists between the upper and lower limbs. The relation may persist till the last stage of motor recovery. The objective of the present study was to analyze the relation between the motor components of the upper extremity and lower extremity in stroke subjects. A cross-sectional and correlational design. Rehabilitation Institute. Fifty-nine poststroke chronic hemiparetic subjects (39 men; Mean age = 48.81 years; Mean poststroke duration = 11.22 months and 34 right-side paresis). Not-applicable. Fugl-Meyer Assessment (FMA): upper extremity (FMA-UE) and lower extremity (FMA-LE). A moderate positive correlation (r = .65, p < .001) was found between FMA-UE and FMA-LE. FMA-UE (51%) was found to be significantly inferior (p < .001; 95% CI = 6 to 17) in comparison to FMA-LE (63%). | In poststroke subjects, there is a moderate positive relation between the recovery components of affected upper limb and lower limb. Stroke rehabilitation should consider hierarchical motor components of the lower limb and upper limb simultaneously. | closed_qa |
Can physical therapy centred on cognitive and behavioural principles improve pain self-efficacy in symptomatic lumbar isthmic spondylolisthesis? | Pain-related self-efficacy is defined as "the beliefs held by people with chronic pain that were able to carry out certain activities, even when experiencing pain", and it is considered a relevant mediator in the relationship between pain and disability in chronic low back pain. This case series describes a treatment aiming to improve pain self-efficacy in patients with symptomatic lumbar spondylolisthesis. Ten consecutive outpatients with lumbar spondylolisthesis and chronic LBP referred to a rehabilitative clinic participated in this study. Cognitive and behavioural principles were integrated with functional and graded approach in each individual physical therapy program. The outcome measures concerned clinical instability and endurance tests, pain, disability and self-efficacy. Pain self-efficacy and lumbar function improved in 7 out of 10 patients; clinical tests improved in 9 out of 10 patients. | A rehabilitation program carried out by a physical therapist, centred on cognitive and behavioural principles, appeared useful in improving pain self-efficacy and lumbar function. These results may be interesting for future controlled trials. | closed_qa |
Acute care surgery: trauma, critical care, emergency general surgery … and preventative health? | Acute care surgeons (ACS) often care for patients with limited access to health care. They may not participate in preventative screenings and interventions (PSIs) such as mammography, colonoscopy, or pneumococcal vaccinations (VAs). We sought to identify barriers to compliance and determine if ACS have an opportunity to facilitate PSI participation. All patients evaluated by an ACS were considered for inclusion in the study. Patients meeting national PSI inclusion criteria were enrolled. Surveys were administered to assess compliance and identify barriers to participation. The overall compliance rate with PSIs was 57%. Patients without a primary care physician had a compliance rate of 23%. The most common barrier to participation was lack of knowledge of PSI recommendations (42%). Males were less compliant than females (47% vs 62%). | ACS evaluate a large number of general surgery and trauma patients. The acute care surgeon-patient encounter represents a valuable opportunity for education and improved PSI compliance. Additional research should focus on developing interventional strategies and evaluating their impact on patient outcomes. | closed_qa |
Inpatient Pediatric Migraine Treatment: Does Choice of Abortive Therapy Affect Length of Stay? | To describe the inpatient management of pediatric migraine and the association between specific medications and hospital length of stay (LOS). Historical cohort study review of patients age<19 years of age admitted to a single tertiary care children's hospital between 2010 and 2015 for treatment of migraine headache. The cohort consisted of 58 encounters with an average patient age of 14.3 years (SD 3.2 years) with a female predominance (62%). The mean number of inpatient medications received by patients was 3 (range 1-7), with dopamine antagonists and dihydroergotamine used most commonly (67% and 59% of encounters, respectively). The average LOS was 56 hours (95% CI 48.2-63.2) and did not vary by medication received, although patients who received an opioid had a significantly longer LOS (79.2 vs 47.9 hours respectively; P < .001). | Children admitted to the hospital for treatment of migraine headache frequently require a large number of medications over an average hospital LOS of more than 2 days without apparent differences based on medication received other than prolonged stays for subjects who received opioids. | closed_qa |
Do diabetes-specialty clinics differ in management approach and outcome? | To evaluate management approach and outcome in two endocrinologist-managed clinics using data on treatment adherence, diabetes-specific parameters, prescribed medications and self-management practices among ambulatory type 2 diabetes patients. Opinion on cause(s) and perceived fear about diabetes were also explored. A cross-sectional prospective study using semi-structured interview among consented patients for eightweek, and a review of participants' case notes at 3-month post-interactive contact for details of diabetes-specific parameters and antidiabetes medications. The University College Hospital (UCH) and Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) in southwestern Nigeria. Adult patients with type 2 diabetes, on therapies for>3-month and who had average fasting blood glucose (FBG)>6.0mmol/L were enrolled. All patients with type 1 diabetes, and type 2 diabetes who decline participation were excluded. Out of 185 participants who were approached, 176(95.1%) consented and completed the study including 113(64.2%) from UCH and 63(35.8%) in OAUTHC. Mean FBG for patients were 9.6mmol/L in UCH and 11.0mmol/L in OAUTHC (p=0.03). Medication adherence among patients was 47(46.5%) in UCH and 31(52.5%) in OAUTHC (p=0.46). Prescribed antidiabetes medications between the clinics significantly differ. Practice of self-monitoring of blood glucose among participants was 26(23.0%) in UCH and 13(20.6%) in OAUTHC (p=0.72). Thirty-two participants (29.4%) in UCH and 33(43.4%) from OAUTHC (p=0.02) mentioned complications as perceived fear about type 2 diabetes. | There are differences and similarities between the diabetes-specialty clinics with respect to diabetes management and outcome. This underscores the necessity for a protocol-driven treatment approach in ensuring improved diabetes care and outcome. | closed_qa |
Do anthropometric measures accurately reflect body composition in preterm infants? | Recent literature suggests that neonatal adiposity is predictive of later metabolic health, while neonatal lean mass is predictive of later cognitive function amongst preterm infants. Anthropometric indices that accurately reflect neonatal body composition could improve clinical care and aid future research, but their validity has not been systematically tested in preterm infants. To determine the weight/length indices that best reflect neonatal body composition in preterm infants. Weight and length were measured, and body composition (fat-free mass (FFM), fat mass (FM) and percent body fat (%BF)) was assessed using air-displacement plethysmography within 72 h of birth in 218 preterm infants. The best weight/length proxy for FFM, FM and %BF were those with the highest proportion variance explained (R2) and lowest root mean square error (RMSE) in linear regression models. Among all of the weight/length indices tested, weight/length2was the best proxy for %BF, but nonetheless exhibited very low variance explained (R2 = 0.27) and high prediction error (RMSE = 3.5% fat). Body weight unadjusted for length was strongly associated with FFM (R2 = 0.97). | No weight/length index accurately reflected %BF. Weight/length indices are not appropriate for assessment of relative adiposity in preterm infants near birth. What's known on this subject: Compared with term infants, preterm infants have increased fat mass and diminished fat-free mass upon hospital discharge. Early adiposity predicts later metabolic health, while early lean mass is predictive of later neurodevelopmental outcomes. Optimal anthropometric proxies for preterm body composition at birth are not established. | closed_qa |
Can brain games help smokers quit? | Deficits in cognitive function are observed during nicotine withdrawal and present a challenge to successful smoking cessation. This clinical trial evaluated a cognitive exercise training (CT) program to improve smoking cessation rates. Adult treatment-seeking smokers (n=213) were randomized to receive nicotine patch therapy and 12 weeks of either computerized CT or computerized relaxation (control) training. Smoking status was biochemically verified at the end of treatment and 6-month follow-up. Quit rates did not differ by treatment arm at either time-point, nor were there effects on withdrawal symptoms or smoking urges. Reaction time for emotion recognition and verbal interference tasks showed improvement in the CT group. When including only successful quitters, improvements in recognition memory, verbal interference accuracy, and attention switching error rate were also observed in the CT group, while commission errors on the continuous performance task decreased in the control group. | Despite modest changes in cognitive performance, these results do not support the efficacy of computerized cognitive training as an adjunctive therapy for smoking cessation. | closed_qa |
Is da Vinci Xi Better than da Vinci Si in Robotic Rectal Cancer Surgery? | We aimed to compare perioperative outcomes for procedures using the latest generation of da Vinci robot versus its previous version in rectal cancer surgery. Fifty-three patients undergoing robotic rectal cancer surgery between January 2010 and March 2015 were included. Patients were classified into 2 groups (Xi, n=28 vs. Si, n=25) and perioperative outcomes were analyzed. The groups had significant differences including operative procedure, hybrid technique and redocking (P>0.05). In univariate analysis, the Xi group had shorter console times (265.7 vs. 317.1 min, P=0.006) and total operative times (321.6 vs. 360.4 min, P=0.04) and higher number of lymph nodes harvested (27.5 vs. 17.0, P=0.008). In multivariate analysis, Xi robot was associated with a shorter console time (odds ratio: 0.09, P=0.004) with no significant differences regarding other outcomes. | Both generations of da Vinci robot led to similar short-term outcomes in rectal cancer surgery, but the Xi robot allowed shorter console times. | closed_qa |
Do Pediatric Teams Affect Outcomes of Injured Children Requiring Inter-hospital Transport? | Studies show that pediatric trauma centers produce better outcomes and reduced mortality for injured children. Yet, most children do not have timely access to a pediatric trauma center and require stabilization locally with subsequent transfer. Investigators have demonstrated that pediatric transport teams (PTT) improve outcomes for critically ill children; however, these studies did not differentiate outcomes for injured children. It may be that moderate to severely injured children actually fare worse with PTT due to slower transport times inherent to their remote locations and thus delays in important interventions. The purpose of this study was to determine if outcomes for injured children are affected by use of PTT for inter-hospital transfer. We conducted a retrospective chart review of 1,177 children transferred to a pediatric trauma center for injury care between March 1st, 2012 and December 31st, 2013. We compared children who were transported by PTT (ground/air) to those transported by ground advanced life support (ALS) and air critical care (ACC). We described patient characteristics and transport times. For PTT vs. ALS and ACC, we compared hospital length of stay (LOS), transport interventions and adverse events. 1,177 injured children were transferred by the following modes: 68% ALS, 13% ACC, 11% Ground PTT, and 9% Air PTT. Children transported by PTT were younger and had higher ISS and lower GCS scores. PTT had a longer total transport time, departure preparation time, and patient bedside time. After controlling for age, ISS, GCS, transport mode, distance, and time, we found no significant difference in LOS between PTT vs. ALS and ACC. A subgroup analysis of children with higher ISS scores demonstrated a 65% longer LOS for children transported by ACC vs. PTT. There were no differences between transport teams with regard to acidosis, hypocarbia or hypercarbia, or maintenance of tubes and lines. | Children transported by PTT were younger and sicker (vs. ACC and ALS). Despite longer transport times, children transported by PTT did not have a longer hospital LOS or adverse events during transport. However, for those children with higher ISS, transport by ACC resulted in longer hospital LOS vs. PTT. | closed_qa |
Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma? | Prehospital provider assessment of the use of anticoagulant or antiplatelet medications in older adults with head trauma is important. These patients are at increased risk for traumatic intracranial hemorrhage and therefore field triage guidelines recommend transporting these patients to centers capable of rapid evaluation and treatment. Our objective was to evaluate EMS ascertainment of anticoagulant and antiplatelet medication use in older adults with head trauma. A retrospective study of older adults with head trauma was conducted throughout Sacramento County. All 5 transporting EMS agencies and all 11 hospitals in the county were included in the study, which ran from January 2012 to December 2012. Patients ≥55 years who were transported to a hospital by EMS after head trauma were included. We excluded patients transferred between two facilities, patients with penetrating head trauma, prisoners, and patients with unmatched hospital data. Anticoagulant and antiplatelet use were categorized as: warfarin, direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, and apixaban), aspirin, and other antiplatelet agents (e.g., clopidogrel and ticagrelor). We calculated the percent agreement and kappa statistic for binary variables between EMS and emergency department (ED)/hospital providers. A kappa statistic ≥0.60 was considered acceptable agreement. After excluding 174 (7.6%) patients, 2,110 patients were included for analysis; median age was 73 years (interquartile range 62-85 years) and 1,259 (60%) were male. Per ED/hospital providers, the use of any anticoagulant or antiplatelet agent was identified in 595 (28.2%) patients. Kappa statistics between EMS and ED/hospital providers for the specific agents were: 0.76 (95% CI 0.71-0.82) for warfarin, 0.45 (95% CI 0.19-0.71) for DOAC agents, 0.33 (95% CI 0.28-0.39) for aspirin, and 0.51 (95% CI 0.42-0.60) for other antiplatelet agents. | The use of antiplatelet or anticoagulant medications in older adults who are transported by EMS for head trauma is common. EMS and ED/hospital providers have acceptable agreement with preinjury warfarin use but not with DOAC, aspirin, and other antiplatelet use. | closed_qa |
Nonretractable foreskin in boys without complaints : An indication for circumcision? | Removing boys' foreskins, even for medical reasons, is increasingly and critically discussed. The aim of this study is to retrospectively verify if the indication for the removal of boys' foreskins was justified. The study is based on the records of boys who underwent preputial operation in an outpatient medical office for pediatric surgery. Preoperative clinical findings, complaints, applied conservative and/or surgical procedures and histological results of the resected foreskins of boys, who underwent preputial operation between 2013-2015, were retrospectively analyzed. A total of 176 boys (age 5 on average) underwent a preputial operation. In 85 % of the cases it was completely removed. Most frequent clinical findings (80 %) were that the prepuce was simply not retractable. 86 % of the boys were free of complaints. The most frequent histological findings were a discrete to moderately pronounced chronic fibrous posthitis (69 %) and subepithelial fibrosis (18 %), In the first case 78 % of the boys had been free of complaints, in the latter 72 %. | The majority of the treated boys were free of complaints; however, most of them underwent a complete removal of their foreskin simply because it was nonretractable. The foreskin represents the most sensitive part of the male genital, preputiolysis is a natural process that can go on until early adolescence. Irreversible surgical procedures, such as a complete foreskin removal, should thus be restricted to a clear medical indication. | closed_qa |
Is Increased Acetabular Cartilage or Fossa Size Associated With Pincer Femoroacetabular Impingement? | Surgical treatment for pincer femoroacetabular impingement (FAI) of the hip remains controversial, between trimming the prominent acetabular rim and reverse periacetabular osteotomy (PAO) that reorients the acetabulum. However, rim trimming may decrease articular surface size to a critical threshold where increased joint contact forces lead to joint degeneration. Therefore, knowledge of how much acetabular articular cartilage is available for resection is important when evaluating between the two surgical options. In addition, it remains unclear whether the acetabulum rim in pincer FAI is a prominent rim because of increased cartilage size or increased fossa size.QUESTIONS/ We used reformatted MR and CT data to establish linear length dimensions of the lunate cartilage and cotyloid fossa in normal, dysplastic, and deep acetabula. We reviewed the last 200 hips undergoing PAO, reverse PAO, and surgical dislocation for acetabular rim trimming at one institution. We compared MR images of symptomatic hips with acetabular dysplasia (20 hips), pincer FAI (29 hips), and CT scans of asymptomatic hips from patients who underwent CT scans for reasons other than hip pain (20 hips). These hips were chosen sequentially from the underlying pool of 200 potential subjects to identify the first 10 male and the first 10 female hips in each group that met inclusion criteria. As a result of low numbers, we included all hips that had undergone reverse PAO and met inclusion criteria. Cartilage width was measured medially from the cotyloid fossa to the lateral labrochondral junction. Cotyloid fossa linear height was measured from superior to inferior and cotyloid fossa width was measured from anterior to posterior. Superior lunate cartilage width (SLCW) and cotyloid fossa height (CFH) were measured on MR and CT oblique coronal reformats; anterior lunate cartilage width (ALCW), posterior lunate cartilage width (PLCW), and cotyloid fossa width (CFW) were measured on MR and CT oblique axial reformats. Cohorts were compared using multivariate analysis of variance with Bonferroni's adjustment for multiple comparisons. Compared with control acetabula, dysplastic acetabula had smaller SLCW (2.08 ± 0.29 mm versus 2.63 ± 0.42 mm, mean difference = -0.55 mm; 95% confidence interval [CI] = -0.83 to -0.27; p<0.01), ALCW (1.20 ± 0.34 mm versus 1.64 ± 0.21 mm, mean difference = -0.44 mm; 95% CI = -0.70 to -0.18; p = 0.00), CFH (2.84 ± 0.37 mm versus 3.42 ± 0.57 mm, mean difference = -0.59 mm; 95% CI = -0.96 to -0.21; p<0.01), and CFW (1.98 ± 0.50 mm versus 2.77 ± 0.33 mm, mean difference = -0.80 mm; 95% CI = -1.16 to -0.42; p<0.0001). Based on the results, we identified two subtypes of deep acetabula. Compared with controls, deep subtype 1 had normal CFH and CFW but increased ALCW (2.09 ± 0.42 mm versus 1.64 ± 0.21 mm; p<0.001) and PLCW (2.32 ± 0.36 mm versus 2.00 ± 0.32 mm; p = 0.04). Compared with controls, deep subtype 2 had increased CFH (4.37 ± 0.51 mm versus 3.42 ± 0.57 mm; p<0.01) and CFW (2.76 ± 0.54 mm versus 2.77 ± 0.33 mm; p = 1.0) but smaller SCLW (2.12 ± 0.40 mm versus 2.63 ± 0.42 mm; p<0.01). | Deep acetabula have two distinct morphologies: subtype 1 with increased anterior and posterior cartilage lengths and subtype 2 with a larger fossa in height and width and smaller superior cartilage length. | closed_qa |
Do accountable care organizations (ACOs) help or hinder primary care physicians' ability to deliver high-quality care? | Many view advanced primary care models such as the patient-centered medical home as foundational for accountable care organizations (ACOs), but it remains unclear how these two delivery reforms are complementary and how they may produce conflict. The objective of this study was to identify how joining an ACO could help or hinder a primary care practice's efforts to deliver high-quality care. This qualitative study involved interviews with a purposive sample of 32 early adopters of advanced primary care and/or ACO models, drawn from across the U.S. and conducted in mid-2014. Interview notes were coded using qualitative data analysis software, permitting topic-specific queries which were then summarized. Respondents perceived many potential benefits of joining an ACO, including care coordination staff, data analytics, and improved communication with other providers. However, respondents were also concerned about added "bureaucratic" requirements, referral restrictions, and a potential inability to recoup investments in practice improvements. | Interviewees generally thought joining an ACO could complement a practice's efforts to deliver high-quality care, yet noted some concerns that could undermine these synergies. Both the advantages and disadvantages of joining an ACO seemed exacerbated for small practices, since they are most likely to benefit from additional resources yet are most likely to chafe under added bureaucratic requirements. | closed_qa |
General continuous-time Markov model of sequence evolution via insertions/deletions: are alignment probabilities factorable? | Insertions and deletions (indels) account for more nucleotide differences between two related DNA sequences than substitutions do, and thus it is imperative to develop a stochastic evolutionary model that enables us to reliably calculate the probability of the sequence evolution through indel processes. Recently, indel probabilistic models are mostly based on either hidden Markov models (HMMs) or transducer theories, both of which give the indel component of the probability of a given sequence alignment as a product of either probabilities of column-to-column transitions or block-wise contributions along the alignment. However, it is not a priori clear how these models are related with any genuine stochastic evolutionary model, which describes the stochastic evolution of an entire sequence along the time-axis. Moreover, currently none of these models can fully accommodate biologically realistic features, such as overlapping indels, power-law indel-length distributions, and indel rate variation across regions. Here, we theoretically dissect the ab initio calculation of the probability of a given sequence alignment under a genuine stochastic evolutionary model, more specifically, a general continuous-time Markov model of the evolution of an entire sequence via insertions and deletions. Our model is a simple extension of the general "substitution/insertion/deletion (SID) model". Using the operator representation of indels and the technique of time-dependent perturbation theory, we express the ab initio probability as a summation over all alignment-consistent indel histories. Exploiting the equivalence relations between different indel histories, we find a "sufficient and nearly necessary" set of conditions under which the probability can be factorized into the product of an overall factor and the contributions from regions separated by gapless columns of the alignment, thus providing a sort of generalized HMM. The conditions distinguish evolutionary models with factorable alignment probabilities from those without ones. The former category includes the "long indel" model (a space-homogeneous SID model) and the model used by Dawg, a genuine sequence evolution simulator. | With intuitive clarity and mathematical preciseness, our theoretical formulation will help further advance the ab initio calculation of alignment probabilities under biologically realistic models of sequence evolution via indels. | closed_qa |
Hemimandibular Elongation: Is the Corrected Occlusion Maintained Long-Term? | The purpose of this study was to assess for the maintenance of a corrected occlusion and ongoing mandibular growth in a group of patients younger than 26 years with hemimandibular elongation (HME) who underwent bimaxillary orthognathic reconstruction. We conducted a retrospective cohort study of HME patients operated on by a single surgeon at 1 institution between 1999 and 2013. At a minimum, all patients underwent Le Fort I and bilateral sagittal ramus osteotomies. Study exclusions included patients aged 26 years or older; those with clefts, craniofacial disorders, or tumors; and those with a history of temporomandibular joint or orthognathic surgery. The study variables included age, gender, side of condylar hyperactivity, premolar extractions, extent of mandibular deformity and malocclusion, planned surgical change, and longitudinal follow-up. The outcome variables studied were the achievement and maintenance of a corrected occlusion and the occurrence of continued mandibular growth after surgery. We compared the occlusion at intervals including the following: before surgery (T1), 5 weeks postoperatively (T2), and either 6 to 24 months after surgery (T3) or more than 2 years after surgery (T4). Anterior occlusion assessment included evaluation of overjet, overbite, and dental midline position. Posterior occlusion assessment included the Angle classification, first molar vertical position, and first molar transverse position. If the corrected anterior occlusion remained stable and no posterior open bite occurred, then no clinically significant condylar hyperactivity and/or ongoing mandibular growth was judged to have occurred. Seventy-six consecutive patients met the inclusion criteria. Age at operation averaged 18 years (range, 14.5 to 25 years), and the study included 44 female patients (58%). T3patients (10 of 76, 13%) had documentation of occlusion at a mean of 19 months after surgery. T4patients (66 of 76, 87%) had documentation of occlusion at a mean of 5 years 8 months after surgery. Only 1 of the 76 study patients (1%) was judged to have clinically significant ongoing mandibular growth after reconstruction. For all other patients, a corrected anterior occlusion was maintained long-term, and a posterior open bite did not develop in any. In 7 of the 76 patients (9%), there was a recurrent posterior crossbite by 1 year after completion of orthodontics but without the need for retreatment. An association was confirmed between mandibular setback and long-term posterior malocclusion even with simultaneous maxillary advancement (P = .05). | In HME, a favorable occlusion can be reliably achieved and maintained long-term in most cases using standard bimaxillary orthognathic technique. The need for mandibular setback, even in the presence of simultaneous maxillary advancement, proved to be a factor in the recurrence of long-term posterior malocclusion, although the risk remains low. The results clarify that in patients with HME, by use of the described techniques and timing for surgery, there is no need for an ablative open joint procedure to arrest condylar growth. | closed_qa |
Is the six-minute walk test a useful tool to prescribe high-intensity exercise in patients with chronic obstructive pulmonary disease? | It is not yet completely known whether the 6MWT can be used to prescribe high-intensity exercise for patients with COPD. To evaluate the ability of the six-minute walk test (6MWT) to prescribe high-intensity exercise for patients with chronic obstructive pulmonary disease (COPD). Lung function, maximal inspiratory strength, symptoms and exercise capacity were evaluated in patients with COPD (n = 27) before and after a 12-week high-intensity exercise program. Criteria for high-intensity training were: 1) ≥75% of the 6MWT average speed; 2) American Thoracic Society/European Respiratory Society (ATS/ERS) criteria (≥60% of the maximal incremental shuttle walk test speed). The 6MWT showed good positive and negative predictive values (0.69 and 0.71, respectively), and accuracy (0.70), good reliability (ICC 0.70 [95%CI 0.45-0.85]) and moderate agreement (k 0.41 [95%CI 0.13-0.67]) with the ATS/ERS criteria. | The 6MWT has good predictive ability and accuracy in relation to high-intensity exercise for patients with COPD. | closed_qa |
Does the internal jugular vein affect the elasticity of the common carotid artery? | Arterial stiffness is an early marker of atherosclerosis. The carotid arteries are easily accessible by ultrasound and are commonly used for the evaluation of atherosclerosis development. However, this stiffness assessment is based on the elastic properties of the artery, which may be influenced by the adjacent internal jugular vein (IJV). The aim of the present study is to evaluate the influence of internal jugular vein morphology on the stiffness of the common carotid artery. Bilateral carotid ultrasound was performed in 248 individuals. When no carotid plaque was detected (90.9 % cases), the distensibility coefficient and β - stiffness index were calculated. The global and segmental circumferential strain parameters of the carotid wall were evaluated with 2D-Speckle Tracking. The cross-sectional area of the IJV and degree of its adherence to the carotid wall (angle of adherence) were measured. The morphology of the IJV did not influence the standard stiffness parameters nor the global circumferential strain. However, segmental analysis found the sector adjacent to the IJV to have significantly higher strain parameters than its opposite counterpart. In addition, the strain correlated significantly and positively with IJV cross-sectional area and angle of adherence. | The movement of the carotid artery wall caused by the passage of the pulse wave is not homogeneous. The greatest strain is observed in a segment adjacent to the IJV, and the degree of wall deformation is associated with the size of the vein and the degree of its adherence. | closed_qa |
Bladder stones in vesicovaginal fistula: is concurrent repair an option? | The objective was to assess the outcomes of a one-stage approach to bladder stones in the setting of a vesicovaginal fistula, performing fistula repair concurrently with stone extraction. Retrospective review of urogenital fistula surgeries at Evangel VVF Center in Jos, Nigeria, between December 2003 and April 2014, identified 87 women with bladder stones accompanying their fistulas and 2,979 repaired without stones. Concurrent stone extraction and fistula repair were performed in 51 patients. Outcomes were compared with respect to fistula size, classification, and fibrosis. Women presenting with bladder stones were older and had larger fistulas than those without stones (P < 0.001). Additionally, their fistulas were more often classifiable as large and less often as high (P = 0.02), and were more fibrotic (P = 0.003). Twenty-six (51 %) patients with concurrent repair successfully became dry. Comparing results by classification, concurrent repair of high fistulas with stones was very likely to be successful (OR 8.8, 95% CI 1.0-78.2), whereas low fistulas were not (OR 0.2, 95% CI 0.02-0.7). Outcomes were similar to those of patients without stones, except for low fistulas, which were 5 times more likely to fail (P = 0.04). | Concurrent closure of vesicovaginal fistula at the time of bladder stone extraction is possible and, in many respects, preferable to a staged approach, particularly among high or midvaginal fistulas. | closed_qa |
Measuring Erythrocyte Thiopurine Methyltransferase Activity in Children-Is It Helpful? | To assess the profile of thiopurine transmethyltransferase (TPMT) enzyme activities in children and discuss the utility of measuring TPMT levels before commencing azathioprine therapy. Retrospective study in a single pediatric center of all patients who had TPMT enzyme assay measured during a 3-year period before the start of azathioprine therapy. Patients' TPMT enzyme activities were classified as normal (26-50 pmol/h/mgHb), intermediate (10-25 pmol/h/mgHb), and deficient (<10 pmol/h/mgHb). Medical and electronic prescribing records were studied, with records of patients' demographic data, diagnoses, dosages, and adverse drug reactions monitored. A total of 228 (45% female) patients ages 1-18 years (median 10 years) were tested for TPMT activity. They were all subsequently commenced on azathioprine. Erythrocyte TPMT activities were 14-76 (median 33.7) pmol/h/mgHb with 88% and 12% of patient having normal and intermediate activity respectively (none were deficient). The initial prescribed dosage of azathioprine was 0.7-3.5 (median 2.0) mg/kg/day. Only 2 patients developed mild neutropenia and required reduction of azathioprine dosage. | This large cohort study demonstrates that the majority of pediatric patients had normal TMPT activities. We would recommend close monitoring of full blood counts after instituting azathioprine therapy but would question the cost-effectiveness of pretreatment TPMT activity in pediatric practice. | closed_qa |
Prehospital Emergency Medical Services Departure Interval: Does Patient Age Matter? | This was a 3-year observational study. Departure intervals of ambulances, according to age of patients, were analyzed and a multivariate analysis, according to time of day and suspected medical problem, was performed. A total of 44,113 missions were included, 2,417 (5.5%) in the pediatric group. Mean departure delay for the adult group was 152.9 seconds, whereas it was 149.3 seconds for the pediatric group (P =.018). | A statistically significant departure interval difference between missions for children and adults was found. The difference, however, probably was not significant from a clinical point of view (four seconds). Schnegg B , Pasquier M , Carron PN , Yersin B , Dami F . Prehospital Emergency Medical Services departure interval: does patient age matter? Prehosp Disaster Med. 2016;31(6):608-613. | closed_qa |
Resident and attending assessments of operative involvement: Do we agree? | General surgery residents' (GSRs') operative experience likely improves with increased involvement. We explored GSRs and attending surgeons' (ASs') perceptions of GSRs' operative roles. GSRs and ASs completed surveys postoperatively regarding responsibility for several operative tasks (incision opening, dissection of minor and major structures, major suturing, and incision closure). Analyses used chi-square test (P<.05) and Spearman's rank correlation (ρ). A total of 151 pairs of surveys were collected. Interpair agreement on GSRs involvement varied for each category (ρ range: .30 to .67), and GSRs underestimated their involvement for every step. GSRs frequently performed the majority of each task (range: 86% to 97%). Decreasing operational complexity, acute operations, and junior ASs (<5 years in practice) were each associated with increased agreement and GSRs involvement in operative tasks. | GSRs involvement was extensive, and agreement with ASs was high overall. Some discrepancies remain in several categories based on operational complexity, acuity, and ASs experience. | closed_qa |
Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6months after uterine evacuation? | To compare the outcomes of Brazilian patients with molar pregnancy who continue human chorionic gonadotropin (hCG) surveillance with those treated with chemotherapy when hCG was still positive, but falling at 6months after uterine evacuation. Retrospective chart review of 12,526 patients with hydatidiform mole treated at one of nine Brazilian reference centers from January 1990 to May 2016. At 6months from uterine evacuation, 96 (0.8%) patients had hCG levels raised but falling. In 15/96 (15.6%) patients, chemotherapy was initiated immediately per FIGO 2000 criteria, while 81/96 (84.4%) patients were managed expectantly. Among the latter, 65/81 (80.2%) achieved spontaneous remission and 16 (19.8%) developed postmolar gestational trophoblastic neoplasia (GTN). Patients who received chemotherapy following expectant management required more time for remission (11 versus 8months; p=0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6months; p<0.001), and presented with a median WHO/FIGO risk score higher than women treated according to FIGO 2000 criteria (4 versus 2, p=0.04), but there were no significant differences in the need for multiagent treatment regimens (1/15 versus 3/16 patients, p=0.60). None of the women relapsed, and no deaths occurred in either group. | In order to avoid unnecessary exposure of women to chemotherapy, we no longer follow the FIGO 2000 recommendation to treat all patients with molar pregnancy and hCG raised but falling at 6months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients. | closed_qa |
Testing a Social Mechanism: Does Alcohol Outlet Density Moderate the Relationship Between Levels of Alcohol Use and Child Physical Abuse? | Parental alcohol use and alcohol outlet density are both associated with child abuse. Guided by alcohol availability theory, this article examines whether alcohol outlet density moderates the relationship between parental alcohol use and child physical abuse. A general population telephone survey of 3,023 parents or legal guardians 18 years or older was conducted across 50 California cities, whereas densities of alcohol outlets were measured for by zip code. Data were analyzed via overdispersed multilevel Poisson models. Ex-drinkers, light drinkers, and heavy drinkers use physical abuse more often than lifetime abstainers. Moderate drinking was not related to child physical abuse. Proportion of bars was negatively related to frequency of physical abuse. Moderating relationships between alcohol outlet density and drinking categories were found for all drinking patterns. | Different types of alcohol outlets may be differentially related to drinking patterns, indicating that the interaction of drinking patterns and the drinking environment may place children at greater risk for being physically abused. | closed_qa |
Specimen retrieval during elective laparoscopic cholecystectomy: is it safe not to use a retrieval bag? | Since the introduction of laparoscopic surgery for gallbladder disease different types of retrieval devices have been used to extract the gallbladder from the peritoneal cavity. These devises infer additional costs and may lead to associated risks and complications. We aimed to evaluate the safety of gallbladder retrieval without the use of a retrieval device. A prospective study was conducted across two teaching hospitals in the Republic of Ireland from July 2010-2013. Patients undergoing planed elective day case laparoscopic cholecystectomy in the two institutions were included in the study. Data were collected on patient demographics, the use of a bag, any need for extension of fascial incision, any unexpected over night stay, any 30-day post operative complications and presence of port site hernia within 1 year surgery. There were 373 planned elective day case laparoscopic cholecystectomy performed during the study period. A bag was not used to retrieve the gallbladder in 41 % (n = 152) patients. A retrieval bag was used in the majority of patients (71 %) who required over night stay due to pain. Overall wound infection rate was low (2.4 %), with 57 % of those being in patients where no retrieval bag was used. An increase incision in the fascia was required in 9.7 % of patients. The majority of these were in patients in whom a retrieval bag was used (75 %). At 1 year follow up, there were no recorded cases of port site hernia for the no retrieval bag group and two (0.9 %) cases of umbilical port site hernias in the group where retrieval bag was used. | In cases of elective uncomplicated laparoscopic cholecystectomy for radiologically confirmed benign disease there was no benefit in using a retrieval bag. Furthermore, not using a bag was associated with less need for increasing the size of the fascial incision thereby reducing post operative pain and risk of port site hernia. | closed_qa |
Is night eating syndrome associated with obstructive sleep apnea, BMI, and depressed mood in patients from a sleep laboratory study? | The aim of this study was to assess night eating syndrome (NES) in patients referred for polysomnography and its association with obstructive sleep apnea (OSA). We also assessed whether participants with OSA were more likely to get up and eat at night, and whether these behaviors were associated with the apnea-hypopnea sleep index (AHI). We additionally examined whether NES and OSA were associated with BMI, and assessed depressed mood among participants with NES or OSA. The Night Eating Diagnostic Questionnaire (NEDQ), Zung Depression Scale, and demographic and medical questionnaires were used to evaluate 84 qualified participants. Polysomnography was used to assess AHI, and therefore OSA. Thirty individuals met full or sub-threshold NES (NES[St]) criteria, and 54 had no night eating (Normal). Eighty-nine percent of the sample had OSA with AHI≥5. Neither AHI nor BMI differed between NES(St) and Normal, F(1,82)=1.67, p=0.20 and F(1, 82)=2.2, p=0.14, respectively. Participants with NES(St) were, however, more likely than Normal to have depressed mood (mild, moderately, or severely depressed), χ2=4.47 p=0.03. There was a positive correlation between AHI and BMI, r=0.37, p=0.001. Those with OSA were not more likely to eat at night, F(1,82)=0.04, p=0.84, or get out of bed more often, F(1,13)=0.23, p=0.64, and there was no correlation between AHI and eating at night (r=-0.11, p=0.31). However, there was a positive correlation between AHI and the number of times participants got up out of bed (r=0.81, p<0.001). | We found that NES was not associated with BMI or AHI severity. The findings show that NES is primarily an eating disorder, rather than a sleep disorder, and that there is an association between NES and depressed mood. | closed_qa |
Is pregnancy a teachable moment to promote handwashing with soap among primiparous women in rural Bangladesh? | Promoting handwashing with soap to mothers of young children can significantly reduce diarrhoea and pneumonia morbidity among children, but studies that measured long-term behaviour after interventions rarely found improvements in handwashing habits. Expecting mothers may experience emotional and social changes that create a unique environment that may encourage adoption of improved handwashing habits. The objective of this study was to determine whether exposure to an intensive handwashing intervention in the perinatal period (perinatal arm) was associated with improved maternal handwashing behaviour vs. exposure to the same intervention after the end of the perinatal period (post-neonatal arm). We identified primiparous women previously enrolled a randomised controlled handwashing intervention trial (November 2010-December 2011) and observed handwashing behaviours at the home 1-14 months after completion of the RCT (January-May 2012). We observed maternal handwashing and estimated the prevalence ratio (PR) of maternal handwashing using log-binomial regression. We enrolled 107 mothers in the perinatal arm and 105 mothers in the post-neonatal arm. Handwashing with soap at recommended times was low overall (4.6%) and comparable between arms (PR = 0.9, 95% CI 0.5, 1.5). | This handwashing intervention was unable to develop and establish improved handwashing practices in primiparous women in rural Bangladesh. While pregnancy may present an opportunity and motivation to do so, further studies should assess whether social, individual and environmental influences overcome this motivation and prevent handwashing with soap among new mothers. | closed_qa |
Do Health Care Providers Use Online Patient Ratings to Improve the Quality of Care? | Physician-rating websites have become a popular tool to create more transparency about the quality of health care providers. So far, it remains unknown whether online-based rating websites have the potential to contribute to a better standard of care. Our goal was to examine which health care providers use online rating websites and for what purposes, and whether health care providers use online patient ratings to improve patient care. We conducted an online-based cross-sectional study by surveying 2360 physicians and other health care providers (September 2015). In addition to descriptive statistics, we performed multilevel logistic regression models to ascertain the effects of providers' demographics as well as report card-related variables on the likelihood that providers implement measures to improve patient care. Overall, more than half of the responding providers surveyed (54.66%, 1290/2360) used online ratings to derive measures to improve patient care (implemented measures: mean 3.06, SD 2.29). Ophthalmologists (68%, 40/59) and gynecologists (65.4%, 123/188) were most likely to implement any measures. The most widely implemented quality measures were related to communication with patients (28.77%, 679/2360), the appointment scheduling process (23.60%, 557/2360), and office workflow (21.23%, 501/2360). Scaled-survey results had a greater impact on deriving measures than narrative comments. Multilevel logistic regression models revealed medical specialty, the frequency of report card use, and the appraisal of the trustworthiness of scaled-survey ratings to be significantly associated predictors for implementing measures to improve patient care because of online ratings. | Our results suggest that online ratings displayed on physician-rating websites have an impact on patient care. Despite the limitations of our study and unintended consequences of physician-rating websites, they still may have the potential to improve patient care. | closed_qa |
Does Microinvasive Adenocarcinoma of Cervix Have Poorer Treatment Outcomes than Microinvasive Squamous Cell Carcinoma? | To compare the pathological findings and oncologic outcomes of stage IA cervical carcinoma patients, between adenocarcinoma and squamous cell carcinoma cases. A total of 151 medical records of stage IA cervical carcinoma patients undergoing primary surgical treatment during 2006-2013 were reviewed. Information from pathological diagnosis and recurrence rates were compared with descriptive statistical analysis. The Kaplan-Meier method and Cox proportional hazards model were used for survival analysis. The median age was 48.9 years. There was no significant difference in rates of lymph node, parametrium, uterine, vaginal, or ovarian metastasis, when comparing adenocarcinoma with squamous cell carcinoma. Overall recurrence rates of adenocarcinoma (5.7%) and squamous cell carcinoma (2.6%) were not statistically significant different, even when stratified by stage. When comparing progression free survival with squamous cell carcinoma, adenocarcinoma had an HR of 0.448 (0.073-2.746), p=0.386. | Microinvasive adenocarcinoma of cervix has similar rate of extracervical involvement and oncologic outcomes to squamous cell carcinoma. | closed_qa |
p16 - a Possible Surrogate Marker for High-Risk Human Papillomaviruses in Oral Cancer? | High-risk human papillomaviruses (HR-HPV), particularly types 16 and 18, have been found to play an important role in head and neck cancer, including oropharyngeal squamous cell carcinoma (OPSCC) and oral squamous cell carcinoma (OSCC). p16, a cell cycle inhibitor, has been postulated as a surrogate marker for HR-HPV, since p16 is aberrantly overexpressed in such lesions, especially in HR-HPV-positive OPSCC. However, p16 as a surrogate marker for HR-HPV infection in cancers of the oral cavity remains controversial. The objectives of the study were to investigate the expression of p16 and the presence of HR-HPV in OSCC and oral verrucous carcinoma (VC) and to determine if p16 could be used as a surrogate marker for HR-HPV. Forty one formalin-fixed, paraffin-embedded tissues of OSCC (n=37) or VC (n=4) with clinical and histopathologic data of each case were collected. Expression of p16 was determined by immunohistochemistry, focusing on both staining intensity and numbers of positive cells. The presence of HPV types 16 and 18 was detected by polymerase chain reaction (PCR). Descriptive statistics were employed to describe the demographic, clinical, and histopathologic parameters. Associations between p16 overexpression, HR-HPV and all variables were determined by Fisher's exact test, odds ratios (ORs) and corresponding 95% confidence intervals (CIs). In addition, the use of p16 as a surrogate marker for HR-HPV was analyzed by sensitivity and specificity tests. p16 was overexpressed in 8/37 cases (21.6%) of OSCC and 2/4 cases (50%) of VC. HPV-16 was detected in 4/34 OSCC cases (11.8%) and HPV-18 was detected in 1/34 OSCC cases (2.9%). Co-infection of HPV-16/18 was detected in 1/4 VC cases (25%). Both p16 overexpression and HR-HPV were significantly associated with young patients with both OSCC and VC (<0.05, OR 20, 95% CI 1.9-211.8;<0.05, OR 23.3, 95% CI 2.4-229.7, respectively). p16 was able to predict the presence of HPV-16/18 in OSCC with 40% sensitivity and 79.3% specificity and in VC with 100% sensitivity and 66.7% specificity, respectively. | p16 overexpression was found in 24.4% of both OSCC and VC. HR-HPV, regardless of type, was detected in 15.8% in cases of OSCC and VC combined. The results of sensitivity and specificity tests suggest that p16 can be used as a surrogate marker for HR-HPV in OSCC and VC. | closed_qa |
Conservative management in very elderly patients with severe aortic stenosis: Time to change? | Despite current recommendations, a high percentage of patients with severe symptomatic aortic stenosis are managed conservatively. The aim of this study was to study symptomatic patients undergoing conservative management from the IDEAS registry, describing their baseline clinical characteristics, mortality, and the causes according to the reason for conservative management. Consecutive patients with severe aortic stenosis diagnosed at 48 centers during January 2014 were included. Baseline clinical characteristics, echocardiographic data, Charlson index, and EuroSCORE-II were registered, including vital status and performance of valve intervention during one-year follow-up. For the purpose of this substudy we assessed symptomatic patients undergoing conservative management, including them in 5 groups according to the reason for performing conservative management [I: comorbidity/frailty (128, 43.8%); II: dementia 18 (6.2%); III: advanced age 34 (11.6%); IV: patients' refusal 62 (21.2%); and V: other reasons 50 (17.1%)]. We included 292 patients aged 81.5±9 years. Patients from group I had higher Charlson index (4±2.3), higher EuroSCORE-II (7.5±6), and a higher overall (42.2%) and non-cardiac mortality (16.4%) than the other groups. In contrast, patients from group III had fewer comorbidities, lower EuroSCORE-II (4±2.5), and low overall (20.6%) and non-cardiac mortality (5.9%). | Patients with severe symptomatic aortic stenosis managed conservatively have different baseline characteristics and clinical course according to the reason for performing conservative management. A prospective assessment of comorbidity and other geriatric syndromes might contribute to improve therapeutic strategy in this clinical setting. | closed_qa |
Longitudinal enlargement of the lesion after spinal cord injury in the rat: a consequence of malignant edema? | Experimental animal study. Quantitative analysis of secondary changes in lesion size after experimental spinal cord injury (SCI) in the rat, with special emphasis to the formation of dorsal column lesions. Slovakia. After SCI in the rat, animals survived for different periods ranging from 5 min to 7 days. Their whole spinal cords were cut transversally into 1 mm thick slabs. On each slab, the lesion profile was outlined. The overall shape of the lesion was reconstructed from a series of consecutive profiles and its length was measured. Immediately after injury, a spindle-shaped hemorrhagic contusive lesion was observed, with the length of ~15 mm. After a quiescent phase lasting for at least 1 h, there was a dramatic secondary enlargement of the lesion and its length increased up to 40 mm between 1 and 48 h. The fully developed lesion consisted of the spindle-shaped epicenter and long cranial and caudal protrusions located in the midline between dorsal columns. | We propose that secondary enlargement of the lesion can be explained by posttraumatic swelling. The expanding tissues are pushed out in longitudinal axis along the mechanically weakest parts of the spinal cord. Additional data that support this hypothesis are presented. Our findings indicate that malignant posttraumatic edema might have an important role in pathomechanisms of secondary injury after SCI. | closed_qa |
Neopuff T-piece resuscitator: does device design affect delivered ventilation? | The T-piece resuscitator (TPR) is in common use worldwide to deliver positive pressure ventilation during resuscitation of infants<10 kg. Ease of use, ability to provide positive end-expiratory pressure (PEEP), availability of devices inbuilt into resuscitaires and cheaper disposable options have increased its popularity as a first-line device for term infant resuscitation. Research into its ventilation performance is limited to preterm infant and animal studies. Efficacy of providing PEEP and the use of TPR during term infant resuscitation are not established.AIM: The aim of this study is to determine if delivered ventilation with the Neopuff brand TPR varied with differing (preterm to term) test lung compliances (Crs) and set peak inspiratory pressures (PIP). A single operator experienced in newborn resuscitation provided positive pressure ventilation in a randomised sequence to three different Crs models (0.5, 1 and 3 mL/cmH2O) at three different set PIP (20, 30 and 40 cmH2O). Set PEEP (5 cmH2O), gas flow rate and inflation rate were the same for each sequence. A total of 1087 inflations were analysed. The delivered mean PEEP was Crs dependent across set PIP range, rising from 4.9 to 8.2 cmH2O. At set PIP 40 cmH2O and Crs 3 mL/cmH2O, the delivered mean PIP was significantly lower at 35.3 cmH2O. | As Crs increases, the Neopuff TPR can produce clinically significant levels of auto-PEEP and thus may not be optimal for the resuscitation of term infants with healthy lungs. | closed_qa |
Is the simplification of the immunization schedule applied? | Study conducted on Internet among a representative sample of mothers reporting their child's vaccination record. The removal of the dose of DTPa-Hib at the age of 3 months was quickly adopted since only 1 % of children aged 6 months had received three doses of DTPa in 2014 compared to 96 % in 2012. The booster dose is administered earlier for the DTPa and hepatitis B components. The shift of MMR vaccination from 9 months of age for children participating in community structures to 12 months for all children was closely followed since only 2 % of 9- to 11-month-old children received a MMR vaccine in 2014 compared to 33 % in 2012. The second dose of MMR recommended at 16-18 months of age rather than between 13 and 24 months was actually followed by an earlier administration of this dose. At 18-20 months of age, 60 % received two doses of MMR in 2014 versus 41 % in 2012. Finally, for meningitis C vaccination, a significant increase of VC was observed in children 15-23 months of age (66 % in 2014 versus 44 % in 2012). | The simplification of the infant immunization schedule was quickly applied and received excellent support from healthcare professionals. However, this measure alone is still not sufficient to meet the CV objectives defined by the HCSP. | closed_qa |
Do Radiographic Parameters of Dysplasia Improve to Normal Ranges After Bernese Periacetabular Osteotomy? | The goal of periacetabular osteotomy (PAO) is to improve the insufficient coverage of the femoral head and achieve joint stability without creating secondary femoroacetabular impingement. However, the complex tridimensional morphology of the dysplastic acetabulum presents a challenge to restoration of normal radiographic parameters. Accurate acetabular correction is important to achieve long-term function and pain improvement. There are limited data about the proportion of patients who have normal radiographic parameters restored after PAO and the factors associated with under- and overcorrection.QUESTIONS/ (1) What is the proportion of patients undergoing PAO in which the acetabular correction as assessed by the lateral center-edge angle (LCEA), anterior center-edge angle (ACEA), acetabular inclination (AI), and extrusion index (EI) is within defined target ranges? (2) What patient and preoperative factors are associated with undercorrection of the acetabulum as defined by a LCEA<22°, a factor that has been reported to be associated with PAO failure at 10-year followup? Between January 2007 and December 2011 we performed 132 PAOs in 116 patients for treatment of symptomatic acetabular dysplasia. One patient with Legg-Calvé-Perthes disease, one with multiple osteochondromatosis, and two with concomitant femoral osteotomy were excluded. A total of 128 hips (112 patients) were included. The hip cohort was 76% (97 of 128) female and the mean age at surgery was 28.5 years (SD 8.7 years). Correction of LCEA between 25° and 40°, ACEA between 18° and 38°, Tönnis angle between 0° and 10°, and EI ≤ 20% were defined as adequate based on normative values. Values lower than the established parameters were considered undercorrection for the LCEA and ACEA and those higher than the established values were considered overcorrection. Because postoperative LCEA<22ohas been previously associated with PAO failure at a minimum of 10-year followup, in this study we sought to measure whether demographic factors including age, gender, body mass index, and severity of acetabular dysplasia assessed by preoperative LCEA, ACEA, AI, and EI were associated with undercorrection. Postoperative radiographs were obtained at minimum of 1 month after surgery (mean, 7 months; range, 1-44 months) and were measured by a professional research assistant and a hip reconstruction fellow not involved in the clinical care of the patients. No patient was lost to followup. Of the 128 hips, the proportion of hips with radiographic parameters within the established range was 78% (100 hips) for the LCEA, 86% (110 hips) for the ACEA, 89% (114 hips) for the AI, and 80% (102 hips) for the EI. For hips with an inadequate correction, the LCEA was more often undercorrected than overcorrected (20% versus 2%; 95% confidence interval [CI], 11%-27%; p<0.001), whereas the ACEA was more often overcorrected than undercorrected (11% versus 3%; 95% CI, 1%-15%; p = 0.03) After adjusting for age, sex, body mass index, and preoperative radiographic parameters including ACEA, AI, and EI, we found that the preoperative LCEA was the only independent factor associated with a postoperative LCEA<22° (odds ratio, 0.92; 95% CI, 0.87-0.97; p = 0.003), indicating that hips with lower preoperative LCEA were more likely to have a LCEA<22°. For each additional degree of preoperative LCEA, the odds of LCEA<22° were reduced by 15%. | Acetabular correction after PAO performed by two experienced surgeons was adequate for individual radiographic parameters in most but not all hips. Hips with more severe dysplasia preoperatively are at higher risk for undercorrection as assessed by the LCEA. This intuitive information may help surgeons performing PAO in severely dysplastic hips plan for possible combined procedures including a femoral osteotomy if PAO alone does not allow for adequate correction of femoral head coverage and a congruous concentric hip. Further studies are planned to determine whether the long-term hip function and pain in patients whose hips were corrected within these established parameters will be improved in comparison to those that were under- or overcorrected. | closed_qa |
Does acid etching morphologically and chemically affect lithium disilicate glass ceramic surfaces? | This study evaluated the surface morphology, chemical composition and adhesiveness of lithium disilicate glass ceramic after acid etching with hydrofluoric acid or phosphoric acid. Lithium disilicate glass ceramic specimens polished by 600-grit silicon carbide paper were subjected to one or a combination of these surface treatments: airborne particle abrasion with 50-μm alumina (AA), etching with 5% hydrofluoric acid (HF) or 36% phosphoric acid (Phos), and application of silane coupling agent (Si). Stainless steel rods of 3.6-mm diameter and 2.0-mm height were cemented onto treated ceramic surfaces with a self-adhesive resin cement (Clearfil SA Cement). Shear bond strengths between ceramic and cement were measured after 24-hour storage in 37°C distilled water. SEM images of AA revealed the formation of conventional microretentive grooves, but acid etching with HF or Phos produced a porous surface. Bond strengths of AA+HF+Si (28.1 ± 6.0 MPa), AA+Phos+Si (17.5 ± 4.1 MPa) and HF+Si (21.0 ± 3.0 MPa) were significantly greater than those of non-pretreated controls with Si (9.7 ± 3.7 MPa) and without Si (4.1 ± 2.4 MPa) (p<0.05). In addition, HF etching alone (26.2 ± 7.5 MPa) had significantly higher bond strength than AA alone (11.5 ± 4.0 MPa) (p<0.05). AA+HF, AA+Phos and HF showed cohesive failures. | Etching with HF or Phos yielded higher bond strength between lithium disilicate glass ceramic and self-adhesive resin cement without microcrack formation. | closed_qa |
Is micro-computed tomography useful for wear assessment of ceramic femoral heads? | Wear associated with hip components represents the main clinical problem in these patients, and it is important to develop new techniques for more accurate measurements of that wear. Currently, the gravimetric method is the gold standard for assessing mass measurements in preclinical evaluations. However, this method does not give other information such as volumetric loss or surface deviation. This work aimed to develop and validate a new technique to quantify ceramic volume loss from in vitro experiments using micro-computed tomography (micro-CT). An alumina (BIOLOX® forte) femoral head (Ø = 28 mm) was used. Mass and volume loss were approached by gravimetric method (using a four decimal place digital microbalance) and by using Skyscan 1176 microtomographic system, respectively. Standard error and coefficient of variance of both gravimetric and experimental groups demonstrated the reliability of the micro-CT analysis technique. | In conclusion, the findings of the present study suggest that this new protocol could be considered an important tool for wear assessment and that we have found a reliable metrological protocol for volumetric analysis of ceramic femoral head prostheses, demonstrating that the micro-CT technique can be an important tool for wear assessment. | closed_qa |
Can Interim 18F-FDG PET or Diffusion-Weighted MRI Predict End-of-Treatment Outcome in FDG-Avid MALT Lymphoma After Rituximab-Based Therapy? | To determine whether interim F-FDG PET or interim diffusion-weighted magnetic resonance imaging (DWI) can predict the end-of-treatment (EOT) outcome after immunotherapy in patients with FDG-avid extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT). Patients with untreated MALT lymphoma prospectively underwent whole-body F-FDG PET/CT and DWI before treatment (baseline), and after three cycles (interim) of rituximab-based immunotherapy. Maximum and mean standardized uptake values (SUVmax, SUVmean), and minimum and mean apparent diffusion coefficients (ADCmin, ADCmean), were measured for up to three target lesions per patient. Rates of change between baseline and interim examinations (ΔSUVmax, ΔSUVmean, ΔADCmin, and ΔADCmean) were compared, using ANOVAs, between the four end-of-treatment (EOT, after six cycles of immunotherapy) outcomes: complete remission (CR), partial remission (PR), stable disease (SD), or progressive disease (PD). Fifteen patients with 25 lesions were included. Lesion-based post hoc tests showed significant differences between CR and PR for ΔSUVmax (P<0.001), ΔSUVmean (P<0.001), and ΔADCmin (P = 0.044), and between CR and SD for ΔSUVmax (P<0.001), ΔSUVmean (P<0.001), ΔADCmin (P = 0.021), and ΔADCmean (P = 0.022). No lesion showed PD at EOT. | Both quantitative interim F-FDG PET and interim DWI may possibly be useful to predict complete remission at end-of-treatment in MALT lymphoma patients after immunotherapy. | closed_qa |
Does Gender Influence Colour Choice in the Treatment of Visual Stress? | Visual Stress (VS) is a condition in which words appear blurred, in motion, or otherwise distorted when reading. Some people diagnosed with VS find that viewing black text on white paper through coloured overlays or precision tinted lenses (PTLs) reduces symptoms attributed to VS. The aim of the present study is to determine whether the choice of colour of overlays or PTLs is influenced by a patient's gender. Records of all patients attending a VS assessment in two optometry practices between 2009 and 2014 were reviewed retrospectively. Patients who reported a significant and consistent reduction in symptoms with either overlay and or PTL were included in the analysis. Overlays and PTLs were categorized as stereotypical male, female or neutral colours based on gender preferences as described in the literature. Chi-square analysis was carried out to determine whether gender (across all ages or within age groups) was associated with overlay or PTL colour choice. 279 patients (133 males and 146 females, mean age 17 years) consistently showed a reduction in symptoms with an overlay and were included. Chi-square analysis revealed no significant association between the colour of overlay chosen and male or female gender (Chi-square 0.788, p = 0.674). 244 patients (120 males and 124 females, mean age 24.5 years) consistently showed a reduction in symptoms with PTLs and were included. Chi-square analysis revealed a significant association between stereotypical male/female/neutral colours of PTLs chosen and male/female gender (Chi-square 6.46, p = 0.040). More males preferred stereotypical male colour PTLs including blue and green while more females preferred stereotypical female colour PTLs including pink and purple. | For some VS patients, the choice of PTL colour is influenced not only by the alleviation of symptoms but also by other non-visual factors such as gender. | closed_qa |
Can a graft be placed over a flap in complex hypospadias surgery? | To develop a rabbit experimental study to test the hypothesis that surgical repair of hypospadias with severe ventral curvatures might be completed in one stage, if a graft, such as buccal mucosa, could be placed over the tunica vaginalis flap used in corporoplasty for ventral lengthening, with the addition of an onlay preputial island. flap to complete the urethroplasty. The experimental procedure with rabbits included a tunica vaginalis flap for reconstruction of the corpora after corporotomy, simulating a ventral lengthening operation. A buccal mucosa graft was placed directly on top of the flap, and the urethroplasty was completed with an onlay preputial island flap. Eight rabbits were divided into 4 groups, sacrificed at 2, 4, 8 and 12 weeks postoperatively, and submitted to histological evaluation. We observed a large number of complications, such as fistula (75%), urinary retention (50%) and stenosis (50%). There were two deaths related to the procedure. Histological evaluation demonstrated a severe and persistent inflammatory reaction. No viable tunica vaginalis or buccal mucosa was identified. | In this animal model, the association of a buccal mucosa graft over the tunica vaginalis flap was not successful, and resulted in complete loss of both tissues. | closed_qa |
Does Internet-based guided-self-help for depression cause harm? | Almost nothing is known about the potential negative effects of Internet-based psychological treatments for depression. This study aims at investigating deterioration and its moderators within randomized trials on Internet-based guided self-help for adult depression, using an individual patient data meta-analyses (IPDMA) approach. Studies were identified through systematic searches (PubMed, PsycINFO, EMBASE, Cochrane Library). Deterioration in participants was defined as a significant symptom increase according to the reliable change index (i.e. 7.68 points in the CES-D; 7.63 points in the BDI). Two-step IPDMA procedures, with a random-effects model were used to pool data. A total of 18 studies (21 comparisons, 2079 participants) contributed data to the analysis. The risk for a reliable deterioration from baseline to post-treatment was significantly lower in the intervention v. control conditions (3.36 v. 7.60; relative risk 0.47, 95% confidence interval 0.29-0.75). Education moderated effects on deterioration, with patients with low education displaying a higher risk for deterioration than patients with higher education. Deterioration rates for patients with low education did not differ statistically significantly between intervention and control groups. The benefit-risk ratio for patients with low education indicated that 9.38 patients achieve a treatment response for each patient experiencing a symptom deterioration. | Internet-based guided self-help is associated with a mean reduced risk for a symptom deterioration compared to controls. Treatment and symptom progress of patients with low education should be closely monitored, as some patients might face an increased risk for symptom deterioration. Future studies should examine predictors of deterioration in patients with low education. | closed_qa |
Study on the use of focus harmonic scalpel in thyroidectomies: is it useful also in preserving voice function? | The aim of this randomized study is to evaluate the real benefits of the FOCUS Harmonic Scalpel in total thyroidectomies compared with conventional ligation, regarding operative time, postoperative blood loss, length of stay and complications. Furthermore, as never seen in other studies, we studied the effects of using the FOCUS during thyroidectomy analyzing the vocal production of patients before and after surgery. We enrolled 361 patients who underwent total thyroidectomy from 2008 to 2014. It was a randomized clinical trial in which all the surgical procedures were performed by the same surgeon. Patients were randomized into two groups according to the haemostatic technique: 187 patients were included in a "conventional" group (C) in whom dissection and haemostasis were performed using conventional materials (Vicryl, stitches, V titanium hemostatic clips and monopolar or bipolar electrocautery); 174 patients were included in a group in which the FOCUS was used (F group). Our data show that the FOCUS allows a one-third time-saving vs. classic haemostasis. Moreover, the use of the FOCUS would allow reduced traction and reduced manipulation of the thyroid during surgery. Our data demonstrate that the rate of complications in the Focus group might not be significantly reduced. In our series, we noticed that the quantitative acoustic assessment of voice quality show important alterations in several parameters (Shim, Jitt, sPPQ, sAPQ studied with the Multi Dimensional Voice Program evaluation) between the C group and F group. | The FOCUS Harmonic Scalpel reduces the operative time, post-operative blood loss and length of hospital stay in thyroidectomy. Besides, important vocal alterations after thyroidectomy seem more severe using the conventional technique instead of FOCUS. | closed_qa |
A retrospective analysis of 1.011 percutaneous liver biopsies performed in patients with liver transplantation or liver disease: ultrasonography can reduce complications? | In the last decades, liver biopsy was the reference procedure for the diagnosis and follow-up of liver disease. Aim of present retrospective analysis was to assess the prevalence of complications and risk factors after Percutaneous Liver Biopsy (PLB) performed for diagnosis and staging in patients with chronic liver disease and for monitoring the graft in liver transplanted patients Data were collected from a total of 1.011 PLB performed with the Menghini technique between January 2004 and December 2014 at the Hepatology and Transplant Units of the University of Rome Tor Vergata. The indications for biopsy were: follow-up of liver transplantation, chronic Hepatitis B Virus (HBV) or Hepatitis C Virus (HCV), with or without Human Immunodeficiency Virus (HIV) and alcohol-related liver disease. Our patients were divided into two groups according to the biopsy indication: follow-up of liver transplantation (Group A) and chronic liver disease (Group B). All the procedures were performed in Day Hospital regimen. After the biopsy, patients remained in bed for about 4-6 hours. In the absence of complications, they were then discharged on the same day. The most frequent complication after biopsy was pain (Group A n. 57, 8.8%; Group B n. 105, 29.0%), hypotension as a result of a vasovagal reaction resolved spontaneously (Group A n. 7, 1.1%; Group B n. 6, 1.7%), and intrahepatic bleeding resolved with conservative therapy (Group A n. 1, 0.2%; Group B n. 6, 1.7%). Two cases of pneumothorax in the Group A (0.3%) were treated with a chest tube. Other complications did not have a significant impact. Also, we did not observe statistically significant differences in patients who underwent PLB without and with ultrasound guidance. | Liver biopsy is not a replaceable tool in diagnosis and follow-up of several chronic liver diseases. The Menghini technique with the percutaneous trans costal approach, might be preferred because less traumatic and related with a low occurrence of minor and major complications. According to our case load and comparing our findings with the previous published data, we speculate that ultrasound guidance is not crucial in the prevention of major complications. | closed_qa |
Key gaps in pathologic reporting for appendiceal mucinous neoplasms: time for universal synoptic reporting? | The prognosis of appendiceal mucinous neoplasms (AMN) is directly related to their histopathology. Existing classification schemes encompass tumors with widely divergent clinical behaviors within a single diagnosis, making it difficult for clinicians to interpret pathology reports to counsel patients on optimal management. We sought to examine pathology reports generated for AMN for inclusion of essential histologic features. Pathology reports of appendectomy specimens with a diagnosis of AMN (2002-2015) at our center ("internal") and from referring institutions ("external") were retrospectively reviewed for inclusion of the following 5 essential items: layer of invasion, mucin dissection (low grade neoplasms only), perforation, margins, and serosal implants. Sixty-nine patients were included, 54 with external reports available. Benign/low grade tumors comprised 29.0% and 27.8% of internal and external reports, respectively. Thirty-seven internal reports (53.6%) were signed out by specialist gastrointestinal pathologists. External reports were 66.7% complete for layer of invasion, 26.7% for mucin dissection, 64.8% for perforation, 68.5% for margins, 53.7% for serosal implants, and 18.5% for all items. Internal reports were 75.4% complete for layer of invasion, 40.0% for mucin dissection, 40.6% for perforation, 82.6% for margins, 69.6% for serosal implants, and 17.4% for all items. Eight external (14.8%) and 24 internal (34.8%) reports were synoptic. Synoptic reports were more likely to be complete for all key items both external and internal. | Most pathology reports are incomplete for essential features needed for management and discussion of AMN with patients. Synoptic reports improve completeness of reporting for these tumors. | closed_qa |
Can a virtual reality assessment of fine motor skill predict successful central line insertion? | Due to the increased use of peripherally inserted central catheter lines, central lines are not performed as frequently. The aim of this study is to evaluate whether a virtual reality (VR)-based assessment of fine motor skills can be used as a valid and objective assessment of central line skills. Surgical residents (N = 43) from 7 general surgery programs performed a subclavian central line in a simulated setting. Then, they participated in a force discrimination task in a VR environment. Hand movements from the subclavian central line simulation were tracked by electromagnetic sensors. Gross movements as monitored by the electromagnetic sensors were compared with the fine motor metrics calculated from the force discrimination tasks in the VR environment. Long periods of inactivity (idle time) during needle insertion and lack of smooth movements, as detected by the electromagnetic sensors, showed a significant correlation with poor force discrimination in the VR environment. Also, long periods of needle insertion time correlated to the poor performance in force discrimination in the VR environment. | This study shows that force discrimination in a defined VR environment correlates to needle insertion time, idle time, and hand smoothness when performing subclavian central line placement. Fine motor force discrimination may serve as a valid and objective assessment of the skills required for successful needle insertion when placing central lines. | closed_qa |
Differential expression of the inflammation marker IL12p40 in the at-risk mental state for psychosis: a predictor of transition to psychotic disorder? | The identification of biomarkers of transition from the at-risk mental state (ARMS) to psychotic disorder is important because early treatment of psychosis is associated with improved outcome. Increasing evidence points to an inflammatory contribution to psychosis. We questioned whether raised levels of plasma inflammatory markers predict transition from ARMS to psychotic disorder and whether any such predictors could be reduced by omega-3 (ω-3) polyunsaturated fatty acids (PUFAs). We measured the levels of 40 neuroinflammation biomarkers using a commercially available immunoassay kit. Firstly, we compared inflammatory markers in subjects in the ARMS who transitioned to psychotic disorder (n = 11) compared to subjects who did not (n = 28). Then we compared inflammatory markers in all subjects before and after ω-3 PUFA treatment (n = 40). Our data provides preliminary evidence that elevations in the baseline plasma levels of the inflammatory marker IL12/IL23p40 are associated with transition from ARMS to psychotic disorder. IL12/IL23p40 levels did not change following 12 weeks administration of ω-3 PUFAs. These findings provide evidence that elevated plasma IL12/IL23p40 is a potential biomarker of increased risk for transition to psychotic disorder. | Further studies are required to confirm and extend this finding. Our results do not provide support for the possibility that administration of ω-3 PUFAs act to reduced transition to psychotic disorder by reducing blood levels of IL12/IL23p40. | closed_qa |
Preoperative Sentinel Node Mapping in Sentinel Node Biopsy in Early Breast Cancers - Is It Cost-Effective? | Sentinel lymph node (SLN) biopsy is currently the gold standard of treatment in early breast cancers. Identification of SLNs by preoperative scintigraphy has been carried out to improve the detection of SLNs intraoperatively, but the evidence of its cost-effectiveness is lacking. Here, we analyze the cost-effectiveness of the utilization of scintigraphy in detection of SLNs. Clinical and operative details were retrieved from a prospectively maintained database. The resources and cost data from each patient who had undergone SLN biopsy with preoperative scintigraphy were retrieved. From January 2008 to December 2012, 400 patients underwent SLN biopsy for breast cancer. A total of 329 had preoperative SLN mapping with scintigraphy, Baseline patient demographic data for both arms were comparable. The relapse and recurrence rate of both arms were not statistically different. The detection rate of SLNs of both arms was the same (100%), and there were no grade 2 or above lymphedema in both groups of patients. However, the cost of each patient undergoing SLN mapping was USD $345.8. | Preoperative SLN mapping does not improve the SLN detection rate. In addition, it does not affect the surgical outcomes in terms of complication, local relapse, and recurrence. The use of preoperative SLN mapping is no longer cost-effective. | closed_qa |
Could gonadal and adrenal androgen deficiencies contribute to the depressive symptoms in men with systolic heart failure? | Testosterone (TT) and dehydroepiandrosterone sulphate (DHEAS) are neurosteroids and their deficiencies constitute the hormone risk factors promoting the development of depression in elderly otherwise healthy men. We investigated the link between hypogonadism and depression in accordance with age and concomitant diseases in men with systolic HF using the novel scale previously dedicated for elderly population. We analysed the prevalence of depression and severity of depressive symptoms in population of 226 men with systolic HF (40-80 years) compared to 379 healthy peers. The severity of depression was assessed using the Polish long version of Geriatric Depression Scale (GDS). In men aged 40-59 years the severity of depressive symptoms was greater in NYHA classes III-IV compared to NYHA classes I-II and reference group. In men aged 60-80 years depressive symptoms were more severe in NYHA class III-IV compared to controls (all p ≤ 0.001). In multivariate logistic regression model in men aged 40-59 years advanced NYHA class was associated with higher prevalence of mild depression (OR = 2.14, 95%CI: 1.07-4.29) and chronic obstructive pulmonary disease (COPD) with higher prevalence of severe depression (OR = 69.1, 95%CI: 2.11-2264.3). In men aged 60-80 years advanced NYHA class and TT deficiency were related to higher prevalence of mild depression (respectively: OR = 2.9, 95%CI: 1.3-6.4; OR = 3.6, 95%CI: 1.2-10.63). | TT deficiency, COPD and advanced NYHA class were associated with higher prevalence of depression in men with systolic HF. | closed_qa |
Host plant range of a fruit fly community (Diptera: Tephritidae): does fruit composition influence larval performance? | Phytophagous insects differ in their degree of specialisation on host plants, and range from strictly monophagous species that can develop on only one host plant to extremely polyphagous species that can develop on hundreds of plant species in many families. Nutritional compounds in host fruits affect several larval traits that may be related to adult fitness. In this study, we determined the relationship between fruit nutrient composition and the degree of host specialisation of seven of the eight tephritid species present in La Réunion; these species are known to have very different host ranges in natura. In the laboratory, larval survival, larval developmental time, and pupal weight were assessed on 22 fruit species occurring in La Réunion. In addition, data on fruit nutritional composition were obtained from existing databases. For each tephritid, the three larval traits were significantly affected by fruit species and the effects of fruits on larval traits differed among tephritids. As expected, the polyphagous species Bactrocera zonata, Ceratitis catoirii, C. rosa, and C. capitata were able to survive on a larger range of fruits than the oligophagous species Zeugodacus cucurbitae, Dacus demmerezi, and Neoceratitis cyanescens. Pupal weight was positively correlated with larval survival and was negatively correlated with developmental time for polyphagous species. Canonical correspondence analysis of the relationship between fruit nutrient composition and tephritid survival showed that polyphagous species survived better than oligophagous ones in fruits containing higher concentrations of carbohydrate, fibre, and lipid. | Nutrient composition of host fruit at least partly explains the suitability of host fruits for larvae. Completed with female preferences experiments these results will increase our understanding of factors affecting tephritid host range. | closed_qa |
Total thyroidectomy: a clue to understanding the metabolic changes induced by subclinical hyperthyroidism? | The effects of endogenous subclinical hyperthyroidism (eSCH) on heart and bone have been well documented. There are only limited data available regarding the impact of eSCH on weight regulation and lipid metabolism. Our aim was to evaluate the changes in body weight and metabolic parameters after total thyroidectomy in patients with pre-operative eSCH compared with pre-operative patients with euthyroid (EUT). A retrospective study of 505 patients who underwent total thyroidectomy for benign multinodular goitre in an academic hospital in Brussels (Belgium) was performed.PATIENT' Two hundred and 25 patients were included (eSCH group: n = 74; EUT group: n = 151). The mean follow-up time was 26·1 ± 0·8 months and was similar in both groups. Absolute BMI gain was significantly greater in the eSCH group than in the EUT group (1·11 ± 0·17 vs 0·33 ± 0·13 kg/m2; P = 0·003). A significant increase in LDL cholesterol was observed in the eSCH group (16·1 ± 3·8 mg/dl; P < 0·001) but not in the EUT group (0·0 ± 3·0 mg/dl; P = 0·88). In a multivariate model, pre-operative TSH levels were the main factor significantly associated with increases in BMI or LDL cholesterol. Post-operative median TSH levels and L-thyroxine substitution were similar in both groups. | After total thyroidectomy, increases in weight and serum cholesterol were observed in the eSCH group. Given that post-operative TSH levels were similar in the two groups, these observations are probably due to the correction of eSCH, suggesting a direct effect of eSCH on body weight regulation and lipid metabolism. | closed_qa |
Does catheter shape influence the success of right adrenal venous sampling? | To evaluate the importance of selecting an appropriate catheter shape for the right adrenal vein (RAV) anatomy on CT to the success of right adrenal venous sampling (RAVS) by elucidating the interactions of anatomical factors with catheter shape. 130 patients with enhanced CT underwent RAVS using two catheters: catheter 1 was planar and catheter 2 was a three-dimensional shape. The following anatomical factors on CT were evaluated in each patient: presence of a right adrenal tumor, presence of a common trunk with an accessory right hepatic vein, diameter of the RAV, short and long diameters of the IVC, ratio of the long to the short diameter of IVC, and the transverse, modified transverse, and vertical angles of the RAV. RAVs were classified by direction on CT as lateral-caudal, lateral-cranial, medial-caudal, or medial-cranial. The technical feasibility of each catheter was evaluated by intragroup analysis. 108 patients underwent technically successful RAVS with one or both catheters. Eight of the 22 patients in whom RAVS was not successfully achieved by either catheter within ten minutes required microcatheters; other catheters were used in the other 14. The factors that were found to be associated with RAVS success were the modified transverse and the vertical angles (p < 0.01) of RAV on CT. Catheters 1 and 2 provided stable sampling in the lateral-caudal and medial groups, respectively. | Adapting the shape of the catheter to the anatomy of the RAV can make RAVS more feasible. The anatomical factors that were found to be associated with RAVS success were the transverse angle modified by the IVC axis as well as the vertical angle of RAV on CT. | closed_qa |
Long-Term Prediction of Severe Hypoglycemia in Type 1 Diabetes: Is It Really Possible? | Prediction of risk of severe hypoglycemia (SH) in patients with type 1 diabetes is important to prevent future episodes, but it is unknown if it is possible to predict the long-term risk of SH. The aim of the study is to assess if long-term prediction of SH is possible in type 1 diabetes. A follow-up study was performed with 98 patients with type 1 diabetes. At baseline and at follow-up, the patients filled in a questionnaire about diabetes history and complications, number of SH in the preceding year and state of awareness, and HbA1c and C-peptide levels were measured. During the 12 years of follow-up, there was a decrease in HbA1c, C-peptide levels, and incidence of SH (1.1 to 0.4 episodes per patient-year; P<.001). At baseline, the relative rate of SH was 3.6 (P = .001) and 10.9 (P<.0001) in patients with impaired awareness and unawareness of hypoglycemia, respectively, as compared to patients with normal awareness. At follow-up, patients with unawareness at baseline tended to have maintained an increased rate of SH (RR = 3.1; P = .07). Impaired awareness, HbA1c and C-peptide determined at baseline did not correspond with an increased rate of SH at follow-up. | Long-term prediction of severe hypoglycemia in type 1 diabetes was not possible, although baseline hypoglycemia unawareness tended to remain a predictor for risk of SH at follow-up. Therefore, it is important repeatedly to assess the different risk factors of SH to determine the actual risk. | closed_qa |
Do statins really cause diabetes? | To investigate and establish the relationship between the use of statin therapy and the risk of development of diabetes. PubMed and the Cochrane Central Register of Controlled Trials was searched for randomized controlled end-point trials of statins, with more than 1000 subjects and a minimum of one-year follow-up period, published until August 2015. The odds ratio (OR) of diabetes incidence with overall statin therapy as well as with different statins in question was calculated through random effect meta-analysis model. Fourteen studies were included in the analysis with a total of 94,943 participants. Of these, 2392 subjects developed incident diabetes in the statin and 2167 in the placebo groups during a 4-year follow-up. The OR of diabetes incidence with statin therapy was significantly higher as compared with the placebo group (OR=1.11; 95% confidence interval = 1.0 to 1.2; p=0.007). There was an insignificant level of heterogeneity between the included trials (Cochran Q= 19.463, p=0.109, I2=33.20). Subgroup analysis showed that only 2 statins namely, atorvastatin (OR= 1.29; p=0.042) and rosuvastatin (OR = 1.17; p=0.01) were significantly associated. | Statin therapy can slightly increase risk of incident diabetes in subjects with hypercholesterolemia. | closed_qa |
Is polysomnographic examination necessary for subjects with diaphragm pathologies? | While respiratory distress is accepted as the only indication for diaphragmatic plication surgery, sleep disorders have been underestimated. In this study, we aimed to detect the sleep disorders that accompany diaphragm pathologies. Specifically, the association of obstructive sleep apnea syndrome with diaphragm eventration and diaphragm paralysis was evaluated. This study was performed in Süreyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital between 2014-2016. All patients had symptoms of obstructive sleep apnea (snoring and/or cessation of breath during sleep and/or daytime sleepiness) and underwent diaphragmatic plication via video-assisted mini-thoracotomy. Additionally, all patients underwent pre- and postoperative full-night polysomnography. Pre- and postoperative clinical findings, polysomnography results, Epworth sleepiness scale scores and pulmonary function test results were compared. Twelve patients (7 males) with a mean age of 48 (range, 27-60) years and a mean body mass index of 25 (range, 20-30) kg/m2 were included in the study. Preoperative polysomnography showed obstructive sleep apnea syndrome in 9 of the 12 patients (75%), while 3 of the patients (25%) were regarded as normal. Postoperatively, patient complaints, apnea hypopnea indices, Epworth sleepiness scale scores and pulmonary function test results all demonstrated remarkable improvement. | All patients suffering from diaphragm pathologies with symptoms should undergo polysomnography, and patients diagnosed with obstructive sleep apnea syndrome should be operated on. In this way, long-term comorbidities of sleep disorders may be prevented. | closed_qa |
Estrogen deficiency in ovariectomized rats: can resistance training re-establish angiogenesis in visceral adipose tissue? | The purpose of this study was to investigate the effects of resistance training on angiogenesis markers of visceral adipose tissue in ovariectomized rats. Adult Sprague-Dawley female rats were divided into four groups (n=6 per group): sham-sedentary, ovariectomized sedentary, sham-resistance training and ovariectomized resistance training. The rats were allowed to climb a 1.1-m vertical ladder with weights attached to their tails and the weights were progressively increased. Sessions were performed three times per week for 10 weeks. Visceral adipose tissue angiogenesis and morphology were analyzed by histology. VEGF-A mRNA and protein levels were analyzed by real-time PCR and ELISA, respectively. Ovariectomy resulted in higher body mass (p=0.0003), adipocyte hypertrophy (p=0.0003), decreased VEGF-A mRNA (p=0.0004) and protein levels (p=0.0009), and decreased micro-vascular density (p=0.0181) in the visceral adipose tissue of the rats. Resistance training for 10 weeks was not able to attenuate the reduced angiogenesis in the visceral adipose tissue of the ovariectomized rats. | Our findings indicate that the resistance training program used in this study could not ameliorate low angiogenesis in the visceral adipose tissue of ovariectomized rats. | closed_qa |
Is there an association between skeletal asymmetry and tooth absence? | Facial skeletal asymmetry is commonly found in humans and its main characteristic is menton deviation. The literature suggests that occlusal and masticatory problems arising from tooth absence could be related to the development of such asymmetries. The aim of this cross-sectional study was to estimate the prevalence of mandibular skeletal asymmetries and to investigate its association with posterior tooth absences. Tomographic images of 952 individuals aged from 18 to 75 years old were used. Asymmetry was the analyzed outcome, and it was categorized into three groups according to gnathion displacement in relation to the midsagittal plane (relative symmetry, moderate asymmetry, and severe asymmetry). Patients were sorted by the presence of all posterior teeth, unilateral posterior tooth absence, or bilateral posterior tooth absence. Chi-square test with a significance level of 5% was used to verify the association between posterior tooth absence and asymmetry. Results show relative symmetry present in 55.3% of the sample, as well as the prevalence of 27.3% for moderate mandibular asymmetry and 17.4% for severe asymmetry. Moderate and severe mandibular asymmetries occurred in a higher proportion in patients with unilateral posterior tooth absence. However, there was no statistically significant difference between the analyzed groups (p = 0.691). | In this study, mandibular asymmetries did not present any association with the absence of teeth on the posterior area of the arch. | closed_qa |
Is There a Difference in Tachycardia Cycle Length during SVT in Children with AVRT and AVNRT? | There are limited adult data suggesting the tachycardia cycle length (TCL) of atrioventricular reentry tachycardia (AVRT) is shorter than atrioventricular nodal reentry tachycardia (AVNRT), though little data exist in children. We sought to determine if there is a difference in TCL between AVRT and AVNRT in children. A single-center retrospective review of children with supraventricular tachycardia (SVT) from 2000 to 2015 was performed. Age ≤ 18 years, invasive electrophysiology study (EPS) confirming AVRT or AVNRT. Atypical AVNRT, congenital heart disease, antiarrhythmic medication use at time of EPS. Data were compared between patients with AVRT and AVNRT via t-test, χ2test, and linear regression. A total of 835 patients were included (12 ± 4 years, 52 ± 31 kg, TCL 321 ± 55 ms), 539 (65%) with AVRT (270 Wolff-Parkinson-White, 269 concealed pathways) and 296 (35%) with AVNRT. Patients with AVRT were younger (11.7 ± 4.1 years vs 13.0 ± 3.6 years, P<0.001) and smaller (49 ± 22 kg vs 57 ± 43 kg, P<0.001). In the baseline state, the TCL was shorter in AVRT than AVRNT (329 ± 51 ms vs 340 ± 60 ms, P = 0.04). In patients requiring isoproterenol to induce SVT, there was no difference in TCL (290 ± 49 ms vs 297 ± 49 ms, P = 0.26). When controlling for age, there was no difference in TCL between AVRT and AVNRT at baseline or on isoproterenol. The regression equation for TCL in the baseline state was TCL = 290 + 4 (age), indicating the TCL will increase by 4 ms above a baseline of 290 ms for each year of life. | When controlling for age, there is no difference in the TCL between AVRT and AVNRT in children. Age, not tachycardia mechanism, is the most significant factor in predicting TCL. | closed_qa |
Do outcome measures for trauma triage agree? | The goal of trauma triage is to match resources to the needs of seriously injured patients. The trauma triage literature has used a variety of outcome measures to assess appropriate trauma activation. The objective of this study was to determine the agreement between procedural and nonprocedural outcome measures in a population of seriously injured patients transported to a single trauma center. Study authors reviewed all "level 2" trauma activations (January 2002-December 2003) at an American College of Surgeons (ACS) Level 1 trauma center. "Level 2" trauma activations were based on modified ACS Committee on Trauma (COT) triage criteria. Outcomes were classified as nonprocedural (Injury Severity Score [ISS]>15 and intensive care unit [ICU] admission) and procedural (nonorthopedic emergent surgery, emergency chest tube placement, emergency department intubation, emergency department transfusion, or emergent interventional radiology care). Of 479 patients, five were transferred out of hospital. The remaining 474 were predominantly male (62%), with a mean age of 39.7 years. Their average ISS was 13.2. There were nine deaths. For all subjects, 144 (30%) were admitted to the ICU, 172 (36%) had an ISS>15, 80 (17%) received an emergent procedure, and 46 (10%) went for emergent surgery. Kappas comparing agreement of ISS>15 with emergent resuscitation and emergent surgery were 0.31 and 0.15, respectively. Kappas comparing ICU admission with emergent resuscitation and emergent surgery were 0.51 and 0.26, respectively. | We identify moderate to poor agreement between nonprocedural and procedural outcomes of trauma triage in this population. | closed_qa |
Can emergency medical dispatch codes predict prehospital interventions for common 9-1-1 call types? | The Medical Priority Dispatch System is an emergency medical dispatch (EMD) system that is widely used to categorize 9-1-1 calls and optimize resource allocation. This study evaluates the ability of EMD and non-EMD codes (calls not processed by EMD) to predict prehospital use of medications and procedures. All transported prehospital patients placed in an EMD or non-EMD category that exceeded 500 total calls from January 1, 2004, to December 31, 2006, in a suburban California county were matched with their prehospital electronic patient care record. These records (N = 69,541) were queried for the following prehospital interventions: basic life support (BLS) care only, intravenous line placement only, medication given, and procedures. Advanced life support (ALS) interventions were defined as the administration of a medications or a procedure. The numbers of medications and procedures that were performed on patients in each EMD code were measured. Thirty-one of 141 EMD and non-EMD codes met inclusion criteria and comprised 73% of all calls during the study period. Non-EMD codes accounted for 48% of all calls in this study. Patients with shortness of breath, chest pain, diabetic problems, and altered mental status received the most medications. High rates of medication administration were also seen in the following codes: 17A (fall, 27%), 17B (fall, 14%), EMDX (unable to complete EMD process, 22%), MED (medical aid requested--details to follow, 26%), and MED3 (medical aid requested by police--code 3, 18%). Procedures were performed on only 0.9% of all calls, of which 75% were related to advanced airways. Higher rates of ALS interventions in higher-acuity categories (Alpha, Bravo, etc.) were seen in a number of EMD categories, including seizure, laceration/hemorrhage, sick, and traffic accident, but not seen in many categories, including abdominal pain, falls, and chest pain. | This study demonstrated only a modest ability of the EMD system to predict which patients would require ALS intervention. There were limited differences noted in the ALS rates between the different codes (Alpha, Bravo, etc.) in the same complaint category, bringing into question the utility of the multiple subgroups. Non-EMD codes made up a large portion of calls (48%) and should be included in future studies. | closed_qa |
Can emergency medical dispatch systems safely reduce first-responder call volume? | Emergency medical dispatch (EMD) protocols are intended to match response resources with patient needs. In a small city that previously sent a first-responder basic life support (BLS) engine company lights-and-siren response to every emergency medical services (EMS) call, regardless of nature or severity, an EMD system was implemented in order to reduce the number of such responses. The study objectives were to determine the effects of the EMD system on first-responder call volume and to assess the safety of the system. This was a prospective, before-after trial. Using computer-assisted dispatch (CAD) records, all EMS calls in the 120 days before implementation of the EMD protocol and the 120 days after implementation were identified (excluding a one-month wash-in period). In the "after" phase, patient care reports of a random sample of cases in which an ambulance was dispatched with no first responders was manually reviewed to assess whether there might have been any benefit to first-responder dispatch. Given the lack of accepted clinical criteria for need for first responders, the investigators' clinical judgment was used. Paired t-tests were used to compare groups. There were 9,820 EMS calls in the "before" phase, with 8,278 first-responder engine runs (84.3%), and 9,943 EMS calls in the "after" phase, with 3,804 first-responder engine runs (39.1%). The first-responder companies were dispatched to a median of 5.65 runs/day (range 1.1-12.7) in the "before" phase, and 3.17 runs/day (range 0.6-5.0) in the "after" phase (p = 0.0008 by paired t-test). Review of 1,816 "after" phase ambulance-only patient care reports (PCRs) found ten (0.55%) in which first-responder dispatch might have been beneficial, but review of EMS and emergency department (ED) records found no adverse outcomes in these ten patients. | This study suggests that a formal EMD system can reduce first-responder call volume by roughly one-half. The system appears to be safe for patients, with an undertriage rate of about one-half of one percent. | closed_qa |
Is online pediatric continuing education effective in a rural state? | This prospective study was designed to evaluate the effectiveness of online pediatric education for prehospital emergency medical technicians (EMTs). Online emergency medical services (EMS) continuing education modules, on various pediatric emergency topics, were developed for dissemination statewide. Pre- and posttest scores were compared by EMT level of training, rural versus urban location, and individual module performance. A total of 539 participants completed both the pre- and posttests. Of these, more than one-third (38.0%) reported Bernalillo County, the only urban county in the state, as the county in which they worked. Pretest scores ranged from 0 to 15 (mean = 8.5; 95% confidence interval [CI] = 8.2, 8.7), with a median of 8.0 and a mode of 8.0. Posttest scores were higher, ranging from 4 to 15 (mean = 11.6; 95% CI = 11.4, 11.7). For the posttest, the median score was 12.0 and the mode was 13.0. Urban and rural EMTs improved in posttestscomparably. EMT-Basic participants' scores improved (mean change in score = 3.4, 95% CI = 3.1, 3.7) more than those of EMT-Intermediates (mean = 2.9, 95% CI = 2.5, 3.2) or EMT-Paramedics (mean = 2.7, 95% CI = 2.2, 3.3). | 1) The New Mexico EMS for Children (EMSC) online pediatric continuing education program increased EMTs' cognitive knowledge; 2) rural EMTs accessed the training more than urban EMTs; and 3) although pre- and posttest results varied by EMT licensure level, improvements in scores also varied such that posttest scores were more similar than pretest scores. | closed_qa |
The extracellular polymer substance of Pseudomonas aeruginosa: too slippery for neutrophils to migrate on? | Biofilm formation is increasingly recognized as the cause of persistent infections and there is evidence that P. aeruginosa organized into biofilms are quite resistant toward host defence mechanisms, particularly against an attack by polymorphonuclear neutrophils (PMN). Apparently, the migration of PMN through the biofilms is impaired, and thus the bactericidal activity remains highly localized. The aim of this study was to directly investigate the interaction of PMN with the biofilm and the extracted extracellular polymeric substance (EPS) of P. aeruginosa. Chemotaxis and random migration of PMN through P. aeruginosa biofilms was tested, as was their migration through and along the EPS. We found that the EPS and mature biofilms, but not immature or developing ones, reduced the chemotactic migration of PMN. On EPS, rather than immobilize the cells, their random, spontaneous migration was enhanced. | We propose that on EPS, the PMN lose their capacity to sense the direction and just slide over the EPS in a disoriented manner. | closed_qa |
Do the results of renal biopsy depend on non-renal symptoms of Schönlein-Henoch nephropathy (SHN) in children? | The study population comprised 33 children with SHN, who underwent renal biopsy. Nephropathy was classified according to WHO classification, activity index (Ai) and chronicity index (CI). The patients were divided into 3 groups: Group 1--children with skin, abdominal and articular symptoms, Group 2--with isolated skin symptoms, Group 3--skin-articular or skin-abdominal symptoms. In Group 1 nephropathy was present significantly earlier (p<0.05) than in Group 2, 3. We not observed any correlation between grade of WHO, IA, IP in Groups 1,2,3. | The result of renal biopsy in children with SHN is not depend on non-renal symptoms of this disease. | closed_qa |
Platelet count to spleen diameter ratio for the diagnosis of esophageal varices: Is it feasible? | The laboratory and ultrasonographic variables were prospectively evaluated in 150 patients with liver cirrhosis. Only stable patients were included in the study. Patients with active gastrointestinal bleeding at the time of admission were excluded. All patients underwent screening upper gastrointestinal endoscopy. The platelet count, spleen diameter and platelet count to spleen diameter ratio in patients with EVs were significantly different from patients without EVs. The platelet count to spleen diameter ratio had the highest accuracy among the three parameters. By applying receiver operating characteristic curves, a platelet count to spleen diameter ratio cut-off value of 1014 was obtained, which gave positive and negative predictive values of 95.4% and 95.1%, respectively. The accuracy of this cut-off value as evaluated by applying receiver operating characteristic curves was 0.942 (95% CI 0.890 to 0.995). | Among the noninvasive parameters studied, platelet count to spleen diameter ratio had the highest accuracy for diagnosing EVs. However, the evidence for the noninvasive diagnosis is not yet sufficient to replace endoscopy as a diagnostic screening tool for EVs in all cirrhotic patients. The platelet count to spleen diameter ratio may be a useful tool for diagnosing EVs in liver cirrhosis noninvasively when endoscopy facilities are not available. | closed_qa |
Is serum hepcidin causative in hemochromatosis? | Hepcidin is a circulating hepatic hormone that regulates iron balance. It has been speculated that hepcidin insufficiency or dysregulation may be the primary defect in genetic hemochromatosis. A 62-year-old woman underwent elective liver transplantation for chronic hepatitis C cirrhosis. Genetic testing for hemochromatosis was subsequently performed on the donor and recipient. Liver iron concentration was measured in the donated liver at the time of transplantation, and at day 2 and day 652 post-transplant. Serum hepcidin was measured at day 935 in the recipient and in three other liver transplant recipients. The donor was discovered to have significant iron overload without fibrosis, with a liver iron concentration of 326 micromol/g (normal is 0 micromol/g to 35 micromol/g). Genetic testing confirmed that the 89-year-old female donor was a typical C282Y homozygote for hemochromatosis. The recipient did not carry either the C282Y or the H63D mutation of the HFE gene for hemochromatosis. Liver biopsy was performed on the recipient on day 2 and day 652 post-transplant; the liver iron concentrations were 333 micromol/g and 253 micromol/g, respectively. Serum hepcidin in the recipient was elevated at 111 ng/mL compared with that of the three other ambulatory liver transplant recipients (66 ng/mL, 76 ng/mL and 81 ng/mL). | The liver transplant recipient described in the present report demonstrated a slight decrease in liver iron concentration over a 1.8-year follow-up period without specific therapy. Hepcidin insufficiency as a primary cause of genetic hemochromatosis seems unlikely based on the clinical profile of the present patient and the hepcidin measurements. | closed_qa |
Progressive resistance training in elderly HIV-positive patients: does it work? | Elderly people present alterations in body composition and physical fitness, compromising their quality of life. Chronic diseases, including HIV/AIDS, worsen this situation. Resistance exercises are prescribed to improve fitness and promote healthier and independent aging. Recovery of strength and physical fitness is the goal of exercise in AIDS wasting syndrome. This study describes a case series of HIV-positive elderly patients who participated in a progressive resistance training program and evaluates their body composition, muscular strength, physical fitness and the evolution of CD4+ and CD8+ cell counts. Subjects were prospectively recruited for nine months. The training program consisted of three sets of 8-12 repetitions of leg press, seated row, lumbar extension and chest press, performed with free weight machines hts, twice/week for one year. Infectious disease physicians followed patients and reported all relevant clinical data. Body composition was assessed by anthropometric measures and dual-energy x-ray absorptiometry before and after the training program. Fourteen patients, aged 62-71 years old, of both genders, without regular physical activity who had an average of nine years of HIV/AIDS history were enrolled. The strengths of major muscle groups increased (74%-122%, p=0.003-0.021) with a corresponding improvement in sit-standing and walking 2.4 m tests (p=0.003). There were no changes in clinical conditions and body composition measures, but triceps and thigh skinfolds were significantly reduced (p=0.037). In addition, there were significant increases in the CD4+ counts (N=151 cells; p=0.008) and the CD4+/CD8+ ratio (0.63 to 0.81, p=0.009). | Resistance training increased strength, improved physical fitness, reduced upper and lower limb skinfolds, and were associated with an improvement in the CD4+ and CD4+/CD8+ counts in HIV positive elderly patients without significant side effects. | closed_qa |
Do patients with alcohol dependence respond to placebo? | The purpose of this study was to examine the nature of the effect of placebo medication plus accompanying medical management in the treatment of alcohol dependence. The National Institute on Alcohol Abuse and Alcoholism COMBINE (Combining Medications and Behavioral Interventions) study, a randomized controlled double-blind trial of 1,383 alcohol-dependent patients, compared combinations of medications (acamprosate [Campral] and naltrexone [ReVia]) and behavioral therapy (medical management and specialist-delivered behavioral therapy) for alcohol dependence. This report focuses on a subset of that study population (n = 466) receiving (1) specialized behavioral therapy alone (without pills), (2) specialized behavioral therapy + placebo medication + medical management, or (3) placebo + medical management. During 16 weeks of treatment, participants receiving behavioral therapy alone had a lower percentage of days abstinent (66.6%) than did the participants receiving placebo and medical management (73.1%) or those receiving specialized behavioral therapy + placebo + medical management (79.4%). The group receiving behavioral therapy alone relapsed to heavy drinking more often (79.0%) than those receiving behavioral therapy + placebo + medical management (71.2%). This report focuses on potential explanations for this finding. The two groups of participants receiving placebo + medical management were more likely to attend Alcoholics Anonymous meetings during treatment (32.7% and 32.0% vs 20.4%) and were less likely to withdraw from treatment (14.1% and 22.9% vs 29.3%). | There appeared to be a significant "placebo effect" in the COMBINE Study, consisting of pill taking and seeing a health care professional. Contributing factors to the placebo response may have included pill taking itself, the benefits of meeting with a medical professional, repeated advice to attend Alcoholics Anonymous, and optimism about a medication effect. | closed_qa |
Substance-use problems: are uninsured workers at greater risk? | This study examined how problem drinking and drug use and their related treatment received by workers varied by health insurance coverage and employment characteristics. We used National Survey on Drug Use and Health data on civilian workers ages 18 years and older from the 2002 and 2003 public-use files. Multivariate logistic regressions estimated the relationship between workers' uninsured status and problem use, dependence, and treatment while controlling for worker demographics, education, income, and job characteristics. Controlling for differences in worker and workplace characteristics, uninsured workers were significantly more likely than privately insured workers to be illicit drug users or heavy drinkers. Among dependent workers, the lack of insurance was associated with a reduction in treatment received for problem drinkers (odds ratio = 0.31, p = .13). By contrast, a large, positive-albeit statistically nonsignificant-association between being uninsured and receiving treatment prevailed among uninsured workers using illicit drugs. Workplace substance-use policies were associated with a significant reduction in the odds of treatment received or treatment needed among problem drinkers without insurance coverage. Employee assistance programs were not good predictors of treatment received among uninsured workers. | Uninsured workers were more likely to be heavy drinkers or illicit drug users than were workers with health insurance. Health insurance coverage was not significantly associated with treatment received among workers reporting problem use. Uninsured workers may be unable to benefit fully from employee assistance programs' treatment and referral services, whose utility depends on adequate behavioral health coverage for workers. | closed_qa |
Could FIV zoonosis responsible of the breakdown of the pathocenosis which has reduced the European CCR5-Delta32 allele frequencies? | In Europe, the north-south downhill cline frequency of the chemokine receptor CCR5 allele with a 32-bp deletion (CCR5-Delta32) raises interesting questions for evolutionary biologists. We had suggested first that, in the past, the European colonizers, principally Romans, might have been instrumental of a progressively decrease of the frequencies southwards. Indeed, statistical analyses suggested strong negative correlations between the allele frequency and historical parameters including the colonization dates by Mediterranean civilisations. The gene flows from colonizers to native populations were extremely low but colonizers are responsible of the spread of several diseases suggesting that the dissemination of parasites in naive populations could have induced a breakdown rupture of the fragile pathocenosis changing the balance among diseases. The new equilibrium state has been reached through a negative selection of the null allele. Most of the human diseases are zoonoses and cat might have been instrumental in the decrease of the allele frequency, because its diffusion through Europe was a gradual process, due principally to Romans; and that several cat zoonoses could be transmitted to man. The possible implication of a feline lentivirus (FIV) which does not use CCR5 as co-receptor is discussed. This virus can infect primate cells in vitro and induces clinical signs in macaque. Moreover, most of the historical regions with null or low frequency of CCR5-Delta32 allele coincide with historical range of the wild felid species which harbor species-specific FIVs. | We proposed the hypothesis that the actual European CCR5 allelic frequencies are the result of a negative selection due to a disease spreading. A cat zoonosis, could be the most plausible hypothesis. Future studies could provide if CCR5 can play an antimicrobial role in FIV pathogenesis. Moreover, studies of ancient DNA could provide more evidences regarding the implications of zoonoses in the actual CCR5-Delta32 distribution. | closed_qa |
Does esophageal atresia influence the mother-infant interaction? | Chronic illness in infancy may influence parent-infant interaction. We assessed quality of mother-infant interaction in children with esophageal atresia (EA) and searched for predictors for impaired interaction. The study group comprised 37 one-year-old infants with EA born in 1999 to 2002 and their mothers. A comparison group comprised 10 infants with urologic problems without feeding difficulties and their mothers. Parent Child Early Relational Assessment was used to assess mother-child interaction in feeding and play situation. General Health Questionnaire and State Trait Anxiety Inventory were used to assess maternal psychological distress and anxiety. Many aspects of mother-EA infant interaction showed strength. However, mothers of EA children were compared to control-mothers significantly influenced in their ability to interact and the EA-mothers' "positive affective involvement, sensitivity, and responsiveness" during feeding was in range of concern. Small but significant effect of the mother's feeling of incompetence on their interaction was found. | Mothers' attitude during feeding was negatively influenced in interaction between mother and infant with EA. The results suggest possibility for improvement in mother infant interaction by enhancing mothers' welfare when caring for infants with EA in medical services. | closed_qa |
Acute neonatal arterial occlusion: is thrombolysis safe and effective? | We report our experience of the management of arterial occlusion in the newborn. A case note review was carried out after ethical approval. Doppler ultrasonography confirmed the occlusion. Thrombolysis was the primary intervention. Surgery was used selectively. A good outcome was one without tissue loss or functional impairment or minimal tissue loss without functional impairment. Data are presented as medians with ranges. Ten patients (9 male; median gestational age, 35.5 weeks [range, 28-39 weeks]) presented on day 1 (range, 1-8 days). Initial management included systemic tissue plasminogen activator (8 patients) and surgery (2 infants in whom thrombolysis was contraindicated). Improvement was noted in 7 of 8 infants treated medically and in both who underwent surgery. Three infants had significant tissue loss. Outcome at 29 months (range, 1.3-95.4 months) was good in the remaining 7. | A multidisciplinary approach, thrombolysis and selective surgery achieved tissue preservation and function in the majority while minimizing complications. Early referral to centers with multidisciplinary teams is recommended. | closed_qa |
Forensic sexual assault examination and genital injury: is skin color a source of health disparity? | The study objectives were to (1) estimate the frequency, prevalence, type, and location of anogenital injury in black and white women after consensual sex and (2) investigate the role of skin color in the detection of injury during the forensic sexual assault examination. A cross-sectional descriptive design was used with 120 healthy volunteers who underwent a well-controlled forensic examination after consensual sexual intercourse. Fifty-five percent of the sample had at least 1 anogenital injury after consensual intercourse; percentages significantly differed between white (68%) and black (43%) participants (P = .02). Race/ethnicity was a significant predictor of injury prevalence and frequency in the external genitalia but not in the internal genitalia or anus. However, skin color variables--lightness/darkness-, redness/greenness-, and yellowness/blueness-confounded the original relationship between race/ethnicity and injury occurrence and frequency in the external genitalia, and 1 skin color variable--redness/greenness--was significantly associated with injury occurrence and frequency in the internal genitalia. | Although differences exist in anogenital injury frequency and prevalence between black and white women, such differences can be more fully explained by variations in skin color rather than race/ethnicity. Clinical recommendations and criminal justice implications are discussed. | closed_qa |
Is lymphocytic bronchiolitis a marker of acute rejection? | Guidelines for the diagnosis and grading of lymphocytic bronchiolitis (LB) have been available for more than a decade, but agreement is lacking concerning the clinical implications of this histologic finding. Study goals were to describe the overall prevalence and incidence of LB in a consecutive cohort of lung transplant recipients and identify risk factors for the onset, frequency, and severity of LB. A retrospective analysis was done of 2,697 transbronchial biopsy (TBB) specimens obtained during the first 2 years after transplantation from 299 consecutive patients who underwent transplantation between 1996 and 2006. Full diameter membranous bronchioli were missing in approximately 30% of TBB specimens. The proportion of patients demonstrating LB remained constant during follow-up (trend test, p = 0.2). The cumulative incidence of LB (>or=B2) was 33%, 53%, 62%, and 68% at 1-, 3-, 6-, and 12-months, respectively. Approximately one-quarter and one-half of the patients had a second episode of>or=B2 within 3 months and 2-years of transplantation, respectively. Exposure to LB during the first 2 years after transplantation was independently associated with the frequency and/or severity of acute cellular rejection (p<0.0001). The choice between anti-thymocyte globulin or daclizumab induction did not alter the overall frequency and/or severity of LB (p = 0.7). LB grade B2 or higher was associated with increased histologic bronchiolitis obliterans (odds ratio, 3.3, 95% confidence interval, 1.5-6.9, p = 0.001). | The frequency and severity of LB was associated with the occurrence and severity of acute cellular rejection. | closed_qa |
A novel end point to assess a resident's ability to perform hand-assisted versus straight laparoscopy for left colectomy: is there really a difference? | It has been suggested that hand-assisted colectomy (HAC) may help residents progress along the learning curve, but there is currently no evidence to support this claim. Previous studies address procedures performed by staff surgeons or residents at various skill levels and report operative times and conversion rates as their primary end points. We measured the percentage of cases completed by a resident as the operating surgeon as the primary end point to determine the most effective approach for teaching laparoscopic colectomy. All patients who underwent left-sided HAC or straight laparoscopic colectomy (SLC) by a single resident starting as the primary surgeon were included. If the assisting attending physician assumed the role of the operating surgeon during the case, it was recorded as an incomplete case for the resident. Operative times and conversions were included as secondary end points. A single resident started 147 laparoscopic colectomies as the primary surgeon during residency and colorectal fellowship, including 81 left-sided procedures. There were 44 patients in the HAC group and 37 SLC patients. Cases done by straight laparoscopy were more likely to be completed by the resident than those done by HAC (SLC, 88%; HAC, 72%; p=0.06). There were also differences in mean operative time favoring SLC (HAC, 142 minutes [range 100 to 170 minutes] versus SLC, 133 minutes [range 95 to 195 minutes]; p=0.04). Complications were similar in the 2 groups (HAC, 19% versus SLC, 21%), as were conversions (HAC, 5.6% versus SLC, 4.5%). | Both hand-assisted and straight laparoscopic techniques for left colectomy can be applied to successfully train surgical residents with the assistance of a staff surgeon outside of their learning curve. Residents and colorectal fellows may have more success completing straight laparoscopic colectomy than adjusting to the novel hand-assisted approach during training. | closed_qa |
Is there a role for drain use in elective laparoscopic cholecystectomy? | Although the issue of drain use in open cholecystectomy has been adequately addressed by prospective randomized trials, there is lack of evidence on the usefulness of drains in elective laparoscopic cholecystectomy, and the surgeons follow their beliefs and bias on this debate. Therefore, a controlled randomized trial was designed to assess the value of drains in elective laparoscopic cholecystectomy. During a 5-year period (January 2002 to December 2006), 284 patients were randomized to have a drain placed (group A), whereas 281 patients were randomized not to have a drain (group B) placed in the subhepatic space. End points of this trial were to detect any differences in morbidity, postoperative pain, and hospital stay between the 2 groups. There was no mortality in either group and no statistically significant difference in morbidity or hospital stay between the 2 groups. However, postoperative pain was significantly increased in patients who had a drain placed; median visual analog scale (VAS) score was 5 (range 1 to 8) versus 3 (range 1 to 8), in the non-drained group (P<.0001). Interestingly, in 2 of 3 patients in whom a drain was placed against randomization because of bile leak suspicion, a bile leak occurred. | The routine use of a drain in elective laparoscopic cholecystectomy has nothing to offer; in contrast, it is associated with increased pain. It would be reasonable, however, to leave a drain if there is a worry about an unsolved or potential bile leak, bearing in mind that drain placement, although sometimes providing a false sense of security, does not guarantee either prevention or treatment of postoperative bile collections, bleeding, or bile peritonitis. | closed_qa |
Carboplatin and pemetrexed in the management of malignant pleural mesothelioma: a realistic treatment option? | Malignant pleural mesothelioma is an aggressive cancer. Chemotherapy with cisplatin and pemetrexed can improve overall survival but has a toxic profile. Substitution of cisplatin with carboplatin may avoid some potential side-effects. Therefore, we undertook a retrospective review to assess the effectiveness and tolerability of carboplatin and pemetrexed in patients with malignant pleural mesothelioma in clinical practice. Patients with malignant pleural mesothelioma who had been treated with carboplatin and pemetrexed were retrospectively identified from pharmacy databases. The endpoints were disease control rate, time to treatment failure, clinical improvement rate and overall survival. We also evaluated any significant haematological and non-haematological toxicities. A total of 49 patients were identified. Of 45 evaluable cases, the disease control rate was achieved in 34 patients (69%, 95% CI 55-82, intention to treat analysis). The clinical response rate was achieved in 34 out of 49 patients (69%, 95% CI 55-82). The median time to treatment failure was 4.6 months (95% CI 3.4-5.8) and median overall survival was 14 months (95% CI 9.5-18.5). Grade 3/4 haematological toxicities were observed in 7 patients (14.3%). Grade 3/4 non-haematological toxicities were seen in 12 patients (24.5%). No toxic deaths were recorded. | The combination of carboplatin and pemetrexed may be a viable option in the treatment of malignant pleural mesothelioma. | closed_qa |
Tobacco and cannabis co-occurrence: does route of administration matter? | Qualitative research suggests that a shared route of administration (i.e. via inhalation) for the common forms of both tobacco (i.e. cigarettes) and cannabis (i.e. joints) may contribute to their co-occurring use. We used data on 43,093 U.S. adults who participated in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to examine whether cannabis use and abuse/dependence were associated with smoked (cigarettes, cigars, pipes) versus smokeless (snuff, chewed tobacco) forms of tobacco use, even after controlling for socio-demographic, psychiatric and substance-related covariates. Tobacco smoking was associated with a 3.3-4.5 times increased risk for cannabis use and abuse/dependence respectively. After covariate adjustment, importantly for nicotine dependence, smoking tobacco (but not smokeless tobacco) was still significantly associated with both cannabis use (multinomial odds-ratio (MOR) 1.99) and cannabis dependence (MOR 1.55). In contrast, use of smokeless tobacco was not significantly correlated with elevated rates of cannabis use (MOR 0.96) or abuse/dependence (MOR 1.04). | Route of administration may play an important role in the observed association between tobacco and cannabis use. This may represent a physiological adaptation of the aero-respiratory system and/or index social and cultural influences surrounding the use of smoked versus smokeless forms of tobacco. | closed_qa |
Does eccentric-exercise-induced jaw muscle soreness influence brainstem reflexes? | To investigate the effects of soreness evoked by eccentric jaw exercises on two types of brainstem reflexes: the short-latency stretch reflex and the longer-latency exteroceptive suppression (ES), and to test for possible relationships between magnitude of soreness and reflex responses. The brainstem reflexes of jaw-closing muscles were recorded before (Baseline), immediately after (Post-task), and 1 day after (1-day-after) a 30-min eccentric exercise in 15 healthy men. All subjects participated in a control session without exercise. Soreness sensations at rest and during maximum biting were significantly elevated until 1-day-after the eccentric exercise (P<0.014). The ES responses tended to be increased (more inhibition) at Post-task and 1-day-after. There was a significant correlation between the ES response and the soreness sensation during maximum biting (P<0.04). The jaw-stretch reflex did not show significant change after the eccentric exercise. | Muscle soreness associated with eccentric jaw exercises has a differential impact on the jaw-stretch reflex and the ES response. | closed_qa |
The evolution of renal transplantation in clinical practice: for better, for worse? | Kidney transplantation is the optimal form of renal replacement therapy for most patients with end-stage renal disease. Attempting to improve graft and recipient survival remains challenging in clinical practice.AIM: To identify the factors that have significantly changed over the past four decades and assess their impact on renal transplant outcomes. Retrospective review of all renal transplant procedures in a single UK region. All 1346 renal transplant procedures performed between 1 January 1967 and 31 December 2006 were reviewed. Clinical data, histological reports and outcomes were available from a prospectively recorded database. The study period was divided into four decades to assess the changes in renal transplantation over time. Significant changes that have occurred include an increase in donor and recipient ages, a greater proportion of recipients with diabetic nephropathy, a longer wait before the first transplant procedure, a fall in the incidence and impact of acute rejection, a smaller proportion of deaths due to cardiovascular disease, (P<0.001 for all) and a trend to increased deaths from malignancy (P = 0.06) over time. In multivariate analysis, death censored graft survival was significantly influenced by the era of transplantation, donor and recipient ages, living vs. deceased donor status, and histological evidence of acute rejection, chronic allograft nephropathy, or disease recurrence. Significant factors in recipient survival were the era of transplantation, recipient age, a primary renal diagnosis of diabetic nephropathy or unspecified chronic renal failure, and biopsy proven acute rejection. | There have been major changes in the clinical practice related to renal transplantation over the past four decades; some have been beneficial and others detrimental to survival. Regular review of outcomes is essential to guide renal services development and maximize graft and recipient survival. | closed_qa |
Shoulder dystocia: what is the risk of recurrence? | To study the recurrence risk of shoulder dystocia in women who have previously experienced at least once shoulder dystocia. A retrospective study of vaginal deliveries complicated by shoulder dystocia. Setting. American University of Beirut Medical Center - Lebanon. Vaginal deliveries complicated by shoulder dystocia over a 15-year period who had subsequent vaginal delivery. Methods. Charts of index and subsequent deliveries beyond 24 weeks' gestation were reviewed for demographics and intrapartum events. Women were divided into those with recurrent shoulder dystocia (group I) and those with uncomplicated subsequent delivery (group II) and compared. Recurrent shoulder dystocia and characteristics of women with recurrence. The incidence of shoulder dystocia was 0.9% of all vaginal deliveries. Of 193 shoulder dystocia cases, 48 women had a subsequent delivery. After excluding cesarean deliveries (n=4), 44 women were analyzed. Eleven had recurrent shoulder dystocia (25.0%). Mean birthweight was larger (4,019+/-430 vs. 3,599+/-398 g, p=0.005) with a higher rate of macrosomia>or =4,000 g (63.6 vs. 15.2%, p=0.004) and the birthweight in the subsequent pregnancy was larger than the index pregnancy in a significantly larger proportion of women in group I compared with group II (72.7% vs. 33.3%, p=0.035). Otherwise, maternal age, gestational age at delivery, parity, duration of labor, gender, history of macrosomia, and interval between pregnancies were similar. | The risk of recurrence of shoulder dystocia is around 25%. When counseling women about recurrence risk, the absence of macrosomia and a smaller birthweight than the previous pregnancy could be reassuring. | closed_qa |
Can ischemic preconditioning ameliorate renal ischemia-reperfusion injury in a single-kidney porcine model? | Ischemic preconditioning (IP) refers to the phenomenon of a brief ischemia-reperfusion event providing resistance to injury from subsequent ischemic periods. We sought to determine the effect of a specific preconditioning regimen on ischemia-reperfusion renal injury in a single-kidney porcine model. Immediately following right laparoscopic nephrectomy, 12 female pigs had complete left hilar dissections and 1 of 2 interventions: (1) 60 minutes of complete WI (WI; n = 6) or (2) 10 minutes of IP followed by 60 minutes of complete WI (IP; n = 6). IP consisted of 5 minutes of clamping followed by 5 minutes of reperfusion. Serum creatinine (sCr) was obtained preoperatively and on postoperative day (POD) 1, 2, 6, 9, and 14. Mean sCr was compared by group. The left kidney was harvested on POD 14 for blinded histologic review. Mean sCr values were significantly increased at all time points in the WI and IP groups compared with baseline. Peak postoperative sCr was noted on POD 1 in both groups after which there was a downward trend. The WI and IP groups had similar mean sCr values at all time points. The study groups were histologically indistinguishable with no difference in the degree of tissue injury. | A simple intervention which successfully prevents renal warm-ischemic damage would expand the number of surgeons and patients who benefit from laparoscopic NSS. There is no evidence that this preconditioning regimen ameliorated the ischemia-reperfusion injury. Endeavors are ongoing to determine if alternative preconditioning regimens may be beneficial. | closed_qa |
Does sealing of the tract with absorbable gelatin (Spongostan) facilitate tubeless PCNL? | To prospectively evaluate and study the role, relative safety, and efficacy of using absorbable gelatin tissue hemosealant (Spongostan) in patients selected for a gelatin-assisted "tubeless" percutaneous nephrolithotomy (PCNL); to study whether it facilitates and further reduces the morbidity vis-à-vis tubeless PCNL without gelatin; and to compare postoperative pain, analgesia requirement, hospital stay, return to work time, and other parameters in patients undergoing tubeless PCNL with gelatin and tubeless PCNL without the gelatin sealant. In addition, we briefly review various hemosealants used in tubeless PCNL by other workers. Fifty selected previously qualified patients underwent tubeless PCNL. All procedures were performed by a single urologist (IS), and a resident administered random chit numbers and recorded pain scores and results of all the chosen parameters. Patients who fulfilled our criteria for tubeless PCNL were randomized to either the placement of a gelatin sealant or its omission. The data were analyzed with respect to several parameters. The mean age, stone burden, preoperative hemoglobin, blood urea, and serum creatinine values, hematocrit drop, and the time to return to work were not significantly different between the two groups. The hospital stay (P = 0.057), urinary extravasation (P<0.001), and analgesia requirement (P<0.001) were significantly lower in the patients who had undergone gelatin-sealant-assisted tubeless PCNL. | Significantly less pain, lower analgesia requirement, and shorter hospital stay with lower wound soakage/discomfort were observed in the gelatin-assisted tubeless PCNL group v tubeless PCNL without gelatin packing. The use of absorbable gelatin sealant is safe, feasible, and a useful adjunct toward a safer tubeless PCNL in patients who previously qualified for tubeless PCNL. | closed_qa |
Does atopy affect the radiological extent of pulmonary tuberculosis? | Th1 cytokines, IL-2 and IFN-gamma , have critical importance in the CD4 cell driven antimycobacterial activity. Th2 type immune response is a characteristic feature of atopic disorders. Th1 and Th2 cells have been reported to negatively cross-regulate each other in vitro and in experimental animals. Our aim in the present study is to determine whether the atopy affects radiological extent of pulmonary tuberculosis (TB) and disease severity. A total of 82 male patients with pulmonary TB were prospectively enrolled in the study between March 2005 and March 2006. All patients were evaluated for atopic symptoms and TB related systemic symptoms. Radiological dissemination was scored and cavitation was noted. The skin prick test (SPT) was performed and serum total IgE level was measured. The SPTs were positive in 28 of 82 (34.1 %) patients. There was no distinction between SPT-positive and negative patients in terms of pulmonary cavitation and radiological dissemination. The median IgE level of moderate-severe radiologically disseminated TB patients was significantly higher than that of mild radiologically disseminated TB patients (130 IU/ml vs. 58 IU/ml). Cavitary TB patients had also significantly higher median IgE levels (78 IU/ml vs. 46 IU/ml) (p<0.05) | This study suggests that SPT-positivity and atopic respiratory phenotype do not affect the formation of cavitation, radiological dissemination and systemic symptoms of pulmonary TB. The high level of IgE in patients with cavitary and radiologically disseminated TB may be a consequence of a dysregulated immune response to infection or reflect disease activity. | closed_qa |
Perinatal outcomes in low-risk term pregnancies: do they differ by week of gestation? | The objective of the study was to examine whether the risk of perinatal complications increases with increasing gestational age among term pregnancies. This is a retrospective cohort study of low-risk women with term, singleton births in 2003 in the United States. Gestational age was subgrouped into 37, 38, 39, 40, and 41 completed weeks. Statistical comparison was performed using chi(2) test and multivariable logistic regression models, with 39 weeks' gestation as the referent. There were 2,527,766 women meeting study criteria. Compared with 39 weeks, delivery at 37 or 38 weeks had lower risk of febrile morbidity but slightly higher risk of cesarean delivery. Delivery at 40 or 41 weeks was also associated with higher overall maternal morbidity. For neonates, delivery at 40 or 41 weeks had higher risk of birthweight greater than 4500 g, neonatal injury (40 weeks: adjusted odds ratio [aOR] 1.11 [95% confidence interval (CI), 1.05-1.18]; 41 weeks: aOR 1.27 [95% CI, 1.17-1.37]) and meconium aspiration (40 weeks: aOR 1.55 [95% CI, 1.43-1.69]; 41 weeks: aOR 2.12 [95% CI, 1.91-2.35]). Delivery at 37 or 38 weeks had higher risk of hyaline membrane disease (37 weeks: aOR 3.12 [95% CI, 2.90-3.38]); 38 weeks: aOR 1.30 [95% CI, 1.19-1.43]) but lower risk of meconium aspiration. | The risk of cesarean delivery and neonatal morbidity in low-risk women increases at 40 weeks and beyond, whereas the odds of serious neonatal pulmonary disease were highest at 37 weeks. Recognition of such variation in term outcomes should lead providers to avoid iatrogenic morbidity and consider interventions to prevent complications of late-term pregnancy. | closed_qa |
Can placental pathology explain second-trimester pregnancy loss and subsequent pregnancy outcomes? | This study sought to determine whether specific placental pathology may provide further insight into the mechanisms of second-trimester pregnancy loss, particularly in cases without inflammation. A blinded pathologist examined placentas from 90 patients with spontaneous second-trimester pregnancy loss and 17 controls who presented for induction of labor for fetal indications. Inflammation was staged and evidence of other vascular pathology recorded. Significant associations were determined by chi(2) analysis and Fisher's exact test. A secondary analysis examined losses without inflammation. Twelve patients with a subsequent pregnancy were also evaluated. Acute inflammation was more prevalent in cases than controls (P<.001). Sixty-seven percent of all cases and none of the controls showed a stage 2-3 inflammatory response. Histologic abruption was also more prevalent in cases than controls (P = .05). | Second-trimester pregnancy loss is strongly associated with placental inflammation. Histologic abruption is likely another etiology. Future research should focus on subsequent pregnancy outcomes in these women based on initial placental pathology to help determine etiology and recurrence risk. | closed_qa |
Do secondary conditions explain the relationship between depression and health care cost in women with physical disabilities? | To examine the influence of depression on health care utilization and costs among women with disabilities and to determine whether the severity of other secondary health conditions affects this association. A time series of 7 interviews over a 1-year period. Large, southern metropolitan area. Community-dwelling women (N=349) with a self-identified diagnosis of a physical disability. Not applicable. Primary disability, secondary health conditions (Health Conditions Checklist), depressive symptoms (Beck Depression Inventory-Second Edition), and health care utilization (based on the Health and Social Service Utilization Questionnaire and the Stanford Health Assessment Questionnaire). We estimated health care costs using standardized criteria and published average costs. Outpatient and emergency department health care utilization and overall costs were higher in women with depressive symptoms and increased with the frequency and severity of the symptoms. Depressive symptoms were highly correlated with the severity of secondary health conditions. Adjusting for demographics and primary disability, both the presence and severity of depressive symptoms were associated with significantly higher health care costs. However, secondary health condition severity explained the association between depressive symptoms and cost; it also substantially increased the variance in cost that was explained by the multivariate models. | Secondary health conditions are significantly associated with depressive symptoms and higher health care costs, with secondary health conditions accounting for the association between depressive symptoms and costs. This association suggests that effective management of secondary health conditions may help reduce both depressive symptomatology and health care costs. | closed_qa |
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