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Are frequent inner cannula changes necessary? | To determine the incidence of obstruction and colonization in adult patients in the surgical and medical intensive care units who received inner cannula changes daily versus those who did not. Quasi-experimental prospective study using a convenience sample of patients randomly assigned to one of two methods. Mid-Atlantic university-affiliated tertiary care center. Sixty patients within 24 hours of receiving a surgical tracheostomy. Obstruction and bacterial colonization of inner cannula. All inner cannulas were checked daily for obstruction and cultured on postoperative days 1 and 3. No statistically significant difference was noted in colonization (p = 0.13) between protocols, and no obstructions were noted in either. | The study suggests that the routine practice in critical care units of changing tracheostomy inner cannulas may be unnecessary. Although the results of this study are limited, and may not be generalized to other populations, it demonstrates that practice standards related to the care of tracheostomy inner cannula need to be challenged. | closed_qa |
Pyloric stenosis: is over-reliance on ultrasound scans leading to negative explorations? | Over a 2-year period, 76 neonates underwent laparotomy with a preoperative diagnosis of pyloric stenosis (PS). There were 57 males and 19 females, age ranged from 10 days to 7 weeks. Six patients proceeded straight to surgery after undergoing a test feed. The remaining 70 patients had one or more imaging investigations. Of these; 56 patients had an ultrasound only, 5 had a barium meal only while 9 patients had both investigations. Ultrasound showed evolving lesions in 2 patients. It was equivocal or falsely negative in 8 - all were diagnosed correctly after undergoing barium meals. Fifty-two patients were diagnosed correctly on ultrasound. There were, however, 3 false-positive ultrasonic diagnosis--i.e., at laparotomy the pylorus was found to be normal. One of these patients even had a "diagnostic" barium meal. The factors leading to these negative explorations are discussed. | Pyloric "tumours" can be difficult to palpate early in the evolution of the disease. Reliance upon the ultrasound appearance of the pylorus without taking into account other important diagnostic evidence will increase the risk of false-positive diagnoses and unnecessary laparotomy. The importance of clinical examination and test feed is emphasised. | closed_qa |
Is the profile of antihypertensive drug utilization justified? | To describe the use of drugs to combat hypertension and to assess prescription in function of their counterindications to diuretics and beta blockers. A descriptive cross-sectional study by means of an outside audit of clinical records. 11 urban Health Districts opened before 1991. 326 histories of adult hyperintense patients under pharmacological treatment were chosen at random (June-December, 1994). Data were gathered on age, sex, present and former medication, reason for change, and counter-indications to diuretic or beta blocker treatments. Average age was 64.7 (SD 11.6); 66% were women. 437 active principles (AP) were used, of which Enalapril (68 patients) and Captopril (67) were the most common. 203 patients (62.3%; Cl 95%, 57.0-67.5) took one AP; 90 (27.6%; Cl 95%, 22.8-32.5) took two APs; 30 (9.2%), three APs; and 3 (0.9%), four APs. 47.8% of monotherapy was performed with ACE inhibitors; 27.6% with calcium antagonists; 15.3% with diuretics; 7.9% with beta blockers and 1.5% with alpha inhibitors. Diuretics were the drugs most commonly used in association. | There is little use of diuretics and beta blockers, but two-thirds of the prescription of other treatments are justified by a counter-indication to first-choice drugs. | closed_qa |
Alpha 1-antichymotrypsin-PSA (ACT-PSA): a useful marker in the differential diagnosis of benign hyperplasia and cancer of the prostate? | This study examined the clinical relevance of the determination of alpha 1-antichymotrypsin complexed PSA (ACT-PSA) in addition to total PSA antigen (t-PSA). Both total PSA- and ACT-PSA-values of frozen sera obtained pretherapeutically from 93 patients with carcinoma (PC) and 132 patients with benign hyperplasia of the prostate (BPH) were analyzed by means of PSA sandwich-ELISA (Dianova GmbH) and ACT-PSA sandwich-ELISA (Dianova GmbH). At 95% specificity (true negative test results), a cutoff value of 18.9 [micrograms/L] was obtained for total PSA (7 patients with BPH [5%]were above this value). For this cutoff value we calculated a sensitivity (true positive test results) of 41%. Using the same criteria for the ratio Q = ACT-PSA: t-PSA (percentage of ACT-PSA) a cutoff of 6.0 was found again at a specificity of 95%. In a second step only patients with total PSA values below the cutoff level of 18.9 [micrograms/L]) were considered. Out of these patients 119 of 125 with BPH and 3 of 54 with PC were below the above mentioned ratio (Q = 6.0). Considering both steps (total PSA and Q) 42 patients with PC were detected correctly and 15 patients with BPH would have been biopsied unnecessarily. | High total PSA levels are a very good indicator for the presence of prostate cancer. There is still concern to improve the differentiation of the diagnosis between BPH and PC, when an intermediate or low value (<or = 95% specificity) is observed. The determination of Q = ACT-PSA: t-PSA is not to be recommended because it might not be helpful for the clinicians decision to perform biopsy. | closed_qa |
One-two rural residency tracks in family practice: are they getting the job done? | In the 1990s, the Residency Review Committee for Family Practice (RRCFP) and the American Board of Family Practice used the development of rural training programs as a strategy to bridge training experiences across urban referral centers and rural community hospitals. These programs are relatively small and attract trainees who are predisposed to rural practice. Aggregating data from several programs yields insight about their challenges and their ability to produce graduates who enter rural practice. This descriptive analysis is based on self-reported data from a 1996 survey mailed to the residency program directors of rural training programs, identified by the RRCFP office as one-two programs. More than half of the rural training programs surveyed were located in health professions shortage areas, most in communities with little urban influence. These programs are equally likely to be sponsored by university- or community-based residency programs. Most (75%) placed two or fewer residents per year in the rural site; minorities accounted for 4% of placements. Thirty percent of programs report unfilled positions. Seventy-five percent use televideo communications and find experiences in surgery and obstetrics relatively easy to arrange but dermatology and critical care difficult. Seventy-six percent of graduates enter rural practice after graduation. | This survey suggests that family practice rural one-two residencies are meeting the goal of providing trainees with a rural immersion experience, in anticipation of selecting rural practice after graduation. | closed_qa |
Does the timing of the first family planning visit still matter? | The timing of a first family planning visit relative to first intercourse can affect the likelihood of an early unintended pregnancy. Nationally representative data from the 1982, 1988 and 1995 cycles of the National Survey of Family Growth were used to examine changes in the timing of first family planning visits and to explore the degree to which young women are now more likely than in the past to practice contraception independently of making a visit to a provider. Cox proportional hazards models were used to estimate how background variables, visit status and the initiation of contraceptive use affected risks of unintended pregnancy in the four years preceding each survey. The proportion of women who waited a month or more after their first intercourse to see a provider grew slightly between 1978 and 1995, from 76% to 79%; women waited a median of 22 months after first intercourse in 1991-1995. Any contraceptive use at first intercourse increased among both women who delayed a first visit (from 51% to 75%) and among those whose first visit occurred before their first intercourse or within the same month (from 61% to 91%). Cox proportional hazards analysis suggests that the protective effect of a first family planning visit decreased over the period studied, due in part to the increase in early contraceptive use. | The importance of the first family planning visit appears to be declining, as sexually active young women who delay their first visit increasingly do so because they are already using a provider-independent method (primarily the condom). Thus, a multifaceted approach to providing family planning may now be needed, in which independent method use and visits to providers both play a role. | closed_qa |
Are we selecting the right patients for treatment of localized prostate cancer? | To determine our accuracy in selecting patients with at least a 10-year life expectancy for aggressive treatment of localized prostate cancer. The medical records of 261 consecutive patients who underwent radical retropubic prostatectomy were submitted to the actuarial division of American General Life and Accident Insurance Company (AGLA) for estimation of life expectancy, excluding the diagnosis of prostate cancer. Survival curves were generated from predicted individual survivals. In patients with less than a 10-year life expectancy, AGLA provided us with the basis for assigning suboptimal survival rates. The mean life expectancy for the group was 15.2 years. Two hundred ten men (80%) were projected to have a life expectancy of more than 10 years, including 27 of 55 (49%) and 4 of 8 (50%) men who were older than or equal to 70 and 75 years of age, respectively. Coronary artery disease and diabetes mellitus were the most common coexisting medical conditions that adversely affected risk as single disease entities. | Although clinicians do not estimate life expectancy with the scientific exactitude of an actuary, the ability to assess the patient in person and assimilate pertinent medical information in a less rigid format yields similar results. Selection of men for definitive treatment of localized prostate cancer should be based on the inherent aggressiveness of the disease and the health of the individual and should not be limited by specific age cutoffs. Populations of men undergoing radical prostatectomy are younger and healthier than those in reported series of watchful waiting for prostate cancer. | closed_qa |
Should continent diversion be performed in patients with locally advanced bladder cancer? | To assess the effect of local, regional, and distant recurrence on pouch function in patients with locally advanced bladder cancer treated by cystectomy and continent diversion. A review of 64 consecutive patients undergoing orthotopic (n = 40) or continent cutaneous (n = 24) urinary diversion was performed; 25 patients (39.1%) had locally advanced cancers as defined by deep muscle invasion, extension into perivesical fat, stromal invasion of the prostate, or node-positive disease. Patients were followed at 6-month intervals with physical examination, assessment of voiding function, and computed tomography (CT) scans. The pelvic recurrence rate was 4.7% in the overall group and 12% in patients with locally advanced disease. In the 39 patients with organ-confined tumors, 34 (87%) are alive without evidence of recurrence and have normal pouch function with a median follow-up of 27 months. Four patients in this group receiving systemic chemotherapy for clinical recurrences have retained normal pouch function until last follow-up or death. In the 25 patients with locally advanced tumors, 15 (60%) are alive without evidence of recurrence and have normal pouch function with a median follow-up of 15 months. Seven patients in this group received a median three cycles of adjuvant chemotherapy, and 4 patients received chemotherapy for clinically evident recurrences. Surgical recovery did not delay the onset of adjuvant therapy in any patient, nor did problems specifically related to the presence of a continent pouch delay any cycle of chemotherapy in those patients treated for recurrent disease in either group. Only 1 patient (1.5%) experienced treatment-related toxicity related to the presence of a continent diversion. | This experience suggests that the use of orthotopic or continent cutaneous diversions after cystectomy in patients with locally advanced bladder cancer is safe, does not interfere with the delivery of subsequent therapy, and allows most patients to anticipate normal pouch function even in the presence of recurrent disease. | closed_qa |
Does endoscopic hemostasis effect the reduction of mortality in patients with hemorrhage from the digestive tract? | Endoscopy is the method of choice for localizing the sites of hemorrhage and transendoscopic hemostatic procedures in patients with hemorrhage from the digestive tract. The aim of the study was to establish the efficacy of endoscopic hemostasis and to analyze the mortality of patients with upper digestive tract hemorrhage. The retrospective analysis included those patients who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions with injection sclerotherapy, laser photocoagulation or electrocoagulation of the hemorrhaging spot in the period between January 1994 and May 1995. 1000 patients were examined, 638 men and 362 women. In only 312 patients (31.2%) the examination revealed signs of acute or recent hemorrhage. Hemostatic interventions were performed in 275 (27.5%) cases. During hospitalization at the medical wards, 14 (9/275, 5.1%) patients died. In 9 patients (9/275, 3%) with acute hemorrhage, endoscopic hemostasis did not prove successful, therefore after several unsuccessfully repeated endoscopic interventions (21 in all), the patients were treated operatively. During the postoperative period, 4 patients died due to complications. | Despite the development of endoscopic instruments and improved methods of hemostasis, mortality due to hemorrhage from the digestive tract has not dramatically decreased. Numerous demanding endoscopic procedures are usually carried out in older patients which also suffer from other diseases. These diseases represent the risk factors for eventual surgical treatment and the ensuing complications. | closed_qa |
Alcohol use in the Greek system: follow the leader? | This study was designed to identify drinking patterns, consequences of use, and belief systems about alcohol among college students according to their level of involvement in campus fraternity and sorority life. This study of 25,411 (15,100 female) students who completed the Core Alcohol and Drug Survey, from 61 institutions, compared alcohol consumption, binge drinking, consequences of use and beliefs about drinking according to students' level of involvement in fraternities and sororities, ranging from no involvement to that of attending functions only, to active involvement, to leadership positions within Greek organizations. Analyses indicated that students in the Greek system averaged significantly more drinks per week, engaged in heavy drinking more often and, with minor exceptions, suffered more negative consequences than non-Greeks. The leaders of fraternities and sororities consumed alcohol, engaged in heavy drinking and experienced negative consequences at levels at least as high and in some cases higher than that of other Greek members. In terms of their views about alcohol, fraternity and sorority members believed that alcohol was a vehicle for friendship, social activity and sexuality to a greater extent than non-Greeks. The beliefs of the leaders did not stand out compared to other members. | In addition to corroborating earlier reports that show that fraternity and sorority members use more alcohol than nonmembers, this study indicates that the leadership of Greek organizations are participating in setting heavy-drinking norms. Suggestions are made concerning targeting prevention programming efforts toward this group. | closed_qa |
Is partial nephrectomy appropriate treatment for unilateral Wilms' tumor? | After nephrectomy for unilateral Wilms' tumor (WT), two potential hazards threaten the remaining kidney. The development of a metachronous WT (2% to 3%), and decrease in renal function after chemotherapy. Our study aims included: (1) to clarify how many WT patients could benefit from partial nephrectomy (PN) without jeopardizing the high cure rate, (2) to establish the function of the kidney remnant, and (3) to test the radiological criteria for preoperative selection of PN candidates. A retrospective analysis of 90 consecutive cases of histologically verified WT (1982 to 1992) was carried out. Data were studied independently by the surgeon, the radiologist, and the pathologist. The preoperative selection criteria for PN were functioning kidney, tumor confined to upper or lower pole leaving two thirds of the kidney tumor free, and no hilar or vascular structures involved. After PN, renal function was estimated by a calculated creatinine clearance (CC) combined with the assessment of the relative function of each kidney by renal scintigraphy. There were 46 boys and 44 girls with median age at diagnosis of 3 years 6 months (range, 3 months to 16 years 7 months). Stage I disease occurred in 40 patients, stage II in 23, stage III in 16, and stage IV occurred in 11 patients. Nearly all patients received preoperative chemotherapy. Radiological analysis of 85 available data sets (5 missing) suggested that PN was possible in 13 patients, and data were inconclusive in two. All 13 patients selected by the radiologist appeared to be in agreement with the pathological criteria for resectability. Of these cases, complete resection by PN was performed in five, could have been possible in retrospect in two, and appeared impossible in six. In two more patients, PN was performed; in both cases the radiologist had predicted PN to be impossible. Median follow-up after PN was 61 months, range, 45 to 167 months. Two patients died of distant metastasis, and no local recurrence occurred. Five are in remission with a median CC level of 110 mL/min, range, 85 to 124. Relative functions of the kidney remnants were 20% to 50%. Contralateral nephrectomy for progressive obstruction was performed in one, but CC level remained normal (85 mL/min). Comparing the preoperative radiological prediction with the combined surgical and pathological findings in a 2 x 2 frequency table, the sensitivity of the radiological findings could be calculated to be 80%, the specificity 97%, and the accuracy 87%. | (1) Partial nephrectomy is safe in approximately 10% of Wilms' tumor patients. (2) The function of the kidney remnant remains well, and even permits contralateral nephrectomy. (3) Preoperative imaging shows an accuracy of 87% to predict the possibility for partial nephrectomy. | closed_qa |
Impact of trauma attending surgeon case volume on outcome: is more better? | To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons. The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience. There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience. | Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers. | closed_qa |
Do metallothioneins affect the response to treatment in testis cancers? | Data on the involvement of elevated metallothionein (MT) expression in resistance to some of the commonly used anticancer treatments are scattered and conflicting. This encouraged us to examine further the contribution of metallothionein expression to the development of this resistance phenotype. Formalin-fixed, paraffin-embedded blocks of primary untreated germ cell testicular tumor specimens, obtained from 77 patients following radical orchiectomy, were examined for their MT expression using monoclonal antibody and immunohistochemistry. Clinical staging, the chemotherapeutic schedule and evaluation of response to treatment (defining objective response) were performed according to UICC criteria. All tumor types, including seminomas and nonseminomas, expressed MT, regardless of their histology and clinical stage. The immunoreactivity of MT showed a significant positive correlation with the clinical sensitivity of cancer to antitumor therapy (P = 0.0001). | In patients with germ cell testicular tumors, high MT expression, as detected by immunohistochemistry, predicts a better response rate to chemotherapy whereas tumors lacking or demonstrating low MT expression show a worse prognosis. These data do not support the hypothesis that MT overexpression contributes to cisplatinum resistance, at least in this tumor type. | closed_qa |
Joint-space width in the weight-bearing radiogram of the tibiofemoral joint. Should the patient stand on one leg or two? | The aim of the study was to compare the minimal joint-space (MJS) width of the tibiofemoral joint (TFJ) in weight-bearing radiograms with the patient in two different positions. From a study of 54 patients with chronic knee pain (aged 42-59 years, mean 52 years), we selected 21 consecutive patients for this study. In these 21 patients, both knees were examined by means of p.a. weight-bearing radiograms in semiflexion with fluoroscopic guidance. The patient stood with the weight: 1) almost entirely on the examined leg; and 2) equally distributed on both legs. The MJS was measured with a scale loupe in tenths of a millimeter in the medial and lateral compartments of the TFJ. With the patient standing on one leg, the MJS was 0.18 mm wider (p<0.006) in the medial compartment and 0.18 mm narrower (p<0.029) in the lateral compartment as compared to standing on both legs. | With the technique used, the assessment of the MJS width in the p.a. view of the TFJ in weight-bearing examinations should be performed with equal weight on both legs. Standing on only the examined leg might be an option in cases of suspected narrowing in the lateral compartment. | closed_qa |
Is dobutamine-induced sinus node deceleration a marker of significant stenosis of the right coronary artery? | Sinus node deceleration during exercise is a highly specific marker for significant stenosis of the right coronary artery. Prior studies of dobutamine-induced sinus node deceleration have contained relatively few patients, and the purpose of this study was to determine if sinus node deceleration is an accurate marker of right coronary artery disease in a much larger study population. Dobutamine stress echocardiography was performed in a cohort of patients, and submaximal exercise testing and coronary angiography were performed in most of the patients. A university hospital. Dobutamine stress echocardiography was performed in 757 patients, and symptom-limited submaximal treadmill ECG was also performed in 571 of those patients. Sinus node deceleration was defined as a decrease in the heart rate at peak stress compared with that at the previous stage. Coronary angiography was performed in 631 patients, 184 of whom were found to have significant right coronary artery stenosis. The prevalence of dobutamine-induced sinus node deceleration (54 [7%] of 757 patients) was significantly higher than that induced during treadmill ECG (3 [0.5%]of 571 patients; p<0.001). The prevalence of inferior ischemia by echocardiography did not differ between patients with dobutamine-induced sinus node deceleration (26%) and those without (30%). There was also no significant difference in the prevalence of right coronary artery stenosis between the two groups (27% vs 29%). The specificity of dobutamine-induced sinus node deceleration for detecting significant stenosis of the right coronary artery (92%) was higher than that of echocardiography (84%; p<0.00), but the positive predictive value was lower (28% vs 64%; p<0.001). | Although sinus node deceleration during dobutamine stress echocardiography is a relatively more common finding, it does not always accompany significant stenosis in the right coronary artery. The mechanism for its induction is postulated to be vagal activation caused by multiple factors. | closed_qa |
Can quantitative capnometry differentiate between cardiac and obstructive causes of respiratory distress? | To determine whether quantitative measurement of end-tidal carbon dioxide (ETCO2) can differentiate between cardiac and obstructive causes of respiratory distress. Prospective observational study. Emergency department (ED) of a tertiary care hospital. Adult patients who presented to the ED with moderate-to-severe dyspnea. Patients were excluded if they were unable to cooperate with the performance of peak expiratory flow rate (PEFR) or ETCO2 tests, were younger than 18 years of age, or had received prehospital intervention for their respiratory distress. Physicians obtained an ETCO2 level and PEFR prior to ED pharmacologic intervention. A hand-held capnometer with digital read-out was used to obtain the ETCO2 level. The patient's age, sex, initial vital signs, breath sounds and medication history, the presence or absence of diaphoresis and/or orthopnea, the duration of symptoms, the chest radiograph interpretation, and final diagnosis were also recorded. Forty-two patients were eligible for inclusion in the analysis. The mean ETCO2 level was 31.1+/-9.4 mm Hg; the mean PEFR was 161.3+/-53.1 L/min. The ETCO2 levels for pulmonary edema/congestive heart failure (CHF) patients differed significantly from those of asthma/COPD patients (27.1+/-7.8 mm Hg vs 33.4+/-9.6 mm Hg; p=0.0375). However, no single ETCO2 level was found to be a reliable predictor of diagnosis. | ETCO2 levels for pulmonary edema/CHF patients differ significantly from those of asthma/COPD patients. However, no single ETCO2 level reliably differentiates between the two disease processes. | closed_qa |
Radial keratotomy: can we predict results? | Results after keratotomy may be less than satisfactory. Based on different parameters, we performed statistical efficiency tests in order to improve criteria for good and poor prognosis for the first procedure. This study used the registries of 155 surgical procedures performed by the same team. Data collected from patient records included degree of myopia, preoperative keratometry, close preoperative pachymetry and postoperative visual acuity. Preoperative factors predicting poor postoperative visual acuity in this population were screened with several statistical tests: one simple test, one two-way (linear or barycentric) test and one principal component factorial test using visual analysis. Prognosis was very different depending on whether myopia was greater than or less than 3.25 diopters. The visual analysis method gave maps capable of screening for prognosis. Results mapping is a new approach. | Chance of success is greatest in less myopic eyes (<3.25 diopters) with low keratometry (<43.5 diopters). Other eyes should not be operated. Easy-to-use maps were obtained and provided hetero unreached prognostic precision. Nevertheless, because of population composition, none of the methods could identify perfectly satisfactory prognosis criteria. | closed_qa |
Should sacrospinous ligament fixation for the management of pelvic support defects be part of a residency program procedure? | The objective of this article is to determine the safety and effectiveness of transvaginal sacrospinous ligament fixation as part of the management of pelvic support defects in a residency program. A retrospective chart review of patients undergoing sacrospinous ligament fixation at the Division of Gynecology, Jackson Memorial Hospital, University of Miami School of Medicine, between July 1990 and December 1995, was performed. Patients with vaginal vault prolapse and uterine prolapse with documented preoperative evaluation were included in this study. Data were obtained using a detailed predetermined flow sheet. A total of 160 patients was included in the study. All patients underwent right sacrospinous ligament fixation, anterior and posterior colporrhaphy, and perineorrhaphy. In addition, 31 (19%) underwent enterocele repair, 5 (3%) underwent trachelectomy, and 9 (6%) underwent Burch procedure. Complications included fever 13 (8.1%), urinary tract infection 16 (10%), blood loss requiring transfusion 7 (4.3%), sciatic neuralgia 2 (1.2%), and rectovaginal fistula 2 (1.2%). The mean follow-up was 40 months (range 18 to 78 months). The success of the operation was gauged by recurrence. Ninety-four percent of the patients had no evidence of vaginal vault prolapse on follow-up, and 85% had no recurrence of any pelvic support defect. Eleven of the 24 patients with recurrence underwent repeat surgery, whereas 13 opted for conservative management with pessaries. | Transvaginal unilateral sacrospinous ligament fixation is a safe and successful operation for the treatment of pelvic support defect and should be an essential component in the training of gynecologic residents. | closed_qa |
Is lipoprotein(a) an independent risk factor for ischemic heart disease in men? | This study was undertaken to determine whether lipoprotein(a) [Lp(a)] is an independent risk factor for ischemic heart disease (IHD) and to establish the relation of Lp(a) to the other lipid fractions. Several, but not all, studies have shown that elevated Lp(a) concentrations may be associated with IHD; very few have been prospective. A 5-year prospective follow-up study was conducted in 2,156 French Canadian men 47 to 76 years old, without clinical evidence of IHD. Lipid measurements obtained at baseline included total cholesterol, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, apoprotein B and Lp(a). During the follow-up period, there were 116 first IHD events (myocardial infarction, angina, death). Adjusted proportional hazards models were used to estimate the relative risk for the different variables. The cohort was also classified according to Lp(a) levels and other lipid risk factor tertiles to evaluate the relation of elevated Lp(a) levels to these risk factors. A cutoff value of 30 mg/dl was used for Lp(a). Risk ratios were calculated using the group with low Lp(a) levels and the first tertile of lipid measures as a reference. Lp(a) was not an independent risk factor for IHD but seemed to increase the deleterious effects of mildly elevated LDL cholesterol and elevated total cholesterol and apoprotein B levels and seemed to counteract the beneficial effects associated with elevated HDL cholesterol levels. | In this cohort, Lp(a) was not an independent risk factor for IHD but appeared to increase the risk associated with other lipid risk factors. | closed_qa |
Volume therapy in the critically ill: is there a difference? | There are still several concerns about the extensive and prolonged use of hydroxyethylstarch solution (HES) in critically ill patients. The effects of volume replacement with HES over 5 days on hemodynamics, laboratory data, and organ function were compared with volume therapy using human albumin (HA). Prospective, randomized study. Clinical investigations on a surgical intensive care unit (ICU) of a university hospital. 150 traumatized patients (injury severity score>15) and 150 postoperative patients with sepsis were analyzed. Either 10% low-molecular weight HES (HES-trauma, n = 75; HES-sepsis, n = 75) or 20% HA (HA-trauma, n = 75; HA-sepsis, n = 75) was given for 5 days to maintain the pulmonary capillary wedge pressure (PCWP) between 12 and 15 torr. The entire management of therapy of the patients was performed by physicians who were not involved in the study and blinded to the infusion regimen. In addition to extensive cardiorespiratory monitoring, several routine laboratory parameters for assessing pulmonary, renal, hepatic, and coagulation function were analyzed from arterial blood samples on the day of admission to the ICU and on the day of sepsis diagnosis, respectively ("baseline" value) and daily over the following 5 days. Mortality during and after the study did not differ significantly between the infusion groups. There were also no differences between the incidence of pulmonary, renal, or hepatic failure in the two subgroups. Mean arterial pressure, heart rate, and PCWP were similar in both subgroups, whereas cardiac index, oxygen delivery index, oxygen consumption index, and the ratio between the partial pressure of oxygen in arterial blood and fractional inspired oxygen were higher in the HES- than in the HA-treated groups. Standard coagulation parameters did not differ, albumin concentration increased significantly in both HA groups, and lactate concentrations decreased only in the HES-sepsis patients (from 2.8 +/- 0.5 to 1.5 +/- 0.4 mg/dl). Volume replacement using albumin was significantly (p<0.001) more costly than therapy with HES. | Volume therapy with 10% HES for 5 days in the ICU patient showed no disadvantages compared with an infusion regimen using 20% albumin. Volume replacement using HES may even be associated with improved hemodynamics. HES appears to be a valuable and significantly cheaper alternative to albumin--even for prolonged volume therapy in the critically ill patient. | closed_qa |
Lacrimal-duct-probing-induced bacteremia: should children with congenital heart defects receive antibiotic prophylaxis? | To determine the incidence of bacteremia following lacrimal-duct probing in children, and to evaluate the potential need for antibiotic prophylaxis in children who are at an increased risk of infectious endocarditis (IE). In a prospective study beginning in October 1994, 40 consecutive children requiring lacrimal-duct probing performed by a single pediatric ophthalmologist received preoperative lacrimal and blood cultures followed by postoperative probe-induced transient bacteremia that was defined as a negative preoperative blood culture, followed by a positive postoperative blood culture of the same bacteria identified in the positive lacrimal culture. The overall infection rate as described above was 7 of 40 children (17.5%) with a 95% confidence interval of 7.3% to 32.8%. Of these, four children had positive postoperative cultures for Haemophilus influenzae (10.0%) and 3 were positive for Streptococcus pneumoniae (7.5%) One child had a negative preoperative blood and lacrimal culture with a postoperative blood culture positive for Streptococcus viridans. | This study shows a significant incidence of lacrimal-probe-induced bacteremia with organisms that have been documented as etiological agents for IE in children. IE, although less common in children, remains a serious, potentially life threatening infection with high mortality. Although lacrimal-duct probing has never been clearly associated with documented endocarditis, it is the authors' recommendation that it be prudent for patients who are at known high risk for endocarditis to receive SBE prophylaxis considering the low cost/benefit ratio. | closed_qa |
Preventive care and continuity of attendance. Is there a risk? | To explore whether there are associations between continuity of care and the provision of items of preventive care in Australian general practice. Patient completed questionnaires from a 'consecutive' sample of Australian general practitioners enrolled in the Patient Participation Program of the Quality Assurance and Continuing Medical Education Program of the Royal Australian College of General Practitioners. An association was sought between the length of time patients reported attending their practitioner, whether they regularly attended more than one practice, and whether they were provided with preventive care. Data from 12,605 questionnaires, completed by patients from 133 practices throughout Australia found that patients who reported only visiting one practice on a regular basis were significantly more likely to report the provision of: blood pressure screening within the past 12 months; cholesterol screening in the past 5 years; adequate smoking cessation information if required; to have discussed the benefits of diet and exercise; to have received a cervical smear in the past 2 years; and to have received adequate instruction in the technique of breast self examination. Patients attending the same practices for longer periods were significantly more likely to have received the above items with the exception of adequate information to enable them to stop smoking if they desired; and cervical smears in the past 2 years. Such patients were less likely to report the provision of tetanus immunisation in the past 10 years and cervical smears in the past 2 years. | Patients reporting greater continuity of care measured by only consulting at one practice or visiting the practice for a longer time period reported a greater provision of preventive care than patients who did not report these characteristics. | closed_qa |
Is there a relationship between leptin and insulin sensitivity independent of obesity? | It has been shown previously in smaller studies that fasting serum leptin and insulin concentrations are highly correlated, and insulin sensitive men have lower leptin levels than insulin resistant men matched for fat mass. We have examined the association between insulin resistance (assessed by fasting insulin) and leptin after controlling for overall and central adiposity in a population-based cohort. Leptin levels were compared across insulin resistance quartiles within three categories of obesity (tertiles of body mass index (BMI)). Partial correlation coefficents and multiple linear regression models were used to assess the relationship between leptin and fasting insulin after adjusting for BMI and waist to hip ratio (WHR) or waist circumference. Subjects were normoglycemic participants of a 1987 non-communicable diseases survey conducted in the multiethnic population of Mauritius. 1227 men and 1310 women of Asian Indian, Creole and Chinese ethnicity had normal glucose tolerance and fasting serum leptin measurements. Mean serum leptin concentration increased across quartiles of fasting insulin in each BMI group and gender, after controlling for BMI, WHR and age. Furthermore, fasting insulin was a significant determinant of serum leptin concentration, independent of BMI and WHR, in both men and women. Similar results were found if waist circumference replaced BMI and WHR in the model. | These results suggest that insulin resistance/concentration may contribute to the relatively wide variation in leptin levels seen at similar levels of body mass or alternatively, leptin may play a role in the etiology of insulin resistance. Further studies will be important to determine whether the hyperleptinemia/insulin resistance relationship has a role in the natural history of obesity, Type 2 diabetes mellitus and the other metabolic abnormalities associated with insulin resistance. | closed_qa |
Is the SF-36 suitable for assessing health status of older stroke patients? | The Medical Outcomes Study short form 36 health survey (SF-36) is being increasingly used and recommended as a suitable measure of subjective health status. However, it is unlikely that any measure will be appropriate for all groups. We wished to determine the suitability of the SF-36 for assessing quality of life in older stroke patients. A screening questionnaire was used to identify prevalent cases of stroke from a random sample of 2000 subjects aged 45 years and over. The SF-36 was included as part of a self-completion questionnaire posted to each stroke patient. Data quality indicators were analysed. We identified 104 cases of stroke and the response rate for the SF-36 questionnaires sent was 83%. Completion rates for individual items ranged from 66 to 96%. All items in the role physical and role emotional scales had completion rates<75%. The percentage of subjects for whom an individual scale score could be computed ranged from 67 to 96%, being lowest for the role physical and role emotional scales. Floor effects were high (>15%) for these two scales and for the social functioning and physical functioning scales. Ceiling effects were substantial (>15%) for the two role effect scales and for social functioning and bodily pain. | This study has shown high response rates from older stroke patients to a postal questionnaire incorporating the SF-36. The poor completion rates and consequent inability to compute scores for a large proportion of responders in certain scales raises concerns about the perceived relevance of these sections. Results for the response effects suggest that, on its own, the instrument is not suitable for assessing outcome. When data quality indicators were examined, it appears that postal administration of the SF-36 is not appropriate for assessing quality of life of older stroke patients. | closed_qa |
Double grafting of the left anterior descending artery: is the distance between the internal mammary artery and supplemental vein graft anastomoses relevant in graft survival? | Under certain conditions (small internal mammary artery (IMA) or large runoff), double grafting of the left anterior descending (LAD) artery system is necessary to avoid the ominous consequences of myocardial hypoperfusion. Previous studies have shown that a saphenous vein (SVG) adjacent to an IMA graft leads to failure of the IMA. This study compares IMA flow patterns when adjacent (<1 cm) and separated (3-4 cm) from a SVG placed on a proximally occluded LAD. A SVG and right IMA (PIMA) to proximal LAD (2.5-3 mm) coronary bypass were performed in 12 mongrel dogs. The left IMA (DIMA) was anastomosed to the distal LAD (1.5 mm). All anastomoses were carried out without cardiopulmonary bypass. The native LAD was occluded proximally to the PIMA anastomosis, and all graft flows were measured in competitive and non-competitive flow conditions. Isolated graft to LAD flows were similar for the three conduits. There was a drop in flow in both the PIMA and DIMA when placed in competition with the SVG (10.1+/-3.0 vs. 19.1+/-4.6 ml/min; P<0.05). The total drop in flow was significantly greater in the PIMA (67.6 vs. 39.9%; P<0.05). Diastolic flow was better preserved in the distal IMA graft (19.6 + 5.6 vs. 10.2+/-3.0 ml/min; P<0.05). The patterns of flow were much different during competition and there was significant retrograde systolic flow in all PIMA grafts while there was no (n = 5) or minimal retrograde flow (n = 7) in the DIMA grafts. | An IMA graft, when adjacent to a SVG, sustains a significant decrease in both total and diastolic flows and develops an oscillating pattern of flow in early systole (retrograde then antegrade). Placing the IMA more distally on the LAD improves flow and decreases retrograde flow. In clinical situations requiring double grafting on the LAD, distance between grafts may be an important factor in maintaining IMA patency. | closed_qa |
Do beta-blockers affect the diagnostic sensitivity of dobutamine stress thallium-201 single photon emission computed tomographic imaging? | The effects of beta-blockers on dobutamine stress 201Tl tomographic imaging are not known. This study was undertaken to examine whether beta-blockers affect the sensitivity of dobutamine stress 201Tl imaging. One hundred ten patients without previous myocardial infarction underwent dobutamine stress 201Tl single photon emission computed tomography (SPECT) and coronary arteriography, both studies within a 1-week period. Dobutamine was infused at rates of 5, 10, 20, 30, and 40 microg/kg/min in 3-minute stages. Atropine (as much as 1 mg) was injected intravenously when the patient's heart rate was<100 beats/min. Patients in group 1 (n = 72) were receiving beta-blockers and patients in group 2 (n = 38) were not. The SPECT images in group 1 showed perfusion abnormalities in 62%, 87%, and 94% of patients with one-, two-, and three-vessel coronary artery disease (>or = 50% diameter stenosis), respectively, compared with 75%, 71% and 100% in group 2 (p not significant). The overall sensitivities were 82% (37 of 45) in group 1 and 80% (16 of 20) in group 2 (p not significant). The specificities were 81% (22 of 27) in group 1 and 83% (15 of 18) in group 2 (p not significant). The overall accuracies were the same for both groups (82%). Atropine was added more often in group 1 than in group 2 (37/72 vs 5/38, p<0.001). | Our results suggest that beta-blockers do not affect the sensitivity, specificity, and accuracy of dobutamine stress 201Tl SPECT imaging for detecting coronary artery disease if atropine is given when the chronotropic response is inadequate. In patients receiving beta-blockers, however, the addition of atropine to dobutamine stress is more frequently required. | closed_qa |
Dietary intake of middle-aged men from an East and a West German city after the German reunification: do differences still exist? | To compare the diets of men from East and West Germany after the reunification under the new food market conditions in the East. Both dietary surveys were part of the third MONICA surveys in population based random samples. City of Erfurt in the Federal State of Thuringia, East Germany (dietary survey in 1991/92) and city of Augsburg in the Federal State of Bavaria, West Germany (dietary survey in 1994/95). Comparable samples of 185 Erfurt vs 331 Augsburg men, aged 45-64 y. Data on food and nutrient intakes and percentage of users of foods are derived from 3 d weighed records from Erfurt and three matching days of 7 d weighed records from Augsburg. Nutrient intakes show the pattern of a typical Western diet in both samples with 15.2 en% from protein, 39.5 en% from fat, 38.8 en% from carbohydrates and 6.2 en% from alcohol in Erfurt. Corresponding figures for Augsburg are 16.4 en%, 37.9 en%, 39.0 en% and 6.5 en%. Intake of animal protein, cholesterol, water and selected micronutrients is distinctly higher in Augsburg. | Dietary differences still exist, but the pattern of difference has changed. It is unclear, whether differences between East and West exceed regional differences in the West. | closed_qa |
Is macronutrient composition of dietary intake data affected by underreporting? | To investigate whether subjects with low reported relative energy intake differ from those with higher relative energy intake according to characteristics such as obesity, physical activity, and macronutrient composition of the diet. Cross-sectional data from a cohort study employing a semi-quantitative food frequency questionnaire (SFFQ). To determine energy intake relative BMR the ratio of reported energy intake (EI) to BMR was used and categorized by quintiles. East German (Potsdam) cohort of the EPIC study (European Prospective Investigation into Cancer and Nutrition) 2862 women and 2356 men taking part in the EPIC-Potsdam study from January 1st to December 31st 1995. A significant declining trend could be observed for BMI, percentage of body fat, and body weight from the lower to the highest quintile of EI/BMR. BMR was slightly decreasing, whereas physical activity was slightly increasing with quintiles of EI/BMR. Absolute macronutrient intake was directly related to EI/BMR. Percent macronutrient intake indicated lower fat intake, and higher carbohydrate and protein intake in low energy reporters. Energy adjusted macronutrient intake by the residual method showed no dependencies on EI/BMR. | Underestimation of energy intake is related to obesity and affects the relation of macronutrients in the reported diet. This implies, that the assumption of adequate ranking of subjects by a SFFQ cannot be maintained. Energy adjusted intake values according to the residual method should be employed in diet-disease risk analysis since they are found to be independent of the methodological influence of underreporting. | closed_qa |
Diagnostic anterior chamber paracentesis in uveitis: a safe procedure? | Differentiation between infectious and non-infectious uveitis is of crucial value for accurate management of patients with uveitis. Tests performed on aqueous humour yield more relevant information than those done in serum. The objective of this study was to evaluate whether the aqueous humour tap for diagnostic purposes is a safe procedure to perform in uveitis patients. In this retrospective study 361 patients with uveitis, who underwent a diagnostic anterior chamber paracentesis in an outpatient clinic, were investigated. 72 of the 361 patients were examined 30 minutes after the puncture. The site of the paracentesis, the depth of the anterior chamber, and cells in the anterior chamber were examined. All 361 patients were evaluated within 2 weeks after the paracentesis was performed. The final follow up period varied from 6 months to more than 3 years. The clinical data were analysed with the emphasis on the occurrence of cataract and a history of corneal infections or endophthalmitis. In this series no serious side effects such as cataract, keratitis, or endophthalmitis were observed. The depth of the anterior chamber of all evaluated patients was restored after 30 minutes. In five out of 72 cases (three AIDS patients with cytomegalovirus retinitis and two patients with anterior uveitis due to herpes simplex virus) a small hyphaema was observed 30 minutes after the paracentesis took place. | Anterior chamber paracentesis appears to be a safe procedure in the hands of an experienced ophthalmologist. | closed_qa |
Is the association between irritable bowel syndrome and abuse explained by neuroticism? | In outpatients and the community, an association between abuse (particularly sexual abuse) and irritable bowel syndrome (IBS) has been observed, but whether there is a causal link continues to be disputed. To test the hypothesis that psychological factors explain the apparent association between abuse and IBS. A sample of residents of Penrith (a Sydney suburb sociodemographically similar to the Australian population) selected randomly from the electoral rolls (that by law include the entire population of age 18 years and above) was mailed a validated self report questionnaire. Measured were gastrointestinal (GI) symptoms including the Rome criteria for IBS, abuse (including the standardised Drossman questions), neuroticism (Eysenck Personality Questionnaire), and psychological morbidity (General Health Questionnaire). The response rate was 64% (n = 730); 12% fulfilled the Rome criteria for IBS. Overall abuse in childhood (odds ratio (OR) = 2.02, 95% confidence interval (CI) 1.29 to 3.15) but not adulthood (OR = 1.39, 95% CI 0.88 to 2.19) was associated with IBS univariately. Neuroticism and psychological morbidity were also univariately associated with abuse in childhood, abuse in adulthood and IBS, respectively. However, by logistic regression, abuse in childhood was not associated with IBS after controlling for age, gender, and psychological factors (OR = 1.34, 95% CI 0.83 to 2.17). The results were not altered by restricting the analyses to more severe forms of abuse, and were not explained by interactions between abuse and psychological variables. | There is an association between abuse and IBS in the community, but this may be explained in part by other psychological factors. Based on a path analysis, we postulate that abuse may induce the expression of neuroticism that in turn leads to IBS. | closed_qa |
Anti-endothelial cell antibodies: another cause for pregnancy loss? | Previous studies demonstrated that unique tissue-specific antigens expressed on vascular endothelial cells can serve as immunogens, and the apparent association between transplant rejection and antiendothelial cell (EC) antibodies is well established. A common feature of some placentas from women with recurrent pregnancy loss is the diffuse formation of microthrombi associated with changes in thromboresistant properties of endothelial cells, similar to the findings in rejected organs. Therefore, the prevalence of anti-EC antibodies in patients with recurrent pregnancy loss and the role of these antibodies in cultured human endothelial cells from umbilical cord vein were studied. To evaluate the frequency of anti-EC antibodies, sera from 160 nonpregnant patients with recurrent pregnancy loss after absorption with pooled platelets and pooled leukocytes were tested using cultured human umbilical cord vein endothelial cells (HUVEC) by flow cytometry. To study the role of anti-EC antibodies, purified anti-EC IgGs were added to HUVEC cultures and hemostatic, fibrinolytic, and anticoagulation pathway markers (tissue factor, tissue plasminogen activator, palsminogen-activator inhibitor, thrombomodulin, heparan-sulfate proteoglican, antithrombin III, von Willebrand factor, CD54, human leukocyte antigens-DR, and transferin receptor) were detected by specific antibodies and flow cytometry. Immunoblotting analyses were done by using purified anti-EC IgGs against cell membrane proteins from endothelial cells and leukocytes extracted by detergent solubilization. Thirty-nine (24%) of the patients were positive for EC antibodies. Antipaternal lymphocyte antibodies were tested as well and were found in 37 (23%) of the patients as 25 sera (15.6%) showed reactivity with both EC and lymphocytes. Certain patient sera were reactive with HUVEC lines from some but not other umbilical cords, which suggests allotypy. Sera from 70 normal healthy male and nonpregnant female controls did not react with any of the individual HUVEC lines used. The purified anti-EC immunoglobulin G (IgGs) recognized bands, from HUVEC surface membrane protein preparations, with molecular weights of 120 kDa. Both hemostatic and fibrinolytic pathway markers were found activated in the presence of anti-EC IgGs, suggesting an altered endothelial cell surface activation state. | The results indicate that anti-EC antibody is another marker for a subset of recurrent spontaneous aborters who may have activation of hemostasis and fibrinolysis as a mechanism involved in their losses. | closed_qa |
Bone marrow staging in patients with non-Hodgkin's lymphoma: is flow cytometry a useful test? | Flow cytometric analysis of bone marrow often is used as an adjunct to morphologic evaluation in the staging of patients with non-Hodgkin's lymphoma (NHL). The goal of this study was to define objectively the benefit of flow cytometry in this setting. The authors reviewed retrospectively all bone marrow specimens submitted between January 1992 and December 1994 to the Washington University Department of Pathology for flow cytometric immunophenotyping to rule out NHL. Results of morphologic examination and flow cytometry were reviewed independently and the ability to detect bone marrow involvement compared. Two hundred and seventy-three bone marrow specimens from 190 patients with an established diagnosis of NHL were submitted for flow cytometric analysis at initial presentation, restaging, and/or recurrence. Morphologic evaluation was negative in 69%, positive in 23%, and equivocal in 8%. Flow cytometry was negative in all but 1 morphologically negative bone marrow specimens and 40% of morphologically involved bone marrow specimens. Two of 23 morphologically equivocal bone marrow specimens were positive by flow cytometry. An additional 86 specimens were obtained to rule out NHL in patients without an established diagnosis of NHL. The majority of patients had a history of human immunodeficiency virus infection, cytopenia, or unexplained fevers. Morphologically, one specimen was involved with NHL, 5 were equivocal, and 80 were negative. All specimens were negative by flow cytometry. | In this study, flow cytometric analysis improved the detection of NHL in bone marrow in only 3 of 273 samples, 2 of which were suspicious morphologically. Flow cytometry of bone marrow aspirates has a limited role in the routine staging and follow-up of patients with an established diagnosis of NHL. | closed_qa |
Do infants with cystic fibrosis need a protein hydrolysate formula? | We compared the nutritional benefits of a protein hydrolysate and a conventional infant formula in infants newly diagnosed with cystic fibrosis (CF). Twenty-three infants with CF (<6 months of age) and pancreatic insufficiency were randomized to receive a hydrolysate formula (Alimentum) or a cow's milk-based formula (Similac). Each patient was monitored at 1 month and then every 3 months for 1 year. Eighteen patients (8 Alimentum, 10 Similac) completed the study. At entry, the age distribution and clinical characteristics of each group were comparable. Energy intake with each formula was the same at 1 and 3 months, but at 6 and 12 months the hydrolysate-fed infants had higher age-adjusted energy intake. There were no differences in fecal energy or fecal fat at entry or throughout the study. Although the hydrolysate-fed infants were slightly more malnourished at diagnosis, growth velocity and nutritional status of infants with CF in each group were the same throughout the study. | The results of this randomized study fail to support the use of a hydrolyzed formula for the routine care of infants newly diagnosed with CF. | closed_qa |
High serum cholesterol levels in persons with 'high-normal' TSH levels: should one extend the definition of subclinical hypothyroidism? | The association between established hypothyroidism and high cholesterol levels is well known. The aim of the present study was to investigate the effect of thyroxine (T4) administration on cholesterol levels in hypercholesterolemic subjects with TSH levels within the normal range ('high-normal' TSH compared with 'low-normal' TSH). We determined TSH levels in 110 consecutive patients referred for hypercholesterolemia (serum cholesterol>7.5 mmol/l). Those with 'high-normal' TSH (2.0-4.0 microU/ml) as well as those with 'low-normal' TSH (0.40-1.99 microU/ml) were randomly assigned to receive either 25 or 50 microg T4 daily for two months. Thus, groups A and B (low-normal TSH) received 25 and 50 microg T4 respectively and groups C and D (high-normal TSH) received 25 and 50 microg T4 respectively. Serum T4, tri-iodothyronine (T3), TSH, free thyroxine index, resin T3 uptake and thyroid autoantibodies (ThAab) as well as total cholesterol, high and low density lipoprotein cholesterol (HDL, LDL), and triglycerides were determined before and at the end of the two-month treatment period. TSH levels were reduced in all groups. The most striking effect was observed in group D (TSH levels before: 2.77+/-0.55, after: 1.41+/-0.85 microU/ml, P<0.01). Subjects in groups C and D had a higher probability of having positive ThAabs. A significant reduction in total cholesterol (P<0.01) and LDL (P<0.01) was observed after treatment only in group D. In those subjects in group D who were ThAab negative, there was no significant effect of thyroxine on cholesterol levels. | Subjects with high-normal TSH levels combined with ThAabs may, in fact, have subclinical hypothyroidism presenting with elevated cholesterol levels. It is possible that these patients might benefit from thyroxine administration. | closed_qa |
Enterococcus faecium bacteremia: does vancomycin resistance make a difference? | Enterococcus faecium has received increased attention, primarily due to the emergence of vancomycin resistance. The purpose of this investigation was to study the epidemiological characteristics of vancomycin-resistant E faecium (VRE) bacteremia and to determine the clinical impact of vancomycin resistance on the outcome of patients with this infection. We retrospectively analyzed the clinical features and outcome of 53 patients with E faecium bacteremia. From January 1992 until December 1995, there were 32 episodes of bacteremia caused by vancomycin-susceptible E faecium (VSE) and 21 caused by VRE. An intra-abdominal site was the most common source of bacteremia in both groups. All of the VRE and 78% of VSE bacteremia cases were nosocomially acquired. Previous administration of vancomycin was associated with VRE bacteremia (P<.001), as were indwelling bladder catheters (P=.01). Fifty-nine percent of the patients with VSE bacteremia survived vs 24% with VRE (P=.009), despite similar severity-of-illness scores. In 62% of the patients with VRE sepsis, death was related to the bacteremia (P=.01). Patients infected with VRE had longer hospitalizations than those with VSE (34.8 vs 16.7 days, respectively) (P=.004), were more likely to be on the medical service (P=.03), and on the average, had hospitalization costs of more than $27,000 per episode than did patients with VSE bloodstream infection ($83,897 vs $56,707, respectively) (P=.04). | Vancomycin-resistant E faecium bacteremia is a complication of prolonged hospitalization in debilitated patients. Vancomycin resistance has a negative impact on survival in patients with E faecium bacteremia and leads to higher health care costs. | closed_qa |
Perioperative transoesophageal echocardiography with low-dose dobutamine stress for evaluation of myocardial viability: a feasible approach? | The feasibility of low-dose dobutamine stress combined with transoesophageal echocardiography (TEE) to detect viable left ventricular myocardium was evaluated in 22 anaesthetised patients prior to sternotomy for elective coronary artery bypass grafting (CABG). After baseline measurements, a dobutamine infusion beginning with 5 micrograms.kg-1.min-1 was started and eventually increased to 10 micrograms.kg-1.min-1. Viability was assessed as visual improvement of left ventricular wall motion (LVWM). The criteria for discontinuation of the infusion were: 1. any changes in LVWM, 2. an increase in preanaesthetic blood pressure exceeding 40 mmHg, and/or a>20% increase in preanaesthetic heart rate compared to preanaesthetic levels. An off-line evaluation of LVWM was based upon visualisation of the left ventricle in a transgastric short-axis mid-papillary (mid-P) view, and the left ventricle was divided into anterior, septal, inferior, and lateral segments. Moreover, an off-line semiautomatic analysing system was used for assessing regional and global LVWM. With this analysis the effects on LVWM from changes in preload and afterload could be addressed. 19 patients showed a decreased LVWM in one or several segments at baseline. A total of 36 segments exhibited decreased LVWM (an average of 1.9 segments/patient). Of these, 22 segments (61%) improved with dobutamine, while 12 segments (33%) did not, and 2 (6%) became more dysfunctional. Another 6 segments with normal motion at baseline became dysfunctional with dobutamine. According to the off-line semiautomatic analysing system for LVWM, there were no statistically significant changes with dobutamine stimulation. Only one patient showed an increased postoperative aspartateaminotransferase (ASAT) value (3.0 mmol.l-1) but no ECG changes. | Since we regard the visual assessment of LVWM as being more applicable for this protocol than the semiautomatic analysis, we conclude that low-dose dobutamine stress echocardiography seems to be a feasible method for detecting viable myocardium in the anaesthetised patient scheduled for elective CABG surgery. However, the semiautomatic analysis complemented our findings, since the variations in pre- and afterload did not significantly change the size of the left ventricle, which hereby would imply LVWM changes. | closed_qa |
Does anastomotic method affect functional outcome of low anterior resection for rectal carcinoma? | Anorectal dysfunction may occur following sphincter-saving resection for rectal carcinoma. The dysfunction may present clinically with increased stool frequency and varying degrees of fecal incontinence. It is postulated that these presentations come about from reduced neorectal capacity, as well as internal anal sphincter injury, during transanal instrumentation or through damage to the nerve supply in the course of rectal dissection. The purpose of this study was to assess the functional results of low anterior resection (LAR), and the relative importance of each mechanism. Thirty-one patients were included in this study, eighteen of whom had standard LAR for rectal carcinoma. Bowel continuity was reestablished by handsewn (HS) 2-layer suture in 10 patients and stapled EEA (U.S. Surgical Corporation) anastomosis in the other 8 patients. Thirteen patients who had received abdominal surgery other than LAR were the control group. Anorectal manometry was performed preoperatively and one week, then six months post-operatively. Clinical assessment was done pre-operatively and six months post-operatively. Resting anal pressure was significantly reduced in both HS and EEA groups post-operatively (HS: 69.4 +/- 14.8 mmHg, median: 71.5 mmHg vs. 43.7 +/- 16.2 mmHg, median: 48.5 mmHg, 95% confidence interval of mean difference: 6.4-24.6 mmHg; EEA: 51.3 +/- 14.6 mmHg, median: 48.0 mmHg vs. 38.8 +/- 16.6 mmHg, median: 41.5 mmHg, 95% confidence interval of mean difference: 5.6-49.8 mmHg), partial recovery was noted in the HS group six months later. The squeeze pressure and functional length of the anal canal showed no difference pre- and post-operatively. Rectoanal inhibitory reflex was present in 90% of the patients preoperatively, but in only 70% of the HS, and 38% of the EEA group, six months post-operatively. Clinically, increased bowel frequency and varying degrees of incontinence were experienced postoperatively. There was no difference in bowel frequency between the two groups, but worse continence grade was seen in the EEA group. | LAR for rectal carcinoma resulted in impaired anorectal function. Handsewn anastomosis seemed to have a better functional outcome than EEA stapled anastomosis. | closed_qa |
Relationship between potential doubling time (Tpot), labeling index and duration of DNA synthesis in 60 esophageal and 35 breast tumors: Is it worthwhile to measure Tpot? | In recent years Tpot (potential doubling time) has been measured before treatment in human tumors in an attempt to estimate the proliferation taking place during a course of irradiation. Tpot is defined as Ts/LI, where Ts is the duration of DNA synthesis and LI is the labeling index (proportion of cells synthesizing DNA). Ts is more difficult to measure than LI, so the question arises whether variation introduced during the determination of Ts is compensated by the theoretically better relevance of the quotient Tpot than of LI alone. It is not clear from comparisons with clinical outcome whether Tpot is a useful indicator of proliferation or whether LI is more prognostic, as suggested by a currently ongoing multicenter analysis elsewhere. Therefore, we investigated intercomparisons between Tpot and its components LI and Ts in two in their proliferation rates contrasting types of tumor where multiple biopsies were taken from each tumor. Sixty patients with esophageal carcinoma and 57 patients with breast cancer were included in this study. All patients were injected with IUdR 6-8 h before surgery. From each tumor three to five biopsies were taken at surgery. Using flow cytometry, LI and Ts were measured on all biopsies in order to calculate Tpot. Logarithmic transformations of the distributions were used to examine correlations. Kappa-tests were used to assess how reliable an LI value could be in predicting the corresponding Tpot. Ts and LI were not completely independent, based on the within-tumor coefficients of variation (CVw). The ratio of between-tumor coefficient of variation (CVb) to the CVw suggested that the discriminative power of Tpot was higher than LI for esophagus, but the reverse in breast tumors, which had a larger range. Pearson correlation coefficients were high for log Tpot versus log LI in both types of tumor, but the predictive power was low, as shown by kappa-values of only 0.3-0.41 starting with LI and trying to predict the corresponding value of Tpot. Increasing widths of a central 'gray zone' were investigated for improved discrimination between fast and slow proliferation. Multiples of the within-tumor standard deviation, equally on each side of the median, were used to vary the width of the gray zone. Without a gray zone no more than 70% successful matching was obtained in esophagus tumors, compared with 80% in breast tumors. However, by excluding about half of the esophageal tumors an 80% success rate was achieved. In breast tumors over 90% matching was obtained more easily, keeping 80% of the tumors classifiable. For both tumor types correlations between Ts and Tpot were weak, with a trend towards short Ts associated with short Tpot and also with low LI. The latter correlation was significant for esophageal tumors and resulted in Tpot values having a smaller range than the LIs. | Although there were good correlation coefficients between Tpot and LI, the predictive power of either from the other was not reliable, except by excluding a significant number of tumors close to the medians. The predictive value of LI for Tpot was higher for breast tumors because the spread in cell kinetic measurements was wide. Until more clinical data become available on outcome in comparison with LI or Tpot, it is still worthwhile to measure Tpot and to assess the prognostic value of both LI and Tpot in relation to outcome. | closed_qa |
Normal serum concentrations of S-100 protein and changes in cerebrospinal fluid concentrations of S-100 protein during and after thoracoabdominal aortic aneurysm surgery: Is S-100 protein a biochemical marker of clinical value in detecting spinal cord ischemia? | This study was performed to determine the concentration of S-100 protein in serum and in the cerebrospinal fluid (CSF) during and 24 hours after thoracoabdominal aortic aneurysm repair. This prospective study was performed at St. Antonius Hospital in Nieuwegein, The Netherlands. Eight patients who underwent elective thoracoabdominal aortic surgery participated in the study. Arterial blood and CSF samples for analysis of S-100 protein were drawn after induction of anesthesia, during the cross-clamp period of the critical segment, after 5 minutes of reperfusion, during the closure of the skin, and 24 hours after closure of the skin. No increase in S-100 protein concentration could be detected in serum (<0.2 microg/L). The S-100 protein concentration in CSF increased during the procedure in all patients (4.2 +/- 3.1 microg/L). However, in one patient, who became paraplegic, the S-100 protein concentration in CSF increased even further after 24 hours (10 microg/L). | The preliminary results suggest that S-100 protein in CSF may be a marker of clinical value in evaluating the effects of measures to detect and reduce spinal cord ischemia. | closed_qa |
Is ileal pouch-anal anastomosis really the procedure of choice for patients with ulcerative colitis? | Ileal pouch-anal anastomosis is widely claimed to have replaced total proctocolectomy with ileostomy as the "procedure of choice" for ulcerative colitis, largely on the basis of a perceived improved quality of life. There exists relatively little support for this assertion in the literature. Our aim was to determine if educated patients choosing total proctocolectomy with ileostomy have a similar quality of life as with ileal pouch-anal anastomosis. All patients with ulcerative colitis referred to a single surgeon and deemed an appropriate surgical candidate were educated and then offered ileal pouch-anal anastomosis or total proctocolectomy with ileostomy. Age, gender, and complications (including pouchitis) were recorded prospectively, and all patients were questioned regarding functional outcome and level of satisfaction. They were then asked to complete a slightly modified Inflammatory Bowel Disease Questionnaire, which was analyzed by categoric and overall scores. Sixty-seven patients underwent elective surgery for ulcerative colitis during the study period. Fifty-five patients chose ileal pouch-anal anastomosis, and 12 had total proctocolectomy with ileostomy. The groups were similar except for younger age and longer follow-up in the ileal pouch-anal anastomosis group. Patients undergoing ileal pouch-anal anastomosis had significantly more short-term or long-term complications (49 vs. 8 percent), with pouchitis being the most frequent complication. There was no difference in level of satisfaction between the two groups, and no patient in either group wishes they had undergone the other procedure. There was no difference in the overall or any categoric Inflammatory Bowel Disease Questionnaire score. | Patient satisfaction with both procedures was similarly high. Patients who undergo ileal pouch-anal anastomosis can expect a high level of satisfaction, with a good quality of life. However, educated patients choosing an ileostomy can achieve the same quality of life, without the higher complication rate associated with a pelvic pouch. | closed_qa |
Does chronic otitis media cause sensorineural hearing loss? | The purpose of this study was to determine whether chronic middle ear infection is associated with sensorineural hearing loss. Audiometric data from 123 patients with unilateral chronic otitis media were compared using the non-involved ear as a control. The average bone threshold at 500, 1000, and 2000 Hz, the speech reception threshold, and the extent of the disease was compared using the t-test, linear regression, and MANOVA techniques. A highly significant association was found between the presence of chronic otitis media and sensorineural hearing loss. The great variability in our data imply that some individuals are particularly susceptible to chronic otitis media. We offer one suggestion as to why this may occur. | Sensorineural hearing loss is associated with chronic ear infection with some persons being particularly vulnerable. | closed_qa |
Is there a safe cold ischemia time interval for the renal graft? | It is aimed to characterize the true relationship of the cold ischemia time (CIT) with graft survival and with the principal post-transplantation events. We analyzed 378 kidney transplants, studying the relationship of the CIT with graft survival using a univariate analysis according to the COX model and seeking the optimum cutoff according to the Kaplan-Meier method and log-rank test. The relationship between CIT and the principal events of the post-transplant was studied using the binary logistic regression. The mean follow-up of all the group was 77.8 months (± 51 SD) and the mean CIT was 14.8 hours (± 5.1 SD). The univariate analysis revealed that the CIT was not related with the graft survival as a continuous variable (OR=1.04; 95% CI: 0.9-1.08; p>0.05). On establishing the cutoff at 18 hours, we found differences in the actuarial survival. Survival at 5 years was 91% with CIT<18 h versus 84% with CIT>18 h. Each hour of cold ischemia increased risk of delay in the graft function by 10% (OR=1.1; 95% CI: 1.05-1.15; p<0.001) and also conditioned a greater incidence of acute rejection (41.5% vs. 55.3%; p=0.02) and less time to the first rejection episode (72.6 days±137 vs. 272.2 days±614.8; p=0.023) after 18 hours. The CIT did not seem to be related (p<0.05) with the rest of the post-transplantation events, such as surgical complications or hospital admissions. | In our experience, cold ischemia under 18 hours does not seem to negatively affect graft survival. | closed_qa |
Is endoscopic injection therapy a reasonable treatment option for low-grade vesicoureteral reflux in association with overactive bladder? | To assess the clinical outcome of endoscopic injection in children with vesicoureteral reflux (VUR) and concomittant overactive bladder (OAB). A total of 41 patients with VUR and OAB underwent endoscopic injection of dextranomer/hyaluronic acid. At surgery, 13 patients had been successfully treated for their OAB (urgency with or without wetting) with behavior modification with or without anticholinergic therapy, and 28 had persistent OAB despite treatment. Voiding cystourethrogram was obtained 6-12 weeks postoperatively, and patients were followed up clinically for 1-5 years. Negative voiding cystourethrogram findings after a single treatment were seen in 34 (82.9%) of 41 patients. The radiographic success rate in patients with well-controlled OAB was 76.9% (10 of 13) compared with 85.7% (24 of 28) of those with poorly controlled OAB. The overall clinical success rate, defined as no evidence of urinary tract infection in the setting of negative voiding cystourethrogram findings, reached 78.0% (32 of 41). After successful endoscopic treatment, an unanticipated return to normal voiding patterns without the need for postoperative anticholinergic therapy was seen in 4 of the children with well-controlled OAB (40.0%) and in 4 with poorly controlled OAB (16.7%). | Our data suggest that endoscopic injection is a viable treatment option for VUR in those with OAB, with postoperative rates of resolution comparable to those found in patients without OAB. Furthermore, 40.0% of children with well-controlled OAB no longer required therapy for OAB after resolution of their VUR. | closed_qa |
Pathology of idiopathic nephrotic syndrome in children: are the adolescents different from young children? | There is no specific data on the pathological lesions underlying idiopathic nephrotic syndrome (INS) in adolescents in Pakistan. Moreover, it is not known whether the pathological lesions in adolescents differ significantly from young children with INS in our setup. Materials and methods. A retrospective analysis was carried out on all patients with INS with onset ≤ 18 years of age. They were split into two groups: patients with onset of INS ≤ 12 years (young children group) and patients with onset ≥ 13 through 18 years of age (adolescent group). Renal biopsies were evaluated by light microscopy, immunoflourescence and electron microscopy. The histopathological lesions on renal biopsies were analyzed and compared between the two groups. The adolescents comprised 173 (32.1%) patients, and there were 365 young children (67.8%). The mean age of adolescents at the time of onset of INS was 15.12 ± 1.5 years and there were 113 boys (65.3%) and 60 girls (34.6%). The mean age of young children was 7.26 ± 3.24 years and there were 231 boys (63.2%) and 134 girls (36.7%). Focal segmental glomerulosclerosis was the most common histopathological lesion in adolescents (36.4%) followed by minimal change disease (MCD) (28.9%). Adolescent-onset INS had a significantly higher frequency of membranous glomerulonephritis and membranoproliferative glomerulonephritis (MPGN) (P<0.05) and significantly lower frequency of MCD (P<0.05) than early childhood-onset INS. | Our data indicate that the pathological lesions in adolescent INS are different from younger children and resemble more closely those seen in adults. Our findings are concordant with the few previously published studies on this subject. | closed_qa |
Do sons reduce parental mortality? | Although sons are thought to impose greater physiological costs on mothers than daughters, sons may be advantageous for parental survival in some social contexts. The authors examined the relationship between the sex composition of offspring and parental survival in contemporary China and Taiwan. Because of the importance of sons for the provision of support to elderly parents in these populations, the authors hypothesised that sons would have a beneficial effect on parental survival relative to daughters. The authors used data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) and the Taiwan Longitudinal Study of Aging (TLSA). The CLHLS sample consisted of 4132 individuals aged 65 years and over in 2002. The TLSA sample comprised two cohorts: 3409 persons aged 60 years and over in 1989 and 2193 persons aged 50-66 years in 1996. These cohorts were followed up for 3, 18 and 11 years, respectively. The Cox proportional hazards model was used to estimate the relationship between the sex composition of offspring and parental mortality. Based on seven measures of sex composition, no protective effect of sons was found in either China or Taiwan. For example, in the 1989 Taiwan sample, the hazard ratio (HR) for maternal mortality associated with having an eldest son was 0.979 (95% CI 0.863 to 1.111). In Taiwan, daughters may have been more beneficial than sons in reducing mortality in recent years. | The authors offer several explanations for these findings, including possible benefits associated with emotional and interpersonal forms of support provided by daughters and negative impacts of conflicts arising between parents and resident daughters-in-law. | closed_qa |
Does a defunctioning stoma affect anorectal function after low rectal resection? | Anorectal function is often impaired after low anterior resection of the rectum. Many factors affect the functional outcome and not all are known. This trial aimed to assess whether a temporary defunctioning stoma affected anorectal function after the patients had been stoma-free for a year. Multicenter randomized controlled trial. Twenty-one Swedish hospitals performing surgery for rectal cancer participated. Patients who had undergone low anterior resection for adenocarcinoma of the rectum were eligible. Patients were randomly assigned to receive a defunctioning stoma or no stoma. Anorectal function was evaluated with a questionnaire after patients had been without a stoma for 12 months. Questions pertained to stool frequency, urgency, fragmentation of bowel movements, evacuation difficulties, incontinence, lifestyle alterations, and whether patients would prefer a permanent stoma. After exclusion of patients in whom stomas became permanent, a total of 181 (90%) of 201 patients answered the questionnaire (90 in the stoma group and 91 in the no-stoma group). The median number of stools was 3 during the day and 0 at night in both groups. Inability to defer defecation for 15 minutes was reported in 35% of patients in the stoma group and 25% in the no stoma group (P = .15). Median scores were the same in each group regarding need for medication, evacuation difficulties, fragmentation of bowel movements, incontinence, and effects on well-being. Two patients (2.2%) in the stoma group and 3 patients (3.3%) in the no-stoma group would have preferred a permanent stoma. Because this study was an analysis of secondary end points of a randomized trial, no prestudy power calculation was performed. | A defunctioning stoma after low anterior resection did not affect anorectal function evaluated after 1 year. Many patients experienced impaired anorectal function, but nearly all preferred having impaired anorectal function to a permanent stoma. | closed_qa |
Diagnosis of neuromyelitis optica (NMO) spectrum disorders: is MRI obsolete? | Neuromyelitis optica (NMO) is a severe demyelinating disease that preferentially involves spinal cord and optic nerve. It is part of a spectrum of neurological conditions associated with antibodies to aquaporin-4 (AQP4). This study investigates the role of MRI where novel, more sensitive AQP4 antibody immunoassay techniques are being used. Retrospective review of neuroimaging in 69 patients (25 antibody positive, 44 antibody negative), investigated in the context of suspected NMO or NMO spectrum disorder, was performed independently by two consultant neuroradiologists. Longitudinally extensive, central spinal cord lesions were more frequent in AQP4 positive patients (95.2% vs 35.5%, p < 0.0001; 85.7% vs 45.2%, p = 0.015). Multiple sclerosis diagnostic criteria were less frequently fulfilled on brain MRI in antibody positive patients (5.6% vs 33.3%, p = 0.035). Juxtacortical and corpus callosal lesions were also less common in this group (16.7% vs 46.7%, p = 0.063; 5.6% vs 46.7%, p = 0.0034). Hypothalamic and periependymal disease related to the aqueduct was not seen in antibody negative patients. T1 hypointensity was more common in cord lesions of antibody positive patients (75.0% vs 35.3%, p = 0.037). However, this characteristic did not discriminate antibody positive and negative longitudinally extensive cord lesions (73.3% vs 62.5%, p = 0.66). | The NMO spectrum of diseases are among an increasing number of neurological conditions defined by serological tests. However, despite improved immunoassay techniques, MRI of the brain and spinal cord continues to be among the first-line investigations in these patients, providing valuable diagnostic information that will help guide patient management. | closed_qa |
Significantly high expression of platelet-derived growth factor (PDGF) in benign nodules of the thyroid: relevance in the development of goitre recurrence? | Platelet-derived growth factor (PDGF) is a critical regulator of cell proliferation and influences the development of tumors. The role of PDGF in benign thyroid diseases is presently not well-determined. The purpose is to evaluate PDGF isoforms and receptors in primary culture of thyrocytes isolated from human thyroid tissue. Forty patients with uninodular (n = 11), multinodular (n = 15) and recurrent goitre (n = 14) were investigated. Nodular and corresponding paranodular thyroid tissues were characterized. RNA and protein were extracted from primary thyrocyte monoculture. RT-PCR, western blot and ELISA were performed to evaluate PDGF isoforms AA, BB, CC, DD and PDGF receptors α and β. Significantly higher mRNA expression of PDGF-AA, -BB, -CC and PDGFR molecules α and β was measured by RT-PCR in thyrocytes from uninodular and recurrent nodular tissue compared with corresponding paranodular tissue. Elevated PDGF protein and PDGFR-α and -β were confirmed by western blot. Likewise, higher secretion of PDGF-AA and -BB was detected in the supernatant of thyrocyte culture from all nodular tissue compared with paranodular tissue. Interestingly, comparison of nodular and corresponding paranodular tissues in multinodular goitre did not show significant difference of expression levels of PDGF isoforms or receptors. | These findings suggest that the overexpression of PDGF isoforms and receptors may play a crucial role in the development of thyroid nodules and recurrent goitre. | closed_qa |
"Menstrual irregularities in PCOS. Does it matter when it starts? | PCOS is presented by a broad spectrum of menstrual irregularities appearing often at puberty or later on during the reproductive years in women suffering from this multifaceted syndrome. To our knowledge, there is no evidence to suggest whether the time of onset of menstrual irregularities (peri or post pubertal) indicates a differential metabolic and/or hormonal profile as well as ovarian ultrasonographic findings, in adulthood in women with PCOS. To compare anthropometric, hormonal-metabolic profile and ultrasound findings in PCOS women with peripubertal onset of menstrual disorders with the corresponding data obtained from PCOS patients with post pubertal onset of menstrual irregularities, matched for BMI and age.PATIENTS- 89 PCOS women were evaluated cross-sectionally at the age of 25 years. In 49 subjects menstrual irregularities were present from menarche, whereas in 40 women the irregularities appeared at least 3 years post menarche. Anthropometric parameters were comparable between the 2 groups. The 2 groups did not differ on metabolic and hormonal profile as well as ovarian ultrasound findings. | These data indicate that the timing of menstrual irregularities, do not appear to have an impact, on hormonal/metabolic profile and ovarian ultrasound morphology in patients diagnosed with PCOS, later in life. | closed_qa |
Pediatric septic shoulder arthritis. Is routine arthrotomy still necessary? | Arthrotomy is recommended as a routine treatment for childhood septic arthritis of the shoulder, although scientific evidence is lacking. Suggested alternatives are arthroscopic lavage, serial aspirations and a mere diagnostic aspiration. 9 patients with septic arthritis of the shoulder aged 3 months to 12 years underwent a diagnostic aspiration after which large dose antimicrobials were given qid (clindamycin or 1st generation cephalosporin). One child underwent arthrotomy, otherwise all patients recovered normally. There were no sequelae. | Routine arthrotomy for all patients is of questionable value in the emergency treatment of septic shoulder arthritis in children. | closed_qa |
Ischemic versus non-ischemic cardiomyopathy--are there differences in prognosis? | Previous studies have associated heart failure (HF) of ischemic etiology with worse prognosis compared to HF from non-ischemic cardiomyopathy. HF treatment has evolved significantly in recent years. Has this evolution had an impact on this prognostic gap? The aim of our study was to compare patients with advanced HF--nonischemic versus ischemic etiology--in terms of baseline characteristics, treatment, and in-hospital and long-term prognosis (including death, heart transplantation and hospital readmission). We performed a retrospective study including 286 consecutive patients with systolic HF admitted to an HF unit between January 2003 and June 2006. We compared two groups according to HF etiology: Group A--ischemic cardiomyopathy (n = 109); Group B--non-ischemic cardiomyopathy (n = 177). Mean follow-up was 41 months. Group A were older (62.2 +/- 10.4 vs. 55.9 +/- 15.2 years, p<0.001), with a higher proportion of males (80.7 vs. 67.8%, p = 0.017), diabetes, anemia, dyslipidemia and smokers; they required more prolonged treatment with inotropic drugs and more frequent treatment with statins, antiplatelet agents and nitrates. On admission, Group B patients presented with lower serum sodium and higher aminotransferase levels. There were no differences in the occurrence of cardiogenic shock or dysrhythmias, baseline ECG rhythm, frequency of left bundle branch block, renal function, BNP, left ventricular ejection fraction, heart rate or implantation of intracardiac devices. Group A had higher in-hospital mortality (11.0 vs. 4.0%, p = 0.020). Multivariate analysis showed that the only predictor of in-hospital mortality was serum sodium<133 mmol/l and also showed that HF etiology was not a predictor of this endpoint; previous medication with angiotensin-converting enzyme inhibitors was a protective factor. On Kaplan-Meier analysis, it was observed that, in the long-term, there were no significant differences in either survival rates (70.0 vs. 76.8%, p = 0.258), or the combined endpoints of survival free of death or heart transplantation (55.7 vs. 54.5%, p = 0.899) and survival free of death, heart transplantation or hospital readmission (38.0 vs. 32.8%, p = 0.386). | Although in-hospital mortality was higher in ischemic cardiomyopathy, this variable was not an independent predictor of mortality and the difference appears to fade in the long-term, in contrast to what had been reported in older studies, but in agreement with more recent data. | closed_qa |
Do low-numeracy people avoid shared decision making? | Doctors have been increasingly encouraged to involve patients in decision making rather than pursuing the paternalistic model in which they make the decisions for their patients. But do patients want to participate in making decisions about their health? Is there a relationship between their preferences for shared decision making and numeracy skills? Are those preferences different in countries with different medical systems, and for different age groups? Extant studies cannot answer these questions because most are based on nonprobabilistic, highly selective patient samples that prevent generalizations to a broader population. In a survey on probabilistic national samples in the United States and Germany, we interviewed participants with low numeracy skills (Germany: n = 127, mean numeracy = 37; United States: n = 117, mean numeracy = 36) and high numeracy skills (Germany: n = 133, mean numeracy = 96; U.S.: n = 121, mean numeracy = 91). Usual and preferred role in medical decision making. A significant number of people with low numeracy in both the United States (35%, SE = 8.2) and Germany (30%, SE = 6.1) preferred to be more passive than they currently were. High-numeracy people, in contrast, were mostly satisfied with their current role. On average, Americans were more active than Germans. Middle-aged participants preferred to be more active compared to both younger and older ones. | Shared decision-making preferences are related to numeracy skills, country, and age. Education efforts to increase numeracy, as well as using nonquantitative communication formats, may foster involvement of low-numeracy patients in decisions about their health. | closed_qa |
Respondent-driven sampling on the Thailand-Cambodia border. I. Can malaria cases be contained in mobile migrant workers? | Reliable information on mobility patterns of migrants is a crucial part of the strategy to contain the spread of artemisinin-resistant malaria parasites in South-East Asia, and may also be helpful to efforts to address other public health problems for migrants and members of host communities. In order to limit the spread of malarial drug resistance, the malaria prevention and control programme will need to devise strategies to reach cross-border and mobile migrant populations. The Respondent-driven sampling (RDS) method was used to survey migrant workers from Cambodia and Myanmar, both registered and undocumented, in three Thai provinces on the Thailand-Cambodia border in close proximity to areas with documented artemisinin-resistant malaria parasites. 1,719 participants (828 Cambodian and 891 Myanmar migrants) were recruited. Subpopulations of migrant workers were analysed using the Thailand Ministry of Health classification based on length of residence in Thailand of greater than six months (long-term, or M1) or less than six months (short-term, or M2). Key information collected on the structured questionnaire included patterns of mobility and migration, demographic characteristics, treatment-seeking behaviours, and knowledge, perceptions, and practices about malaria. Workers from Cambodia came from provinces across Cambodia, and 22% of Cambodian M1 and 72% of Cambodian M2 migrants had been in Cambodia in the last three months. Less than 6% returned with a frequency of greater than once per month. Of migrants from Cambodia, 32% of M1 and 68% of M2 were planning to return, and named provinces across Cambodia as their likely next destinations. Most workers from Myanmar came from Mon state (86%), had never returned to Myanmar (85%), and only 4% stated plans to return. | Information on migratory patterns of migrants from Myanmar and Cambodia along the malaria endemic Thailand-Cambodian border within the artemisinin resistance containment zone will help target health interventions, including treatment follow-up and surveillance. | closed_qa |
Can we rely on the presence of dextranomer-hyaluronic acid copolymer mounds on ultrasound to predict vesicoureteral reflux resolution after injection therapy? | We determined whether the presence or absence of dextranomer-hyaluronic acid copolymer mounds on bladder ultrasound coincides with voiding cystourethrogram results after injection therapy in children with primary vesicoureteral reflux. We retrospectively reviewed consecutive cases of dextranomer-hyaluronic acid copolymer injection for primary vesicoureteral reflux. The primary outcome investigated was the appearance of dextranomer-hyaluronic acid copolymer mounds on ultrasound and their association with voiding cystourethrogram results postoperatively. An intramural dextranomer-hyaluronic acid copolymer mound on ultrasound was considered a negative test result for vesicoureteral reflux. A total of 187 cases were identified, of which 132 had imaging available for evaluation. Intramural mounds were seen on ultrasound in 86 cases postoperatively, of which 34 (40%) had a positive voiding cystourethrogram. Of 46 cases in which no mound was identified 21 (46%) had a positive voiding cystourethrogram. The sensitivity of ultrasound to determine the presence or absence of vesicoureteral reflux was 38%, specificity was 67%, accuracy was 55%, the positive predictive value was 46% and the negative predictive value was 60%. | Our results indicate poor correlation of dextranomer-hyaluronic acid copolymer mound appearance on ultrasound with voiding cystourethrogram results after injection. To adequately evaluate for the resolution of vesicoureteral reflux a voiding cystogram or nuclear medicine cystogram needs to be performed after injection therapy. | closed_qa |
Using Objective Structured Clinical Examination (OSCE) in undergraduate psychiatric nursing education: is it reliable and valid? | While there is widespread use of OSCE in general nursing specialties, psychiatric nursing has been slow to adopt this evaluation method and it has only recently been introduced to psychiatric nursing education.AIM: The main aim of the present study is to test the first application, validity and reliability of the OSCE in undergraduate psychiatric nursing education. OSCE was developed to assess undergraduate psychiatric nursing students' clinical skills. The students' evaluation of the OSCE process was obtained after the completion of each OSCE circuit. The psychiatric nursing OSCE proved to be a reliable and valid method in assessing psychiatric nursing clinical competencies. In general, the students perceived OSCE as a positive experience and stressful on the other hand. | OSCE is a reliable and valid method of assessing the students' psychiatric nursing competency skills. It has been shown to have many advantages over traditional methods of assessment and has the ability to objectively assess psychiatric nursing skills. | closed_qa |
Is laparoscopic hysterectomy feasible for uteri larger than 1000 g? | To evaluate the feasibility of laparoscopic hysterectomy for uteri weighing more than 1000 g. A retrospective study was conducted in a tertiary center of laparoscopic surgery including 38 women submitted to hysterectomy for uteri weighing more than 1000 g. Patients submitted to open hysterectomy were compared to those submitted to laparoscopic hysterectomy. The primary statistical endpoint was the complication rate. Secondary endpoints were operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy. The patients' mean age was 49.4 years and mean BMI was 25.2 kg/m(2). The surgical intent was laparoscopic hysterectomy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%). Conversion to open surgery was required in 4 patients (17.4%) due to inaccessibility of the pelvis at the beginning of surgery (n=2), technical difficulties during surgery (n=1), and intraoperative bleeding (n=1). One patient in the laparotomy group had an intraoperative ureteral injury. Despite longer operative time (130 vs. 80 min, p=0.002), laparoscopic surgery was associated with reduced length of hospital stay (3 vs. 6 days, p<0.001). Intraoperative bleeding was evaluated by the difference of pre- and post-operative hemoglobin and was equivalent in both groups (2.2 vs. 1.6g/dL; p=0.84). There was a tendency for more postoperative complications in the laparotomic group (33.4% vs. 8.7%; p=0.05). | Laparoscopic hysterectomy is feasible for selected patients with uteri weighing more than 1000 g. | closed_qa |
Lymph nodes, tumor deposits, and TNM: are we getting better? | New editions of the TNM staging system for colorectal cancer have been subject to extensive criticism. In the current study, we evaluate each edition of TNM and analyze stage migration caused by the different versions. Two independent test populations were used: participants derived from a randomized surgical trial from the United Kingdom (n = 455) and patients from a population-based series from Sweden (n = 505). All slides from these patient cases were reviewed with special attention for the presence of tumor deposits. Tumor deposits were classified according to the fifth, sixth, and seventh editions of TNM and correlated with prognosis. Every change in edition of TNM led to a stage migration of between 33% and 64% in patients with tumor deposits. Reproducibility was best in the fifth edition of TNM. The prognostic value of the seventh edition was best only when all tumor deposits irrespective of size or contour were included as lymph nodes. The prognostic value of the fifth edition was better than that of the sixth. | We demonstrate there is a place for tumor deposits in the staging of patients with colorectal cancer. However, many questions remain about their definition and the reproducibility and use of this category in special situations, such as after neoadjuvant treatment. These should be the subject of additional research before use as a factor in TNM staging. This work demonstrates the necessity of testing modifications before their introduction. | closed_qa |
Did General Douglas MacArthur have Parkinson disease? | Historians have suggested that MacArthur had Parkinson disease (PD), and that this may have influenced his military judgment. There is little evidence to support or to refute this suggestion. We aimed in this article to review multiple cinematic images, as well as the personal writings of Douglas MacArthur to determine the likelihood that he had PD. A complete review of the Western literature on Douglas MacArthur, including YouTube, Google Scholar/Google Images/Google Video, PubMed, and HighWirePress was undertaken. Over 200 minutes of film footage was analyzed, including such factors as MacArthur's facial profiles, facial expression, gait, posture, and movement. Handwriting samples from over 6 decades were compared for evidence of micrographia. Videos and handwriting samples were independently reviewed by 3 fellowship-trained movement disorders neurologists. Examination of video footage showed evidence of progression of head tremors, postural action tremors, and voice tremors. There were no clear indications of a masked face, rigidity, bradykinesia, or a resting tremor on film footage recorded from 1906 to 1964. There was no evidence of micrographia in handwriting samples. Oral testimony and letters written by an attending gastroenterologist present at MacArthur's death in 1964 revealed no evidence of parkinsonian features. | We conclude that MacArthur had mild essential tremor that was more evident in his postmilitary career. There was no evidence to suggest that he had a clinical diagnosis of progressive PD. | closed_qa |
Does haptoglobin genotype affect early onset of diabetic retinopathy in patients with type 2 diabetes? | There are 2 common alleles for Hp (Hp-1 and Hp-2) and 3 common Hp genotypes: Hp1-1, Hp2-1, and Hp2-2. The haptoglobin genotype may play a dual role in morbidities of diabetes: Hp1-1, protective and Hp2-2, provocative. This study investigated the possible association of haptoglobin genotypes with onset of retinopathy in Type 2 diabetes (DM2). The sample included 98 consecutive adults with DM2 under routine outpatient follow-up from 2007 to 2009 who met the criteria for either no retinopathy at ≥10 years after diagnosis (Group 1) or proliferative retinopathy at ≤10 years after diagnosis (Group 2). Blood samples were collected for haptoglobin genotyping by polymerase chain reaction. Findings were compared between and within groups. Eighty-four patients had no retinopathy and 14 had early proliferative retinopathy. The distributions of the Hp genotypes were as follows: no-retinopathy group: 28.6% Hp1-1, 35.7% Hp2-1, and 35.7% Hp2-2 and proliferative retinopathy group: 22.6% Hp1-1, 27.4% Hp2-1, and 50% Hp2-2 (NS). On statistical analysis (limited to the larger no-retinopathy group), a predominance of Hp1-1 was noted in older patients; Hp2-2 was associated with an increased rate of stroke. | The Hp genotype apparently plays no role in the development or worsening of proliferative retinopathy in DM2. Hp1-1 may be involved in delaying the onset of diabetes. Hp2-2 may pose a microvascular risk. | closed_qa |
Does inflammation predispose to recurrent vascular events after recent transient ischaemic attack and minor stroke? | Inflammation is implicated in the pathogenesis and outcome of ischaemic injury. Poststroke inflammation is associated with outcome but it remains unclear whether such inflammation precedes or results from ischaemic injury. We hypothesised that inflammatory markers are associated with an increased risk of recurrent vascular events soon after transient ischaemic attack and minor stroke. This was a multicentre, prospective, nested case-control study. Plasma concentrations of C-reactive protein, interleukin-6, interleukin-1-receptor antagonist and fibrinogen, leucocyte counts, erythrocyte sedimentation rate and inflammatory gene allele frequencies were analysed in 711 patients with recent transient ischaemic attack or minor stroke. Cases were defined by the incidence of one or more recurrent vascular events during the three-month follow-up. Association of inflammatory markers with case-status was determined using conditional logistic regression. Plasma concentrations of C-reactive protein, interleukin-1-receptor antagonist and interleukin-6 were not associated with case-status. In secondary analyses, only erythrocyte sedimentation rate was significantly associated with case-status (odds ratio 1·39, 95% confidence interval 1·03-1·85; P=0·03), but this effect did not persist after adjustment for smoking and past history of transient ischaemic attack or stroke. Single nucleotide polymorphisms in four inflammatory genes (interleukin-6, fibrinogen, P-selectin and vascular cell adhesion molecule-1) were nominally associated with case-status. | Circulating inflammatory markers were not associated with recurrent vascular events. Nominally significant associations between genetic markers and case-status will require replication. These data provide little evidence for an inflammatory state predisposing to stroke and other vascular events in a susceptible population. | closed_qa |
Stroke unit care: does ischemic stroke subtype matter? | Stroke unit care improves outcomes following ischemic stroke. However, it is not known whether all ischemic stroke subtypes benefit equally from stroke unit admission. To determine whether the benefit of stroke unit admission is similar among all ischemic stroke subtypes. Design, setting and patients Prospective cohort study including patients admitted with an acute ischemic stroke between July 2003 and September 2007 to stroke centers participating institutions in the Registry of the Canadian Stroke Network. Ischemic stroke subtype information was determined according to the modified Trial of Org 10 172 in Acute Stroke Treatment criteria and categorized as small vessel disease (lacunar), large artery atherosclerotic disease, cardioembolic, or other (including both other determined and undetermined causes). Main outcome measures The primary outcome measure was all-cause mortality at 30 days after stroke. Secondary outcomes were seven-day mortality and death or institutionalization at discharge. Among 6223 eligible patients with ischemic stroke admitted to regional stroke centers in Ontario, the mean age was 72 years and 52·4% were male. Overall 30-day mortality was 12·2%. The 30-day risk-adjusted mortality was lower for stroke unit care across all stroke subtypes (for lacunar stroke 3·0% vs. 5·3%; for large artery disease 7·5% vs. 14·5%; for cardioembolic 15·3% vs. 23·3%; and for other causes 8·9% vs. 15·9%). In multivariable analysis, after controlling for age, gender, medical comorbidities, and stroke severity, there was a significant reduction in stroke mortality associated with stroke unit admission in all stroke subtypes (odds ratio (95% confidence interval) for lacunar stroke 0·48 (0·27-0·88), for large artery atherosclerotic disease 0·39 (0·27-0·56), for cardioembolic 0·46 (0·36-0·59), and for other causes 0·45 (0·29-0·70)). The results remained similar after a sensitivity analysis excluding patients receiving palliative care, and a secondary analysis including 3215 patients with missing Trial of Org 10 172 in Acute Stroke Treatment classification. | This study provides 'real-world' evidence that all ischemic stroke subtypes do benefit from a stroke unit admission regardless of the etiology. There is no justification for withholding access to stroke unit care based on stroke subtype. | closed_qa |
Does the diet of Tehranian adults ensure compliance with nutritional targets? | To analyse dietary compliance with WHO/FAO nutritional objectives, identify food subgroups that contribute to discrepancies between dietary intakes and recommendations, and assess food patterns and risk factor profiles at common nutritional targets. The study was a population-based, cross-sectional assessment of the dietary patterns of Tehranian adults. Usual dietary intake was assessed in relation to common nutritional targets of public health (fat, saturated fat, dietary fibre, fruit and vegetables) using a validated FFQ. Metabolic syndrome (MetS) risk factors were diagnosed based on the Iranian-modified diagnostic criteria of the National Cholesterol Education Program Adult Treatment Panel III. The Tehran Lipid and Glucose Study (2005-2008). A total of 2510 individuals (1121 men and 1389 women), aged between 19 and 70 years. Generally, 68·5 % of total grain ounce-equivalents were derived from refined grains, with rice making up 36·6 % of all grains consumed. Solid fat (61·1 %) contributed more to discretionary energy than did added sugars (38·9 %). There was a twofold difference in fruit and vegetable consumption between the lowest and highest quartile categories of dietary fibre intake. The probability of having MetS was significantly lower in the highest quartile of fibre intake v. the lowest (OR = 0·69, 95 % CI 0·58, 0·84 v. OR = 0·92, 95 % CI 0·80, 1·03; P -trend<0·001), whereas it was higher in the highest quartile of SFA intake v. the lowest (OR = 0·92, 95 % CI 0·78, 0·98 v. OR = 0·71, 95 % CI 0·62, 0·89; P-trend = 0·01). | Complying with common nutritional targets of public health is inversely associated with MetS risk factors in Tehranian adults. These results may initiate measures for future development of regional food-based dietary guidelines. | closed_qa |
Child-, adolescent- and young adult-onset depressions: differential risk factors in development? | Previous research reported that childhood adversity predicts juvenile- onset but not adult-onset depression, but studies confounded potentially genuine differences in adversity with differences in the recency with which adversity was experienced. The current study paper took into account the recency of risk when testing for differences among child-, adolescent- and young adult-onset depressions. Up to nine waves of data were used per subject from two cohorts of the Great Smoky Mountains Study (GSMS; n=1004), covering children in the community aged 9-16, 19 and 21 years. Youth and one of their parents were interviewed using the Child and Adolescent Psychiatric Assessment (CAPA) between ages 9 and 16; these same youth were interviewed using the Young Adult Psychiatric Assessment (YAPA) at ages 19 and 21. The most common psychosocial risk factors for depression were assessed: poverty, life events, parental psychopathology, maltreatment, and family dysfunction. Consistent with previous research, most childhood psychosocial risk factors were more strongly associated with child-onset than with adolescent-/adult-onset depression. When potentially genuine risk differences among the depression-onset groups were disentangled from differences due to the recency of risk, child- and young adult-onset depression were no longer different from one another. Adolescent-onset depression was associated with few psychosocial risk factors. | There were no differences in putative risk factors between child- and young adult-onset depression when the recency of risk was taken into account. Adolescent-onset depression was associated with few psychosocial risk factors. It is possible that some adolescent-onset depression cases differ in terms of risk from child- and young adult-onset depression. | closed_qa |
Does the prophylactic administration of magnesium sulphate to patients undergoing thoracotomy prevent postoperative supraventricular arrhythmias? | Supraventricular arrhythmias (SVA) are common after thoracic surgery and are associated with increased morbidity and mortality. This prospective, randomized, double-blind, placebo-controlled trial examined the effects of perioperative magnesium on the development of postoperative SVA. Two hundred patients undergoing thoracotomy for lobectomy, bi-lobectomy, pneumonectomy, or oesophagectomy were recruited and randomly allocated into two groups. The treatment group received magnesium (5 g daily) intraoperatively, and on days 1 and 2 after operation, the control group received placebo. The primary outcome of the study was the development of SVA within the first 5 days after operation. There were 100 patients in each arm of the study, with one withdrawal and three lost to follow-up in the treatment group and four withdrawals in the control group. Ninety-six patients received magnesium and 96 received placebo. There was no difference in the incidence of SVA between the treatment and control groups, 16.7% (16/96) vs 25% (24/96), P=0.16. In the predefined subgroup analysis, patients at highest risk of arrhythmias (those undergoing pneumonectomy) had a significant reduction in the frequency of SVA, 11.1% (2/18) vs 52.9% (9/17), P=0.008. There were no differences in hospital length of stay or mortality. Patients receiving i.v. magnesium experienced a higher frequency of minor side-effects (stinging at injection site). The treatment was otherwise well tolerated. | Overall, prophylactic magnesium did not reduce the incidence of SVA in patients undergoing thoracotomy. However, it reduced the incidence of SVA in the high-risk cohort of patients undergoing pneumonectomy. (ISRCTN22028180.). | closed_qa |
Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error? | We aimed to assess whether routine data produced by an electronic prescribing system might be useful in identifying doctors at higher risk of making a serious prescribing error. Retrospective analysis of prescribing by junior doctors over 12 months using an electronic prescribing information and communication system. The system issues a graded series of prescribing alerts (low-level, intermediate, and high-level), and warnings and prompts to respond to abnormal test results. These may be overridden or heeded, except for high-level prescribing alerts, which are indicative of a potentially serious error and impose a 'hard stop'. A large teaching hospital. All junior doctors in the study setting. Rates of prescribing alerts and laboratory warnings and doctors' responses. Altogether 848,678 completed prescriptions issued by 381 doctors (median 1538 prescriptions per doctor, interquartile range [IQR] 328-3275) were analysed. We identified 895,029 low-level alerts (median 1033 per 1000 prescriptions per doctor, IQR 903-1205) with a median of 34% (IQR 31-39%) heeded; 172,434 intermediate alerts (median 196 per 1000 prescriptions per doctor, IQR 159-266), with a median of 23% (IQR 16-30%) heeded; and 11,940 high-level 'hard stop' alerts. Doctors vary greatly in the extent to which they trigger and respond to alerts of different types. The rate of high-level alerts showed weak correlation with the rate of intermediate prescribing alerts (correlation coefficient, r = 0.40, P =<0.001); very weak correlation with low-level alerts (r = 0.12, P = 0.019); and showed weak (and sometimes negative) correlation with propensity to heed test-related warnings or alarms. The degree of correlation between generation of intermediate and high-level alerts is insufficient to identify doctors at high risk of making serious errors. | Routine data from an electronic prescribing system should not be used to identify doctors who are at risk of making serious errors. Careful evaluation of the kinds of quality assurance questions for which routine data are suitable will be increasingly valuable. | closed_qa |
Does adding information on job strain improve risk prediction for coronary heart disease beyond the standard Framingham risk score? | Guidelines for coronary heart disease (CHD) prevention recommend using multifactorial risk prediction algorithms, particularly the Framingham risk score. We sought to examine whether adding information on job strain to the Framingham model improves its predictive power in a low-risk working population. Our analyses are based on data from the prospective Whitehall II cohort study, UK. Job strain among 5533 adults (mean age 48.9 years, 1666 women) was ascertained in Phases 1 (1985-88), 2 (1989-90) and 3 (1991-93). Variables comprising the Framingham score (blood lipids, blood pressure, diabetes and smoking) were measured at Phase 3. In men and women who were CHD free at baseline, CHD mortality and non-fatal myocardial infarction (MI) were ascertained from 5-yearly screenings and linkage to mortality and hospital records until Phase 7 (2002-04). A total of 160 coronary deaths and non-fatal MIs occurred during the mean follow-up period of 11.3 years. The addition of indicators of job strain to the Framingham score increased the C-statistics from 0.725 [95% confidence intervals (95% CIs): 0.575-0.854] to only 0.726 (0.577-0.855), corresponding to a net reclassification improvement of 0.7% (95% CIs: -4.2 to 5.6%). The findings were similar after inclusion of definite angina in the CHD outcome (352 total cases) and when using alternative operational definitions for job strain. | In this middle-aged low-risk working population, job strain was associated with an increased risk of CHD. However, when compared with the Framingham algorithm, adding job strain did not improve the model's predictive performance. | closed_qa |
Increased conjunctival expression of protease activated receptor 2 (PAR-2) in seasonal allergic conjunctivitis: a role for abnormal conjunctival epithelial permeability in disease pathogenesis? | Aeroallergen exposure to the conjunctival epithelium in seasonal allergic conjunctivitis (SAC) may induce a cellular stress response that disrupts the barrier properties of the conjunctival epithelium, resulting in allergic disease. Whether such changes occur in SAC is unknown. Epithelial permeability is known to be increased when protease activated receptor 2 (PAR-2) is activated. We evaluated the expression of PAR-2 in patients with SAC-in-season (SACS) and compared it with control non-atopic subjects or those with out-of-season allergic conjunctivitis (OSAC). Six SACS, eight normal and four OSAC specimens were examined immunohistochemically for PAR-2 and quantified in a masked fashion for the percentage of epithelia stained for each marker using Image-J software. Conjunctival epithelial heights were measured in all groups to confirm the presence of allergic eye disease. Mean percentage staining of PAR-2 was significantly greater in SACS that in normal specimens (73.4 ± 15.4% vs 32.8 ± 30.0%, p=0.038) or in OSAC (73.4 ± 15.4% vs 1.4 ± 2.2%, p=0.01). Mean conjunctival epithelial height was significantly raised in SACS (63.8 ± 9.0 μm) versus controls (44.7 ± 11.2 μm) (p=0.003, unpaired t test). | Conjunctival epithelial PAR-2 is significantly upregulated in SAC. This supports the view that disruption of the barrier properties of the conjunctival epithelium is an important event in SAC pathogenesis. | closed_qa |
Is the ACT two minutes after heparin injection reliable? | Blood for activated clotting time (ACT) measurement to verify the effect of the initial dose of heparin before cannulation in heart surgery has traditionally been drawn 5 minutes (min) after injection of the heparin. However, there has been an increasing demand to reduce the waiting time. The aim of this study was to investigate if ACT measured 1, 2, 3 and 4 min after heparin injection is as reliable as ACT measured 5 min after heparin injection. Fifty adult patients undergoing routine cardiac surgery with a heart-lung machine. Heparinization was obtained with unfractioned porcine heparin. The ACT was measured with 5 Hemochron® Jr. machines 1, 2, 3, 4 and 5 min after the heparin injection. Full heparinization was defined as an ACT>400 seconds. At 1 and 2 min, 94% (n=47) of the ACTs were>400. All ACTs>400 seconds after 2 min remained>400 seconds at 3, 4 and 5 min. Mean values declined from 533 to 498. ANOVA analysis showed statistically significantly higher values at 1, 2 and 3 min, compared to 5 min, but not at 4 min. However, the estimated differences were small: 3.7-36 seconds. There was no significant difference between variances for the five sample times. Standard deviation declined from 123 to 100. Values at 2 min correlated as well as those at 5 min with mean 1-5 min values. | The range of the ACT values tends to diminish over time and, consequently, the reliability of the results increases. However, the difference is small and has little or no clinical relevance. Giving time for the circulation to distribute the heparin in the bloodstream, we recommend measuring the ACT two min after heparin administration. | closed_qa |
Does state regulation of quality impose costs on nursing homes? | Government regulation is intended to enhance quality, safety, fairness, or competition in the regulated industry. Such regulation entails both direct and indirect costs. To estimate the costs associated with the regulation of quality of the nursing home industry. This study includes 11,168 free-standing nursing homes nationally, between 2004 and 2006. Data included information from the Medicare cost reports, Minimum Data Set, Medicare Denominator file, OSCAR, and a survey of States' Certification and Licensing Offices conducted by the authors. These data were used to create variables measuring nursing homes costs, outputs, wages, competition, adjusted deficiency citations, ownership, state-fixed effects, and an index of each state's regulatory stringency. We estimated hybrid cost functions which included the regulatory stringency index. The estimated cost functions demonstrated the typical behavior expected of nursing home cost functions. The stringency index was positively and significantly associated with costs, indicating that nursing homes located in states with more stringent regulatory requirements face higher costs, ceteris paribus. The average incremental costs of a 1 standard deviation increase in the stringency index resulted in a 1.1% increase in costs. | This study for the first time places a price tag on the regulation of quality in nursing homes. It offers an order of magnitude on the costs to the industry of complying with the current set of standards and given the current level of enforcement. Complementary studies of the benefits that these regulations entail are needed to gain a comprehensive assessment of the effect of the regulation. | closed_qa |
Does diet cost mediate the relation between socioeconomic position and diet quality? | Socioeconomic disparities in diet quality are well established. This study tested the hypothesis that such disparities are mediated, in part, by diet cost.SUBJECTS/ The Seattle Obesity Study (S.O.S) was a cross-sectional study based on a representative sample of 1266 adults of King County, WA, conducted in 2008-09. Demographic and socioeconomic variables were obtained through telephone survey. Income and education were used as indicators of socioeconomic position. Dietary intake data were obtained using a food frequency questionnaire (FFQ). Diet cost was calculated based on retail prices for FFQ component foods. Energy density (KJ/g) and mean adequacy ratio (MAR) were used as two indices of overall diet quality. Higher income and education were each associated with lower energy density and higher MAR scores, adjusting for covariates. Higher income and education were also associated with higher energy adjusted diet cost. Higher quality diets were in turn associated with higher diet costs. All these associations were significant (P<0.0001). In formal mediation analyses, diet cost significantly mediated the pathway between income and diet quality measures, adjusting for covariates (P<0.05 each). Further, income-diet cost-diet quality pathway was found to be moderated by education level. | The social gradient in diet quality may be explained by diet cost. Strategies to improve diet quality among lower socioeconomic strata may need to take food prices and diet cost along with nutrition education into account. | closed_qa |
Is ¹⁵³Samarium-ethylene-diamine-tetramethyl-phosphonate (EDTMP) bone uptake influenced by bisphosphonates in patients with castration-resistant prostate cancer? | To evaluate the impact of biphosphonate administration on subsequent (153)Samarium-ethylene-diamine-tetramethyl-phosphonate (EDTMP) uptake in bone metastases of patients with castration-resistant prostate cancer. The bone uptake of (153)Sm-EDTMP was assessed in 40 consecutive patients with castration-resistant prostate cancer and multiple painful bone metastases and no prior bisphosphonate therapy. (153)Sm-EDTMP was repeated after 3 months in the presence of bisphosphonates (zoledronic acid every 4 weeks, first administration 1 week after (153)Sm-EDTMP administration). The retained activity in bone was evaluated 20 h after application using whole-body scintigraphy (acquisition 15 cm/min). Mean patient age was 69 ± 4.8 years (range 57-77 years). Mean PSA level at study entry was 18.2 ± 21.0 ng/ml. (153)Sm-EDTMP uptake ranged from 36.3 to 75.3% (mean 55.1 ± 10.9%) before bisphosphonate administration and 35.6 to 73.3% (mean 55.2 ± 10.4%) after bisphosphonate administration. No significant intra-individual difference with or without bisphosphonate treatment was observed (P = 0.647). | Bisphosphonate treatment does not affect (153)Sm-EDTMP bone uptake in patients with castration-resistant metastatic prostate cancer. Thus, bisphosphonate treatment can be continued safely during samarium therapy. | closed_qa |
Asperger syndrome: can the disorder be diagnosed in the adult age? | Asperger Syndrome (AS) is characterized by a qualitative disorder of social interaction, a pattern of restrictive, repetitive and stereotyped behavior, interests and activities, with normal intellectual capacity and normal language skills in the areas of grammar and vocabulary. Since its inclusion in international taxonomies, there has been much controversy regarding its nosological validity. A patient with a diagnosis of AS in adulthood is described. Results from the psychopathological, personality and cognitive functioning assessment are included. | Asperger Syndrome can also be diagnosed in adulthood and should be suspected whenever retrospective information and clinical assessment point to this diagnosis. | closed_qa |
Surgery for ischemic mitral regurgitation: should the valve be repaired? | Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) often have concomitant mitral regurgitation (MR). Repairing the valve at the time of surgery is not universally accepted. The results of CABG with or without mitral valve annuloplasty (MVA) were compared in patients with reduced left ventricular (LV) function and ischemic MR. Among a total of 195 patients, 108 underwent isolated CABG, and 87 underwent CABG with MVA. The study end-points included survival, degree of MR, and NYHA functional class. Patients in the MVA group were younger (mean age 63 +/- 10 versus 68 +/- 9 years; p<0.001), but had a more severe cardiac pathology, with severe LV dysfunction in 45% versus 26% (p = 0.006) and severe MR in 82% versus 14% (p<0.001). The operative mortality was 9%, and similar in both groups. The follow up was complete, with a mean survival period of 87 +/- 50 months. Although, overall, no improvement was seen in LV function, symptomatic improvement was more pronounced in the MVA group (p = 0.006). At follow up, residual MR was present in 2% of the MVA group and in 47% of the CABG-only group (p<0.0001). For the MVA and CABG-only groups, respectively, survival at five and 10 years was 68% and 46% versus 77% and 52% (p = NS). By multivariate analysis, neither degree of MR nor LV function at follow up had any impact on survival. | In patients with a reduced LV function undergoing CABG, the addition of a mitral annuloplasty does not increase the operative risk. Although patients in the MVA group were more ill, there was a better symptomatic improvement in this group, and they attained a similar survival. It is recommended that MVA be performed at the time of CABG in patients having moderate or greater MR associated with a reduced LV function. | closed_qa |
Do transdermal opioids reduce healthcare use in an Australian rural pain population? | To determine whether transdermal (TD) opioids reduce healthcare contacts when compared with oral opioids in a rural population with chronic noncancer pain (CNCP). An observational longitudinal study to measure the changes in self-reported healthcare use by the route of opioid administration over time (monthly for 1 year). Subjects were opioid-treated CNCP patients from North West Tasmania. The subjects completed the monthly datasheets by recording all healthcare contacts and the routes of opioid administration. The outcome measures of mean monthly healthcare contacts (MHCs) by the routes of opioid administration were analyzed using generalized estimating equations with robust standard errors. The details of 10,564 healthcare contacts from 198 subjects were obtained during the study. General practitioner (GP) mean MHCs were 2.01 (95% confidence intervals [CI] = 1.58-2.45) for oral opioids and significantly (p = 0.02) lower by 0.38 (95% CI = -0.70 to -0.05) contacts for TD opioids. Pharmacy mean MHCs were 2.44 (95% CI = 1.88-3.00) for oral opioids and unchanged (p = 0.86) by -0.04 (95% CI = -0.44-0.37) for TD opioids. Total mean MHCs with oral opioid use were 5.98 (95% CI = 4.93-7.03). With TD opioid use, this was nonsignificantly lower (p = 0.12) by 0.62 (95% CI = -1.40-0.15) contacts. | The use of TD opioid preparations, with their prolonged analgesic effect, may reduce total healthcare activity and significantly reduce GP contact. This may particularly benefit a rural population where there is a relative shortage of doctors. | closed_qa |
Is ductal carcinoma in situ with "possible invasion" more predictive of invasive carcinoma than pure ductal carcinoma in situ? | To compare the underestimation of ductal carcinoma in situ (DCIS) vs DCIS with "possible invasion" at breast biopsy and to determine if any factors related to clinical indication, imaging abnormality, biopsy, or DCIS-grade affected the likelihood of underestimation. Of 3836 consecutive lesions that were biopsied by using a 14-gauge needle, 117 lesions revealed DCIS. Surgical pathology results of invasive carcinoma were compared with needle biopsy results of DCIS or DCIS with possible invasion. Clinical indication, imaging abnormality, biopsy guidance modality, sample number, and histologic grade were recorded. Yates corrected χ(2) and Fisher exact tests were used to determine differences between groups. A total of 101 lesions were DCIS and 16 were DCIS with possible invasion at biopsy. Thirty-six of 117 lesions (31%) revealed invasive carcinoma at resection pathology. Invasive carcinoma was present more often when DCIS with possible invasion was diagnosed compared with pure DCIS (7/16 [44%] vs 29/101 [29%], P = .36). No factor, including clinical indication, imaging abnormality, biopsy guidance method, sample number, or grade, was found to significantly affect the likelihood of underestimation for lesions diagnosed as DCIS vs DCIS with "possible invasion." The likelihood of pure DCIS underestimation significantly increased when lesions were high grade compared with either intermediate or low grade (18/44 [41%] vs 9/44 [21%]vs 2/10 [20%], P = .03). | For lesions biopsied by using a 14-gauge needle, there is a trend towards underestimation of the presence of invasive carcinoma when pathology reveals DCIS with possible invasion compared with pure DCIS. High-grade DCIS was significantly more likely to be underestimated. | closed_qa |
Is relative leg length a biomarker of childhood nutrition? | Relative leg length is frequently used as a biomarker of childhood nutrition in epidemiological studies, but evidence is lacking. We examined the association between supplemental nutrition in pregnancy and childhood and relative proportions of components of height in adolescence. In a community trial of nutritional supplementation, villages from adjacent administrative areas were selected to serve as intervention (n = 15) and control (n = 14) arms. In the intervention villages, balanced protein-calorie supplementation (2.51 MJ, 20 g protein) was offered daily to pregnant women and their offspring until the age of 6 years. Children born in the trial were re-examined 15 years later to assess components of height. A total of 1165 adolescents (intervention: 654, 49% of trial participants; control: 511, 41% of trial participants) aged 13-18 years were examined. Supplemented children were 10 mm taller [95% confidence interval (CI): 1.4 to 18.7 mm], but almost all of the increase was in trunk length (9 mm, 95% CI: 2.6 to 15.4 mm). The age- and gender-adjusted β-coefficients for the association of nutritional supplementation with relative trunk, leg and lower leg lengths (expressed as standard deviation scores) were 0.26 (95% CI: 0.11 to 0.42), 0.08 (95% CI: -0.03 to 0.19) and 0.03 (95% CI: -0.08 to 0.15) respectively, thereby unsupportive of cephalocaudal gradient in growth. | In this nutritional supplementation trial in an undernourished population, we were unable to confirm relative leg length as a biomarker of childhood nutrition. Alternative explanations may underlie the reported associations between childhood conditions and relative leg length. | closed_qa |
Is patient autonomy a critical determinant of quality of life in Korea? | We aimed to investigate the current practice of the involvement in decision making from the perspectives of terminal cancer patients, and to explore its possible associations with quality of life and quality of death in Korea. A multi-center, cross-sectional survey was performed on 93 terminal cancer patients. The questionnaire solicited their opinions regarding participation in treatment decision making, as well as quality of life (European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire for Palliative Care) and quality of death (Good Death Inventory-Patient Version). A total of 78.5% of the patients had awareness of their terminal status, while 21.5% did not; 42.4% stated that they knew their condition and shared the decision-making responsibility with the medical staff and their family, while 21.7% made decisions on their own, and 35.9% left the decision-making responsibility to others. Patients who were aware of their illness and who actively participated in the decision making did not score higher than others on outcome measures of quality of life and quality of death. Moreover, the former even showed lower scores in some domains, including the 'physical and psychological comfort' (4.99 versus 5.61, p = 0.03), 'environmental comfort' (5.51 versus 6.04, p = 0.08), and 'emotional functioning' (55.70 versus 71.01, p = 0.06). | in Korea, patient autonomy is not a universally accepted value from the perspectives of terminal cancer patients, nor is patient involvement in decision making always conducive to high quality of life or quality of death. The level of information and the pace at which it is provided should be tailored to each individual's ability, preference, need, and culture. | closed_qa |
Does maternal weight gain in pregnancy have long-term effects on offspring adiposity? | A small number of relatively small studies have found greater gestational weight gain to be associated with greater offspring body mass index (BMI; in kg/m(2)), but whether this association is caused by intrauterine mechanisms or by shared genetic and environmental risk factors for adiposity is unclear. The objective was to examine the association of greater maternal weight gain (MWG; postnatal weight minus weight at the first antenatal clinic assessment) with greater offspring BMI and to explore whether any observed association is explained by intrauterine mechanisms. This was a prospective cohort study that used record linkage data (n = 146,894 individuals from 136,050 families). To compare the within-sibling and between-nonsibling associations, we used fixed- and between-cluster linear regression models. Associations of MWG with later offspring BMI differed by the mother's early-pregnancy overweight or obesity status (P for interaction<0.0001). MWG was positively associated with BMI at a mean age of 18 y in the offspring of normal-weight women but only between unrelated men (0.07; 95% CI: 0.06, 0.07) per 1-kg greater MWG; no within-sibling association (0.00; 95% CI: -0.02, 0.02) per 1-kg greater MWG was found. In contrast, in overweight and obese women we found a within-sibling association (0.06; 95% CI: 0.01, 0.12) and an association between unrelated men (0.02; 95% CI: 0.01, 0.03) per 1-kg greater MWG. | In normal-weight mothers, most of the association between MWG and later offspring BMI is explained by shared familial (genetic and early environmental) characteristics, whereas evidence indicates a contribution of intrauterine mechanisms in overweight and obese women. | closed_qa |
Does filial piety decrease depression among family caregivers? | To examine the effects of filial piety - the practice of filial respect of and care for parents - on depressive symptoms among adult children caregivers of elderly Arab parents in Israel, and to identify factors that may mediate the association. Cross-sectional data were collected in 2006-2007 by a structured interview from 250 randomly sampled Arab-Israeli adult children caregivers (response rate, 94%). Path analysis was used to examine the study objectives. Filial piety was not directly related to depression, but rather worked indirectly through caregiving burden. Caregiver depression was predicted positively by caregiving burden, while burden was predicted negatively by filial piety. Sense of mastery emerged as a major (negative) predictor and as a mediator between caregiving burden and depressive symptoms. | The analysis showed that caregiving burden in this population of traditional caregivers was associated with depressive symptoms, while most other variables were mediated through caregiving burden, sense of mastery, or filial piety. Researchers and practitioners should be sensitive to issues of family care among such traditional populations in transition. | closed_qa |
Is the magnetization transfer ratio a marker for myelin in multiple sclerosis? | To investigate the correlation between water content (WC) and magnetization transfer ratio (MTR) in normal and multiple sclerosis (MS) brain. The MTR has been proposed as a marker for myelin in central nervous system tissue. However, changes in WC due to inflammation and edema may also affect the MTR. Seven MS subjects with active disease and seven age- and gender-matched controls were scanned using quantitative magnetic resonance techniques. WC, myelin water content, T(1) relaxation time, and MTR were calculated from areas of lesion (divided into new lesions less than 2 months old, isointense T(1) lesions, and hypointense T(1) lesions), contralateral normal-appearing white matter (NAWM), and location-matched normal white matter (NWM) in controls. Linear regression was used to determine the correlation between WC and MTR. A significant correlation was found between WC and MTR across all tissue (R = -0.65, P<0.0005). | MTR was correlated with WC in MS tissue, indicating that inflammation and edema influence MTR. Therefore, caution should be used when associating MTR exclusively with myelin content. | closed_qa |
Do infants treated in the neonatal intensive care unit need multi-stage, universal hearing screening testing? | The universal hearing screening program has special value for neonatal intensive care unit (NICU) patients because of the multiple risk factors of hearing loss they are subjected to.AIM: To summarize the results of hearing tests on consecutive stages of the screening program and to evaluate the value of hearing loss factors. The group included 851 infants born between 1.10.2006 - 31.12.2009 and treated in the NICU of the University Children's Hospital in Cracow, Poland. Infants with abnormal screening test results (TEOAE) and/or with hearing loss risk factors, or absent from the first stage of the test were qualified for the next stage hearing diagnostics (TEOAE+ABR). Multivariate logistic regression was used in order to evaluate hearing loss risk factors. 679 (80%) newborns were screened by the first stage hearing test. 579 (68%) were tested on the second level diagnostics. 60 patients are still under control. 11/519 (2.1%) had hearing impairment (sensorineual or mixed). 10 had bilateral and 1 had unilateral hearing impairment. The family history was negative for congenital hypoacusis. 1st minute Apgar score<4 points, congenital TORCH infections and craniofacial anomalies were independent risk factors of hearing loss, however it was not possible to predict more than 2/11 patients with hearing loss based on these factors. Patients with abnormal result of the first stage test had lower birth weight and gestation age than that with normal result. The sensitivity of the first TEOAE test was 82%, specificity 70%, PPV 6.2%, NPV 99%. | Hearing impairment was rarely a complication of treatment in the NICU, although it was 10 times more frequent in comparison to the whole newborn population. Because the sensitivity, specificity and PPV of first hearing test is not satisfactory, next stage diagnostics in the audiology department are strongly recommended. | closed_qa |
Can we continue to ignore gender differences in performance on simulation trainers? | There are differences between the genders in their innate performances on simulation trainers, which may impair accurate assessment of psychomotor skills. The performance of fourth-year students with no exposure to the Minimally Invasive Surgical Trainer compared based on gender, and other psychomotor skills. Our study included 16 male and 16 female students. After adjusting for choice of medical specialty (P<.001), current video game use (P=.6), and experience in the operating room (P=.4), female sex was an independent factor for worse performance (P=.04) in multivariate models. Women took more time than men (P<.01) and made more errors (29 versus 25 on 3 reps, P<.01). | Among medical students with no previous exposure to laparoscopic trainers, female students perform worse than male students after adjusting for confounding factors. This difference must be recognized by training programs while using simulators for training and evaluation. | closed_qa |
Thinking critically about critical thinking: ability, disposition or both? | The objectives of this study were to determine the extent to which clinician-educators agree on definitions of critical thinking and to determine whether their descriptions of critical thinking in clinical practice are consistent with these definitions. Ninety-seven medical educators at five medical schools were surveyed. Respondents were asked to define critical thinking, to describe a clinical scenario in which critical thinking would be important, and to state the actions of a clinician in that situation who was thinking critically and those of another who was not. Qualitative content analysis was conducted to identify patterns and themes. The definitions mostly described critical thinking as a process or an ability; a minority of respondents described it as a personal disposition. In the scenarios, however, the majority of the actions manifesting an absence of critical thinking resulted from heuristic thinking and a lack of cognitive effort, consistent with a dispositional approach, rather than a lack of ability to analyse or synthesise. | If we are to foster critical thinking among medical students, we must reconcile the way it is defined with the manner in which clinician-educators describe critical thinking--and its absence--in action. Such a reconciliation would include consideration of clinicians' sensitivity to complexity and their inclination to exert cognitive effort, in addition to their ability to master material and process information. | closed_qa |
Could different hydration protocols affect the quality of 18F-FDG PET/CT images? | In a group of oncologic patients undergoing (18)F-FDG PET/CT, we compared 4 different protocols of hydration to investigate their impact on image quality and to choose the best practice. One hundred twenty subjects undergoing (18)F-FDG PET/CT were randomized into 4 groups: group A, receiving free oral hydration; group B, receiving an intravenous injection of 10 mg of furosemide and infusion of 500 mL of saline solution starting 5 min after tracer injection; group C, receiving oral hydration with 500 mL of water; and group D, receiving intravenous injection of 10 mg of furosemide and infusion of 250 mL of the saline solution starting 30 min after the (18)F-FDG injection. The maximum standardized uptake value of muscular and adipose tissues, blood pool (aortic and left ventricular cavity), bladder, and renal parenchyma was calculated for each subject. These 4 groups were comparable in age, body mass index, blood glucose level, and serum creatinine level. Group A showed the worst results. The controlled hydration protocols (groups B, C, and D) provided lower background activity in the soft tissues and lower urinary activity in the bladder and kidney without significant differences in blood activity. The administration of furosemide produces lower activity in the urinary tract without significant changes in (18)F-FDG distribution in the muscle, fat, or blood pool. The best results were in group D. | Controlled hydration, particularly with standardized parenteral protocols, reduces the background activity in the soft tissues with the potential benefit of increasing the tumor-to-background contrast. Furosemide does not change tracer distribution in normal tissues but improves the quality of PET/CT images, reducing activity in the excretory system, particularly if the furosemide is administered late after (18)F-FDG injection. | closed_qa |
Could polyunsaturated fatty acids deficiency explain some dysfunctions found in ADHD? | The objective is to evaluate possible mechanisms explaining the link between polyunsaturated fatty acid (PUFA) deficiencies and ADHD, based on findings from animal research. The authors consulted peer-reviewed publications from the last 10 years (Medline and resulting reference lists). PUFA deficiency in rodents results in behavioral changes (increased motor activity and decreased learning abilities) and dysregulations of monoamine neurotransmission. Behavioral improvement following a PUFA recovery diet is observed, but recovery of brain monoamine dysregulation is not fully demonstrated. Anti-inflammatory processes could damage neural membranes, but the direct link with ADHD model is not documented. Synaptic growth and neurogenesis impairment could account for working memory dysregulations, but research is at its early start. | Induced PUFA deficiencies in animals show several noteworthy similarities with brain dysregulations seen in ADHD human children. However, the mechanisms of partial recovery after PUFA supplementation are not fully understood, and rigorous clinical trials have yet to show PUFA supplementation is an effective complementary treatment for ADHD. | closed_qa |
Are distal protection devices 'protective' during carotid angioplasty and stenting? | To evaluate the periprocedural outcome after carotid artery stenting with embolic brain protection (EBP+) versus without embolic brain protection (EBP-). We retrospectively reviewed data from a prospective nonrandomized database of 357 patients who underwent carotid artery stenting in the neuroradiology division of our institution from 1999 to 2009. One hundred five patients underwent angioplasty and stenting without distal protection, whereas 252 were treated with distal protection. Patients were analyzed according to their EBP status (+ or -) for the primary end points of perioperative stroke, death, or myocardial infarction. Unprotected stenting was mostly performed in the early years of this study and this is reflected in significant baseline differences between the two groups. In our earlier experience, carotid artery stenting was used in patients with more significant comorbidities. Diabetes mellitus (P=0.04), previous coronary artery disease (P=0.02) and myocardial infarction (P=0.04), and symptomatic lesion (P=0.01) were significantly more common in the EBP- cohort. Despite these baseline differences, there were no significant differences in the primary end points (2% in the EBP+ group and 4.8% in the EBP-, P=0.15). The incidence of ipsilateral stroke in the EBP- and in the EBP+ group was 3.8% versus 0.8%, respectively (P=0.6). There were 2 perioperative deaths (1 in each group) and 4 myocardial infarctions (3 in the EBP+ arm and 1 in the EBP- arm, all non-Q infarcts; P=nonsignificant). | In accordance with recent literature, this series cast doubts as to the real effectiveness of distal embolic protection devices in reducing periprocedural complications. | closed_qa |
Surgical approach to the cervicothoracic junction: can a standard Smith-Robinson approach be utilized? | Retrospective case series study. To determine when the standard Smith-Robinson approach can be used successfully to approach the cervicothoracic junction (CTJ). Most of techniques for exposing the anterior CTJ are associated with significant morbidity. To our knowledge, there is no reliable technique, which described to determine when the standard Smith-Robinson approach is adequate and when a more invasive approach, such as a sternal splitting approach, is necessary to approach the CTJ anteriorly. We evaluated the ability of the following technique to preoperatively determine whether a standard Smith-Robinson approach can be used to approach the CTJ: on the lateral plain radiograph, a line was drawn from the intended skin incision site to the top of the manubrium (at the suprasternal notch) to the level of the disc space. If it appeared that this trajectory would allow adequate exposure of the CTJ, then the operation was performed through the standard Smith-Robinson approach. The records and radiographs of all patients who had undergone anterior cervicothoracic arthrodesis to T1 or below were evaluated. A total of 99 patients who underwent an anterior cervicothoracic fusion using the standard Smith-Robinson approach were identifed. Using the proposed technique, there were no cases in which the planned lowest instrumented vertebra could not be safely reached through the standard Smith-Robinson approach. No procedure was abandoned or converted to a sternotomy approach. | Our results suggest that if the lowest instrumented vertebra can be seen on a lateral radiograph and a line passing from the intended skin incision site to this level lies on top of the manubrium, a routine Smith-Robinson approach can be used to expose the level. To our knowledge, this is the largest series outlining a simple guideline for approaching the anterior CTJ. | closed_qa |
Should large cell neuroendocrine lung carcinoma be classified and treated as a small cell lung cancer or with other large cell carcinomas? | To compare the presenting and prognostic characteristics of patients with large cell neuroendocrine lung cancer (LCNELC) with those of patients with small cell lung cancer (SCLC) or other large cell carcinomas (OLCs) and to compare overall survival (OS) and lung cancer-specific survival (LCSS) rates for patients undergoing definitive resection without radiotherapy (S-NoRT). The Surveillance Epidemiology and End Results Database-17 from 2001 to 2007 was used. Differences between population characteristics were compared using χ(2) and Wilcoxon tests. The log-rank test and Cox models were used to compare differences in OS and LCSS. There were 1211 patients with LCNELC (324 in the S-NoRT group), 8295 patients with OLC (1120 S-NoRT), and 35,304 patients with SCLC (355 S-NoRT). The proportion of all large cell carcinomas constituted by LCNELC increased from 8 to 21% during the study period; and the proportion of patients with large cell carcinoma undergoing S-NoRT increased from 16 to 26%. Presenting and histopathologic characteristics and treatment factors of patients undergoing S-NoRT for patients with LCNELC were more similar to those of patients with OLC than to those with SCLC. OS and LCSS rates for patients with LCNELC undergoing resection without radiation were similar to those of patients with OLC and better than those for patients with SCLC, but the differences were not statistically significant on multivariate analysis. | The clinical, histopathologic, and biologic features of LCNELC are more similar to OLC than to SCLC. Therefore, LCNELC should continue to be classified and treated as a large cell carcinoma. | closed_qa |
Staphylococcus-infected tunneled dialysis catheters: is over-the-wire exchange an appropriate management option? | Over-the-wire exchange of tunneled dialysis catheters is the standard of care per K/DOQI guidelines for treating catheter-related bacteremia. However, Gram-positive bacteremia, specifically with staphylococcus species, may compromise over-the-wire exchange due to certain biological properties. This study addressed the effectiveness of over-the-wire exchange of staphylococcus-infected tunneled dialysis catheters compared with non-staphylococcus-infected tunneled dialysis catheters. Patients who received over-the-wire exchange of their tunneled dialysis catheter due to documented or suspected bacteremia were identified from a QA database. Study patients (n = 61) had positive cultures for Staphylococcus aureus, Staphylococcus epidermidis, or coagulase-negative staphylococcus not otherwise specified. Control patients (n = 35) received over-the-wire exchange of their tunneled dialysis catheter due to infection with any organism besides staphylococcus. Overall catheter survival and catheter survival among staphylococcal species were assessed. There was no difference in tunneled dialysis catheter survival between study and control groups (P = 0.46). Median survival time was 96 days for study catheters and 51 days for controls; survival curves were closely superimposed. There also was no difference among the three staphylococcal groups in terms of catheter survival (P = 0.31). The median time until catheter removal was 143 days for SE, 67 days for CNS, and 88 days for SA-infected catheters. | There is no significant difference in tunneled dialysis catheter survival between over-the-wire exchange of staphylococcus-infected tunneled dialysis catheters and those infected with other organisms. | closed_qa |
Do we reach target lipid levels in diabetic and non-diabetic patients with previous myocardial infarction? | Considering that dyslipidaemia is an important factor for cardiovascular diseases, target lipid levels are rarely reached in everyday clinical practice. The objective of this study was to evaluate how often we achieve the treatment goals for the lipid parameters in the diabetic and non-diabetic patients after the previous myocardial infarction (MI). The survey included 118 patients (84 males and 34 females), mean age 59.38 +/- 9.86 years, 34 (28.8%) of them diabetics, with the history of MI in the previous 3 years. The patients were selected from the database of multicentre prospective interventional study "Secondary prevention of coronary heart disease and cerebrovascular diseases", conducted in 2005 on 1,189 patients in Serbia. The patients were further followed in the period from 18 (5th visit) and 36 months (6th visit) after inclusion into the study from 2005-2008. Their lipid status, the use of lipid-lowering drugs, and the independent prognostic factors for major adverse coronary events were identified. In the beginning of the study, all patients were informed about the importance of lifestyle change and active approach to treatment. The accomplishment of secondary preventive measures was estimated on the basis of the European guidelines on secondary prevention of the coronary heart disease. Three years after introduction of the preventive measures, diabetics had a higher prevalence of the target levels of the total cholesterol (21.2% vs. 7.6%) and HDL-cholesterol than non-diabetics (100% vs. 87.3%) (p<0.05). Non-diabetics had significantly higher prevalence of the target levels of LDL-cholesterol than diabetics (19% vs. 3%) (p<0.05). No significant differences were found in the prevalence of the treatment goals of triglycerides in diabetic (42.4%) and non-diabetic patients (60.8%) (p>0.05). At the end of the study, after applying secondary prevention measures, 27.3% of diabetics did not use lipid-lowering drugs. The percentage of non-diabetics using no lipid-lowering drugs was lower (20.3%), but the difference was not statistically significant (p>0.05). By using the method Enter Cox regression multivariant analysis, the change in the level of triglycerides, total and LDL-cholesterol were singled out as independent prognostic factors for major adverse coronary events. | Our study has shown high prevalence of increased plasma concentrations in the total, LDL-cholesterol and triglycerides and low plasma concentrations of HDL-cholesterol, as well as the insufficient use of lipid-lowering drugs in diabetic and non-diabetic patients with previous MI. Decreasing the total cholesterol and increasing the HDL-cholesterol are significant, decreasing of triglycerides and LDL-cholesterol does not suffice. Therefore, secondary prevention measures of cardiovascular events should be intensified, especially in patients with diabetes. | closed_qa |
Is there a treatment advantage when paclitaxel and lovastatin are combined to dose anaplastic thyroid carcinoma cell lines? | Anaplastic thyroid carcinoma (ATC) is the most aggressive type of thyroid carcinoma. The purpose of this study was to evaluate the combined cytotoxic effects of paclitaxel and lovastatin in ATC cell lines. ATC cells were treated with paclitaxel and lovastatin, separately or together, and the cytotoxicity of the compounds was determined by quantifying cell viability and apoptosis. We conducted an isobologram analysis to investigate the combined effect of the two drugs. In 8505C cells, cellular viability was inhibited by lovastatin and paclitaxel in a concentration-dependent manner (p = 0.002 and p = 0.020, respectively). The IC(50) of lovastatin was 3.53 μM and that of paclitaxel was 5.98 nM. In BHT-101 cells, cellular viability was also inhibited in a concentration-dependent manner by lovastatin and paclitaxel (p = 0.020 and p = 0.032, respectively). The IC(50) of lovastatin was 17.13 μM and that of paclitaxel was 35.26 nM. In 8505C cells, paclitaxel and lovastatin alone induced apoptosis in a concentration-dependent manner. However, both an isobologram analysis on inhibition of viability and an analysis of apoptosis demonstrated antagonism between paclitaxel and lovastatin. In BHT-101 cells, however, neither drug had an apoptotic effect when used individually. There was a variable effect when used in combination, depending on the drug concentrations. | Paclitaxel and lovastatin were cytotoxic in two ATC cell lines and increased apoptosis in 8505C cells. However, in these cells, the combination of drugs resulted in antagonism that affected both the cytotoxicity of the compounds and the apoptosis of 8505C cells. The combination of paclitaxel and lovastatin did not enhance the treatment effect in ATC cell lines. | closed_qa |
Is current serologic RhD typing of blood donors sufficient for avoiding immunization of recipients? | Avoiding immunization with clinically important antibodies is a primary objective in transfusion medicine. Therefore, it is central to identify the extent of D antigens that escape routine RhD typing of blood donors and to improve methodology if necessary. We screened 5058 D- donors for the presence of the RHD gene, targeting Exons 5, 7, and 10 with real-time polymerase chain reaction. Samples that were positive in the screen test were investigated further by adsorption-elution, antibody consumption, flow cytometry, and sequencing of all RHD exons with intron-specific primers. Lookback was performed on all recipients of RBCs from RHD+ donors. We found 13 RHD+ samples (0.26%). No variants or chimeras were found. Characterization of DNA revealed a novel DEL type (IVS2-2 A>G). In the lookback of the 136 transfusions with subsequent antibody follow-up, of which 13 were from DEL donors, one recipient developed anti-D. However, in this case, a competing and more likely cause of immunization was the concurrent transfusion of D+ platelets. Eleven recipients were immunized with 13 antibodies different from anti-D, of which five were anti-K. | In our laboratory, serologic RhD typing was safe. We detected all D variants and only missed DEL types. In assessing the immunization risk we included a DEL donor, found previous to this study, that did immunize a recipient with anti-D. We conclude that inadvertent immunization with D antigens in our setting was rare and in the order of 1.4 in 100,000 D- transfusions. | closed_qa |
Exploring the dynamics of the theory of planned behavior in the context of blood donation: does donation experience make a difference? | This study investigates the influence of different variables from the theory of planned behavior (TPB) on intention within multiple donation categories, covering the entire range of lifetime number of donations (LND). Does the same set of variables predict intention equally strong throughout the donor career? Measures of intention, self-efficacy, cognitive and affective attitude, and subjective and moral norms were assessed within a sample of 11,480 whole blood donors. Donors were categorized into 65 donation classes using their LND; for example, all donors with one donation (n = 483) in the first donation class, all donors with two donations (n = 447) in the second donation class, and so on. For each donation class, separately for men and women, linear multiple regression models for intention were fitted using self-efficacy, cognitive attitude, affective attitude, subjective norm, and moral norm as predictor variables. During all stages of the donor career, self-efficacy is the main predictor of intention, with a relatively constant beta (β = 0.64, p<0.001). Cognitive attitude (β = 0.1, p<0.001) and moral norm (β = 0.10, p<0.001) contributed marginally to the prediction. Several sex effects were observed; self-efficacy is a stronger predictor of intention in women, whereas subjective norm predicts intention in men only. | Regardless of the number of lifetime donations, the same set of TPB variables, both in composition and in relative strength, predicts intention. A feeling of self-efficacy remains equally important for all donors. It is worthwhile to study whether directed intervention strategies are necessary to target self-efficacy within donor groups with different levels of donation experience. | closed_qa |
Is non-ablative 1550-nm fractional photothermolysis an effective modality to treat melasma? | Melasma is a common benign pigmentary disease and can pose a substantial therapeutic challenge. Although the use of non-ablative fractional photothermolysis (NFP) has gained much popularity, there are still very few evidence-based data supporting NFP in the treatment of melasma. To assess the efficacy and safety of NFP for the treatment of melasma in a controlled observer-blinded parallel-group study. Fifty-one patients [90.2% women, 9.8% men; mean age 40.3±6.1 (control group) and 41.7±11.4 (treatment group)] received a broad-spectrum sunscreen either alone (n=25; 49.0%) or in combination with a 1550-nm NFP treatment (n=26; 51.0%) [energy: 15 mJ/microthermal zone (MTZ); total density: 1048 MTZs/cm(2); density per pass: 131 MTZs/cm(2); number of passes: 8; total coverage: 20%]. Four sessions of NFP treatment were performed at 3-week intervals on each subject in the treatment group. Patients were evaluated at baseline and 12 weeks after final treatment. The primary efficacy variables were the Melasma Area and Severity Index (MASI) and the physician's global assessment (PGA); secondary efficacy variables were the patients' subjective assessment of improvement and patient satisfaction. Safety was evaluated through the reporting of adverse events. The percentage of subjective improvement was virtually identical in both groups: one-third of the patients reported a 'marked improvement' and another half reported 'some improvement'. Twenty-three patients in each group declared that they were 'satisfied' with the treatment result. The MASI corroborated the patients' subjective estimate, both in terms of the degree of improvement and the lack of a group difference. In both groups, the MASI score and the PGA were reduced significantly after therapy, and the reduction was also clinically relevant. No serious side-effects were reported in either group. | Our findings do not support the hypothesis of NFP providing a substantial benefit in treating melasma when compared with the lone application of a broad-spectrum sunscreen. | closed_qa |
Is coronary computed tomography angiography a resource sparing strategy in the risk stratification and evaluation of acute chest pain? | Annually, almost 6 million U.S. citizens are evaluated for acute chest pain syndromes (ACPSs), and billions of dollars in resources are utilized. A large part of the resource utilization results from precautionary hospitalizations that occur because care providers are unable to exclude the presence of coronary artery disease (CAD) as the underlying cause of ACPSs. The purpose of this study was to examine whether the addition of coronary computerized tomography angiography (CCTA) to the concurrent standard care (SC) during an index emergency department (ED) visit could lower resource utilization when evaluating for the presence of CAD. Sixty participants were assigned randomly to SC or SC + CCTA groups. Participants were interviewed at the index ED visit and at 90 days. Data collected included demographics, perceptions of the value of accessing health care, and clinical outcomes. Resource utilization included services received from both the primary in-network and the primary out-of-network providers. The prospectively defined primary endpoint was the total amount of resources utilized over a 90-day follow-up period when adding CCTA to the SC risk stratification in ACPSs. The mean (± standard deviation [SD]) for total resources utilized at 90 days for in-network plus out-of-network services was less for the participants in the SC + CCTA group ($10,134; SD ±$14,239) versus the SC-only group ($16,579; SD ±$19,148; p = 0.144), as was the median for the SC + CCTA ($4,288) versus SC only ($12,148; p = 0.652; median difference = -$1,291; 95% confidence interval [CI]= -$12,219 to $1,100; p = 0.652). Among the 60 total study patients, only 19 had an established diagnosis of CAD at 90 days. However, 18 (95%) of these diagnosed participants were in the SC + CCTA group. In addition, there were fewer hospital readmissions in the SC + CCTA group (6 of 30 [20%] vs. 16 of 30 [53%]; difference in proportions = -33%; 95% CI = -56% to -10%; p = 0.007). | Adding CCTA to the current ED risk stratification of ACPSs resulted in no difference in the quantity of resources utilized, but an increased diagnosis of CAD, and significantly less recidivism and rehospitalization over a 90-day follow-up period. | closed_qa |
An implementation study of the crisis resolution team model in Norway: are the crisis resolution teams fulfilling their role? | The establishment of crisis resolution teams (CRTs) is part of the national mental health policy in several Western countries. The purpose of the present study is to describe characteristics of CRTs and their patients, explore the differences between CRTs, and examine whether the CRTs in Norway are organized according to the international CRT model. The study was a naturalistic study of eight CRTs and 680 patients referred to these teams in Norway. Mental health problems were assessed using the Health of the Nation Outcome Scales (HoNOS), Global Assessment of Functioning Scales (GAF) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). None of the CRTs operated 24 hours a day, seven days a week (24/7 availability) or had gate-keeping functions for acute wards. The CRTs also treated patients who were not considered for hospital admission. Forty per cent of patients waited more than 24 hours for treatment. Fourteen per cent had psychotic symptoms, and 69% had affective symptoms. There were significant variations between teams in patients' total severity of symptoms and social problems, but no variations between teams with respect to patients' aggressive behaviour, non-accidental self-injury, substance abuse or psychotic symptoms. There was a tendency for teams operating extended hours to treat patients with more severe mental illnesses. | The CRT model has been implemented in Norway without a rapid response, gate-keeping function and 24/7 availability. These findings indicate that the CRTs do not completely fulfil their intended role in the mental health system. | closed_qa |
Long-term follow-up of nonspecific small bowel ulcers with a benign course and no requirement for surgery: is this a distinct group? | Nonspecific small bowel ulcers are rare and surgical intervention is often believed to be elective. Since the extensive investigation of the small bowel in the 1990s, there have been limited reports of these ulcers and the updates have been unsatisfactory. The aim of this study was to explore the clinical features and natural histories of nonspecific small bowel ulcers through prospective observational study. We reviewed the medical records of all patients who had undergone ileocolonoscopy or enteroscopy between 2000 and 2005 in a tertiary referral hospital. Seven patients with small bowel ulcers of unknown cause were identified. These patients were prospectively followed in a prolonged observation until March 2010. All seven patients (mean age: 54.7 years) presented with mild gastrointestinal symptoms, including chronic diarrhea and/or abdominal pain/discomfort, except for one who was asymptomatic when surveyed for colon polyps. Most patients were suspected of having functional bowel disorders for a long time (4.4 years) before small bowel ulcers were demonstrated on ileoscopy. The ulcers were characteristically multiple, superficial, and small (3-6 mm), locating at the terminal ileum and/or ileocecal valve. Various empirical treatments were applied, and most patients felt partly improved, even relieved. However the gastrointestinal symptoms did not always correlate with the presence of ulcers, and the ulcers tended to be either persistent (4 patients) or recurrent (1 patient). Ileocolonoscopy was repeated 4.1 times during follow-up, even after the lesions had healed. The characteristics of the ulcers, if still present during follow-up, were similar to their earlier characteristics. No patient experienced exacerbation or complications, such as intestinal obstruction, perforation, or bleeding. All patient survived and no surgical intervention was involved during the prolonged follow-up (7.0 years). | The reported patients with nonspecific small bowel ulcers experienced benign courses, inconsistent with previous reports. Without extensive investigation, this disease can be confused with functional bowel disorders. | closed_qa |
Does community-based education increase students' motivation to practice community health care? | Community-based education has been introduced in many medical schools around the globe, but evaluation of instructional quality has remained a critical issue. Community-based education is an approach that aims to prepare students for future professional work at the community level. Instructional quality should be measured based on a program's outcomes. However, the association between learning activities and students' attitudes is unknown. The purpose of this study was to clarify what learning activities affect students' attitudes toward community health care. From 2003 to 2009, self-administered pre- and post-questionnaire surveys were given to 693 fifth-year medical students taking a 2-week clinical clerkship. Main items measured were student attitudes, which were: "I think practicing community health care is worthwhile" ("worthwhile") and "I am confident about practicing community health care" ("confidence") using a visual analogue scale (0-100). Other items were gender, training setting, and learning activities. We analyzed the difference in attitudes before and after the clerkships by paired t test and the factors associated with a positive change in attitude by logistic regression analysis. Six hundred forty-five students (93.1%), 494 (76.6%) male and 151(23.4%) female, completed the pre- and post-questionnaires. The VAS scores of the students' attitudes for "worthwhile" and "confidence" after the clerkship were 80.2 ± 17.4 and 57.3 ± 20.1, respectively. Both of the scores increased after the clerkship. Using multivariate logistic regression analysis, "health education" was associated with a positive change for both attitudes of "worthwhile" (adjusted RR: 1.71, 95% CI: 1.10-2.66) and "confidence" (1.56, 1.08-2.25). | Community-based education motivates students to practice community health care. In addition, their motivation is increased by the health education activity. Participating in this activity probably produces a positive effect and improves the instructional quality of the program based on its outcomes. | closed_qa |
Are patients' judgments of health status really different from the general population? | Many studies have found discrepancies in valuations for health states between the general population (healthy people) and people who actually experience illness (patients). Such differences may be explained by referring to various cognitive mechanisms. However, more likely most of these observed differences may be attributable to the methods used to measure these health states. We explored in an experimental setting whether such discrepancies in values for health states exist. It was hypothesized that the more the measurement strategy was incorporated in measurement theory, the more similar the responses of patients and healthy people would be. A sample of the general population and two patient groups (cancer, rheumatoid arthritis) were included. All three study groups judged the same 17 hypothetical EQ-5D health states, each state comprising the same five health domains. The patients did not know that apart from these 17 states their own health status was also included in the set of states they were assessing. Three different measurement strategies were applied: 1) ranking of the health states; 2) placing all the health states simultaneously on a visual analogue scale (VAS); 3) separately assessing the health states with the time trade-off (TTO) technique. Regression analyses were performed to determine whether differences in the VAS and TTO can be ascribed to specific health domains. In addition, effect of being member of one of the two patient groups and the effect of the assessment of the patients' own health status was analyzed. Except for some moderate divergence, no differences were found between patients and healthy people for the ranking task or for the VAS. For the time trade-off technique, however, large differences were observed between patients and healthy people. The regression analyses for the effect of belonging to one of the patient groups and the effect of the value assigned to the patients' own health state showed that only for the TTO these patient-specific parameters did offer some additional information in explaining the 17 hypothetical EQ-5D states. | Patients' assessment of health states is similar to that of the general population when the judgments are made under conditions that are defended by modern measurement theory. | closed_qa |
Does the implementation of an electronic prescribing system create unintended medication errors? | Even though electronic prescribing systems are widely advocated as one of the most effective means of improving patient safety, they may also introduce new risks that are not immediately obvious. Through the study of specific incidents related to the processes involved in the administration of medication, we sought to find out if the prescribing system had unintended consequences in creating new errors. The focus of this study was a large acute hospital in the Midlands in the United Kingdom, which implemented a Prescribing, Information and Communication System (PICS). This exploratory study was based on a survey of routinely collected medication incidents over five months. Data were independently reviewed by two of the investigators with a clinical pharmacology and nursing background respectively, and grouped into broad types: sociotechnical incidents (related to human interactions with the system) and non-sociotechnical incidents. Sociotechnical incidents were distinguished from the others because they occurred at the point where the system and the professional intersected and would not have occurred in the absence of the system. The day of the week and time of day that an incident occurred were tested using univariable and multivariable analyses. We acknowledge the limitations of conducting analyses of data extracted from incident reports as it is widely recognised that most medication errors are not reported and may contain inaccurate data. Interpretation of results must therefore be tentative. Out of a total of 485 incidents, a modest 15% (n = 73) were distinguished as sociotechnical issues and thus may be unique to hospitals that have such systems in place. These incidents were further analysed and subdivided into categories in order to identify aspects of the context which gave rise to adverse situations and possible risks to patient safety. The analysis of sociotechnical incidents by time of day and day of week indicated a trend for increased proportions of these types of incidents occurring on Sundays. | Introducing an electronic prescribing system has the potential to give rise to new types of risks to patient safety. Being aware of these types of errors is important to the clinical and technical implementers of such systems in order to, where possible, design out unintended problems, highlight training requirements, and revise clinical practice protocols. | closed_qa |
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