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Are ribosomal DNA clusters rearrangement hotspots? | Recent advances in comparative genomics have considerably improved our knowledge of the evolution of mammalian karyotype architecture. One of the breakthroughs was the preferential localization of evolutionary breakpoints in regions enriched in repetitive sequences (segmental duplications, telomeres and centromeres). In this context, we investigated the contribution of ribosomal genes to genome reshuffling since they are generally located in pericentromeric or subtelomeric regions, and form repeat clusters on different chromosomes. The target model was the genus Mus which exhibits a high rate of karyotypic change, a large fraction of which involves centromeres. The chromosomal distribution of rDNA clusters was determined by in situ hybridization of mouse probes in 19 species. Using a molecular-based reference tree, the phylogenetic distribution of clusters within the genus was reconstructed, and the temporal association between rDNA clusters, breakpoints and centromeres was tested by maximum likelihood analyses. Our results highlighted the following features of rDNA cluster dynamics in the genus Mus: i) rDNA clusters showed extensive diversity in number between species and an almost exclusive pericentromeric location, ii) a strong association between rDNA sites and centromeres was retrieved which may be related to their shared constraint of concerted evolution, iii) 24% of the observed breakpoints mapped near an rDNA cluster, and iv) a substantial rate of rDNA cluster change (insertion, deletion) also occurred in the absence of chromosomal rearrangements. | This study on the dynamics of rDNA clusters within the genus Mus has revealed a strong evolutionary relationship between rDNA clusters and centromeres. Both of these genomic structures coincide with breakpoints in the genus Mus, suggesting that the accumulation of a large number of repeats in the centromeric region may contribute to the high level of chromosome repatterning observed in this group. However, the elevated rate of rDNA change observed in the chromosomally invariant clade indicates that the presence of these sequences is insufficient to lead to genome instability. In agreement with recent studies, these results suggest that additional factors such as modifications of the epigenetic state of DNA may be required to trigger evolutionary plasticity. | closed_qa |
Can direct immunofluorescence testing still be accurate if performed on biopsy specimens after brief inadvertent immersion in formalin? | Direct immunofluorescence is useful in the diagnosis of autoimmune, vesiculobullous, and connective tissue diseases. Michel medium is typically indicated for transport, but clinicians may inadvertently place samples into formalin. We set out to determine the amount of time that specimens can remain in 10% buffered formalin and still retain their diagnostic properties. Biopsy samples were examined from cases with established diagnoses of bullous pemphigoid (n = 12), dermatitis herpetiformis (n = 6), and pemphigus vulgaris (n = 6) and exposed to formalin for time points ranging from 2 minutes to 4 hours. We found that immunoreactants were detectable in the majority of samples when subjected to 2 minutes of formalin exposure. Dermatitis herpetiformis and pemphigoid samples retained immunogenicity for 10 minutes, whereas pemphigus showed reduced immunogenicity for all samples studied. A nonimmunologic nuclear fluorochroming pattern was noted in some of the specimens after formalin immersion. Sample size, only examining 3 disease processes, and samples already having been in Michel medium were the major limitations in the study. | In direct immunofluorescence studies, formalin exposure to biopsy specimens causes two types of artifactual changes: (1) the shortest exposure (2 minutes) causes complete loss of diagnostic markers of pemphigus; and (2) prolonged exposure changes tissue to a form that allows fluorescein-labeled antibodies to give fluorochroming reactions of nuclei (which can be mistaken for in vivo antinuclear antibody reactions of lupus erythematosus). After time intervals of 10 minutes to 2 hours, direct immunofluorescence studies of proven cases of bullous pemphigoid and dermatitis herpetiformis retained variable levels of specific reactivity. | closed_qa |
Do heart failure disease management programs make financial sense under a bundled payment system? | Policy makers have proposed bundling payments for all heart failure (HF) care within 30 days of an HF hospitalization in an effort to reduce costs. Disease management (DM) programs can reduce costly HF readmissions but have not been economically attractive for caregivers under existing fee-for-service payment. Whether a bundled payment approach can address the negative financial impact of DM programs is unknown. Our study determined the cost-neutral point for the typical DM program and examined whether published HF DM programs can be cost saving under bundled payment programs. We used a decision analytic model using data from retrospective cohort studies, meta-analyses, 5 randomized trials evaluating DM programs, and inpatient claims for all Medicare beneficiaries discharged with an HF diagnosis from 2001 to 2004. We determined the costs of DM programs and inpatient care over 30 and 180 days. With a baseline readmission rate of 22.9%, the average cost for readmissions over 30 days was $2,272 per patient. Under base-case assumptions, a DM program that reduced readmissions by 21% would need to cost $477 per patient to be cost neutral. Among evaluated published DM programs, 2 of the 5 would increase provider costs (+$15 to $283 per patient), whereas 3 programs would be cost saving (-$241 to $347 per patient). If bundled payments were broadened to include care over 180 days, then program saving estimates would increase, ranging from $419 to $1,706 per patient. | Proposed bundled payments for HF admissions provide hospitals with a potential financial incentive to implement DM programs that efficiently reduce readmissions. | closed_qa |
Are shock index and adjusted shock index useful in predicting mortality and length of stay in community-acquired pneumonia? | Community Acquired Pneumonia (CAP) is a common infection which is associated with a significant mortality. Shock index, heart rate divided by blood pressure, has been shown to predict mortality in several conditions including sepsis, acute myocardial infarction and traumatic injuries. Very little is known about the prognostic value of shock index in community acquired pneumonia (CAP). To examine the usefulness of shock index (SI) and adjusted shock index (corrected to temperature) (ASI) in predicting mortality and hospital length of stay in patients admitted to hospital with CAP. A prospective study was conducted in three hospitals in Norfolk&Suffolk, UK. We compared risk of mortality and longer length of stay for low (=<1.0, i.e. heart rate =<systolic BP) and high (>1.0, i.e. heart rate>systolic BP) SI and ASI adjusting for age, sex and other parameters which have been shown to be associated with mortality in CAP. A total of 190 patients were included (males=53%). The age range was 18-101 years (median=76 years). Patients with SI&ASI>1.0 had higher likelihood of dying within 6 weeks from admission. The adjusted odds ratio for 30 days mortality were 2.48 (1.04-5.92; p=0.04) for SI and 3.16 (1.12-8.95; p=0.03) for ASI. There was no evidence to suggest that they predict longer length of stay. | Both SI and ASI of>1.0 predict 6 weeks mortality but not longer length of stay in CAP. | closed_qa |
Malignant melanoma of the vulva: an extension of cutaneous melanoma? | To determine the prognostic significance of the 2002 revisions of the American Joint Committee on Cancer (AJCC) Staging System for cutaneous melanoma in melanoma of the vulva and review the current surgical utilized for treatment of this neoplasm. Demographic, surgical and outcomes data were obtained from the records of vulvar melanoma patients treated from 1990 to 2006 at five academic medical centers. The 2002 modifications of the AJCC staging system for cutaneous melanoma, Breslow thickness and Clark level, were applied to all subjects. Kaplan-Meier Modeling and Linear Regression analysis were utilized for data analysis. Statistics were performed with SAS v 9.1. Seventy-seven patients were identified with a median age of 62 years. 73% had Stage I/II disease. Surgical radicality did not impact recurrence rates or survival. Breslow thickness was associated with recurrence (p=0.002) but not survival. Only the 2002 modified AJCC staging criteria were predictive of overall survival (p=0.006) in patients with malignant melanoma of the vulva. | In the largest multi-site series of vulvar melanoma, the AJCC-2002 staging system for cutaneous malignant melanoma appears to be applicable to primary vulvar melanoma. Moreover, surgical radicality was associated with significant morbidity but not with improvement in survival. Utilization of standard operative staging and resection principles in cutaneous melanoma should be used for all vulvar melanoma patients. Moreover, these patients should also be considered for enrollment in cutaneous melanoma clinical trials. | closed_qa |
Choledocholithiasis management in rural America: health disparity or health opportunity? | Choledocholithiasis (CDL) management is dictated by local expertise, individual training, and availability of appropriate staff. This study evaluates the management of CDL between urban and rural communities. Patients undergoing inpatient management of CDL were identified from the 2007 Healthcare Cost and Utilization Project. Availability of endoscopic retrograde cholangiopancreatography (ERCP) was determined from the 2007 American Hospital Association survey. The proportion of common bile duct exploration (CBDE), ERCP, or percutaneous (PERC) interventions were compared across census regions and National Centers for Health Statistics (NCHS) urban-rural classes. The NCHS urban-rural classification scheme divides counties from most populous (NCHS 1) to rural (NCHS 6). Proportions were compared using the 95% confidence interval (95%CI) approach. We estimated 111,021 CDL hospitalizations in the U.S. in 2007. Of these, 67% had a coded intervention. Intervention frequencies were similar across census regions. Comparisons across NCHS classes revealed higher proportions of ERCP in urban areas (NCHS 1-4) while a higher proportion of CBDE was seen in rural areas (NCHS 5-6). ERCP availability was high in metropolitan areas (available in 35%-44% of hospitals NCHS 1-4) and low in rural areas (25% of NCHS 5 hospitals and 5% NCHS 6). PERC management was similar across NCHS classes. | Rural hospitals and communities need surgeons trained in CBDE, where ERCP expertise may not be readily available. Feasible ways of expanding ERCP coverage to the nation's rural areas need to be explored. These observations may impact surgical training at least for those targeting careers in rural surgery. | closed_qa |
Can data from primary care medical records be used to monitor national smoking prevalence? | Data from primary care records could potentially provide more comprehensive population-level information on smoking prevalence at lower cost and in a more timely fashion than commissioned national surveys. Therefore, we compared smoking prevalence calculated from a database of primary care electronic medical records with that from a 'gold standard' national survey to determine whether or not medical records can provide accurate population-level data on smoking. For each year from 2000 to 2008, the annual recorded prevalence of current smoking among patients in The Health Improvement Network (THIN) Database was compared with the 'General Household Survey (GHS)-predicted prevalence' of smoking in the THIN population, calculated through indirect standardisation by applying age-, sex- and region-specific smoking rates from the corresponding GHS to the THIN population. Completeness of smoking data recording in THIN improved steadily in the study period. By 2008, there was good agreement between recorded smoking prevalence in THIN and the GHS-predicted prevalence; the GHS-predicted prevalence of current smoking in the THIN population was 21.8% for men and 20.2% for women, and the recorded prevalence was 22.4% and 18.9%, respectively. | The prevalence of current smoking recorded within THIN has converged towards that which would be expected if GHS smoking rates are applied to the THIN population. Data from electronic primary care databases such as THIN may provide an alternative means of monitoring national smoking prevalence. | closed_qa |
Can intratympanic dexamethasone protect against cisplatin ototoxicity in mice with age-related hearing loss? | To determine whether intratympanic (i.t.) dexamethasone ameliorates cisplatin-induced ototoxicity in a mouse model of presbycusis. Controlled experimental study. Translational science experimental laboratory. Auditory brainstem response (ABR) thresholds of 24-month-old CBA/J-NIA mice treated with cisplatin were compared 7 days after daily i.t. injections of dexamethasone (24 mg/mL) or saline. Because of high (100%) mortality at 16 mg/kg, a single cisplatin dose of 14 mg/kg intraperitoneally was used. At this latter dose, pre-i.t. and post-i.t. treatment ABR thresholds were available in 13 of 16 mice. In i.t. saline-treated ears, cisplatin produced up to 9.5-dB ABR threshold elevations. In i.t. dexamethasone-treated ears, little protection against cisplatin was observed at 8 or 16 kHz where mean ABR thresholds were elevated. At 24 and 32 kHz, mean ABR threshold elevations were minimal at 0.6 to 1.4 dB. This protection was statistically significant (P ≤ .02). | These results demonstrate, for the first time, a protective effect of a treatment against an ototoxic agent in the presence of age-related hearing loss. In the presence of age-related hearing loss, the protective effect of i.t. dexamethasone has a frequency gradient, being greatest in the high-frequency region of the cochlea. This latter finding contrasts with our previous report in young mice, in which the protective effect of i.t. dexamethasone was in the low-frequency region of the cochlea. | closed_qa |
Does the amount of fat mass predict age-related loss of lean mass, muscle strength, and muscle quality in older adults? | An excessive amount of adipose tissue may contribute to sarcopenia and may be one mechanism underlying accelerated loss of muscle mass and strength with aging. We therefore examined the association of baseline total body fat with changes in leg lean mass, muscle strength, and muscle quality over 7 years of follow-up and whether this link was explained by adipocytokines and insulin resistance. Data were from 2,307 men and women, aged 70-79 years, participating in the Health, Aging, and Body Composition study. Total fat mass was acquired from dual energy X-ray absorptiometry. Leg lean mass was assessed by dual energy X-ray absorptiometry in Years 1, 2, 3, 4, 5, 6, and 8. Knee extension strength was measured by isokinetic dynamometer in Years 1, 2, 4, 6, and 8. Muscle quality was calculated as muscle strength divided by leg lean mass. Every SD greater fat mass was related to 1.3 kg more leg lean mass at baseline in men and 1.5 kg in women (p<.01). Greater fat mass was also associated with a greater decline in leg lean mass in both men and women (0.02 kg/year, p<.01), which was not explained by higher levels of adipocytokines and insulin resistance. Larger fat mass was related to significantly greater muscle strength but significantly lower muscle quality at baseline (p<.01). No significant differences in decline of muscle strength and quality were found. | High fatness was associated with lower muscle quality, and it predicts accelerated loss of lean mass. Prevention of greater fatness in old age may decrease the loss of lean mass and maintain muscle quality and thereby reducing disability and mobility impairments. | closed_qa |
Is the simple auger coring method reliable for below-ground standing biomass estimation in Eucalyptus forest plantations? | Despite their importance for plant production, estimations of below-ground biomass and its distribution in the soil are still difficult and time consuming, and no single reliable methodology is available for different root types. To identify the best method for root biomass estimations, four different methods, with labour requirements, were tested at the same location. The four methods, applied in a 6-year-old Eucalyptus plantation in Congo, were based on different soil sampling volumes: auger (8 cm in diameter), monolith (25 × 25 cm quadrate), half Voronoi trench (1·5 m(3)) and a full Voronoi trench (3 m(3)), chosen as the reference method. With the reference method (0-1m deep), fine-root biomass (FRB, diameter<2 mm) was estimated at 1·8 t ha(-1), medium-root biomass (MRB diameter 2-10 mm) at 2·0 t ha(-1), coarse-root biomass (CRB, diameter>10 mm) at 5·6 t ha(-1) and stump biomass at 6·8 t ha(-1). Total below-ground biomass was estimated at 16·2 t ha(-1) (root : shoot ratio equal to 0·23) for this 800 tree ha(-1) eucalypt plantation density. The density of FRB was very high (0·56 t ha(-1)) in the top soil horizon (0-3 cm layer) and decreased greatly (0·3 t ha(-1)) with depth (50-100 cm). Without labour requirement considerations, no significant differences were found between the four methods for FRB and MRB; however, CRB was better estimated by the half and full Voronoi trenches. When labour requirements were considered, the most effective method was auger coring for FRB, whereas the half and full Voronoi trenches were the most appropriate methods for MRB and CRB, respectively. | As CRB combined with stumps amounted to 78 % of total below-ground biomass, a full Voronoi trench is strongly recommended when estimating total standing root biomass. Conversely, for FRB estimation, auger coring is recommended with a design pattern accounting for the spatial variability of fine-root distribution. | closed_qa |
Motor vehicle transportation in hip spica casts: are our patients safely restrained? | Federal guidelines and state laws mandate that all children must be appropriately restrained while traveling in motor vehicles to reduce the risk of injury and death secondary to motor vehicle accidents. The purpose of this study is to identify the methods of restraint in motor vehicles for children in hip spica casts. Children placed in hip spica casts between August 1, 2006 and August 1, 2008 were recruited. Demographic data, type of spica cast placed, and reason for cast placement were recorded. Before discharge, all children were evaluated by a physical therapist to determine adequate restraint with the least cost. At each follow-up visit and at the time of cast removal, parents filled out standardized nonvalidated questionnaires to determine the method of restraint, mode of transportation, the approximate number of trips taken per week, and the occurrence of traffic violations or accidents. Thirty-one children, average age of 5 years (range, 1.3 to 13 y), in a total of 35 spica casts were enrolled in the study. After evaluation by the physical therapist, none of the children were recommended to be transported in their personal car seat, 12 children were advised to travel by ambulance and 23 were advised to use a specially manufactured car seat. Overall, 8 of 35 children (23%) followed the initial recommendation of the physical therapist. On the basis of our discharge protocol's recommendations, children in 24 spica casts (69%) were suboptimally transported after discharge, 6 children who should have had ambulance transportation and 18 who should have been transported by a specially manufactured car seat. | The majority of children in hip spica casts are not safely restrained when traveling in motor vehicles. Pediatric hospitals must develop better strategies to improve adherence to prescribed safe transportation protocols for patients in hip spica casts. Improved parental education, expansion of insurance coverage for restraints, hospital-based loaner programs and financial assistance to families are potential solutions to explore. | closed_qa |
Are there particular social determinants of health for the world's poorest countries? | The task of improving Social and Economic Determinants of Health (SEDH) imposes a significant challenge to health policy makers in both rich and poor countries. In recent years, while there has been increasing research interest and evidence on the workings of SEDHs, the vast majority of studies on this issue are from developed countries and emphasizes specific concerns of the developed nations of the world. Importantly, they may not fully explain the underlying causal factors and pathways of health inequality in the world's poorest countries. To explore whether there are specific social determinants of health in the world's poorest countries, and if so, how they could be better identified and researched in Africa in order to promote and support the effort that is currently being made for realizing a better health for all. Extensive literature review of existing papers on the social and economic determinants of health. | Most of the existing studies on the social and economic determinants of health studies may not well provide adequate explanation on the historical and contemporary realties of SEDHs in the world's poorest countries. As these factors vary from one country to another, it becomes necessary to understand country-specific conditions and design appropriate policies that take due cognisance of these country-specific circumstances. Therefore, to support the global effort to close gaps in health disparities, further research is needed in the world's poorest countries, especially on African social determinants of health. | closed_qa |
Comparative plasma lipidome between human and cynomolgus monkey: are plasma polar lipids good biomarkers for diabetic monkeys? | Non-human primates (NHP) are now being considered as models for investigating human metabolic diseases including diabetes. Analyses of cholesterol and triglycerides in plasma derived from NHPs can easily be achieved using methods employed in humans. Information pertaining to other lipid species in monkey plasma, however, is lacking and requires comprehensive experimental analysis.METHODOLOGIES/ We examined the plasma lipidome from 16 cynomolgus monkey, Macaca fascicularis, using liquid chromatography coupled with mass spectrometry (LC/MS). We established novel analytical approaches, which are based on a simple gradient elution, to quantify polar lipids in plasma including (i) glycerophospholipids (phosphatidylcholine, PC; phosphatidylethanolamine, PE; phosphatidylinositol, PI; phosphatidylglycerol, PG; phosphatidylserine, PS; phosphatidic acid, PA); (ii) sphingolipids (sphingomyelin, SM; ceramide, Cer; Glucocyl-ceramide, GluCer; ganglioside mannoside 3, GM3). Lipidomic analysis had revealed that the plasma of human and cynomolgus monkey were of similar compositions, with PC, SM, PE, LPC and PI constituting the major polar lipid species present. Human plasma contained significantly higher levels of plasmalogen PE species (p<0.005) and plasmalogen PC species (p<0.0005), while cynomolgus monkey had higher levels of polyunsaturated fatty acyls (PUFA) in PC, PE, PS and PI. Notably, cynomolgus monkey had significantly lower levels of glycosphingolipids, including GluCer (p<0.0005) and GM(3) (p<0.0005), but higher level of Cer (p<0.0005) in plasma than human. We next investigated the biochemical alterations in blood lipids of 8 naturally occurring diabetic cynomolgus monkeys when compared with 8 healthy controls. | For the first time, we demonstrated that the plasma of human and cynomolgus monkey were of similar compositions, but contained different mol distribution of individual molecular species. Diabetic monkeys exhibited decreased levels of sphingolipids, which are microdomain-associated lipids and are thought to be associated with insulin sensitivity. Significant increases in PG species, which are precursors for cardiolipin biosynthesis in mitochondria, were found in fasted diabetic monkeys (n = 8). | closed_qa |
Is Toupet fundoplication the procedure of choice for treating gastroesophageal reflux disease? | Gastroesophageal reflux disease (GERD) is among the most common dysfunctions of the upper gastrointestinal tract. It interferes with quality of life and is a risk factor for the development of adenocarcinoma in the lower esophagus. Laparoscopic fundoplication is an effective treatment of GERD, but the physiologic mechanisms of the different available procedures had not been investigated to date. In this study, 28 German Landrace pigs underwent baseline manometry and 24-h pH monitoring followed by myotomy to induce reflux esophagitis. After new-onset reflux was proved, the pigs were randomized to groups based on four treatments: total fundoplication, anterior hemifundoplication, posterior hemifundoplication, and control. On days 10 and 60 after the intervention, the effectiveness of the different fundoplication modifications was compared with that of the control subjects by 24-h pH monitoring manometry. Finally, the pigs were killed, after which the minimum volume and pressure required to breach the gastroesophageal junction were recorded. After myotomy, a significant increase in the reflux could be confirmed. The findings after fundoplication showed a significant decrease in the fraction of time that the pH fell below four and an increase in the vector volume compared with the measurement after myotomy. Total fundoplication and posterior hemifundoplication were highly effective, whereas measurements after anterior fundoplication still showed increased fraction times. Pharmacologic stimulation with pentagastrin showed an increase in the vector volume of the esophageal sphincter. | Total fundoplication and posterior hemifundoplication are potent operations for the treatment of GERD. Anterior hemifundoplication reduces the reflux as well, but the effects are significantly less than with total and posterior fundoplication. Pharmacologic stimulation showed excellent results after posterior hemifundoplication, and a tendency to overcorrection was shown after total fundoplication. | closed_qa |
Is educational level associated with breast cancer risk in Iranian women? | A high educational level has been found to be a risk factor of breast cancer. However, it is not clear whether such association persists after adjustment for individual risk factors of breast cancer such as parity in Iranian women. We conducted a case-control study of 100 histologically confirmed breast cancer cases and 200 age-matched controls in a genetically homogenous population, in Babol, northern Iran. Demographic, reproductive, and lifestyle data were collected by in-person interviews and clinical examination. Educational level was classified into three levels: (1) illiterate and primary level, (2) elementary level and those who did not finish high school, and (3) high school graduates and those receiving more education. The adjusted odds ratio (OR) was estimated using multiple logistic regression model after controlling for parity and several other potential confounding factors. The unadjusted OR showed a nonsignificant negative association of educational levels with breast cancer risk, but after controlling for several potential confounding factors, higher education level was significantly correlated with a lower breast cancer risk [OR 0.17, 95% confidence interval (CI) 0.06-0.45 for educational level of elementary plus some high school and OR 0.10, 95% CI 0.03-0.34 for educational level of high school or more compared to illiterate and primary level]. | The inverse association of educational level with breast cancer risk observed in this study is not in accordance with education inequalities found in breast cancer risk in Western countries. The present findings provide a rationale for earlier screening in Iranian women with low education. | closed_qa |
Can the job content questionnaire be used to assess structural and organizational properties of the work environment? | The theory behind the Job Content Questionnaire (JCQ) presumes that the "objective" social environment is measurable via self-report inventories such as the JCQ. Hence, it is expected that workers in identical work will respond highly similar. However, since no studies have evaluated this basic assumption, we decided to investigate whether workers performing highly similar work also responded similarly to the JCQ. JCQ data from a rubber-manufacturing (RM: n = 95) and a mechanical assembly company (MA: n = 119) were examined. On each worksite, men and women performed identical machine-paced job tasks. A population sample (n = 8,542) served as a reference group. In both the RM and MA groups, the job support questions were rated most similar. Yet, there was a substantial variation as regards choosing to agree or disagree with single JCQ items. The variation was also reflected in the scale scores. In the RM and MA groups, the variance of job demand and job control scores was 64-87% of that of the population sample. For job support scores, the corresponding variation was 42-87%. | Conducting highly similar work does not lead to highly similar reports in the JCQ. In view of the large response variation, it seems that the attempt to avoid personal influence by minimizing the self-reflexive component in the questions asked, and using response alternative that indicates degree of agreement, does not seem to work as intended. | closed_qa |
Do treatment manuals undermine youth-therapist alliance in community clinical practice? | Some critics of treatment manuals have argued that their use may undermine the quality of the client-therapist alliance. This notion was tested in the context of youth psychotherapy delivered by therapists in community clinics. Seventy-six clinically referred youths (57% female, age 8-15 years, 34% Caucasian) were randomly assigned to receive nonmanualized usual care or manual-guided treatment to address anxiety or depressive disorders. Treatment was provided in community clinics by clinic therapists randomly assigned to treatment condition. Youth-therapist alliance was measured with the Therapy Process Observational Coding System--Alliance (TPOCS-A) scale at 4 points throughout treatment and with the youth report Therapeutic Alliance Scale for Children (TASC) at the end of treatment. Youths who received manual-guided treatment had significantly higher observer-rated alliance than usual care youths early in treatment; the 2 groups converged over time, and mean observer-rated alliance did not differ by condition. Similarly, the manual-guided and usual care groups did not differ on youth report of alliance. | Our findings did not support the contention that using manuals to guide treatment harms the youth-therapist alliance. In fact, use of manuals was related to a stronger alliance in the early phase of treatment. | closed_qa |
Does tailoring on additional theoretical constructs enhance the efficacy of a print-based physical activity promotion intervention? | To enhance a previously efficacious individually tailored physical activity (PA) promotion intervention by adding theoretical constructs to the tailored feedback. We randomly assigned 248 healthy, underactive (moderate to vigorous physical activity [MVPA] min/week<90) adults (mean age = 48.8 years, SD = 10.0) to receive either (a) a theoretically tailored (based on 5 constructs from the transtheoretical model and social-cognitive theory [SCT]) print-based PA promotion intervention (print) or (b) the same theoretically tailored print-based PA promotion intervention plus enhanced tailoring addressing 5 additional SCT constructs (enhanced print). The 7-day physical activity recall administered at baseline, Month 6, and Month 12, with outcomes operationalized as percentage achieving 150 min/week of MVPA. When controlling for covariates, there was a nonsignificant trend in favor of the enhanced print condition reflecting 46% and 50% greater odds of achieving 150 min/week of MVPA at Month 6 and Month 12, respectively. | Enhanced tailoring based on additional theoretical constructs may result in marginal improvements in physical activity outcomes. | closed_qa |
Self-harm and the positive risk taking approach. Can being able to think about the possibility of harm reduce the frequency of actual harm? | This article presents the results of an audit of self-harming across three women's units over a period of 6 years. All three units use a positive risk-taking approach to self-harm whereby the risk that this behaviour presents is considered in an effort to reduce actual harm. To explore patterns and frequency of self-harm across three units within a women's service. Incidents of deliberate self-harm were collected from incident forms completed across the units from 2004 to 2009. Frequency graphs show a reduction of self-harm over the course of admission, and parametric analyses show that there was a significant difference in the frequency of self-harm during the first and last 3 months of admission. | These results are discussed within a psychoanalytical framework, with particular reference to relational security and the value of positive risk-taking. | closed_qa |
Blood transfusion after cardiac surgery: is it the patient or the transfusion that carries the risk? | The transfusion of red blood cells (RBCs) after cardiac surgery has been associated with increased long-term mortality. This study reexamines this hypothesis by including pre-operative hemoglobin (Hb) levels and renal function in the analysis. A retrospective single-center study was performed including 5261 coronary artery bypass grafting (CABG) patients in a Cox proportional hazard survival analysis. Patients with more than eight RBC transfusions, early death (7 days), and emergent cases were excluded. Patients were followed for 7.5 years. Previously known risk factors were entered into the analysis together with pre-operative Hb and estimated glomerular filtration rate (eGFR). In addition, subgroups were formed based on the patients' pre-operative renal function and Hb levels. When classical risk factors were entered into the analysis, transfusion of RBCs was associated with reduced long-term survival. When pre-operative eGFR and Hb was entered into the analysis, however, transfusion of RBCs did not affect survival significantly. In the subgroups, transfusion of RBCs did not have any effect on long-term survival. | When pre-operative Hb levels and renal function are taken into account, moderate transfusions of RBC after CABG surgery do not seem to be associated with reduced long-term survival. | closed_qa |
Psoriasis and melanocytic naevi: does the first confer a protective role against melanocyte progression to naevi? | Some of the cytokines that have effects on melanogenesis are also reported to be involved in psoriasis. We therefore studied the relationship between psoriasis and melanocytic naevi. In particular, the aim of our study was to investigate the number of melanocytic naevi in patients with psoriasis vs. controls. We performed a prospective case-control study, analysing 93 adult patients with psoriasis and 174 adult aged-matched controls. For each participant a questionnaire was completed to establish personal data, personal medical history, and personal and familial history of skin cancer and psoriasis. We analysed interleukin (IL)-1α, IL-6 and tumour necrosis factor (TNF)-α gene expression at the peripheral blood mononuclear cell level in patients with psoriasis and in controls. In our study, patients with psoriasis presented a lower number of areas with naevi in comparison with controls (P<0·0001). Nobody had ever had squamous cell carcinoma or melanoma in the psoriatic group; moreover, there was a significant difference in familial history of melanoma between the two groups (none in the psoriatic group vs. 8% in the control group; P<0·05). IL-1α, IL-6 and TNF-α expression levels were higher in patients with psoriasis. | People with psoriasis had fewer melanocytic naevi. This suggests that the proinflammatory cytokine network in psoriasis skin might inhibit melanogenesis, melanocyte growth and/or progression to naevi. | closed_qa |
Does early school entry prevent obesity among adolescent girls? | To examine the relationship between early school entry and body weight status among adolescent girls. Using nationally representative data from the 1997 cohort of the National Longitudinal Survey of Youth, we exploited state-specific first-grade entrance policy as a quasi-experimental research design to examine the effect of early school entry on the body weight status of adolescent girls. Fixed-effects models were used to compare the body mass index (BMI), BMI z-score, and likelihood of overweight and obesity between teenage girls born before school cut-off dates and those born after, while controlling for age, race/ethnicity, maternal education status, and maternal body weight status. Late starters had higher BMIs and a higher prevalence of overweight and obesity and the results were found to be consistent across age groups. Among girls whose birthdays were within 1 month of the cut-off dates, the coefficient of late starting was significantly positive (β = .311; p = .02), indicating that it might be correlated with weight gain in adolescence. | Early admission to a school environment might have a long-term protective effect in terms of adolescent girls' propensity to obesity. Future studies are needed to examine the effect of early school entry on the eating behavior and physical activities of adolescent girls. | closed_qa |
Are networks for residual language function and recovery consistent across aphasic patients? | If neuroplastic changes in aphasia are consistent across studies, this would imply relatively stereotyped mechanisms of recovery which could guide the design of more efficient noninvasive brain stimulation treatments. To address this question, we performed a meta-analysis of functional neuroimaging studies of chronic aphasia after stroke. Functional neuroimaging articles using language tasks in patients with chronic aphasia after stroke (n = 105) and control subjects (n = 129) were collected. Activation likelihood estimation meta-analysis determined areas of consistent activity in each group. Functional homology between areas recruited by aphasic patients and controls was assessed by determining whether they activated under the same experimental conditions. Controls consistently activated a network of left hemisphere language areas. Aphasic patients consistently activated some spared left hemisphere language nodes, new left hemisphere areas, and right hemisphere areas homotopic to the control subjects' language network. Patients with left inferior frontal lesions recruited right inferior frontal gyrus more reliably than those without. Some areas, including right dorsal pars opercularis, were functionally homologous with corresponding control areas, while others, including right pars triangularis, were not. | The network of brain areas aphasic patients recruit for language functions is largely consistent across studies. Several recruitment mechanisms occur, including persistent function in spared nodes, compensatory recruitment of alternate nodes, and recruitment of areas that may hinder recovery. These findings may guide development of brain stimulation protocols that can be applied across populations of aphasic patients who share common attributes. | closed_qa |
Quantitative diffusion weighted MRI: a functional biomarker of nodal disease in Hodgkin lymphoma? | This study explores the relationship between MRI Apparent Diffusion Coefficient (ADC) and PET Standardized Uptake Value (SUV) measurements in pediatric Hodgkin lymphoma. Sixteen patients (mean age 15.4 yrs, 8 male) with proven Hodgkin lymphoma were recruited and staged using PET-CT, anatomical MRI and additional 1.5T diffusion weighted imaging (DWI) prior to and following chemotherapy. Pre-treatment lymph nodes and anatomically paired post-treatment residual tissue located on MRI were matched to the corresponding PET-CT. Region of interest (ROI) analysis was used to extract quantitative measurements. Mean ADC (ADC(mean)) and maximum SUV (SUV(max)) were recorded and correlation assessed using Spearman statistics. Fifty-three ROIs were sampled. Pre- and post-treatment ADC(mean) ranged from 0.77 × 10(−3) to 1.79 × 10(−3) (median 1.15 × 10(−3) mm(2)s(−1)) and 1.08 × 10(−3) to 3.18 ×10(−3) (median 1.88 × 10(−3) mm(2)s(−1)), and SUV(max) from 2.60 to 25.4 (median 8.85 mg/ml) and 1.00 to 3.50 mg/ml (median 1.90 mg/ml). Median post-treatment ADC(mean) was higher, and median SUV(max) lower than pretreatment values (p<0.0001). There was an inverse correlation between pre-treatment ADC(mean) and SUV(max) (p = 0.005) and between fractional change ([post-treatment – pre-treatment]/pre-treatment)in ADC(mean) and SUV(max) (p =0.002). | Our results confirm a strong reciprocal relationship between nodal ADC(mean) and SUV(max) in Hodgkin lymphoma;supporting the potential application of quantitative DWI as a functional biomarker of disease. | closed_qa |
Can capsule endoscopy be used as a diagnostic tool in the evaluation of nonbleeding indications in daily clinical practice? | To evaluate the diagnostic yield of capsule endoscopy (CE) and its impact on treatment and outcome in patients without bleeding indications. One hundred and sixty-five nonbleeding patients were enrolled in the study. The most common indications for CE were chronic abdominal pain alone (33 patients) or combined with chronic diarrhea (31 patients) and chronic diarrhea alone (30 patients). Among the 165 patients, 129 underwent CE for evaluation of gastrointestinal symptoms and 36 for surveillance or disease staging. CE findings were positive, suspicious and negative in 73 (44.2%), 13 (7.9%) and 79 (47.9%) of cases, respectively. The diagnostic yield was highest in patients with refractory celiac disease (10/10, 100%) and suspected Crohn's disease (5/6, 83.3%), followed by patients with chronic abdominal pain and chronic diarrhea (13/31, 41.9%), established Crohn's disease (2/6, 33.3%), chronic diarrhea alone (8/30, 26.7%), chronic abdominal pain alone (8/33, 24.2%) and other indications (3/13, 23.1%) (p<0.005). The CE findings led to a change of medication in 74 (47.7%) patients, surgery in 15 (9.7%), administration of a strict gluten-free or other special diet in 13 (8.4%) and had other consequences in 11 (6.7%). Management was not modified in 42 (27.1%) patients. Among symptomatic patients (n = 129), 29 (22.5%) were lost to follow-up. The remaining 100 patients were followed up for 8.7 ± 4.0 months (range 2-19). Among the latter, resolution or improvement of symptoms was observed in 86 (86%) patients, no change in 11 (11%) and 3 (3%) died. All 86 patients who experienced resolution or improvement of their symptoms had a modification of their management after CE; only 7/11 patients whose symptoms did not change (63.6%) and 2/3 patients who died (66.7%) had a modification of management (p<0.001). | CE appears to be a useful tool in the evaluation of patients with nonbleeding indications. The outcome of most patients with negative findings was excellent. | closed_qa |
Biomechanical comparison of tibial nail stability in a proximal third fracture: do screw quantity and locked, interlocking screws make a difference? | This study compared the fatigue life of nailed proximal third tibial fractures stabilized with either three or four proximal screws using commercially available nails with both locked (through threaded holes or end caps) and nonlocked proximal interlocking screw configurations. Eight paired and two independent tibiae of known bone mineral density were acquired, divided into three groups, and implanted with three different commercially available nails (n = 6/group). Nails were all 10 mm in diameter and individually sized for length. Individual tibiae from a given pair received different nails. Based on nail design, Nail A received four proximal screws (three that lock into the nail), whereas Nails B and C each received three proximal nonlocking screws. Standard end caps were used with all nails. As a result of its design, in Nail B, the most proximal interlocking screw was "locked" by the nail end cap. All nails used two distal screws. After implantation, an unstable proximal third fracture was created and specimens were tested with combined axial and torsional loads of 40 to 400 N and 0.11 to 1.1 Nm for 500,000 cycles or until failure. The fatigue life of Group A was significantly greater than either Groups B or C (P<0.001 in both cases) with a mean cycle to failure of 392,977 versus 86,476 and 64,595 cycles for Nails B and C, respectively. Fatigue life of Group A was greater or equivalent to all contralateral tibiae; Group B outlasted all contralateral Group C limbs and the Group C constructs did not outlast any contralateral limbs. Bone mineral density correlated positively and significantly with fatigue life across all three groups (P<0.001). | In this study, proximal segment stability was improved with a greater quantity of screws and with locked interlocking screws. | closed_qa |
Can locking screws allow smaller, low-profile plates to achieve comparable stability to larger, standard plates? | The open reduction and internal fixation of radial shaft fractures and osteotomies with standard 3.5-mm plates can be complicated by tendon irritation, hardware prominence, and fracture through the screw holes. With the advent of locking plate technology, implant companies and some surgeons have recommended expanding the indications for these devices; for example, using smaller, low-profile locking plates to suffice where a standard, larger plate would traditionally be used. We analyzed whether there is merit to this strategy. We hypothesized that, in an established cadaveric fracture fixation model, a smaller, low-profile plate with multiple locking screws could maintain adequate fixation stiffness with the potential to minimize hardware-related complications. Seven matched pairs of fresh-frozen cadaver radii were used. A 5-mm osteotomy gap was created at the midpoint of each specimen and the simulated fracture in one radius from each pair was fixed with a 3.5-mm plate and six nonlocking, standard screws. The contralateral radius was fixed using an equivalent-length 2.7-mm plate with eight locking screws. The radii were subjected to controlled bending and torsional loads and the bending and torsional stiffnesses were documented. Cyclic dorsal-to-volar bending was then applied and resistance to fatigue bending assessed. The 2.7-mm locking plate was approximately one third as stiff as the 3.5-mm nonlocking plate (P<0.02). Under physiological loading conditions, the 3.5-mm plate was superior to the 2.7-mm plate with respect to bending stiffness in all four directions, torsional stiffness in both directions, osteotomy gapping, and osteotomy angulation (P<0.02 for all tests). The performance gap did not narrow with cyclic testing. | The theoretical structural benefit from the locking screws did not make up for the smaller size of the 2.7-mm plate. This held true in all bending planes, torsion, and cyclic loading, and outweighed any biologic differences between the specimens, including the presence or absence of osteoporosis. This is the first study to rigorously compare these two constructs and we conclude that the mechanical properties of the standard 3.5-mm plate are superior to the locking 2.7-mm plate in all regimes tested. | closed_qa |
Effects of corticotropin-releasing hormone (CRH) on endothelin-1 and NO release, mediated by CRH receptor subtype R2: a potential link between stress and endothelial dysfunction? | Psychosocial factors, associated with elevated corticotropin releasing hormone (CRH) concentrations, have been reported to be independently associated with coronary heart disease. Endothelin-1 and NO release of human endothelial cells were quantified via ELISA or fluorometrically after treatment with CRH. CRH-receptor subtype 2 (CRH-R2) was visualized on endothelial cells by immunohistochemistry and confirmed by polymerase chain reaction using CRH-R2 primers. CRH induced a significant increase of ET-1 release, and the effect was abolished by the CRH-receptor antagonist astressin. The effect was mediated by CRH-R2. In contrast, NO release was not affected. | CRH-R2 is expressed on human endothelial cells, mediating the CRH-induced stimulation of ET-1 release, whereas NO release is not affected. Thus, peripherally circulating CRH may offset the balance between endothelial vasoconstrictor and vasodilator release with unopposed vasoconstriction. Our data may provide a new concept on how CRH-receptor antagonists may prevent CRH-induced disorders of vascular biology. | closed_qa |
Use of medical doctors, physical therapists, and alternative practitioners by obese adults: does body weight dissatisfaction mediate extant associations? | The objective of this study was to assess the association of obesity with the utilization of general practitioners (GP), medical specialists (MS), physical therapists (PT), and alternative practitioners (AP), and to elucidate whether body weight dissatisfaction mediates extant associations. In an adult population survey (KORA Survey S4 1999/2001) in Augsburg, Germany, anthropometric body mass [body mass index (BMI), kg/m(2)], utilization, physical comorbidities, functional limitations due to body weight, and body weight dissatisfaction were assessed and analyzed via multiple logistic regressions. Obese adults (BMI>or=30) had around double odds of AP, GP, and PT utilization. Regarding AP and, to a lesser extent, PT, body weight dissatisfaction both had direct effects and mediated excess utilization. Most notably, the odds for AP use were about twofold in those who were dissatisfied, and the association of obesity and AP use diminished when adjustment for dissatisfaction was performed. Among overweight participants (25<or=BMI<30), only PT use was elevated and tended to be mediated by dissatisfaction as well. | Body weight dissatisfaction mediates obesity-attributable utilization of nonmedical health care providers, especially AP. Possibly, dissatisfaction leads to demands for psychosocial care that is expected to be offered by complementary and allied health professions. For health services utilization research, results call for a scrutiny of body weight dissatisfaction-a known barrier to adopting long-term healthy lifestyles. For practice, results indicate that AP and PT may have special opportunities to encourage the use of preventive services by obese adults. | closed_qa |
Is there a "mucosa-sparing" benefit of IMRT for head-and-neck cancer? | To investigate whether intensity-modulated radiation therapy (IMRT) allows more mucosal sparing than standard three-field technique (3FT) radiotherapy for early oropharyngeal cancer. Whole-field IMRT plans were generated for 5 patients with early-stage oropharyngeal cancer according to Radiation Therapy Oncology Group 0022 (66 Gy/30 fractions/6 weeks) guidelines with and without a dose objective on the portion of mucosa not overlapping any PTV. 3FT plans were also generated for the same 5 patients with two fractionation schedules: conventional fractionation (CF) to 70 Gy/35 fractions/7 weeks and concomitant boost (CB) to 72 Gy/40 fractions/6 weeks. Cumulative dose volume histograms (DVHs) of the overall mucosal volume (as per in-house definition) from all trials were compared after transformation into the linear quadratic equivalent dose at 2 Gy per fraction with a time factor correction. Compared with IMRT without dose objective on the mucosa, a 30-Gy maximum dose objective on the mucosa allows approximately 20% and approximately 12% mean absolute reduction in the percentage of mucosa volume exposed to a dose equivalent to 30 Gy (p<0.01) and 70 Gy (p<0.01) at 2 Gy in 3 and 7 weeks, respectively, without detrimental effect on the coverage of other regions of interest. Without mucosal dose objective, IMRT is associated with a larger amount of mucosa exposed to clinically relevant doses compared with both concomitant boost and conventional fractionation; however, if a dose objective is placed, the reverse is true, with up to approximately 30% reduction in the volume of the mucosa in the high-dose region compared with both concomitant boost and conventional fractionation (p<0.01). | Intensity-modulated radiation therapy can be potentially provide more mucosal sparing than traditional approaches. | closed_qa |
Ipsilateral silent period: a marker of callosal conduction abnormality in early relapsing-remitting multiple sclerosis? | The corpus callosum (CC) is commonly affected in multiple sclerosis (MS). The ipsilateral silent period (iSP) is a putative electrophysiological marker of callosal demyelination. The purpose of this study was to re-assess, under recently established optimised protocol conditions [Jung P., Ziemann U. Differences of the ipsilateral silent period in small hand muscles. Muscle Nerve in press.], its diagnostic sensitivity in MS, about which conflicting results were reported in previous studies. ISP measurements (onset, duration, and depth) were obtained in the abductor pollicis brevis (APB) muscle of either hand in 49 patients with early relapsing-remitting MS (RRMS) (mean EDSS, 1.3). Standard central motor conduction times to the APB (CMCT(APB)) and tibial anterior muscles (CMCT(TA)), and magnetic resonance images (MRI) were also obtained. ISP measurements showed a similar diagnostic sensitivity (28.6%) as CMCT(APB) (24.5%), while diagnostic sensitivities of CMCT(TA) (69.4%) and MRI of the CC (78.6%) were much higher. Prolongation of iSP duration was the most sensitive single iSP measure. ISP prolongation occurred more frequently when CMCT(APB) to the same hand was also prolonged (40.0% vs. 8.4%, p<0.0001). The correlation between iSP duration and CMCT(APB) was significant (Pearson's r=0.24, p<0.02), suggesting that iSP duration can be contaminated by demyelination of the contralateral corticospinal tract. ISP duration did not correlate with MRI abnormalities of the CC. | ISP measures are neither a sensitive nor a specific marker of callosal conduction abnormality in early RRMS. | closed_qa |
Does sedation practice delay time to extubation? | Criteria for performing a spontaneous breathing trial (SBT) have not been evaluated in controlled trials. An important component of these criteria is neurological status. The objective of this study was to evaluate whether physicians take mental status into consideration before performing an SBT in mechanically ventilated patients. This was a prospective, observational study which included 355 mechanically ventilated patients. Daily assessments were made of whether the patients met criteria for performing a SBT. On the day a patient met the criteria, the level of sedation was evaluated using the Glasgow Coma Scale as modified by Cook and Palma (GCS-Cook) and it was registered whether or not the physician carried out an SBT. Two hundred and four patients (57%) underwent an SBT on the day they met the criteria (cohort 1) and in 151 patients (cohort 2) the SBT was delayed a median time of 1 day (interquartile range 1-2). There were differences in the GCS-Cook score on the day the criteria were met for performing an SBT (mean 13+/-3 points in cohort 1 versus 9+/-3 points in cohort 2; P<0.001). There were differences (P<0.001) between the cohorts in days of intubation and length of stay in the intensive care unit. | Neurological status/level of sedation is a factor in the decision whether or not to perform a spontaneous breathing trial. | closed_qa |
Enterocutaneous fistula: are treatments improving? | We studied the etiology, treatment, and outcome of enterocutaneous fistulas in 106 patients to evaluate our current practice and the impact of newer therapies-octreotide, wound vacuum-assisted closure (VAC), and fibrin glue-on clinical outcomes. Review of the literature and our own 1990 study indicate a mortality rate of 5% to 20% for enterocutaneous fistula, and a healing rate of 75% to 85% after definitive surgery. We reviewed all cases of gastrointestinal-cutaneous fistula from 1997 to 2005 at 2 large teaching hospitals. We identified 106 patients with enterocutaneous fistula; patients with irritable bowel disease and anorectal fistulas were excluded. The origin of the fistula was the small bowel in 67 patients, colon in 26, stomach in 8, and duodenum in 5. The etiology of the fistula was previous operation in 81 patients, trauma in 15, hernia mesh erosion in 6, diverticulitis in 2, and radiation in 2. Of the 106 patients in the study, 31 had a high output fistula (greater than 200 mL/day), 44 had a low output fistula, and, in 31 patients, the fistula output was low but there was no record of volume. Initial treatment was nonoperative except for patients with an abscess who needed urgent drainage. In 24 patients, the effect of octreotide was monitored: in 8 patients, fistula output declined; in 16 patients, octreotide was of no benefit. Fibrin glue was used in 8 patients and was of benefit to 1. The wound VAC was used in 13 patients: 12 patients still required operative repair of the fistula, whereas the fistula was healed in 1 patient. The main benefit of the VAC system was improved wound care in all patients before definitive surgery. Total parenteral nutrition was used in most patients to provide nutritional support. Operative repair was performed in 77 patients and was successful in 69 (89%), failing in 6 patients with persistent cancer or infection. Nonoperative treatment was used in 29 patients and resulted in healing in 60%. Of 106 patients, 7 (7%) died of fistula complications. The cause of death was persistence or recurrence of cancer in 4 patients and persistent sepsis in 3. | Enterocutaneous fistula continues to be a serious surgical problem. The wound VAC and fibrin glue had anecdotal successes (n = 2), and one-third of patients responded to octreotide. We believe that octreotide should be tried in most patients and that the wound VAC has a role in selected patients. Although 7% overall mortality is lower than in previous studies, the number managed without operation (27%) remains the same. In addition to early control of sepsis, nutritional support, and wound care, a well-timed operation was the most effective treatment. | closed_qa |
Should completely intracorporeal anastomosis be considered in obese patients who undergo laparoscopic colectomy for benign or malignant disease of the colon? | The outcome of laparoscopic colectomy with completely intracorporeal anastomosis (LCIA) in obese and nonobese patients is assessed. Forty-five consecutive patients who underwent LCIA for benign or malignant disease of the right and proximal left colon were reviewed prospectively. Obesity was defined as a body mass index of>30 kg/m(2). There were 24 men (53%) and 21 women (47%) with a mean age of 67 years (46-84 years). The mean body mass index was 27 kg/m(2) (16-38 kg/m(2)); 13 patients (29%) were obese. One procedure was converted to a laparoscopic-assisted colectomy. The mean operative time, estimated blood loss, and duration of stay were 218 minutes (110-420 minutes), 82 mL (50-250 mL), and 5 days (2-11 days), respectively. The mean length of the larger incision (extraction site) and the sum of all port incisions was 4 cm (3-8 cm) and 7 cm (6-10 cm), respectively. Complications occurred in 8 of 45 patients (18%), with no deaths. The mean number of harvested lymph nodes per specimen was 11 (3-30 lymph nodes). Obesity had no effect on operative time (obese patients, 232 minutes; nonobese patients, 213 minutes), incision length (obese patients, 4 cm; nonobese patients, 4 cm) estimated blood loss (obese patients, 100 mL; nonobese patients, 76 mL), complications (obese patients, 15%; nonobese patients, 19%), duration of stay (obese patients, 5 days; nonobese patients, 5 days), or number of harvested lymph nodes (obese patients, 11 lymph nodes; nonobese patients, 11 lymph nodes). There were no port-site hernias or metastases during a mean follow-up period of 5 months (1-18 months). | LCIA can offer smaller incisions, improved cosmesis, and low conversion rates while oncologic principles are preserved. LCIA is a feasible and safe technique with equally successful outcomes in thin and obese patients. | closed_qa |
Are disposable prisms an adequate alternative to standard Goldmann tonometry prisms in glaucoma patients? | To evaluate the accuracy and reliability of 2 single-use tonometry devices (Tonosafe and Tonojet) as an alternative to standard Goldmann prisms in patients attending dedicated glaucoma clinics. Prospective experimental study with human subjects. Two hundred forty glaucoma patients who attended 2 glaucoma clinics at the Stepping Hill Hospital between January and February 2005. During each examination, intraocular pressure (IOP) was measured 3 times, using the standard Goldmann prism, Tonosafe, and Tonojet, respectively. The prism sequence was predetermined at random using a computer, and the measurements were taken at 5-minute intervals. Data were analyzed using the Bland-Altman method of differences. Intraocular pressure. Intraocular pressure ranged from 6 to 68 mmHg. Linear regression analysis indicated that there was a proportional bias between Goldmann and Tonosafe (r2 = 0.368, P<.001), especially for values higher than 25 mmHg. On the other hand, there was no statistically significant proportional bias between Goldmann and Tonojet (r2 = 0.006, P = 0.14). | Caution should be exercised when using Tonosafe prisms in the presence of IOP higher than 25 mmHg. On the other hand, Tonojet is an adequate and useful alternative to the Goldman tonometer for glaucoma patients. | closed_qa |
Do device characteristics impact outcome in carotid artery stenting? | The study was conducted to identify patient and procedural parameters that negatively impact the 30-day rates for stroke, death and transient ischemic attack (TIA) after carotid artery stenting (CAS) and that might be modified or further studied in future efforts to improve CAS. This was a retrospective investigation of a dual-center CAS database of 701 consecutive CAS patients (414 men; mean age, 72.4 +/- 8.4). A subset of patient-related, lesion-related, or procedure-related variables (age>or=80, left sided lesion, symptomatic, nicotine abuse, hypertension, diabetes mellitus, other peripheral vascular disease, hypercholesterolemia, embolic protection devices usage, predilation, ulcerated lesion, echolucent plaque, restenosis after surgery) were analyzed for association with occurrence of stroke, death, or TIA<or=30 days after CAS. The odds ratio (OR) and 95% confidence interval (CI) and P value were calculated for each variable to predict adverse outcome. The overall combined rate of stroke, death, and TIA within this database was 3.7% at 30 days. In the total population of 701 patients, only the OR of 2.7 for hypercholesterolemia (95% CI, 1.0 to 7.3; P = .041) was found to be significant. Subgroup analysis of the 304 symptomatic patients (43%) showed that open-cell stent designs and concentric EPD designs yielded an OR of 4.1 (95% CI, 1.4 to 12, P = .0136) and 3.3 (95% CI, 1.016 to 10, P = .0525), respectively, for 30-day stroke/death/TIA within this database. Analysis of open-cell stent designs and concentric EPD designs in patients with echolucent lesions yielded an OR of 3.1 (95% CI,1.2 to 8.2, P = .0343) and 3.7 (95% CI, 1.3 to 10, P = .0174), respectively, for 30-day stroke/death/TIA. | We conclude that increased analysis of device design variables may be necessary. Particularly in symptomatic patients or with echolucent lesions, closed-cell design and eccentric filters seem superior. Prospective investigation comparing open-cell vs closed-cell stents and eccentric vs concentric filter devices may be warranted. | closed_qa |
Are the American College of Cardiology/Emergency Cardiac Care (ACC/ECC) guidelines useful in triaging patients to telemetry units? | To determine if the ACC/ECC guidelines (1991) properly stratify patients according to risk of arrhythmia, defined as a single event on cardiac monitoring, and benefit, defined as a subsequent management change from a recorded telemetry event. In 2003, a prospective study of 217 consecutive patients admitted to a 24-bed telemetry unit was conducted for 25 days at a major academic hospital. Patients were categorized per ACC/ECC guidelines as appropriate (class I&II) or inappropriate (class III) based on a non-cardiologist admission diagnosis. A cardiologist-led group then reclassified patients at the time of admission using a brief interview. Continuous telemetry-recorded arrhythmias and resultant management changes were reviewed and recorded daily. Subgroup analysis of patients admitted with a chief complaint of chest pain was also performed. In 2004, after this trial was performed, the American Heart Association released a scientific statement updating practice standards for ECG monitor; however, this paper is based upon the original 1991 ACC/ECC guidelines. Reclassification significantly decreased the percentage of all class I&II patients from 91% to 71% (P<0.001) and the percentage of class I&II patients with chest pain from 100% to 58% (P<0.001) without increasing the percentage of arrhythmias occurring in class III patients. Class II patients had a statistically significant higher percentage of arrhythmias than class I and III patients before and after reclassification (P<0.001 and P<0.001, respectively). Management changes occurring as a direct result of telemetry events were higher in class II than class I or III patients before and after reclassification (P = 0.01 and P = 0.03). Life-threatening arrhythmias (sustained ventricular tachycardia or ventricular fibrillation) occurred in 1% of the 216 patients enrolled in this study. | (1) Cardiology input using ACC/ECC guidelines and a brief interview at admission safely reduced total admissions primarily by identifying low risk chest pain admissions inappropriate for inpatient telemetry monitoring. (2) Life threatening arrhythmias occurring in patients admitted to telemetry are rare. | closed_qa |
Arterial stiffness and Chlamydia pneumoniae infection in coronary artery disease. Is there a link? | We investigated the possible association between antichlamydial antibodies and pulse wave analysis (PWA) parameters in a cohort of patients with coronary artery disease (CAD). The augmentation index (AI), the reflection time index (RTI) and the time to the beginning of the reflected wave (CT-1) were estimated (Sphygmocor ATCOR Medical). IgA titers>or= 40 and IgG>or=80 were considered as positive (microimmunofluorescence test). Patients also underwent coronary angiography, ultrasound carotid measurements and 24 h ambulatory blood pressure (BP) measurements. No differences existed in the traditional risk factors for CAD between the seronegative and seropositive IgA/ IgG groups. IgA seropositive subjects had higher values of AI (p<0.01) comparing to seronegatives whilst the levels of CT-1 and RTI were lower (p<0.011 and p<0.02 respectively). No differences in AI, CT-1 and RTI values were found between IgG seropositive/ seronegatives patients. | An association was indicated between IgA antichlamydial titers and PWA parameters in patients with CAD, supporting that the connecting link between arterial stiffness and CAD might include this microorganism. | closed_qa |
Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? | Diagnosing attention deficit hyperactivity disorder (ADHD) in adults is difficult when diagnosticians cannot establish an onset before the DSM-IV criterion of age 7 or if the number of symptoms recalled does not achieve DSM's diagnosis threshold. The authors addressed the validity of DSM-IV's age-at-onset and symptom threshold criteria by comparing four groups of adults: 127 subjects with full ADHD who met all DSM-IV criteria for childhood-onset ADHD, 79 subjects with late-onset ADHD who met all criteria except the age-at-onset criterion, 41 subjects with subthreshold ADHD who did not meet full symptom criteria for ADHD, and 123 subjects without ADHD who did not meet any criteria. The authors hypothesized that subjects with late-onset and subthreshold ADHD would show patterns of psychiatric comorbidity, functional impairment, and familial transmission similar to those seen in subjects with full ADHD. Subjects with late-onset and full ADHD had similar patterns of psychiatric comorbidity, functional impairment, and familial transmission. Most children with late onset of ADHD (83%) were younger than 12. Subthreshold ADHD was milder and showed a different pattern of familial transmission than the other forms of ADHD. | The data about the clinical features of probands and the pattern of transmission of ADHD among relatives found little evidence for the validity of subthreshold ADHD among such subjects, who reported a lifetime history of some symptoms that never met DSM-IV's threshold for diagnosis. In contrast, the results suggested that late-onset adult ADHD is valid and that DSM-IV's age-at-onset criterion is too stringent. | closed_qa |
Are there any positive effects of TNF-alpha blockers on bone metabolism? | Secondary osteoporosis (OP) is a well-recognized complication of rheumatoid arthritis (RA). Treatment with TNF-alpha blockers, might influence bone metabolism and prevent structural bone damage in RA, in particular at the periarticular regions. To assess the influence of anti-TNF-alpha therapy, on bone metabolism in RA patients. 36 RA patients were treated with stable therapy of prednisone (7.5 mg/day) and methotrexate (MTX=10 mg/week). Nine of these RA patients further received etanercept (25 mg, twice/weekly) and eleven infliximab (3mg/kg on 0, 2, 6, and every 8 weeks thereafter). A control group included 16 RA patients only with stable therapy (some dosage of prednisone and MTX). Quantitative Ultrasound (QUS) bone densitometry was obtained at the metaphyses of the proximal phalanges of both hands with a DBM Sonic 1200 QUS device (IGEA, Carpi, Italy). Bone mineral density (BMD) of the hip and lumbar spine were performed with a densitometer ( Lunar Prodigy, GE, USA) at baseline and after 12 months. Soluble bone turnover markers [osteocalcin (OC), bone alkaline phospatase (ALP) deoxypyridinoline/creatinine ratio (Dpd/Cr) and cross-linked N-telopeptide of type I collagen / creatinine ratio (NTx/Cr)] were measured using ELISA tests. AD-SoS values were found increased by +4.55% after 12 months of treatment in the RA patients treated with anti-TNF-alpha therapy. On the contrary, the Ad-SoS levels decreased by -4.48% during the same period in the control RA group. BMD increased by +3.64% at lumbar spine and +2.90% at the hip (both p<0.001) in TNF-alpha blockers-treated patients and decreased by -2.89% and -3.10% (both p<0.001, respectively at lumbar spine and at the hip) in RA patients without anti-TNF-alpha therapy. In RA patients treated with TNF-alpha blockers, OC and bone ALP levels were found significantly increased (p<0.01) and Dpd/Cr or NTx/Cr levels were found significantly decreased (p<0.01) at 12 months when compared to baseline values. | During 12 months of treatment of RA patients with TNF-alpha blockers, bone formation seems increased while bone resorption seems decreased. The reduced rate of OP seems supported by the same mechanisms involved in the decreased bone joint resorption during anti-TNF-alpha therapy (i.e. increase of osteoblastic activity and decrease osteoclastic activity). | closed_qa |
Postoperative irradiation in breast cancer patients with one to three positive axillary lymph nodes. Is there an impact of axillary extranodal tumor extension on locoregional and distant control? | To evaluate the impact of extracapsular extension (ECE) on locoregional and distant control in breast cancer patients with one to three positive axillary lymph nodes treated with postoperative irradiation. As shown in literature, ECE is diagnosed in up to 30% of node-positive breast cancer patients. Consequences of ECE and prognosis of these patients are unclear. The medical records of 1,142 node-positive females with a carcinoma of the breast, postoperatively irradiated between 1994 and 2003, were retrospectively reviewed. Of the 274 patients presenting with one to three positive axillary lymph nodes, 91 (33.2%) showed ECE. While all patients were irradiated using tangential fields, only eight out of 274 patients received additional nodal irradiation. Patients' mean age was 58.2 years (range, 28-96 years), and the mean observation period 42.9 months (range, 6.6-101 months). In 93.4% of patients, locoregional control was achieved. On multivariate analysis of metastases-free survival, the hazard ratios for ECE and histological grade 3 were 2.71 (95% confidence interval [CI], 1.316-5.581; p = 0.007) and 2.435 (95% CI, 1.008-5.885; p = 0.048), respectively. The 3-year and 5-year metastases-free survival ratesfor patients with ECE were 78% and 66%, compared to 90% and 87% in patients without ECE (p = 0.0048). | Locoregional recurrence remains low in breast cancer patients (one to three positive axillary lymph nodes +/- ECE) treated with surgery, adequate axillary dissection, and tangential field irradiation only. However, ECE is significantly linked to a considerable risk for subsequent distant failure. | closed_qa |
Contrast-enhanced color duplex sonography (CDS): an alternative for the evaluation of therapy-relevant tumor oxygenation? | To evaluate the predictive value of radiotherapeutically relevant tumor hypoxia by contrast-enhanced color duplex sonography (CDS). The objectification was based on pO(2) histography. 25 patients with metastatic neck lymph node from a primary squamous carcinoma of the head and neck were examined. To visualize as many vessels as possible, a contrast enhancer (Levovist), Schering Corp., Germany) was administered. Horizontal and longitudinal sonographic scans with a thickness of 5 mm were performed on the metastatic neck lymph node. Color pixel density (CPD) was defined as the ratio of colored to gray pixels in a region of interest. It represents the extent of vascularization in the investigated slice. To assess the biological and clinical relevance of oxygenation measurement, the relative frequency of pO(2) readings<or = 2.5, 5.0, and 10.0 mmHg, as well as mean and median pO(2), were documented. In order to investigate the degree of linear association, the Pearson correlation coefficient was calculated. Moderate (/r/>0.5) to high (/r/>0.7) correlation was found between the CPD and the parameters of hypoxic fraction (pO(2) readings with values<or = 5.0 and 10.0 mmHg, as well as mean and median). There was only a slight correlation between CPD and the fraction of pO(2) values<or = 2.5 mmHg (r = -0.479). | CPD represents the mean degree of vascularization. As a noninvasive measurement, this method seems feasible for evaluating the state of global oxygenation in superficial tumors. Nevertheless, this method is limited through its deficiency in describing the vascular heterogeneity of tumors. | closed_qa |
Is the urokinase-type plasminogen activator system a reliable prognostic factor in gastric cancer? | This prospective study analyzed specimens obtained from 105 gastric cancer patients who underwent gastrectomy with extended lymphadenectomy. The immunohistochemical expression of uPA and PAI-1 was studied semiquantitatively in the tumor epithelium and was correlated with the clinicopathological features of each patient. Univariate analysis revealed no statistically significant association of uPA levels with pT and pN category (p=0.655 and 0.053, respectively), grading (p=0.374), depth of tumor invasion (p=0.665), UICC classification (p=0.21) and the Laurén classification (p=0.578). PAI-1 expression showed no statistically significant correlation with pT, pN and M category (p=0.589, 0.414, and 0.167, respectively), grading (p=0.273), and the Laurén classification (p=0.368). Only the UICC classification was significantly correlated with PAI-1 (p=0.016). Kaplan-Meier analysis revealed no significant association of uPA and PAI-1 with overall survival (p=0.0929 and 0.0870, respectively). | Our results could not verify any prognostic value of uPA and PAI-1 levels in patients with gastric carcinoma. Therefore, the uPA-system as a biologically defined prognostic marker to identify high-risk gastric cancers should be applied with caution. However, considering the number of patients involved and the borderline level of significance observed in this study, a larger number of events may have resulted in significant differences. | closed_qa |
Is admission for epistaxis more common in Caucasian than in Asian people? | Epistaxis is a common ENT complaint. Although casual observation suggested that it is more common in Caucasian, compared with Asian people, a literature search failed to find any studies investigating ethnicity and epistaxis. The aim of this study was to identify any differences in emergency admission rates for epistaxis between Asian and Caucasian people. Retrospective observational study using hospital computerised data (HISS). Large University Hospital accepting ENT emergencies. All Asian and Caucasian patients admitted under ENT care as an emergency (1 January 2000 to 30 November 2005), split into two groups: one composed of epistaxis patients, the other of all other ENT emergency admissions. The proportions of Asian and Caucasian patients among the two patient groups, either epistaxis admissions or other ENT emergency admissions. The proportions of Asian and Caucasian patients in the group admitted with emergency epistaxis were 7.1% (100/1410) and 92.9% (1310/1410) respectively. However, the proportions of Asian and Caucasian patients in the group composed of any other ENT emergency were 13.2% (729/5515) and 86.8% (4786/5515), respectively (chi-squared P<0.01). | Caucasian people form an unexpectedly large, and Asians a smaller proportion of emergency epistaxis admissions. The possibility of an ethnic risk factor for epistaxis warrants further investigation. | closed_qa |
Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity? | The aim of the study was to investigate whether the type of instrumental swallowing examination (Fibreoptic Endoscopic Evaluation of Swallowing (FEES) or videofluoroscopy) influences perception of post-swallow pharyngeal residue. Prospective, single-blind assessment of residue from simultaneous videofluoroscopy and FEES recordings. All raters were blind to participant details, to the pairing of the videofluoroscopy and FEES examinations and to the other raters' scores. Tertiary specialist ENT teaching hospital. Fifteen adult participants consecutively recruited; seven women and eight men aged between 22 and 73, mean age 53. All participants underwent one FEES examination and one videofluoroscopy examination performed simultaneously. referred to speech and language therapy for assessment of dysphagia. nil by mouth or judged to be at high risk of aspiration. The FEES and videofluoroscopy examinations were recorded simultaneously. Fifteen speech and language therapists independently scored pharyngeal residue as none, coating, mild, moderate or severe. All examinations were scored twice by all raters. Intra- and inter-rater agreement were similar for both examinations. There were significant differences between FEES and videofluoroscopy pharyngeal residue severity scores (anova, P<0.001). FEES residue scores were consistently higher than videofluoroscopy residue scores. | Pharyngeal residue was consistently perceived to be greater from FEES than from videofluoroscopy. These findings have significant clinical implications as FEES and videofluoroscopy findings are used to judge aspiration risk and to make recommendations for oral intake. Further research is required to examine the impact of FEES and videofluoroscopy examinations on treatment decisions. | closed_qa |
Can acidosis and hyperphosphataemia result in increased erythropoietin dosing in haemodialysis patients? | The clinical records of the patients seen at the Hypertension, Nephrology, Dialysis and Transplantation Clinic from December, 2004 through August, 2005 were reviewed to identify patients who had taken intravenous erythropoietin. Two-tailed, Pearson's correlation was performed to determine correlations between any of the parameters. Analysis of variance and stepwise regression for covariance were used to evaluate the relations of demographic and clinical characteristics and laboratory variables. Analysis of covariance and K means cluster analyses were also performed to examine linkage between variables. Kendall's Tau correlation was used for correlations of non-parametric data. There was a significant direct or positive correlation at the 0.01 levels between dry weight, age, intact parathyroid hormone level (PTH), and serum phosphorus and EPO dose. There was an inverse or negative correlation at that level between the serum bicarbonate and urea reduction ratio (URR) with the EPO dose at the same level while there was a weaker correlation but direct correlation between the white blood count (WBC) and EPO dose. There was significant colinearity between serum phosphorus and PTH but serum phosphorus showed a more significant correlation with EPO overall. Stepwise regression analysis for covariance revealed that phosphorus remained significantly correlated with EPO resistance after the removal of the effect of PTH while PTH lost its significance after the effect of phosphorus was removed. | Acidosis and hyperphosphataemia are associated with apparent increased erythropoietin dosing requirements. While this study did not evaluate the mechanism of such requirements and indeed many mechanisms might be possible, a rightward shift in the oxygen-haemoglobin dissociation curve resulting in down-regulation of erythropoietin receptors is considered consistent with the data and present knowledge. | closed_qa |
Are all-terrain vehicle injuries becoming more severe? | There are several reasons to suspect that injuries from all-terrain vehicles (ATV) have become both more serious and frequent in recent years. These reasons include increasing engine power, younger age of operators and inconsistent enforcement of helmet laws. The purpose of this study was to determine if the increase in ATV injuries was out of proportion to the increase in ATV usage and whether ATV injuries have increased in severity. A retrospective analysis of the Consumer Product Safety Commission (CPSC) ATV injury data and the Pennsylvania Trauma System Foundation (PTSF) database from 1989 to 2002 was performed. ATV use, sales, deaths, trauma center admissions, Injury Severity Score (ISS), hospital length of stay (LOS) and Glascow Coma Score (GCS) were reviewed. ATV sales increased to 316%. In the decade prior to 2003, reported deaths nationally increased from 183 to 357 (95%) nationally and from 5 to 10 (100%) in Pennsylvania (PA). Admissions to trauma centers in PA increased 240%, yet the percentage of deaths to trauma center admissions remained constant at 2.6% during this period (p>.50). ISS and LOS from 1989 to 2002 did not significantly change (all p>.05) and GCS improved significantly. | Despite concerns regarding the increasing dangers associated with ATVs, it appears that the severity of injuries from ATV use has not increased. | closed_qa |
Is transobturator tape as effective as tension-free vaginal tape in patients with borderline maximum urethral closure pressure? | The purpose of this study was to compare transobturator tape (MONARC) with tension-free vaginal tape in patients with borderline low maximum urethral closure pressure. Historical cohort analysis of 3-month outcomes in 145 subjects (MONARC = 85; tension-free vaginal tape = 60). A cut-off point of 42 cm H2O for preoperative maximum urethral closure pressure was identified as predictor of success in the entire cohort. The cohort was stratified by sling type and analyzed. Outcome variables included urodynamic stress incontinence, urethral pressure profiles, subjective stress incontinence symptoms, and complications. The relative risk of postoperative urodynamic stress incontinence 3 months after surgery in patients with a preoperative maximum urethral closure pressure of 42 cm or less H2O was 5.89 (1.02 to 33.90, 95% confidence interval) when we compared MONARC with tension-free vaginal tape. Subjects in the MONARC and tension-free vaginal tape groups did not differ significantly in baseline characteristics. We defined subjects as failures if they demonstrated postoperative objective stress incontinence on multichannel urodynamic testing. | In subjects with maximum urethral closure pressure of 42 cm or less H2O, the MONARC was nearly 6 times more likely to fail than tension-free vaginal tape at 3 months after surgery. Long-term follow-up and randomized controlled trials are needed. | closed_qa |
Obesity and retropubic surgery for stress incontinence: is there really an increased risk of intraoperative complications? | The objective of the study was to evaluate the impact of obesity on length of surgery, blood loss, and intra- and postoperative complications in women who underwent retropubic surgery for stress urinary incontinence. Of 449 women participating in a multicenter, randomized trial evaluating antibiotic prophylaxis in women with suprapubic catheters, 250 women underwent retropubic anti-incontinence procedures. This is a prospective nested cohort study of these women, 79 (32%) of whom were obese (body mass index 30 or greater) and 171 (68%) overweight or normal weight (body mass index less than 30). Data collected included demographic variables, past medical history, physical examination, and intraoperative and postoperative complications. Data were analyzed with Fisher's exact for dichotomous variables, Student t tests for continuous variables, and analysis of variance for multivariate analysis. Significance was set at P<.05. Obese women undergoing stress urinary incontinence surgery were younger than nonobese women (48.7 versus 51.9 years, respectively, P<.019). The number and type of additional surgeries performed were similar between groups with the exception that obese women were less likely to undergo abdominal apical suspensions (P = .006) or abdominal paravaginal repairs (P = .001); therefore, estimated blood loss, change in hematocrit, length of stay, surgery, and suprapubic catheterization comparisons are adjusted for the performance of these procedures. Estimated surgical blood loss was greater for obese women (344 versus 284 P = .03); however, change in hematocrit was lower for obese than nonobese women (6.6 versus 7.3, P = .048). Mean length of surgery was 15 minutes longer in obese women (P = .02). Length of hospital stay did not vary between groups (P = NS). Major intraoperative complications were uncommon (14 [5.6%]), with no difference between weight groups. Incidence of postoperative urinary tract infection, wound infections, or postoperative major complications were likewise similar between groups (all P>.05). | Surgery takes longer for obese patients, but blood loss as recorded by change in hematocrit is lower. Major complications were rare and similar between weight groups, as were infectious complications. | closed_qa |
Is every chronic low back pain benign? | There is a well-recognized association between chronic back pain and the existence of an AAA. In literature, there are few reported AAA cases that describe patients with extensive pressure erosion of the vertebral body. The authors present the case of a 38-year-old woman with chronic low back pain for the last 2 years in whom an AAA was formed during the follow-up period. The patient presented with an episode of low back pain following hard work 2 years ago. MR imaging of the lumbar spine was reported as disc degeneration at the L4-5 and L5-S1 levels. She was given medical treatment and was doing well with occasional back pain for a year. One year later, she suffered another disabling pain attack, and MR imaging revealed an additional focal disc protrusion at the L4-5 level. She was again medically treated. In August 2004, she presented with severe low back pain, and this time, MR imaging showed edema and erosion at the anterior part of L3 vertebra body. MR imaging studies (2- and 3-dimensional) depicted AAA as the cause. She was operated on, and the aneurysm was resected with graft repair of the site. She was pain-free in the postoperative period. | The evaluation of a patient with chronic back pain needs a thorough clinical and radiological workup. Limited evaluation of the bony and nervous structures of the spinal canal radiologically is insufficient. Pre- and paravertebral structures as well as vertebral body should carefully be evaluated to diagnose other causes of pain. | closed_qa |
Internal carotid artery dorsal wall aneurysm with configurational change: Are they all false aneurysms? | Aneurysms arising from nonbranching sites of the ICA, so-called dorsal wall aneurysm, are rare entity, and present as blister type or saccular type. Occasionally configurational changes have been observed on serial cerebral angiography: a small blister-like bulge on ICA wall on initial angiography progressing to a saccular appearance within a few weeks. Such aneurysm showing configurational change has been regarded as a false aneurysm with fragile wall just like blister-type aneurysm, and direct surgical approach has been considered highly risky. A 42-year-old woman with a subarachnoid hemorrhage revealed small "blister-like" aneurysm at the medial wall of the ICA on initial angiography. After 12 days, the following angiograms demonstrated increased aneurysmal size and change of shape into a saccular configuration. Direct surgical approach was performed. The aneurysm had a relatively firm neck, and was successfully clipped without intraoperative rupture. The dome of aneurysm was resected after clipping and the histologic examination revealed it as a true aneurysm. | This case suggests that all dorsal wall aneurysms with configurational change are not false aneurysms, and that angiographic findings do not always correlate with the nature of the aneurysmal wall; therefore, we should give more credence to direct surgical observation rather than preoperative angiographic findings when considering the most suitable surgical option. | closed_qa |
Immunoreactive trypsin/DNA newborn screening for cystic fibrosis: should the R117H variant be included in CFTR mutation panels? | Cystic fibrosis newborn screening is now implemented universally in France, as well as in many states in the United States and in various areas of Europe and Australia. Because the screening protocol usually includes the analysis of the most common CFTR mutations, it is of the utmost importance that only mutations that result in classical cystic fibrosis are included in this test. The panels of mutations used in most cystic fibrosis newborn screening programs enable the detection of a relatively frequent CFTR variant (R117H) whose implication in cystic fibrosis remains unclear. Physicians, therefore, have difficulty managing detected compound heterozygotes with this variant, which raises the issue of the appropriateness of extended testing in families and of the legitimate use of prenatal diagnosis. The aim of this study was to describe the clinical outcome of the children found to be compound heterozygous for R117H by screening in Brittany (western France), where cystic fibrosis newborn screening was set up in 1989, and to assess whether this CFTR variant should be included in the newborn screening mutation panels. Data on clinical status were obtained by the referring pediatricians. Since our screening protocol has enabled detection of R117H (ie, in 1995), 360466 newborns have been screened for cystic fibrosis in Brittany, of whom 124 had elevated immunoreactive trypsin and 2 mutations in the CFTR gene. Nine of these children (7.3%) were compound heterozygous for R117H, which in all cases was linked to the 7T_11TG haplotype [IVS8-nT variant/m(TG) repeat]. Their genotypes were F508del/R117H (n = 7), I507del/R117H (n = 1), or G551D/R117H (n = 1). At the time of this writing, the mean age of these 9 children was 7.0 years (the oldest being>10 years of age), and none of them had yet developed any signs of cystic fibrosis; they have been pancreatic sufficient and have had good nutritional status and pulmonary function. Moreover, we observed that, in Brittany, all the patients carrying the R117H variant have been identified exclusively through cystic fibrosis newborn screening. | In view of the high frequency of R117H-7T identified by cystic fibrosis newborn screening, the uncertain outcome of the asymptomatic children, and physicians' difficulty in managing these situations, we propose the withdrawal of the R117H variant from the panels of CFTR mutations used in cystic fibrosis newborn screening, given the expanding implementation of cystic fibrosis newborn screening. | closed_qa |
Does cause of deafness influence outcome after cochlear implantation in children? | The objective of this study was to evaluate long-term speech perception abilities of comparable groups of postmeningitic and congenitally deaf children after cochlear implantation. This prospective longitudinal study comprised 46 postmeningitic deaf children and 83 congenitally deaf children with age at implantation of<or = 5.6 years. Both groups were comparable with respect to educational setting and mode of communication and included children with additional disabilities. Both postmeningitic and congenitally deaf children showed significant progress after implantation. Most (73% and 77%, respectively) could understand conversation without lip-reading or use the telephone with a known speaker 5 years after implantation, whereas none could do so before implantation. At the same interval, the postmeningitic and congenitally deaf children scored a mean open-set speech perception score of 47 (range: 0-91) and 46 (range: 0-107) words per minute, respectively, on connected discourse tracking. The respective mean scores at the 3-year interval were 22 and 29 correct words per minute, respectively. None of these children could score a single correct word per minute before implantation. The progress in both groups was statistically significant. When the 2 groups were compared, there was no statistically significant difference. | Postmeningitic and congenitally deaf children showed significant improvement in their auditory receptive abilities at the 3- and 5-year intervals after cochlear implantation. There was no statistically significant difference between the outcomes of the 2 groups, suggesting that, provided that children receive an implant early, cause of deafness has little influence on outcome. Although the prevalence of other disabilities was similar in both groups, for individual children, their presence may have profound impact. The study supports the concept of implantation early in life, irrespective of the cause of deafness. | closed_qa |
Evaluation of resident communication skills and professionalism: a matter of perspective? | Evaluation procedures that rely solely on attending physician ratings may not identify residents who display poor communication skills or unprofessional behavior. Inclusion of non-physician evaluators should capture a more complete account of resident competency. No published reports have examined the relationship between resident evaluations obtained from different sources in pediatric settings. The objective of this study was to determine whether parent and nurse ratings of specific resident behaviors significantly differ from those of attending physicians. Thirty-six pediatric residents were evaluated by parents, nurses, and attending physicians during their first year of training. For analysis, the percentage of responses in the highest response category was calculated for each resident on each item. Differences between attending physician ratings and those of parents and nurses were compared using the signed rank test. Parent and attending physician ratings were similar on most items, but attending physicians indicated that they frequently were unable to observe the behaviors of interest. Nurses rated residents lower than did attending physicians on items that related to respecting staff (69% vs 97%), accepting suggestions (56% vs 82%), teamwork (63% vs 88%), being sensitive and empathetic (62% vs 85%), respecting confidentiality (73% vs 97%), demonstrating integrity (75% vs 92%), and demonstrating accountability (67% vs 83%). Nurse responses were higher than attending physicians on anticipating postdischarge needs (46% vs 25%) and effectively planning care (52% vs 33%). | Expanding resident evaluation procedures to include parents and nurses does enhance information that is gathered on resident communication skills and professionalism and may help to target specific behaviors for improvement. Additional research is needed to determine whether receiving feedback on parent and nurse evaluations will have a positive impact on resident competency. | closed_qa |
Are patients being transferred to level-I trauma centers for reasons other than medical necessity? | In the United States, the Emergency Medical Treatment and Active Labor Act defines broad guidelines regarding interhospital transfer of patients who have sought care in the emergency department. However, patient transfers for nonmedical reasons are still considered a common practice. The purpose of this study was to evaluate the possible risk factors for hospital transfer in a population of patients unlikely to require transfer to a level-I center for medical reasons. A retrospective case-control national database study was performed with use of data from the National Trauma Data Bank (version 4.3). The study group consisted of patients with low Injury Severity Scores (<or =9) who were transferred to a level-I trauma center from another hospital. The controls were patients with low Injury Severity Scores who were treated at any hospital that was lower than a level-I trauma center and were not transferred. Hypothesized risk factors for hospital transfer were the age, gender, race, and insurance status of the patient; the time of day the transfer was received; and the number and type of comorbidities. The total sample included 97,393 patients, 21% of whom were transferred to a level-I trauma center. The odds ratios adjusted for all risk factors indicated that transfer rates were higher for male patients compared with female patients (adjusted odds ratio = 1.46), children compared with seniors (3.54), blacks compared with whites (1.28), evening or night transfers compared with morning or afternoon transfers (2.25), patients with Medicaid compared with those with other types of insurance (2.02), and for those with one or more comorbidities compared with those with no comorbidity (2.79). | These results suggest the need for prospective studies to further investigate the relationships between hospital transfer and medical and nonmedical factors. | closed_qa |
Should stored serum of patients previously tested for celiac disease serology be retested for transglutaminase antibodies? | Tissue transglutaminase (tTG) antibodies are currently recognized as a highly sensitive indicator of celiac disease (CD). Although a high concordance rate between tTG antibodies and anti-endomysial antibodies (EMA) has been reported up to a third of known CD patients are positive for only one of these antibodies.AIM: To determine whether in laboratories in which serum samples previously examined for CD serology markers had not been discarded, these samples should be tested for tTG antibodies. Fifty-eight stored (frozen at -70) serum samples of patients previously found to be EMA-negative but positive for one or more of the non-EMA markers: antigliadin antibodies (AGA)-IgA, AGA-IgG, antireticulin antibodies, were tested for anti-tTG antibodies (IMMCO Diagnostics). In patients found to be tTG positive, medical charts were reviewed and patients or their physicians contacted. Twelve of fifty-eight (20.7%) samples were found to be anti-tTG positive. These included: group A: 3/3 samples previously positive for AGA-IgA, AGA-IgG, and antireticulin antibodies. Group B: 3/16 samples positive for AGA-IgA and AGA-IgG. Group C: 3/4 samples positive for AGA-IgA and group D: 3/35 samples positive for AGA-IgG. Of the 12 positive patients, 1 was a 2-year-old boy, 5 were lost to follow up, and 7 underwent an intestinal biopsy. In 3 of these 7 patients, the biopsy was compatible with CD; 2 of these 3 patients were from group A and 1 from group B. | In laboratories where stored serum samples are available, EMA-negative samples previously found to be positive for at least 2 other CD markers should be retested for tTG antibodies. | closed_qa |
Does secretin-stimulated MRCP predict exocrine pancreatic insufficiency? | Data on magnetic resonance cholangiopancreatography with secretin stimulation (S-MRCP) for the assessment of exocrine pancreatic insufficiency (EPI) are limited. We compared pancreatic function tests with the findings of S-MRCP in patients with chronic pancreatitis (CP) and disease controls. S-MRCP was performed in 23 patients (18 CP, 5 disease controls). MRCP images were analyzed for secretin-induced duodenal liquid filling (0=no filling; 1=duodenal bulb; 2=up to lower flexure; 3=beyond lower flexure). EPI was evaluated by fecal elastase, fecal fat concentration, and a 13C mixed chain triglyceride breath test. Clinically relevant EPI was stated if 2 of 3 tests were pathologic. EPI was diagnosed in 10 of 18 patients with CP. Patients without EPI showed either grade 2 (n=4) or grade 3 (n=9) duodenal filling, whereas only 1/10 patients with EPI showed grade 3 duodenal filling. Sensitivity and specificity of S-MRCP for the diagnosis of EPI were 69% and 90%, respectively. | Assessment of duodenal filling should be performed in patients who undergo S-MRCP for the evaluation of pancreatic morphology. However, minor degrees of duodenal filling are equivocal and require further diagnostic evaluation. | closed_qa |
Is transcutaneous oxygen and carbon dioxide monitoring indispensable in short- and long-term therapeutic management of non-reconstructable lower critical limb ischemia? | Twenty-six consecutive patients with CLI (21 with distal trophic lesions, 31 symptomatic limbs) considered unreconstructable after peripheral angiography and with a history of type 2 diabetes mellitus underwent daily parenteral Iloprost treatment for 2-3 weeks. Transcutaneous gas-analytic monitoring (TGM) in non-reconstructable CLI treated with Iloprost divided patients into 2 groups: early responders (ER) with increased TcpO(2) and normalization of TcpCO2, and non responders (NR) with unchanged TcpO(2) and TcpCO(2) parameters. In the NR who underwent a second cycle of Iloprost within a few months of the first, TGM further divided the patients into another subgroup of late responders (LR) with TcpO(2) and TcpCO(2) similar to the ER group and a subgroup of NR, who, after pharmacological treatment failure, should undergo eventual surgical re-timing and/or spinal cord stimulation in a final attempt to save the limb. | In the short-term follow-up of CLI, a marked reduction in supine/dependent TcpO(2) and a marked increase in supine TcpCO(2) at the symptomatic forefoot proved to be significant predictors of major amputation risk. In the long-term follow-up period, TGM showed that, in ER and in LR, the favourable effect of pharmacological therapy observed in the first 6 months will disappear over the next 6 months, suggesting an algorithm of 2- to 3-week cycles of prostanoid therapy repeated every year. In NR treated with surgical and/or alternative therapies who did not undergo major amputations, prolonged instrumental TGM will provide a constant evaluation of metabolic parameters, thus providing the possibility to save the limb with additional pharmacological therapy. | closed_qa |
Central venous cannulation: are routine chest radiographs necessary after B-mode and colour Doppler sonography check? | After the insertion of a central venous catheter, a chest radiograph is usually obtained to ensure correct positioning of the catheter tip. To determine in a paediatric population whether B-mode and colour Doppler sonography after central venous access is useful to evaluate catheter position, thus obviating the need for a postprocedural radiograph. A prospective study of 107 consecutive central venous access procedures placed in a paediatric intensive care unit was performed. At the end of the procedure, B-mode and colour Doppler sonography were used to assess catheter position and check for complications. A postprocedural chest radiograph was obtained in all patients. In 96 patients postprocedural B-mode and colour Doppler sonography showed colour Doppler signals within the vena cava. Among the 11 patients predicted to have a potential complication, there was one pneumothorax and ten malpositions. Chest radiography showed a total of 13 complications-1 pneumothorax and 12 malpositions. The concordance between colour Doppler sonography and chest radiography was 98.1% in the detection of catheter position; sonography had a sensitivity of 84.6% and a specificity of 100%. | The close concordance between B-mode and colour Doppler sonography and chest radiography justifies the more frequent use of sonography to evaluate catheter position because ionizing radiation is eliminated. Chest radiography may then be performed only when there is suspected inappropriate catheter tip position after sonography. | closed_qa |
Does urodynamic investigation improve outcome in patients undergoing prolapse surgery? | Without solid evidence, it has been advocated to perform urodynamic investigation in all patients scheduled for prolapse surgery. If urodynamic investigations were to be valuable in the diagnostic work-up, patients with normal and abnormal findings would have different treatment results. Our policy to never combine prolapse surgery and stress-incontinence surgery allowed us to study whether incontinence after surgery can be predicted from urodynamic investigation results. A retrospective study was performed in consecutive patients undergoing vaginal prolapse surgery (anterior colporraphy and/or posterior colporraphy, and/or vaginal hysterectomy) between 2002 and 2004. All patients underwent pre-operative urodynamic investigation, including filling cystometry, urethral pressure profile measurement, and free flow cystometry. Data were collected from the files about medical history, findings at pelvic examination, findings at urodynamic investigation and presence of stress- and/or urge-incontinence after surgery. We studied 76 patients, of whom 5 (7%) patients reported stress-incontinence and 5 (7%) patients reported urge-incontinence after surgery. Findings at urodynamic investigation could not predict the presence of stress- or urge-incontinence after surgery. Likelihood ratios (LR) of prior presence of urge and stress-incontinence for the presence of post-operative urge- and stress-incontinence were 4.5 and 1.2, respectively. Of all findings at urodynamic investigation, only negative transmission during cough test was associated with presence of stress-incontinence (LR = 1.5). | The prevalence of incontinence after prolapse surgery is low. None of the investigated parameters of the urodynamic investigation tests was associated with the presence of urinary incontinence after surgery. | closed_qa |
Autism spectrum disorder and psychopathy: shared cognitive underpinnings or double hit? | We measured psychopathic traits in boys with autism spectrum disorder (ASD) selected for difficult and aggressive behaviour. We asked (i) whether psychopathic tendencies can be measured in ASD independent of the severity of autistic behaviour; (ii) whether individuals with ASD with callous-unemotional (CU) traits differ in their cognitive profile from those without such traits; and (iii) how the cognitive data from this study compare with previous data of youngsters with psychopathic tendencies. Twenty-eight ASD boys were rated on psychopathic tendencies, autistic traits and a range of cognitive measures assessing mentalizing ability, executive functions, emotion recognition and ability to make moral-conventional distinction. Our results indicate that psychopathic tendencies are not related to severity of ASD. In addition, such tendencies do not seem to be related to core autistic cognitive deficits, specifically in 'mind-reading' or executive function. Boys with co-occurring ASD and CU tendencies share some behaviours and aspects of cognitive profile with boys who have psychopathic tendencies alone. | Callous/psychopathic acts in a small number of individuals with ASD probably reflect a 'double hit' involving an additional impairment of empathic response to distress cues, which is not part and parcel of ASD itself. | closed_qa |
Does continuity of care with a family physician reduce hospitalizations among older adults? | To examine the relation between continuity of primary care and hospitalizations. Survey data from a representative sample of older adults aged 67 or over living in the province of Manitoba (n = 1863) were linked to administrative data, which provide complete records of physician visits and hospitalizations. A visit-based measure of continuity of care was derived using a majority-of-care definition, whereby individuals who made 75% of all their visits to family physicians (FPs) to the same FP were classified as having high continuity of care, and those with less than 75% of their visits to the same FP as having low continuity of care. Whether individuals were hospitalized (for either ambulatory care-sensitive conditions or all conditions) was also determined from administrative records. High continuity of care was associated with reduced odds of ambulatory care-sensitive hospitalizations (adjusted odds ratio = 0.67, confidence interval 0.51-0.90) controlling for demographic and self-reported, health-related measures. It was not related to hospitalizations for all conditions, however. | The study highlights the importance of continuity of primary care in reducing potentially avoidable hospitalizations. | closed_qa |
Is self-care a cost-effective use of resources? | To determine if a whole-system approach to self-management in inflammatory bowel disease (IBD), using a guidebook developed with patients and physicians trained in patient-centred care, leads to cost-effective use of health system resources. Cost-effectiveness analysis over a one-year time horizon comparing the whole systems self-management approach to treatment with usual treatment. Nineteen hospitals in the northwest England were randomized to the intervention or to be controls; 651 patients (285 at intervention sites and 366 at control sites) with established IBD were included. The economic evaluation related differential health service costs, from a UK NHS perspective, to differences in quality-adjusted life years (QALYs) based on patients' responses to the EQ-5D. The intervention was associated with a mean reduction in costs of 148 pounds sterling per patient and a small mean reduction in QALYs of 0.00022 per patient compared with the control group. This resulted in an incremental cost per QALY gained of 676,417 pounds sterling for treatment as usual and a probability of around 63% that the whole-system approach to self-management is cost-effective, assuming a willingness to pay up to 30,000 pounds sterling for an additional QALY. | Although there is uncertainty associated with these estimates, more widespread use of this method in chronic disease management seems likely to reduce health care costs without evidence of adverse effect on patient outcomes. | closed_qa |
Evaluation of Safe Kids Week 2004: age 4 to 9? | To assess the effectiveness of a national one week media campaign promoting booster seat use. Pre-test, post-test design based on nationally representative random digit dialing telephone survey, with control for exposure to campaign. Canada. Parents of children aged 4-9 years. During a one week campaign in May 2004, information on booster seat use was distributed via a national media campaign, retail stores, medical clinics, and community events. Information included pamphlets with guidelines for booster seat use, as well as a growth chart (designed by Safe Kids Canada) to assist parents in determining if their child should be using a booster seat. Assessing seat belt fit was described in detail on the growth chart. Knowledge, attitudes, and self-reported behaviors regarding booster seat use. Respondents in the group exposed to the campaign were twice as likely to report using a booster seat with lap and shoulder belt for their child (47%), compared to those in the pre-test (24%) and the unexposed (23%) groups (p<0.001). However, only small differences in general knowledge regarding booster seat use were found between the groups. | A one week national media campaign substantially increased self-reported use of booster seats. Parents did not remember details of the campaign content, but did remember implications for their own child. | closed_qa |
Medical informatics and bioinformatics: integration or evolution through scientific crises? | To contribute a new perspective on recent investigations into the scientific foundations of medical informatics (MI) and bioinformatics (BI). To support efforts that could generate synergies and new research directions. MI and BI are compared and contrasted from a philosophy of science perspective. Historical examples from MI and BI are analyzed based on contrasting viewpoints about the evolution of scientific disciplines. Our analysis suggests that the scientific approaches of MI and BI involve different assumptions and foundations, which, together with largely non-overlapping communities of researchers for the two disciplines, have led to different courses of development. We indicate how their respective application domains, medicine, and biology may have contributed to these differences in development. | An analysis from the point of view of the philosophy of science is characteristic of established scientific disciplines. From a Kuhnian perspective, both disciplines may be entering a period of scientific crisis, where their foundations are questioned and where new ideas (or paradigm shifts) and a progressive research programme are needed to advance them scientifically. We discuss research directions and trends both supporting and challenging integration of the subdisciplines of MI and BI into a unified field of biomedical informatics (BMI), centered around the evolution of information cybernetics. | closed_qa |
Does gas exchange response to prone position predict mortality in hypoxemic acute respiratory failure? | To determine whether gas exchange response to a first prone position session can predict patient outcome in hypoxemic acute respiratory failure. Data from a previous multicenter randomized controlled trial were retrospectively analyzed for relationship between PaO(2)/FIO(2) ratio and PaCO(2) changes during the first 8-h prone position session to day 28 mortality rate; 370 prone position sessions were analyzed. Arterial blood gas was measured in supine position before proning and in prone position at the end of the session. Gas exchange improvement was defined as increase in the PaO(2)/FIO(2) ratio of more than 20% (PaO(2)R) or decrease in PaCO(2) of more than 1 mmHg (PaCO(2)R). The 28-day mortality rate was 26.5% in PaO(2)R-PaCO(2)R, 31.7% in PaO(2)R-PaCO(2)NR, 38.9% in PaO(2)NR-PaCO(2)R, and 43% in PaO(2)NR-PaCO(2)NR (log-rank 14.02, p = 0.003). In a Cox proportional hazards model the gas exchange response was a significant predictor to patient outcome with a 82.5% increase in risk of death in the case of PaO(2)NR-PaCO(2)R or PaO(2)NR-PaCO(2)NR, relative to the gas exchange improvement response (odds ratio 1.825). However, after adjusting for the difference in oxygenation between day 2 and day 1 the gas exchange response does no longer reach significance. | In patients with hypoxemic acute respiratory failure initial improvement in gas exchange in the first PP session was associated with a better outcome, but this association disappeared when the change in oxygenation from day 1 to day 2 was taken into account, suggesting that underlying illness was the most important predictor of mortality in this patient population. | closed_qa |
Malaria treatment failures after artemisinin-based therapy in three expatriates: could improved manufacturer information help to decrease the risk of treatment failure? | Artemisinin-containing therapies are highly effective against Plasmodium falciparum malaria. Insufficient numbers of tablets and inadequate package inserts result in sub-optimal dosing and possible treatment failure. This study reports the case of three, non-immune, expatriate workers with P. falciparum acquired in Africa, who failed to respond to artemisinin-based therapy. Sub-therapeutic dosing in accordance with the manufacturers' recommendations was the probable cause. Manufacturers information and drug content included in twenty-five artemisinin-containing specialities were reviewed. A substantial number of manufacturers do not follow current WHO recommendations regarding treatment duration and doses. | This study shows that drug packaging and their inserts should be improved. | closed_qa |
Angiolymphoid hyperplasia with eosinophilia: efficacy of isotretinoin? | Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign but potentially disfiguring vascular lesion. It is usually characterized by dermal and subcutaneous nodules, primarily in the head and neck region. Spontaneous regression is common, but persistent or recurrent lesions may require treatment. Several treatments have been reported but surgery is the most efficient one. We report a 32-year-old man presenting with multiple nodules on the cheeks, preauricular region and the scalp and who received treatment with isotretinoin (0.5 mg/kg/day) for 1 year with complete resolution of one of his scalp nodules. The rest of the lesions remained stable and were treated with surgical excision without recurrence. | Isotretinoin may play a role in the treatment of ALHE due to its antiangiogenic properties via a reduction of vascular endothelial growth factor (VEGF) production by keratinocytes. | closed_qa |
Does MYCN amplification manifested as homogeneously staining regions at diagnosis predict a worse outcome in children with neuroblastoma? | MYCN amplification in neuroblastoma tumor cells is manifested primarily as double minutes (dmins), whereas in cell lines it often appears in the form of homogeneously staining regions (HSR), suggesting that HSRs are associated with a more aggressive tumor phenotype and worse clinical outcome. The aim of this study was to determine whether children with neuroblastoma in which MYCN oncogene amplification is manifested as HSRs at diagnosis have a worse prognosis than those whose tumors exhibit dmins. A retrospective analysis of primary neuroblastomas analyzed for MYCN amplification by the Children's Oncology Group between 1993 and 2004 was done. Tumors with MYCN amplification were defined as having dmins, HSRs, or both (dmins + HSRs), and associations with currently used risk group stratification variables and patient outcome were assessed. Of the 4,102 tumor samples analyzed, 800 (19.5%) had MYCN amplification. Among the 677 tumors for which the pattern of amplification was known, 629 (92.9%) had dmins, 40 (5.9%) had HSRs, and 8 (0.1%) had dmins + HSRs. Although MYCN amplification is associated with older age, higher stage, and unfavorable histology, whether the amplification occurred as dmins or HSRs did not significantly affect these risk factors. There were no differences in the event-free survival (EFS) or overall survival in patients with MYCN amplification manifested as either dmins or HSRs (5-year EFS, 35 +/- 3% versus 38 +/- 15%; P = 0.59). Although the eight patients with dmins + HSRs fared worse than either of the individual subgroups (EFS, 18 +/- 16% versus 35 +/- 3% for dmins and 38 +/- 15% for HSRs), these differences were not significant. | MYCN amplification in any form (HSRs or dmins) is associated with a poor outcome. | closed_qa |
Do circulating leucocytes and lymphocyte subtypes increase in response to brief exercise in children with and without asthma? | Exercise can alter health in children in both beneficial (eg reduced long-term risk of atherosclerosis) and adverse (eg exercise-induced asthma) ways. The mechanisms linking exercise and health are not known, but may rest, partly, on the ability of exercise to increase circulating immune cells. Little is known about the effect of brief exercise, more reflective of naturally occurring patterns of physical activity in children, on immune cell responses. To determine whether (1) a 6-min bout of exercise can increase circulating inflammatory cells in healthy children and (2) the effect of brief exercise is greater in children with a history of asthma. Children with mild-moderate persistent asthma and age-matched controls (n = 14 in each group, mean age 13.6 years) performed a 6-min bout of cycle-ergometer exercise. Spirometry was performed at baseline and after exercise. Blood was drawn before and after exercise, leucocytes were quantified and key lymphocyte cell surface markers were assessed by flow cytometry. Exercise decreased spirometry only in children with asthma, but increased (p<0.001) most types of leucocytes (eg lymphocytes (controls, mean (SD) 1210 (208) cells/microl; children with asthma, 1119 (147) cells/microl) and eosinophils (controls, 104 (22) cells/microl; children with asthma, 88 (20) cells/microl)) to the same degree in both groups. Similarly, exercise increased T helper cells (controls, 248 (60) cells/microl; children with asthma, 232 (53) cells/microl) and most other lymphocyte subtypes tested. By contrast, although basophils (16 (5) cells/microl) and CD4+ CD45RO+ RA+ lymphocytes (19 (4) cells/microl) increased in controls, no increase in these cell types was found in children with asthma. | Exercise increased many circulating inflammatory cells in both children with asthma and controls. Circulating inflammatory cells did increase in children with asthma, but not to a greater degree than in controls. In fact, basophils and T helper lymphocyte memory transition cells did not increase in children with asthma, whereas they did increase in controls. Even brief exercise in children and adolescents robustly mobilizes circulating immune cells. | closed_qa |
Practitioner reporting of birth defects in children born following assisted reproductive technology: Does it still have a role in surveillance of birth defects? | National assisted reproductive technology (ART) data collections that rely on practitioners' reports of birth defects have consistently reported lower proportions of children with birth defects than record linkage studies that link ART infants to birth and malformation registers. We compared the birth defect data reported to the national Australian Assisted Conception Data Collection (ACDC) by practitioners at three Western Australian ART clinics with the birth defect data identified on the Western Australian Birth Defects Registry (WABDR) through record linkage of all the pregnancies conceived at these clinics to the WABDR. Cases are reported to the WABDR by multiple statutory and voluntary sources. We found that the national ACDC significantly underestimated the prevalence of birth defects in WA-born ART infants. Less than one-third of ART children identified with a major birth defect on the WABDR were reported to the ACDC. | Although national ART data collections provide valuable information on pregnancy rates and short-term pregnancy outcomes such as multiple birth and birth weight, we strongly recommend that birth defect information used for patient counselling is preferentially drawn from large studies that have used record linkage to high-quality birth defect registers. | closed_qa |
Epidural anaesthesia for labour: does it influence the mode of delivery? | Epidural anaesthesia (EDA) is an effective method to lower labour pain. EDA might have an impact on instrumental delivery rates and on caesarean section rates. The present study compares the mode of delivery in women who were either receiving EDA or not. The indication for EDA was pain relief only in order to switch off a selection bias. During a 1-year duration, we included a total of 1,452 cases. Exclusion criteria were factors that could influence the mode of delivery, independent from EDA, as well as obstetrical indications for administering EDA. 530 women remained in the analysis. The primary outcome variable was the mode of delivery. We detected in both nullipara and multipara a statistically significant accumulatin in patients with EDA and caesarean section combined. Most importantly, the majority of the women without EDA (57% of nullipara and 60% of multipara) delivered within the median timeframe from admission until administration of EDA. | It seems to be obvious to conclude that EDA as performed in our study results in a higher rate of caesarean sections. It is important though to take into consideration that between the period from admission to the delivery ward and administration of EDA most of the parturients without EDA had already delivered. Our results make evident, that the administration of EDA exclusively used for reducing labour pain is a result of a complex collaboration of temporal conditions of labour as well as psychological conditions and also of the mother's wish. | closed_qa |
Myocardial sympathetic innervation in patients with chronic coronary artery disease: is reduction in coronary flow reserve correlated with sympathetic denervation? | Higher sensitivity of sympathetic nerves to ischaemia in comparison with myocytes has been observed and has been claimed to contribute to poor prognosis in patients with coronary artery disease (CAD). The aim of this study was to evaluate the dependency of myocardial sympathetic innervation on restrictions in coronary flow reserve (CFR). We analysed 27 non-diabetic patients with advanced CAD. We determined quantitative myocardial blood flow using (13)N-ammonia PET, myocardial viability with (18)F-FDG PET and cardiac innervation with (11)C-HED PET. Scarred segments were excluded from analysis. We investigated the relationship between regional HED retention, blood flow and CFR. There was no correlation between rest perfusion and HED retention within a flow range from approximately 30 to 120 ml/(100 ml x min). A slight correlation was observed between stress perfusion values and HED retention (p<0.001), and between CFR and HED retention (p<0.001). | In non-diabetic CAD patients, HED retention in vital myocardium does not correlate with myocardial rest perfusion over a large flow range. The observed relation between HED retention and CFR indicates that sympathetic innervation can be preserved even when there is major impairment of myocardial blood supply. Most probably the occurrence of denervation depends not only on reductions in CFR, but also on the duration and severity of resulting ischaemic episodes. | closed_qa |
Are computerised monitoring systems of value to improve pharmacovigilance in paediatric patients? | The aim of the present study was to evaluate a computerised monitoring system (CMS) based on laboratory test results for the detection of adverse drug reactions (ADRs) on a paediatric ward. A prospective, 6-month pharmacoepidemiological survey was performed on a 22-bed paediatric isolation ward. ADRs were identified by intensive chart review. In addition to spontaneous reporting by the treating physician, automatic laboratory signals generated by a CMS were evaluated for their association with ADRs. ADRs were classified by the affected target organs according to the WHO-ART system organ classes. A total of 73 ADRs were identified in 439 admissions (396 patients) by chart review. The CMS alerted 31 (42.4%) ADRs while 23 (31.5%) ADRs were found solely by treating physicians. Eight ADRs were detected by both approaches resulting in a total detection rate of 74% (compared with intensive pharmacovigilance). Out of a total of 27,434 laboratory tests performed routinely, 1,563 were classified as abnormal by the predefined CMS and used as the basis of alerts. The sensitivity of the system with respect to patients alerted was 90.3% and the specificity only 19.6%. | This study demonstrates that, using CMS, a different kind of mild adverse events were detected compared to the observation by the treating physician. The system presented appears to be sufficiently sensitive, but the specificity is too low to make it acceptable for physicians in daily practice. In children, clinically important ADRs can be detected best by intensified surveillance. | closed_qa |
The 'natural' endpoint of dementia: death from cachexia or dehydration following palliative care? | To investigate the causes of death in nursing home patients with dementia, and to compare causes of death in patients who survive until the final phase of dementia with those who die before reaching that phase, adjusted for potential confounders. Observational analysis of a cohort of patients with a prospective follow-up. Psychogeriatric nursing home 'Joachim en Anna' in Nijmegen, the Netherlands. Eight hundred and ninety dementia patients admitted between 1980 and 1989. All patients were followed until death. The final phase of dementia was defined as total impairment on 20 items of a functional status questionnaire. Immediate causes of death (part 1a of the Dutch death certificate) were classified by the International Classification of Health Problems in Primary Care. The three most important reported immediate causes of death were cachexia/dehydration (35.2%), cardio-vascular disorders (20.9%) and acute pulmonary diseases (20.1%), mainly pneumonia. Cachexia/dehydration was particularly common as a cause of death of patients who survived to the final phase (53.2%); survival to the final phase of dementia was an independent predictor of cachexia/dehydration as an immediate cause of death with reference to cardiovascular disorders in multinomial regression adjusted for age at death, gender, and type of dementia. | Patients who survive to the final phase of dementia are more likely to die from cachexia or dehydration than those who die before. The findings contribute to a debate on what should be reported as the immediate cause of death in dementia including perspectives from a palliative care viewpoint. | closed_qa |
Evaluating hospital costs in type 2 diabetes care: does the choice of the model matter? | Awareness of the economic burden of diabetes has led to a number of studies on economic issues. However, comparison among cost-of-illness studies is problematic because different methods are used to arrive at a final cost estimate. The aim of the study is to show how estimates of hospitalisation costs for diabetic patients can vary significantly in relation to the statistical method adopted in the analysis. The study analyses diabetic patients' costs as a function of demographic and clinical covariates, by applying the following statistical survival models: the parametric survival model assuming Weibull distribution, the Cox proportional hazard (PH) model and the Aalen additive regression for modelling costs. The Aalen approach is robust both for the non proportionality in hazard and for departures from normality. In addition it is able to easily model the effect of covariates on the extreme costs. This cost analysis is based on data collected for a retrospective observational study analysing repeated hospitalisations (N = 4816) in a cohort of 3892 diabetic patients. There is agreement in all models with the effects of the considered covariates (age, sex, duration of disease and presence of other pathologies). An effect of over- or under-estimation, according to the chosen model due to arguably inappropriate model fitting, was observed, being more evident for some specific profiles of the patients, and overall accounting for as much as 20% of the estimated effect. The Aalen model was able to cope with all the other models in furnishing unbiased estimates with the advantage of a greater flexibility in representing the covariates' effect on the cost process. | An appropriate choice of the model is crucial in avoiding misinterpretation of cost determinants of type 2 diabetes care. For our data set the Aalen model proved itself to be a realistic and informative way to characterise the effect of covariates on costs. | closed_qa |
Is time to chemotherapy a determinant of prognosis in advanced-stage ovarian cancer? | Clinicians often question when to start chemotherapy after patients undergo surgery for ovarian cancer. A major unproven concern is whether a long postoperative delay reduces the benefits of an extensive procedure and leads to disease progression. Our objectives were to evaluate the correlation between clinical and pathologic variables and to evaluate the effect of the "time to chemotherapy" (TTC) interval on survival. We retrospectively studied data from 218 patients with International Federation of Gynecology and Obstetrics stage IIIC or IV ovarian cancer (TNM stage T3c or T4) who were consecutively treated between January 1, 1994, and December 31, 1998. Mean age at diagnosis was 64 years (range, 24-87 years; median, 65 years), and 206 patients received postoperative platinum-based chemotherapy. Mean TTC interval was 26 days (range, 7-79 days; median, 25 days). No correlation was found between operative time and TTC interval length (P=0.99). Age and performance of rectosigmoidectomy were correlated with longer TTC interval (P=0.009 and P=0.005, respectively), but TTC was not a predictor of overall survival (odds ratio, 1.00; 95% confidence interval, 0.98-1.01; P=0.85). Differences in TTC interval length (<or =17 days, 18-26 days, 27-33 days, or>or =34 days) did not affect survival (P=0.93). Even after categorizing patients by residual disease (<1 cm or>or =1 cm), no statistically significant effect of TTC on prognosis was identified. | Concerns about the TTC interval should not be used to justify spending less time in the operative arena or using a more conservative approach for patients with advanced ovarian cancer. | closed_qa |
Does age matter in palliative care? | To assess whether age has an impact on symptoms, problems and needs of hospitalized advanced cancer patients. A prospective analysis of 181 patients referred to a Palliative Care Team was done using a standardized list of symptoms, problems and needs. Differences between 3 age groups (<60; 60-70;>or =70) were analyzed. Patients>or =70 years had a significantly different prevalence of depressed mood (48% versus 13% of patients 60-70 years and 24% of patients<60 years, p=0.002), urinary tract problems (20% versus 3% versus 8%, p=0.024) and drowsiness (18% versus 42% versus 25%, p=0.039). They expressed more problems with a shortage of informal caregivers (45% versus 42% versus 17%, p<0.001) and less need for support in coping (40% versus 61% versus 63%, p=0.043), relational support (3% versus 8% versus 14%, p=0.019) and support in communication (0% versus 8% versus 11%, p=0.013). | Fewer differences than expected were found. Elderly cancer patients admitted to a hospital have more or less the same symptoms, problems and needs as their younger counterparts. Despite these findings, age-specific assessment of symptoms, problems and needs ought to be part of optimal symptom management. | closed_qa |
Teaching practices of thoracic epidural anesthesia in the United States: should lumbar epidurals be taught before thoracic epidurals? | The purpose of this study was to determine the current teaching practice of thoracic epidural procedures in the United States and to determine the effect of the teaching sequence of thoracic and lumbar epidurals on technical difficulties and complications. The first part was a survey, which was distributed to all American Board of Anesthesiology-accredited programs. The second part was a noninterventional retrospective review of 2,007 epidural procedures in a university teaching program. The survey questions were designed to determine the number of epidural procedures performed monthly on various services, teaching sequence, insertion technique, indications, and service provider. The survey received 81 responses (60%) from 134 programs; 34% of the programs placed more thoracic than lumbar epidurals, 92% of the programs placed epidurals mainly for postoperative pain control, and 88% of programs mainly teach lumbar before thoracic epidurals, whereas only 10 programs (12%) mainly teach residents thoracic before lumbar epidurals. The authors' residents were divided into 2 groups: group 1 (42 residents, 70%) who learned thoracic before lumbar epidurals and group 2 (18 residents, 30%) who learned lumbar before thoracic epidurals during their earlier obstetric anesthesia training. There were no significant differences between the 2 groups in the degree of technical difficulties or the incidence of procedure-related complications. | Thoracic epidurals are widely taught in the United States. Most programs teach lumbar before thoracic epidurals. Thoracic epidurals are safe to teach without prior experience with lumbar epidurals. | closed_qa |
Does subfertility explain the risk of poor perinatal outcome after IVF and ovarian hyperstimulation? | The primary objective of this study was to investigate whether subfertility explains poor perinatal outcome after assisted conception. A secondary objective was to test the hypothesis that ovarian hyperstimulation rather than the IVF procedure may influence the perinatal outcome. Using data from a Dutch population-based historical cohort of women treated for subfertility, we compared perinatal outcome of singletons conceived after controlled ovarian hyperstimulation (COHS) and IVF (IVF + COHS; n = 2239) with perinatal outcome in subfertile women who conceived spontaneously (subfertile controls; n = 6343) and in women who only received COHS (COHS only; n = 84). Furthermore, we compared perinatal outcome of singletons conceived after the transfer of thawed embryos with (Stim + Cryo; n = 66) and without COHS (Stim - Cryo; n = 73). The odds ratios (ORs) for very low birthweight (<1500 g) and low birthweight (1500-2500 g) were 2.8 [95% confidence interval (95% CI) 1.9-3.9] and 1.6 (95% CI 1.2-1.8) in the IVF + COHS group compared with the subfertile control group. The ORs for very preterm birth (<32 weeks) and for preterm birth (32-37 weeks) were 2.0 (95% CI 1.4-2.9) and 1.5 (95% CI 1.3-1.8), respectively. Adjustment for confounders did not materially change these risk estimates. The difference in risk between the COHS-only group and the subfertile group was significant only for very low birthweight (OR 3.5; 95% CI 1.1-11.4), but the association became weaker after adjustment for maternal age and primiparity (OR 3.1; 95% CI 1.0-10.4). No significant difference in birthweight and preterm delivery was found between the group of children conceived after ovarian stimulation/ovulation induction and (Stim + Cryo) and the group of children conceived after embryo transfer of thawed embryos in a spontaneous cycle without ovarian stimulation/ovulation induction (Stim - Cryo). | The poor perinatal outcome in this database could not be explained by subfertility and suggests that other factors may be important in the known association between assisted conception and poor perinatal outcome. | closed_qa |
Are American children and adolescents of low socioeconomic status at increased risk of obesity? | A good understanding of the association between obesity and socioeconomic status (SES) has many important public health and policies implications, particularly for the prevention and management of obesity. The objective was to examine secular trends in the relations between overweight (body mass index>or = 95th percentile) and SES. We examined secular trends in the relation between overweight and SES using nationally representative data collected in the National Health and Nutrition Examination Surveys (NHANES) between 1971 and 2002 for 30 417 US children aged 2-18 y. Poverty income ratio tertiles at each survey were used to indicate low, middle, and high SES. Considerable race, sex, and age differences were observed in the association between overweight and SES. A reverse association only existed in white girls; African American children with a high SES were at increased risk. Socioeconomic disparities in overweight have changed over time, with an overall trend of weakening. Compared with the medium-SES group, the adjusted odds ratios and 95% CIs were 0.79 (0.47, 1.33), 1.08 (0.73, 1.61), 1.24 (0.73, 2.09), and 1.04 (0.82, 1.33) in NHANES I, II, and III and in the 1999-2002 NHANES for the low-SES group and 0.66 (0.43, 1.00), 0.60 (0.35, 1.03), 0.42 (0.23, 0.76), and 0.99 (0.68, 1.43) for the high-SES group, respectively. Between 1988-1994 and 1999-2002, the ratio in the prevalence of overweight between adolescent boys with a low or high SES decreased from 2.5 to 1.1 and from 3.1 to 1.6 in girls. Consistently across almost all SES groups, the prevalence of overweight was much higher in blacks than in whites. | Complex patterns in the association between SES and overweight exist. Efforts solely targeting reductions in income disparities probably cannot effectively reduce racial disparities in obesity. | closed_qa |
Is there a detrimental effect of waiting for radiotherapy for patients with localized prostate cancer? | To evaluate a possible deleterious effect of waiting time to radiotherapy on the biochemical relapse (BR) of patients with localized prostate cancer. Patients included in this retrospective study had localized prostate adenocarcinoma treated with external-beam irradiation alone. Waiting time was defined as the interval between the first consultation and the first radiation treatment. BR was defined as 3 consecutive rises of prostatic specific antigen (PSA). Patients were split into 3 groups of waiting time: group A were treated within 40 days; group B waited 41 to 80 days; group C waited>80 days to receive radiotherapy. The effect of waiting on BR was estimated by the Kaplan-Meier method. Multivariate Cox proportional hazards modeling was adjusted for known prognostic factors. There were 289 patients who participated in the analysis. Median follow-up time was 6.1 year. Overall BR rate was 44% at 5 years. The median waiting time increased over the study period from 26 days in 1992 to 123 days in 2000. In adjusted multivariate analysis there was a nonsignificant higher risk of BR with waiting for 41 to 80 days (hazard ratio [HR] = 0.8; 95% confidence interval [CI]= 0.3-1.6) and for>80 days (HR = 0.6; 95% CI = 0.2-1.5) when compared with patients treated within 40 days after consultation. | Delaying the start of radiotherapy showed little effect on the rate of BR in the group of 288 prostate cancer patients analyzed in this study. | closed_qa |
Radiation exposure during pedicle screw placement in adolescent idiopathic scoliosis: is fluoroscopy safe? | With institutional review board approval, prospective data were collected during fluoroscopically guided pedicle screw placement. To estimate a surgeon's radiation exposure with all screw constructs during surgery to repair idiopathic scoliosis. To our knowledge, there is no established consensus regarding the safety of radiation exposure during fluoroscopically guided procedures. A surgeon was outfitted intraoperatively with a thermoluminescent dosimeter to estimate radiation exposure to his whole body and thyroid gland. The index surgeon is projected to receive 13.49 mSv of whole body ionizing radiation and 4.31 mSv of thyroid gland irradiation annually. The National Council on Radiation Protection's current recommendations set lifetime dose equivalent limits for classified workers (radiologists) at 10 mSv per year of life and at 3 mSv for nonclassified workers (spinal surgeons). At the levels estimated, a surgeon beginning his/her career at age 30 years would exceed the lifetime limit for nonclassified workers in less than 10 years. The National Council on Radiation Protection limits the single-year maximum safe dosage to the thyroid to 500 mSv; the yearly exposure estimated here is significantly less. | The spinal surgeon's intraoperative radiation exposure may be unacceptable. Spinal surgeons should be considered classified workers and monitored accordingly. Methods to lower radiation dosage seem strongly indicated. | closed_qa |
Can we predict which patients are at risk of having an ungradeable digital image for screening for diabetic retinopathy? | We aimed to determine the reasons for, and variables which predicted, ungradeable retinal photographs during screening patients for diabetic retinopathy. Age, duration of diabetes, visual acuity, and HbA1c were recorded. Following dark adaptation, a single 45 degrees nonmydriatic photograph was taken of each fundus. The pupils were then dilated and the photograph repeated. Using slit lamp biomicroscopy, lenticular changes (LOCS III), and fundus appearance were recorded. In ungradeable photographs the fovea could not be visualised in 98% of cases of images from nonmydriatic photography, and in 88% if mydriasis was used. Poor definition in the nonmydriatic image was associated with a subsequent ungradeable mydriatic photograph (P=0.001), however, the positive predictive value was poor (34%). Age, posterior subcapsular cataract, and near vision predicted ungradeable status of nonmydriatic photographs (P<0.001, P=0.004, P=0.006, respectively; regression analysis). Nuclear colour and poor definition of the nonmydriatic photograph predicted ungradeable status of mydriatic photographs (P=0.006&P=0.001, respectively). | Inability to visualise the fovea is the commonest cause of an ungradeable image from digital retinal photography. Age and posterior subcapsular cataract were best predictors of ungradeable status of nonmydriatic fundus photographs. Nuclear colour was the strongest predictor for ungradeable mydriatic photography. | closed_qa |
Nonarteritic anterior ischemic optic neuropathy and 'visual field defects' following vitrectomy: could they be related? | Visual field defects after uncomplicated vitrectomy have been reported but poorly explained. We describe two cases of nonarteritic anterior ischemic optic neuropathy (NAION) observed following vitrectomy. We also reviewed the literature for cases of post-vitrectomy visual field defects for evidence of optic nerve damage. Two patients developed optic disc edema and features of an optic neuropathy after uncomplicated vitrectomy for macular hole and epiretinal membrane. A systematic literature search was conducted to obtain prior reports of visual field defects or ischemic optic neuropathy following vitrectomy. Additional studies were identified from the bibliographies of the retrieved articles. The incidence of visual field defects following vitrectomy has varied from 1-71% across all studies. Overall, we found 160 (14.5%) cases of unexplained visual field defects following vitrectomy out of 1,104 patients. Of these, 31 eyes (19.4%) have shown some sign of optic nerve damage following vitrectomy, including pallor in 29 eyes, relative afferent pupillary defect in eight eyes, and intrapapillary hemorrhage in two eyes. | NAION may develop following vitrectomy. "Visual field defects" following vitrectomy are common and many of the involved eyes demonstrate evidence of optic nerve damage, some of which may have represented NAION. | closed_qa |
Imaging in the early diagnosis of changes in the hand of patients suffering from rheumatoid arthritis. Is ultrasound a true alternative for low-field magnetic resonance scanning, 3-phase bone scintigraphy and conventional x-rays? | Besides the use of conventional x-rays in the diagnostic work-up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The aim of this study was to compare the diagnostic value of ultrasound of the hands with proven methods such as conventional x-rays, low-field MRI and 3P-Sz. A total of 30 patients were studied using a 1 day protocol with ultrasound, 3P-Sz, MRI and x-ray of the hands. Images were visually assessed by two blinded nuclear medicine physicians and radiologists and classified as RA typical and non-RA typical changes. All methods were compared to the summarized findings interpreted by a rheumatologist after 2 years. Of the 30 patients, 19 presented with clinical symptoms of initial changes due to rheumatoid arthritis. Ultrasound revealed 14/19 patients with the correct diagnosis. Conventional x-rays indicated 11/19 patients, while 3P-Sz (100%) and low-field MRI (95%) showed high sensitivity. It was possible to differentiate between inflammation and inconspicuous findings. | An experienced examiner can use ultrasound effectively for the initial diagnosis of RA. Based on its low cost, ultrasound is a valid alternative to conventional x-rays. | closed_qa |
FDG-PET detected thyroid incidentalomas: need for further investigation? | Incidental thyroid abnormalities are increasingly detected in patients undergoing PET scans. The aim of this study was to review our experience with the management of PET detected thyroid incidentalomas in a large single institution series. All PET scans performed from May 2003 to July 2005 were reviewed and patients with incidental thyroid abnormalities were identified. From this group, patients that underwent further investigation were analyzed. Data relating to PET scan findings, FNA diagnoses, operative details, and histopathology was reviewed. In 8,800 patients, 16,300 PET scans were performed of whom 263 patients (2.9% of patients and 1.6% of PET scans) had findings positive for thyroid abnormality. Thyroid malignancy was noted in 42% (24 patients) of the 57 patients that underwent FNA. In the group of 27 patients that were subjected to operative intervention, 74% (20 patients) were noted to have a malignant diagnosis. The final histopathology revealed primary thyroid carcinoma in all these 20 patients (19 patients with papillary carcinoma and one patient with primary thyroid lymphoma). The factors that correlated with an increased risk of malignancy were the presence of physical finding (p = 0.01) and focal (p<0.01) or unilateral uptake (p<0.01) on PET scan. The average SUV was not useful in differentiating benign (9.2) from malignant lesions (8.2, p = 0.7). | PET detected incidental thyroid abnormalities are rare. In patients with positive PET scan findings and suspicious features, the incidence of primary thyroid malignancy is very high. These patients warrant further investigation followed by possible operative intervention. | closed_qa |
Low-density lipoprotein cholesterol goal attainment among high-risk patients: Does a combined intervention targeting patients and providers work? | Physicians are aware of the National Cholesterol Education Program guidelines; however, most patients fail to attain cholesterol goals. To determine whether a combined program of patient education and provider awareness could improve the National Cholesterol Education Program goal attainment among patients at high risk for cardiovascular events. One hundred seven high-risk patients with cardiovascular disease were educated in a single 15-minute session regarding their cholesterol levels, risk factors, and medication adherence. Those with scores of 2 or lower on the Morisky questionnaire were classified as low-adherence patients, and those with scores of 3 or higher were classified as high-adherence patients. Seven physicians were provided this information and were requested to evaluate the dyslipidemia management of these patients. Lipid levels were reevaluated 8 to 12 weeks after the intervention. At the start of the study, 38 (35.5%) of the 107 patients were at target low-density lipoprotein cholesterol (LDL-C) levels, and 64 of the 107 patients (59.8%) were at target levels after the intervention. High-adherence patients decreased their LDL-C levels from a mean of 118.6 mg/dL (3.07 mmol/L) to 98.6 mg/dL (2.55 mmol/L); low-adherence patients increased their LDL-C levels after the intervention from 134.5 mg/dL (3.48 mmol/L) to 142.1 mg/dL (3.68 mmol/L). A comparison between the LDL-C goal achievers vs nonachievers revealed a significant difference in adherence (P = .001). Among the goal achievers, significant decreases in preintervention vs postintervention total cholesterol levels (P = .001) and LDL-C levels (P = .001) were also noted. | This study demonstrates that an intervention simultaneously targeting patients and providers is successful in improving goal attainment among high-risk patients. | closed_qa |
Acral keratosis with eosinophilic dermal deposits: a distinctive clinicopatholgic entity or colloid milium redux? | The differential diagnosis of acral keratoses is broad. Encompassing a variety of infectious, heritable and degenerative disorders, emphasis upon the clinical setting and histologic subtlety are often required to arrive at the correct diagnosis. Herein, we report on a series of adult patients who presented with agminated or solitary papules of the distal finger found on histologic examination to contain amorphous eosinophilic deposits. The eosinophilic deposits were found in close proximity to the overlying epithelium and devoid of apoptotic keratinocytes, plasma cells, or vascular thickening reminiscent of amyloidosis or hyalinosis cutis. Special and immunostains yielded eosinophilic material that was elastin and Protein P negative. Despite a similar histomorphologic appearance to colloid milium, typical clinical features of this entity were not present. | The etiologic significance of this condition is unknown. Potential sources of the material and a discussion of the differential diagnosis follow. | closed_qa |
Do erythropoietin receptors on cancer cells explain unexpected clinical findings? | Recent reports suggest that cancer control may worsen if erythropoietin is administered. We investigated whether erythropoietin receptor expression on cancer cells may correlate with this unexpected finding. Cancer tissue from patients with advanced carcinoma of the head and neck (T3, T4, or nodal involvement) and scheduled for radiotherapy was assayed retrospectively for erythropoietin receptor expression by immunohistochemistry. Patients were anemic and randomized to receive epoetin beta (300 U/kg) or placebo under double-blind conditions, given three times weekly starting 10 to 14 days before and continuing throughout radiotherapy. We administered 60 Gy following complete resection or 64 Gy subsequent to microscopically incomplete resection; 70 Gy were given following macroscopically incomplete resection or for definitive radiotherapy alone. We determined if the effect of epoetin beta on locoregional progression-free survival was correlated with the expression of erythropoietin receptors on cancer cells using a Cox proportional hazards regression model. We studied 154 of 157 randomly assigned patients; 104 samples were positive, and 50 were negative for receptor expression. Locoregional progression-free survival was substantially poorer if epoetin beta was administered to patients positive for receptor expression compared with placebo (adjusted relative risk, 2.07; 95% CI, 1.27 to 3.36; P<.01). In contrast, epoetin beta did not impair outcome in receptor-negative patients (adjusted relative risk, 0.94; 95% CI, 0.47 to 1.90; P = .86). The difference in treatment associated relative risks (2.07 v 0.94) was borderline statistically significant (P = .08). | Erythropoietin might adversely affect prognosis of head and neck cancer patients if cancer cells express erythropoietin receptors. | closed_qa |
Inhibition of restenosis development after mechanical injury: a new field of application for malononitrilamides? | To investigate the efficacy of the malononitrilamide FK778 to prevent vascular smooth muscle cell (SMC) migration/proliferation, and vascular fibrosis, the key events in restenosis development using in vivo and in vitro studies. Since the high rate of restenosis after percutaneous transluminal coronary angioplasty limited its long-term success, the implementation of locally delivered antiproliferative/immunosuppressive agents became advantageous. Rats underwent balloon denudation of the abdominal aorta and received sirolimus, tacrolimus, or FK778 for 28 days in varying doses. Aortas were harvested for histologic evaluation, profibrotic gene expression, and organ chamber studies. Antifibrotic, antiproliferative and antimigratory effects of the immunosuppressants were further evaluated in vitro. Histology of untreated animals revealed marked intimal hyperplasia with moderate luminal obliteration. Neointima formation was dose-dependently attenuated by all three agents with FK778 and sirolimus being most efficacious. Organ chamber relaxation studies showed a leftward shift of the nitroglycerin and the acetylcholine dose-responses in all treatment groups, indicating diminished endothelial dysfunction. In vivo, only FK778 treatment revealed a significant downregulation of the TGF-beta/vasorin system which could be explained by upregulation of the TGF-beta-inhibitory mediator SMAD7. In vitro, FK778 showed most potent antiproliferative and antimigratory effects on SMC compared with sirolimus and tacrolimus. Only the antiproliferative effect of FK778 was due to pyrimidine synthesis blockade and could be reversed by uridine supplementation. | The malononitrilamide FK778 proved highly efficacious against restenosis development by targeting two major components of intimal hyperplasia: SMC proliferation/migration and vascular fibrosis. Thus, the introduction of malononitrilamide-loaded stents may be a promising effort for future strategies. | closed_qa |
The quail mesonephros: a new model for renal senescence? | Renal senescence during normal aging is associated with specific vascular alterations and tissue degeneration. Although the degenerative program executed during embryonic kidney development is known to include vascular alterations, studies yet have to examine whether it involves replicative senescence. In this study, we assessed the potential of the quail mesonephros, a transitory embryonic kidney, as a model of human renal senescence. Quail embryos with developing or degenerating mesonephros were studied on day 6 or day 11 of incubation, respectively. Senescence-associated beta-galactosidase activity, a marker of replicative senescence, was examined on whole mounts and sections. Senescent vascular characterization was performed by the scanning electron-microscopic analysis of vascular corrosion casts. Senescence-associated beta-galactosidase activity was found only in old mesonephros. Moreover, at 11 days of incubation glomerular capillaries showed discontinuities and were thinner and more tortuous than those observed at 6 days, characteristics also reported for the aging human kidney. | The degenerating quail mesonephros is a potential model of renal senescence, showing biochemical and morphological characteristics of the aging human kidney. | closed_qa |
Do serum angiogenic growth factors provide additional information to that of conventional markers in monitoring the course of metastatic breast cancer? | Our work evaluated the potential role of basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) serum levels with respect to that of conventional serum tumour markers, CEA and CA 15-3, in monitoring the course of metastatic breast cancer in 56 female patients treated with cytotoxic chemotherapy. VEGF and bFGF concentrations were determined using a quantitative sandwich enzyme immunoassay technique. The positive predictive value (PPV) of each marker and of marker combinations for different types of clinical response was calculated. The highest PPV for overall disease control was shown by bFGF (70%), which also showed the highest PPV for both partial response (36.4%) and stable disease (63.2%). CEA showed the highest predictive value for progression (69.2%). A combined increase in CEA and bFGF or VEGF was associated with disease progression in all patients. | Information provided by angiogenic factor levels seems to be independent of and is possibly complementary to that provided by conventional serum markers. bFGF showed the maximum predictive value for disease control and provided additional information to that obtained from CEA or CA 15-3 evaluation. It could therefore be a promising candidate for monitoring response to chemotherapy in advanced breast cancer. | closed_qa |
Are there racial differences in breast cancer treatments and clinical outcomes for women treated at M.D. Anderson Cancer Center? | To determine the influence of race on breast cancer treatment and on recurrence and breast cancer specific death. The study population consisted of 6,054 African-American or white women who were diagnosed with breast cancer and received at least one of the treatments including mastectomy or breast conservative surgery, radiation, adjuvant chemotherapy, neo-adjuvant chemotherapy, and adjuvant endocrine therapy at M.D. Anderson Cancer Center between June 1997 and February 2005. The clinical outcomes were disease-free survival and breast-cancer-specific survival. Logistic regression analysis was performed to investigate if race was associated with the selection of each primary treatment while adjusting for tumor characteristics at diagnosis. Cox proportional hazards model was used to determine the effect of race on recurrence-free survival and breast-cancer-specific survival controlling for tumor characteristics, presence of co-morbidity conditions and use of these treatments. The use of any primary treatment for breast cancer was not significantly different by race after adjusting for tumor characteristics and co-morbidity conditions. Although tumor characteristics at diagnosis explained the major differences in clinical outcomes, race remained an independent prognostic factor for breast-cancer-specific survival (P=0.002), and a marginally significant factor for disease-free survival (P=0.063) in multivariate analyses. | Equal treatment may not lead to equal clinical outcomes given similar tumor characteristics at diagnosis. To reduce racial differences in breast cancer recurrence and survival, it is important to have a better understanding of differences in tumor biology by race and to promote the use of early detection programs among African-American women. | closed_qa |
Dental maturation in short and long facial types. Is there a difference? | The purpose of this investigation was to study the relationship between vertical skeletal growth pattern and dental maturation in children with long or short anterior facial height. The sample consisted of the records of 312 Dutch children (153 boys and 159 girls, aged 9-12.9 years, with a mean chronological age of 11.3 years). The subjects were selected according to their lower anterior facial height as a percentage of the total facial height. Two groups, one with long and the other with short anterior facial height, were formed for further comparison. Dental age, according to Demirjian's dental maturity score, was determined for each subject. The power of the study was 79% (2-sided test) and 87% (1-sided test). There was no statistically significant difference in dental age score between the two extreme groups. The subjects with short anterior facial height demonstrated a slight tendency toward more advanced dental age. | The difference in dental age between long and short facial types is not big enough to be clinically relevant. | closed_qa |
Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? | Millions of veterans are eligible to use the Veterans Health Administration (VHA) and Medicare because of their military service and age. This article examines whether an indirect measure of dual use based on inpatient services is associated with increased mortality risk. Data on 1,566 self-responding men (weighted N = 1,522) from the Survey of Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to Medicare claims and the National Death Index. Dual use was indirectly indicated when the self-reported number of hospital episodes in the 12 months prior to baseline was greater than that observed in the Medicare claims. The independent association of dual use with mortality was estimated using proportional hazards regression. 96 (11%) of the veterans were classified as dual users. 766 men (50.3%) had died by December 31, 2002, including 64.9% of the dual users and 49.3% of all others, for an attributable mortality risk of 15.6% (p<.003). Adjusting for demographics, socioeconomics, comorbidity, hospitalization status, and selection bias at baseline, as well as subsequent hospitalization for ambulatory care sensitive conditions, the independent effect of dual use was a 56.1% increased relative risk of mortality (AHR = 1.561; p = .009). | An indirect measure of veterans' dual use of the VHA and Medicare systems, based on inpatient services, was associated with an increased risk of death. Further examination of dual use, especially in the outpatient setting, is needed, because dual inpatient and dual outpatient use may be different phenomena. | closed_qa |
Extended-spectrum betalactamases producing Escherichia coli: a new health-care associated infection threat? | Study the health-care associated infection risk due to Extended-Spectrum Betalactamases Producing Escherichia coli (ESBL Esc) isolated from diagnostic samples. Descriptive, longitudinal and prospective study of 104 diagnostic isolates of ESBL Esc, one per patient, identified in Amiens university hospital between February 1999 and December 2005. Patients (sex, age, contamination risk factor, antecedent hospitalization) and microbiological data were progressively collected, entered into EPI INFO 6.04dFr software (ENSP, France) database, and compared using the chi-square test and Wilcoxon rank sum test, as appropriate. A p value of less than 0.05 was considered significant. Diagnostic ESBL Esc isolates raised, per 1000 isolates of Esc, from 1.2 in 1999 to 6 in 2005. Global and acquired isolates number of ESBL Esc varied from 7 and 3 in 2002 to 25 and 19 in 2003 (P=0.22). ESBL Esc global and acquired incidence per 10(5) patient-days were, 0.8 and 0.6 in 1999 and 4.99 and 3.4 in 2005 (P<10(-6)), but rose from 0.6 acquired isolate in 2002 to 3.9 in 2003 (P=0.002). ESBL Esc, isolated from urines, stools, pulmonary, blood and surgical site samples of patients of>/=65 years aged (68.3%), were imipenem and latamoxef sensitive. Their acquisition risk factors found were hospitalization during the last 6 month period (40/104) and transfer from other institutions (20/104). | ESBL Esc isolates, among ESBL-producing Enterobacteriaceae, constitute an escalating health-care associated risk in our institution. The research at admission time of ESBL-producing Enterobacteriaceae, mainly in acute geriatric wards, strict isolation precaution and hand hygiene observance, rational antibiotic usage, are the key actions to control their cross transmission. Nonetheless, other studies are needed to determine whether we are in front of an ESBL Esc new clone emergence. | closed_qa |
Endothelial dysfunction in geriatric diabetic patients: the role of microalbuminuria in elderly type 2 diabetic patients? | Microalbuminuria is considered a marker of extensive endothelial dysfunction and is associated with excess of other cardiovascular risk factors. Our aim is to assess the importance of the presence of microalbuminuria in elderly diabetic patients. A total of 40 normotensive elderly type 2 diabetic patients of both genders with mean age>65 years were randomly included and were further subdivided according to the presence of persistent microalbuminuria into microalbuminuric and normoalbuminuric groups. All patients in both groups were subjected to thorough clinical and laboratory investigations including the assay of serum thrombomodulin (TM) and glycosylated hemoglobin level. Early-morning midstream urine samples were evaluated for levels of beta 2 microglobulin, alpha 1 microglobulin, TM, and N-acetyl-beta-D-glucosaminidase (NAG). There was no significant difference between both groups regarding the clinical demographic characteristics. There were statistically significant higher values for glycosylated hemoglobin percentage, serum triglycerides and serum TM and urinary B2 microglobulin, urinary alpha 1 microglobulin, urinary NAG and urinary thrombomodulin in microalbuminuric group in comparison to normoalbuminuric group (P<0.05). | Microalbuminuria is associated with markers of endothelial dysfunction in elderly normotensive type 2 diabetic patients. We recommend incorporation of periodic testing for microalbuminuria in this sector of patients. | closed_qa |
Can quantification of faecal occult blood predetermine the need for colonoscopy in patients at risk for non-syndromic familial colorectal cancer? | Patients at risk for non-syndromic (Lynch or polyposis) familial colorectal neoplasia undergo colonoscopic surveillance at intervals determined by clinically ascertained protocols. The quantitative immunochemical faecal occult blood test for human haemoglobin is specific and sensitive for significant colorectal neoplasia (cancer or advanced adenomatous polyp).AIM: To determine immunochemical faecal occult blood test efficacy for identifying significant neoplasia in at-risk patients undergoing elective colonoscopy. We retrospectively identified consecutive at-risk patients who provided three immunochemical faecal occult blood tests before colonoscopy. Quantitative haemoglobin analysis was performed by the OC-MICRO automated instrument using the 100 ng Hb/mL threshold to determine positivity. In 252 at-risk patients undergoing colonoscopy; five had cancer, 14 an advanced adenoma and 46 a non-advanced adenoma. The immunochemical faecal occult blood test was positive in 31 patients (12.3%). Sensitivity, specificity, positive and negative predictive values for cancer were: 100%, 90%, 16% and 100%, and for all significant neoplasia: 74%, 93%, 45% and 98%. With 88% fewer colonoscopies, all colorectal cancers and 74% of all significant neoplasia would have been identified by this one-time immunochemical faecal occult blood test screening. | A sensitive, non-invasive, interval screening test might be useful to predetermine the need for colonoscopy in this at-risk population and minimize unnecessary examinations. This favourable retrospective evaluation will be extended to a prospective study. | closed_qa |
Are physicians ready for patients with Internet-based health information? | An increasing number of patients bring Internet-based health information to medical consultations. However, little is known about how physicians experience, manage, and view these patients. This study aimed to advance the understanding of the effects of incorporating Internet-based health information into routine medical consultations from physicians' perspectives, using a qualitative approach. Six focus groups were conducted with 48 family physicians practising in Toronto. The data were analyzed using qualitative methods of content analysis and constant comparison, derived from grounded theory approach. Three overarching themes were identified: (1) perceived reactions of patients, (2) physician burden, and (3) physician interpretation and contextualization of information. Physicians in our study generally perceived Internet-based health information as problematic when introduced by patients during medical consultations. They believed that Internet information often generated patient misinformation, leading to confusion, distress, or an inclination towards detrimental self-diagnosis and/or self-treatment. Physicians felt these influences added a new interpretive role to their clinical responsibilities. Although most of the physicians felt obliged to carry out this new responsibility, the additional role was often unwelcome. Despite identifying various reactions of patients to Internet-based health information, physicians in our study were unprepared to handle these patients. | Effective initiatives at the level of the health care system are needed. The potential of Internet-based health information to lead to better physician-patient communication and patient outcomes could be facilitated by promoting physician acknowledgment of increasing use of the Internet among patients and by developing patient management guidelines and incentives for physicians. | closed_qa |
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