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Does physiotherapist-guided pelvic floor muscle training reduce urinary incontinence after radical prostatectomy? | Urinary incontinence after radical prostatectomy (RP) is a common problem and may lead to reduced quality of life. To assess the effects of guided pelvic floor muscle training on continence status and perceived problems with urinary function after RP. We conducted a randomised controlled trial at St. Olavs Hospital/Trondheim University Hospital in Norway between September 2005 and December 2007. All men with clinically localised prostate cancer who underwent surgery with open RP were invited to participate, until 85 participants were included. Dropout rate was 6%. Two intervention groups (A and B). Both groups received instructions in correct pelvic floor muscle contractions and were encouraged to train the pelvic floor muscles. Group A was offered additional follow-up training instructions by a physiotherapist throughout the 1-yr period. Primary outcome was continence (0 pads) status, and secondary outcomes were perceived problems with urinary function 6 wk and 3, 6, and 12 mo postoperatively. No statistically significant difference in continence status between groups was found at 3 mo; 46% were continent in group A versus 43% in group B (p=0.73). In group A, 97% reported no or only mild problems with urinary function compared to 78% in group B (p=0.010). After 6 mo there was a clinically relevant difference in continence status between groups: 79% were continent in group A and 58% in group B (p=0.061). Twelve months postsurgery the difference was clinically and statistically significant (p=0.028) in favour of group A; 92% were continent in group A and 72% in group B. | Continence rates were similar 3 mo after RP in groups performing intensive pelvic floor muscle training with or without follow-up instructions by a physiotherapist. However, in the following period up to 1 yr, the group receiving physiotherapist-guided training reduced urinary incontinence significantly more compared to patients training on their own. | closed_qa |
Does a short cessation of HRT decrease mammographic density? | Hormone replacement therapy (HRT) is known to increase breast density, thus decreasing the sensitivity of cancer screening by mammography. Some authors recommend short cessation of HRT before mammography, but evidence showing the effect of such short cessation is limited. The purpose of this study is to examine whether a short cessation of HRT changes mammographic density. Forty-eight women taking HRT agreed to have mammograms taken before and after stopping HRT for 4 weeks. Mammographic density was measured by Wolfe's four-point classification, six-categorical visual scale and two different computer methods (interactive-thresholding and SMF). Density values of mammography before and after the cessation of HRT were compared using Wilcoxon signed-rank test for categorical variables and paired t-test for continuous variables. Changes in breast pain and tenderness during mammography, radiation dose, compression force, and breast thickness were also recorded. No significant changes in mammographic density were observed by either visual or computer methods. There were no significant changes in breast pain or in tenderness on mammograms before and after the month's cessation of HRT. Radiographic measurements were not significantly altered by the 4-week cessation of HRT. | In this screening population, a 4-week cessation of HRT before mammograms did not significantly alter mammographic density. | closed_qa |
Are signal intensity and homogeneity useful parameters for distinguishing between benign and malignant soft tissue masses on MR images? | To objectively identify possible differences in the signal characteristics of benign and malignant soft tissue masses (STM) on magnetic resonance (MR) images by means of texture analysis and to determine the value of these differences for computer-assisted lesion classification. Fifty-eight patients with histologically proven STM (benign, n=30; malignant, n=28) were included. STM texture was analyzed on routine T1-weighted, T2-weighted and short tau inversion recovery (STIR) images obtained with heterogeneous acquisition protocols. Fisher coefficients (F) and the probability of classification error and average correlation coefficients (POE+ACC) were calculated to identify the most discriminative texture features for separation of benign and malignant STM. F>1 indicated adequate discriminative power of texture features. Based on the texture features, computer-assisted classification of the STM by means of k-nearest-neighbor (k-NN) and artificial neural network (ANN) classification was performed, and accuracy, sensitivity and specificity were calculated. Discriminative power was only adequate for two texture features, derived from the gray-level histogram of the STIR images (first and 10th gray-level percentiles). Accordingly, the best results of STM classification were achieved using texture information from STIR images, with an accuracy of 75.0% (sensitivity, 71.4%; specificity, 78.3%) for the k-NN classifier, and an accuracy of 90.5% (sensitivity, 91.1%; specificity, 90.0%) for the ANN classifier. | Texture analysis revealed only small differences in the signal characteristics of benign and malignant STM on routine MR images. Computer-assisted pattern recognition algorithms may aid in the characterization of STM, but more data is necessary to confirm their clinical value. | closed_qa |
Minimum 1-year follow-up for patients with vertical shear sacroiliac joint dislocations treated with iliosacral screws: does joint ankylosis or anatomic reduction contribute to functional outcome? | To prospectively analyze a homogenous group of trauma patients with pure sacroiliac (SI) joint dislocations treated with iliosacral screws (ISS), with specific attention to functional outcome and its correlation with the presence or absence of SI joint ankylosis and quality of reduction. Retrospective chart and radiographic review of initial injury and treatment, with prospective long-term evaluation of radiographs, computed tomography (CT) scans, and functional assessments. Level One Regional Trauma Center. Twenty-three patients who were skeletally mature with traumatic vertical shear pelvic injuries associated with a pure SI joint dislocation. Treatment consisted of closed or open reduction in the supine or prone position and insertion of a single ISS placed percutaneously for the fixation of the posterior ring injury. Each patient was evaluated for functional outcome using version 2 of the Short-Form 36 (SF-36v2), the short version of the Musculoskeletal Functional Assessment (sMFA), the Iowa Pelvic Scoring System, and the Majeed Pelvic Scoring System. Additionally, at the follow-up visit, each patient received plain radiographs of the pelvis and CT scanning of the pelvis. Minimum follow-up was 1 year postindex procedure (13-120 months). In this subset of patients with pure SI dislocations treated with ISS alone, anatomic reduction was the only predictor of a more favorable functional outcome (P = 0.04). Specifically, SI joint ankylosis did not affect functional outcome in these patients. | Based on the results of this study, in the treatment of vertically displaced, pure SI joint dislocations, an anatomic reduction (whether closed or open), followed by ISS fixation should be the goal because this appears to be the only predictor of a more favorable functional outcome in patients with this injury. Complete SI joint ankylosis appears to have no effect, either positive or negative, on functional outcome in these patients. | closed_qa |
Surgical treatment of adult scoliosis: is anterior apical release and fusion necessary for the lumbar curve? | A retrospective study. To analyze radiographic and functional outcomes after posterior segmental spinal instrumentation and fusion (PSSIF) with and without an anterior apical release of the lumbar curve in adult scoliosis patients. No comparison study on PSSIF of adult lumbar scoliosis with apical release versus without has been published. Forty-eight adult patients with lumbar scoliosis (average age at surgery 49.6 years, average follow-up 3.7 years) who underwent PSSIF were analyzed with respect to radiographic change, perioperative and postoperative complications, and Scoliosis Research Society (SRS) outcome scores. Twenty-three patients underwent an anterior apical release of the lumbar curve via a thoracoabdominal approach followed by PSSIF (Group I). The remaining 25 patients underwent a PSSIF of the lumbar curve followed by anterior column support at the lumbosacral region through an anterior paramedian retroperitoneal or posterior transforaminal approach (Group II). Before surgery, Group I showed a somewhat larger lumbar major Cobb angle (63.2 degrees vs. 55.9 degrees , P = 0.07), and both groups demonstrated significant differences in lumbar curve flexibility (26.9% vs. 37.2%, P = 0.02) and thoracolumbar kyphosis (27.0 degrees vs. 15.0 degrees , P = 0.03). After surgery, at the ultimate follow-up, there were no significant differences in major Cobb angle, C7 plumbline to the center sacral vertical line (P = 0.17), C7 plumbline to the posterior superior endplate of S1 (P = 0.44), and sagittal Cobb angles at the proximal junction (P = 0.57), T10-L2 (P = 0.24) and T12-S1 (P = 0.51). There were 4 pseudarthroses in Group I and one in Group II (P = 0.02). Postoperative total normalized SRS outcome scores at ultimate follow-up were significantly higher in Group II (69% vs. 79%, P = 0.01). | Posterior segmental spinal instrumentation and fusion without anterior apical release of lumbar curves in adult scoliosis demonstrated better total SRS outcome scores and no differences in radiographic parameters without differences in clinical complications. However, the use of BMP in some of these patients (44%) may have also contributed to these differences. | closed_qa |
Are narghile smokers different from cigarette smokers? | The extent of smoking related health and economic problems is causing increasing alarm throughout the world. In the last few years a great number of subjects, especially in the developing world, have been smoking narghile and epidemiological studies on narghile smoking are an essential subject for investigation. The objectives of this study are to describe the social and cultural characteristics of narghile smokers in Lebanon compared to tobacco smokers. Our sample is based on the data of 37579 subjects who consulted a non-governmental organisation (NGO), the Hariri Foundation, between 2003 and 2005. This NGO comprises 22 specialised centres distributed throughout Lebanon. The following data concerning exclusive narghile and cigarette smokers were collected: age, sex, the type and duration of tobacco addiction and the level of education. 13776 subjects (36.6% of the sample) were smokers of whom 88% smoked mostly cigarettes. 1529 subjects (11.1%) smoked narghile exclusively, a prevalence of 4.06%. The narghile smokers were younger than the cigarette smokers with a mean age of 36.2+/-8.63 years compared to 45.52+/-1.87 years. The majority of narghile smokers were women (56.57%) giving a male/female ratio of 0.77. A large number of narghile smokers were recent consumers with an exposure of less than 5 years. They differed from the cigarette smokers of whom the majority (72.2%) had smoked for more than 10 years. The proportion of illiterate subjects was greater among the narghile smokers (36.2%) than the cigarette smokers (24.2%). | The consumption of tobacco is a real and frequent problem in Lebanon. The consumption of narghile is scourge that is gaining popularity, notably among women and the young. This problem is becoming a public health issue that needs to be taken into account within the framework of an anti-smoking policy in Lebanon. | closed_qa |
Does osteoarthritis further compromise the postural stability of women with osteoporosis? | It is known that women with osteoporosis display only slight deficits in postural control. However, a condition that often co-exists with OP is osteoarthritis (OA), which has been shown to significantly compromise balance. To establish reasonable inclusion criteria for balance assessment of women with OP and investigate if specific treatment regimens are necessary for those subjects, it is important to evaluate the differences in postural control and postural strategies between the two groups. We compared postural sway in quiet standing measured by the parameters of the center-of-pressure (COP) signals, recorded on a force plate, of 30 women with osteoporosis and 27 women with coexisting mild osteoarthritis. Our results indicated that the latter subjects had higher COP sway in the sagittal compared with the frontal plane, while the former subjects had similar sway in both planes. Subjects with both conditions relied more on vision to preserve postural stability compared with subjects with osteoporosis alone, and they also appeared to compensate further with a higher frequency of their body oscillations. | 1. Even mild symptoms of osteoarthritis may affect balance and misrepresent the observed postural behavior in stabilographic studies. 2. The indications for the treatment regimens of. | closed_qa |
Does prolonged breastfeeding reduce the risk for childhood leukemia and lymphomas? | The study group comprised of 169 patients with acute lymphocytic leukemia (ALL), Hodgkin's (HL) and non-Hodgkin's lymphoma (NHL), age =or<15 years, and 169 healthy controls, matched to patients by age and sex. Mothers of all study subjects provided information via telephone about the history of breastfeeding and parameters seen as proxies for viral infection. The mean age+/-SD of cases was 5.44+/- 3.29 years and of control subjects 5.51+/-3.62 years. The male/female ratio was 1.73. Overall, the mean number of months of breastfeeding in the male patients and controls was 9.1 (95% confidence interval [CI] 7.9-10.4) and 12.1 (95% CI 11.0-13.4), respectively (P<0.001), and in the female patients and controls 8.4 (95% CI 6.9-10.1) and 11.5 (95% CI 10.0-13.0), respectively (P<0.01). In 103 ALL patients, a shorter period of breastfeeding (0-6 months duration), was associated with increased odds ratio (OR) for males (OR=3.1, 95% CI 1.4-6.8) and females (OR=2.2, 95% CI 0.8-6.32) as compared to breastfeeding longer than 6 months. In 103 ALL patients, 32 HL and 34 NHL patients, there were no statistically significant differences in the duration of breastfeeding between the male and female patients and their respective controls. In multivariate analysis, statistically significant risk factors for the development of childhood lymphoid malignancy were: a shorter duration of breastfeeding, lower age and level of education of mother and higher income, larger size of accommodation and birth order in the family. | The current study confirmed that a longer duration of breastfeeding has protective effect against ALL and HL. Additional factors found to be associated with an elevated risk of lymphoid malignancy were low age and low education of mother. All these factors can be related to an increased risk of early childhood infections. | closed_qa |
Time in care of trauma patients in the air rescue service: implications for disposition? | Time plays a crucial role in treating multiple traumatized patients and delays in management worsen the prognosis. Furthermore, current studies show that trauma patients profit from primary delivery to a trauma center. Therefore, the goal of physician-staffed ground and air rescue services in Germany is to treat these patients as quickly as possible and deliver them to a suitable trauma center. The aim of the present study was to investigate prehospital treatment times for the air rescue team in terms of disposition and efficiency when a ground rescue team was already present at the scene. In a nationwide, multicenter analysis emergency missions carried out for traumatological emergencies in 2006 by 28 air rescue centers (ARC) of the TeamDRF and 6 ARC of the federal police were evaluated using the medical database MEDAT of the German Air Rescue Service. A distinction was made between combined missions with (MEDAT 1 group) and without (MEDAT 2 group) physician-staffed ground emergency medical services already being present at the emergency site and in particular the rescue helicopter treatment times for both groups were investigated. Furthermore, combined missions (MAN 1 group) and solo missions (MAN 2 group) for traumatological emergencies in the period 01.05.2006 to 31.01.2007 were investigated in a complementary prospective regional study at the ARC Heidelberg/Mannheim "Christoph 53". In both groups the total treatment times for all physician-staffed emergency systems involved in treatment at the scene were investigated. Nationwide, 26,010 primary missions could be evaluated and of these, 11,464 missions were traumatological emergencies (44.1%) with 2,229 (19.4%) carried out by the MEDAT 1 group and 9,235 (80.6%) by the MEDAT 2 group. For both groups the helicopter treatment times depended on the severity of the injuries (NACA classification) and were between 17+/-12 min (NACA I) and 34+/-19 min (NACA VII) in MEDAT group 1 versus 21+/-10 and 36+/-19 min in MEDAT group 2 (p<0.05, p<0.001), respectively. In the MEDAT 1 group, the average treatment times were between 2.8 min (NACA VII) and 8.1 min (NACA VI) shorter compared with the MEDAT 2 group. Moreover, when taking the severity of the injury into consideration, a regular and significantly higher treatment effort (e.g. intubation, repositioning and chest tube insertion) and a greater proportion of patients who were transported to the clinic via rescue helicopter were observed for the MEDAT 1 group than for the MEDAT 2 group. In the regional study 670 primary missions were evaluated including 382 traumatological emergencies (57%). From these, 90 multiple trauma patients (NACA V) were not resuscitated or died at the scene, 58 from the MAN 1 group and 32 from the MAN 2 group, and were investigated more closely. The helicopter treatment times were comparable to those observed in the nationwide study and were found to be 26+/-12 min and 35+/-20 min (p<0.05), respectively. In the MAN 1 group the treatment times for the ground rescue services up to the time when the helicopter arrived was 22+/-11 min on average; the total treatment time was 48+/-15 min and 12+/-8 min longer than the time for the MAN 2 group, which was statistically significant. In the MAN 1 group the helicopter was alerted on average 17+/-15 min after the physician-staffed ground rescue services arrived at the emergency site. Treatment by the rescue helicopter teams was significantly more extensive in the MAN 1 group. | The treatment times for the helicopter were several minutes shorter when a physician-staffed ground rescue team had already arrived at the emergency site. However, it must be assumed that the total prehospital time is significantly longer for such missions. These results directly affect the disposition at the emergency dispatch center and indicate that when air rescue is required to transport a patient to hospital, the helicopter should be alerted at an early stage. In such settings, it is likely that initiating the operation in this way would improve the prognosis of severely injured patients and save costs. | closed_qa |
Pulse oxygen saturation levels and arterial oxygen tension values in newborns receiving oxygen therapy in the neonatal intensive care unit: is 85% to 93% an acceptable range? | Our aim was to define the relationship of PaO(2) and pulse oxygen saturation values during routine clinical practice and to evaluate whether pulse oxygen saturation values between 85% and 93% were associated with PaO(2) levels of<40 mmHg. Prospective comparison of PaO(2) and pulse oxygen saturation values in 7 NICUs at sea level in 2 countries was performed. The PaO(2) measurements were obtained from indwelling arterial catheters; simultaneous pulse oxygen saturation values were recorded if the pulse oxygen saturation values changed<1% before, during, and after the arterial gas sample was obtained. We evaluated 976 paired PaO(2)/pulse oxygen saturation values in 122 neonates. Of the 976 samples, 176 (18%) from infants breathing room air had a mean pulse oxygen saturation of 93.9 +/- 4.3% and a median of 95.5%. The analysis of 800 samples from infants breathing supplemental oxygen revealed that, when pulse oxygen saturation values were 85% to 93%, the mean PaO(2) was 56 +/- 14.7 mmHg and the median 54 mmHg. At this pulse oxygen saturation level, 86.8% of the samples had PaO(2) values of 40 to 80 mmHg, 8.6% had values of<40 mmHg, and 4.6% had values of>80 mmHg. When the pulse oxygen saturation values were>93%, the mean PaO(2) was 107.3 +/- 59.3 mmHg and the median 91 mmHg. At this pulse oxygen saturation level, 39.5% of the samples had PaO(2) values of 40 to 80 mmHg and 59.5% had values of>80 mmHg. | High PaO(2) occurs very rarely in neonates breathing supplemental oxygen when their pulse oxygen saturation values are 85% to 93%. This pulse oxygen saturation range also is infrequently associated with low PaO(2) values. Pulse oxygen saturation values of>93% are frequently associated with PaO(2) values of>80 mmHg, which may be of risk for some newborns receiving supplemental oxygen. | closed_qa |
Does a low sodium diet improve asthma control? | Observational studies and initial randomized trials have indicated that a low sodium diet may improve asthma control. We tested the hypothesis that a low sodium diet would improve asthma control over a 6-week period. Participants with a physician diagnosis of asthma and measurable bronchial reactivity to methacholine entered a randomized double-blind placebo-controlled trial. All adopted a low sodium diet and were randomized to receive either 80 mmol/day of oral sodium supplements (normal sodium intake) or matched placebo (low sodium intake) for 6 weeks. The primary outcome was change in bronchial reactivity to methacholine; secondary outcomes were change in lung function, morning and evening peak expiratory flow, asthma symptoms score, daily bronchodilator use, Juniper Standardized Asthma Quality of Life Questionnaire score, and atopy. A total of 220 individuals entered the study, of whom 199 completed the protocol. In the low sodium-intake group, mean daily urinary sodium excretion decreased by 20 mmol (SD, 64 mmol) and in the normal-sodium-intake group increased by 28 mmol (SD, 74 mmol). There were no differences between the two groups in the primary or secondary outcome measures; the mean difference in bronchial reactivity between the low- and normal-intake groups was -0.03 doubling doses of methacholine (95% confidence interval, -0.60 to 0.53). | The use of a low sodium diet as an adjunctive therapy to normal treatment has no additional therapeutic benefit in adults with asthma and bronchial reactivity to methacholine. | closed_qa |
Is the routine abdominal ultrasound a sufficiently sensitive method for the detection of colonic malignancy? | This study examined the sensitivity of routine abdominal ultrasound scanning in the detection of colonic malignancy. A case control prospective study included 101 patients hospitalized at the Department of Gastroenterology and Liver Diseases of Zemun Clinical Hospital over a four-year period. Since the complaints pointed to colonic malignancy, the patients underwent routine golden standard diagnostic procedures. These patients were referred to an experienced abdominal ultrasound operator who searched for some characteristic signs of colonic malignancy. All of the participants were surgically treated after the completion of relevant procedures for diagnosing colonic malignancy. SPSS for Windows 10.0 was used for data analysis. The sensitivity of an abdominal ultrasound scan in the detection and location of pathological changes pointed to colonic malignancy was different- 76% and 84% respectively. This method was very reliable in detecting right-sided colonic carcinoma (100%). Some specific ultrasonographic signs of colonic carcinoma were observed at the advanced stages of disease. | The routine abdominal ultrasonography can be used for the screening of colonic malignancy owing to its high sensitivity, particularly in advanced disease, but solely in conjunction with other methods. Finally, abdominal ultrasonography cannot be a definitive diagnostic tool for colonic carcinoma. | closed_qa |
Comorbid anxiety in bipolar disorder: does it have an independent effect on suicidality? | Comorbid anxiety disorder is reported to increase suicidality in bipolar disorder. However, studies of the impact of anxiety disorders on suicidal behavior in mood disorders have shown mixed results. The presence of personality disorders, often comorbid with anxiety and bipolar disorders, may explain these inconsistencies. This study examined the impact of comorbid Cluster B personality disorder and anxiety disorder on suicidality in bipolar disorder. A total of 116 depressed bipolar patients with and without lifetime anxiety disorder were compared. Multiple regression analysis tested the association of comorbid anxiety disorder with past suicide attempts and severity of suicidal ideation, adjusting for the effect of Cluster B personality disorder. The specific effect of panic disorder was also explored. Bipolar patients with and without anxiety disorders did not differ in the rate of past suicide attempt. Suicidal ideation was less severe in those with anxiety disorders. In multiple regression analysis, anxiety disorder was not associated with past suicide attempts or with the severity of suicidal ideation, whereas Cluster B personality disorder was associated with both. The results were comparable when comorbid panic disorder was examined. | Comorbid Cluster B personality disorder appears to exert a stronger influence on suicidality than comorbid anxiety disorder in persons with bipolar disorder. Assessment of suicide risk in patients with bipolar disorder should include evaluation and treatment of Cluster B psychopathology. | closed_qa |
Kaiy as traditional therapy for pain: is it helpful or a myth? | Two cases of traditional kaiy (Arabic for cauterisation) therapy for pain are reported. This technique is unknown in western countries and should be banned following a review of the topic. Many patients in developing countries use alternative, complementary or traditional therapies before seeking medical advice. This may be due to social or religious beliefs. Kaiy is one such traditional therapy which should be discouraged. Two cases are reported, the first with aural pain and the second with thyroid pain (with malignancy later diagnosed). | In these days of modern health care, the practice of kaiy is not science-based and is associated with considerable health risks. Health authorities in the relevant societies should move towards banning this undesirable practice; they should also use multi-media health education to advise of its dangerous outcomes, and enlist the help of community religious leaders to change public opinion and belief. | closed_qa |
Measuring health in patients with cervical and lumbosacral spinal disorders: is the 12-item short-form health survey a valid alternative for the 36-item short-form health survey? | To determine the convergent validity of the 12-Item Short-Form Health Survey, version 2 (SF-12v2), with 36-Item Short-Form Health Survey, version 2 (SF-36v2), in patients with spinal disorders, and to determine other key factors that might further explain the variances between the 2 surveys. Cross-sectional study. Orthopedic ambulatory care. Eligible participants (N=98; 24 with cervical, 74 with lumbosacral disorders) who were aged 18 years and older, scheduled to undergo spinal surgery, and completed the SF-36v2. Not applicable. SF-36v2 and SF-12v2 (extracted from the SF-36v2). The 2 summary scores, physical and mental component scores (r range, .88-.97), and most of the scale scores (r range, .81-.99) correlated strongly between the SF-12v2 and SF-36v2, except for the general health score (cervical group, r=.69; lumbosacral group, r=.76). Stepwise linear regression analyses showed the SF-12v2 general health scores (cervical: beta=.61, P<.001; lumbosacral: beta=.68, P<.001) and the level of comorbidities (cervical: beta=-.37, P=.014; lumbosacral: beta=-.18, P=.039) were significant predictors of the SF-36v2 general health score in both groups, whereas age (beta=.32, P<.001) and smoking history (beta=-.22, P=.005) were additional predictors in the lumbosacral group. | SF-12v2 is a practical and valid alternative for the SF-36v2 in measuring health of patients with cervical or lumbosacral spinal disorders. The validity of the SF-12v2 general health score interpretation is further improved when the level of comorbidities, age, and smoking history are taken into consideration. | closed_qa |
DIEP flaps in women with abdominal scars: are complication rates affected? | Previous abdominal surgery may affect perforator anatomy and complication rates in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. The purpose of this study was to determine whether abdominal scars in DIEP breast reconstruction have an effect on flap and donor-site complications. Over a 3-year period, 168 DIEP flap patients were retrospectively divided into a control group with no previous abdominal operations and a scar group with previous abdominal procedures. Flap and abdominal wound complications were compared between the two groups. Ninety patients (54 percent) underwent 114 flaps in the control group and 78 patients (46 percent) underwent 104 flaps in the scar group. The most common previous incisions were Pfannenstiel, laparoscopic, and midline. There was no significant difference between the groups in age, body mass index (mean 27 kg/m2 in both groups), smoking history, or radiation status. There were no significant differences between the control and scar groups in DIEP flap loss (1.8 percent versus 2.9 percent), partial flap loss (1.8 percent versus 1.0 percent), or fat necrosis (15 percent versus 14 percent, respectively). However, the scar group had a significantly higher rate of abdominal donor-site complications (24 percent) compared with the control group (6.7 percent; p = 0.003). The most common complications were abdominal wound breakdown (12 percent), seroma requiring operative drainage (6.4 percent), and abdominal laxity or bulge (5.1 percent). | With minor technical modifications, DIEP flaps can be performed successfully without increased flap complications in patients with preexisting abdominal incisions. Despite these design modifications, patients should be informed of an increased risk for donor-site complications. | closed_qa |
Combined type versus ADHD predominantly hyperactive-impulsive type: is there a difference in functional impairment? | The purpose of this study was to evaluate whether preschool children with attention-deficit/hyperactivity disorder predominantly hyperactive-impulsive type (ADHD-HI) and ADHD combined type (ADHD-C) have different levels of functional impairment in four domains: externalizing (oppositional and disruptive) behaviors, internalizing (anxious) behaviors, social skills, and preacademic functioning. The subjects were 102 children 3 to 5 years of age, meeting DSM-IV criteria for ADHD. Children with ADHD-C versus ADHD-HI were compared across at least two measures for each of the four functional domains. Oppositional and anxious behaviors were assessed on the Conners Parent and Teacher Rating Scales. In addition, off-task and disruptive behaviors were assessed by direct observation in the preschool setting. Social skills were assessed on the parent and teacher versions of the Social Skills Rating System and preacademic skills were assessed on the letter word identification, passage comprehension, and applied problems subtests of the Woodcock-Johnson III Tests of Achievement and the initial sound fluency subtest of the Dynamic Indicators of Basic Early Literacy Skills 5th Edition. There were no significant differences between the groups on rating scale T scores for parent-reported oppositional symptoms (ADHD-C vs ADHD-HI; 66.7 +/- 13.5 vs 65.7 +/- 11.7; p = .73); parent-reported anxious symptoms (53.5 +/- 11.1 vs 53.2 +/- 9.7; p = .90); teacher-reported oppositional symptoms (70.9 +/- 15.6 vs 75.5 +/- 14.7; p = .17); or teacher reported anxious symptoms (59.2 +/- 11.6 vs 58.5 +/- 12.2; p = .77). No statistically significant differences were found between the groups when examining off-task and/or disruptive behavior during structured and free play observations at school. No significant differences between the subtypes were found for social skills or preacademic functioning. | Across the four areas of functioning assessed in this study, preschool children with ADHD-HI and those with ADHD-C demonstrated similar levels of functioning. This study, in combination with data from longitudinal studies demonstrating that most children with ADHD-HI are later diagnosed with ADHD-C, suggests that ADHD-HI may represent an earlier form of ADHD-C as opposed to a distinct subtype. | closed_qa |
Acute management of hemodynamically unstable pelvic trauma patients: time for a change? | Hemorrhage-related mortality (HRM) associated with pelvic fractures continues to challenge trauma care. This study describes the management and outcome of hemodynamically unstable patients with a pelvic fracture, with emphasis on primary intervention for hemorrhage control and HRM. Blunt trauma patients [Injury Severity Score (ISS)>or=16] with a major pelvic fracture (Abbreviated Injury Score, pelvis>or=3) and hemodynamic instability [admission systolic blood pressure (SBP)<or=90 mmHg or receiving>or=6 units of packed red blood cells (PRBCs)/24 hours) were included into a 48-month (ending in December 2003) multicenter retrospective study of 11 major trauma centers. Data are presented as the mean +/- SD. A total of 217 patients (mean age 41 +/- 19 years, 71% male, ISS 42 +/- 16) were studied. The admission SBP was 96 +/- 37 mmHg and the Glascow Coma Scale (GCS) 11 +/- 5. Patients received 4 +/- 2 liters of fluids including 4 +/- 4 units of PRBCs in the emergency room (ER). In total, 69 (32%) patients died, among whom the HRM was 19%; 29% of the deaths were due to pelvic bleeding. Altogether, 120 of the 217 (55%) patients underwent focused abdominal sonography for trauma (FAST) or diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL); 60 of the 217 (28%) patients were found to have pelvic binding in the ER. In all, 53 of 109 (49%) patients had no bleeding noted at laparotomy, 26 of 106 (25%) had no abdominal findings, and 15 of 53 (28%) had had no prior abdominal investigation (FAST/DPL/computed tomography). Angiography was positive in 48 of 58 (83%) patients. The HRM was highest in patients with laparotomy as the primary intervention (29%) followed by the angiography group (18%), the combined laparotomy/pelvic fixation group (16%), and the pelvic fixation-only group (10%). | HRM associated with major pelvic trauma is unacceptably high especially in the laparotomy group. Hence, nontherapeutic laparotomy must be avoided, concentrating instead on arresting pelvic hemorrhage. Standards of care must be implemented and abided by. | closed_qa |
Is picky eating an eating disorder? | To examine the prevalence of picky eating and the relationship between picky eating, previously supported correlates of picky eating, other child eating and behavioral problems and maternal eating problems in children aged 8-12 years. In a cohort study, 426 8- to 12-year-old children and their primary caretakers (91% mothers) were assessed in a small town community. Potential child eating behaviors associated with picky eating were reported by mothers using the Stanford Feeding Questionnaire. Child eating attitudes and disturbances were obtained from the McKnight Risk Factor Survey, food preferences and avoidances from a food preference list, child behavioral problems were assessed by the Child Behavior Checklist. To assess maternal eating disturbances EDI-subscales 1-3 as well as TFEQ-subscales "disinhibition" and "restraint" were used. Picky and nonpicky eaters differed significantly on all of the child eating behaviors found to be correlates of picky eating in a previous study with younger children. Overall, picky children were reported to avoid foods in general more often than nonpicky eaters. Picky children did not differ from nonpicky children with regard to their own and maternal eating disturbances. However, picky children displayed more problem behaviors comprising both internalizing and externalizing behaviors. | The present study does not support the concept that picky eating is associated with disordered eating but rather with a range of behavioral problems. | closed_qa |
Does an alloimmune response to strong immunogenic red blood cell antigens enhance a response to weaker antigens? | It has been suggested that an immune response against the high immunogenic D antigen also augments the immune response to less immunogenic red blood cell (RBC) antigens. Based on the high antibody frequency, E and K antigens can also be regarded as strong immunogens. The question is whether the immunization against E and K antigens also enhances the formation of other antibody specificities. This question is in particular relevant for patients who are currently transfused with RH- and/or K-matched RBCs. A retrospective multicenter study analyzed FY, JK, and MNS antibodies alone and in combination with anti-E and/or anti-K. Analysis was performed for primary and subsequent antibody responses. In the cohort analyzed, 5016 patients possessed 5981 antibodies. Antibodies directed to multiple blood group systems were present in 606 of the 779 (78%) patients with multiple antibodies. In 88 of 1270 (6.9%) patients, FY, JK, and/or MNS antibodies appeared simultaneous with anti-E and/or anti-K during a primary antibody response after transfusion. Patients formed antibodies to antigens in the FY, JK, and MNS systems equally often as first antibodies followed by anti-E or anti-K than as second antibodies after anti-E or anti-K were already present. Patients with anti-E and/or anti-K or with antibodies to antigens in the FY, JK, and/or MNS systems equally often formed additional antibodies during a second antibody response. | An immune response against allogeneic RBC antigens defines good responders who readily form antibodies against other antigens. No support was found that the response against strong RBC antigens also enhances the formation against weaker antigens. | closed_qa |
Cancer trajectories at the end of life: is there an effect of age and gender? | Few empirical data show the pattern of functional decline at the end of life for cancer patients, especially among older patients. In a mortality follow-back survey (the Italian Survey of the Dying of Cancer - ISDOC) a random sample of 1,271 lay caregivers were interviewed, at a mean of 234 days after bereavement. The main outcome was number of days before death when the patient experienced a permanent functional decline. 1,249 (98%) caregivers answered the question about patient's function. The probability to be free from a functional disability was high (94%) 52 weeks before death, but was lower for older age groups (15% for those aged 85 or more) and women (8%). It remained stable until 18 weeks before death, then fell to 63% at 12 weeks and 49% at 6 weeks before death (among those aged 85 or more the figures were 50% and 41%). The pattern was consistent across sub-groups, except for patients affected by Central Nervous System tumors who experienced a longer, slower functional decline. | This study provides empirical support for the declining trajectory in cancer, and suggests that the decline commences at around 12 weeks in all age groups, even among patients over 85 years. | closed_qa |
Systemic lupus erythematosus after renal transplantation: is complement a good marker for graft survival? | Renal transplantation is considered a safe procedure for patients with systemic lupus erythematosus (SLE). However, the recurrence of disease and its impact on graft survival remains controversial. To analyze the presence of lupus serology activity during dialysis and its impact on lupus recurrence after transplantation, we performed a retrospective analysis of 23 lupus patients who received 26 kidney transplantations. Twenty-three patients received 26 renal transplantations from 1984 to 2003. Twelve patients presented pretransplant lupus activity (low complement and ANA>1/40), without correlation with length of dialysis, but associated with proliferative glomerulonephritis (class IV) pretransplant. Among 26 grafts, 6 were lost in the first 6 months posttransplant. Among the remaining 20 functioning grafts, low complement activity occurred in 8, being associated with recurrence of immune deposits in 3 cases. Analysis of lupus activity showed that only one patient with a normal complement level posttransplant presented SLEDAI>4, associated with persistent proteinuria and a graft biopsy without immune deposits. Graft survival was reduced in the presence of low complement posttransplantation. | Low complement levels after renal transplantation, in association with proteinuria may be considered to be a risk factor for recurrence of immune deposits, with a negative impact on graft survival. | closed_qa |
Should emergency surgical intervention be performed for an octogenarian with type A acute aortic dissection? | The number of octogenarians undergoing emergency surgery is increasing and may negate the impact of the beneficial advances. The aim of this study was to review octogenarians with type A acute aortic dissection and assess the prognosis. Fifty-eight patients with acute aortic dissection, whose average age was 83.2 years, were divided into 2 groups: Group I comprised 30 patients who underwent emergency surgery, and group II comprised 28 patients who were treated conservatively. We compared the 2 groups in terms of mortality and morbidity. In group I, postoperative hospital mortality was 13.3% (4 patients). In group II, 17 patients (60.7%) died in the hospital. In group I, although emergency aortic replacement was successfully completed, 5 patients became bedridden after surgery and 2 patients died of pneumonia or stroke in the early stages of institutional care. Thirteen patients in group I died of malignancies, abdominal aortic rupture, traffic accident, heart failure, or late-stage senility in later phase. There was no difference in actuarial survivals at 5 years, which were 48.5% in group I and 35.4% in group II. | Emergency surgery for octogenarians with acute aortic dissection showed acceptable mortality. However, families had to take responsibility for patients who experienced unconsciousness, had dementia, or became bedridden. It is important to have consensus between the family and surgeons about emergency surgical treatment for octogenarians. | closed_qa |
Does the level of prostate cancer risk affect cancer prevention with finasteride? | Finasteride reduced the risk of prostate cancer by 24.8% in the Prostate Cancer Prevention Trial (PCPT). Whether this represents treatment or prevention and who is most likely to benefit are unknown. We sought to clarify these issues by this investigation. We fit a logistic regression model to men in the placebo group of the PCPT using risk factors for prostate cancer at entry to predict prostate cancer during the subsequent 7 years of study. Men in the two treatment groups were categorized into quintiles of risk of prostate cancer based on the predictive logistic model. A second model was fit evaluating finasteride's effect on prostate cancer for each subgroup defined by quartiles of baseline prostate-specific antigen (PSA) . The magnitude of the prevention effect of finasteride on prostate cancer was then evaluated across risk and PSA strata. Finasteride significantly reduced prostate cancer risk for all risk quintiles. For quintiles 1 through 5, odds ratios were 0.72, 0.52, 0.64, 0.66, and 0.71, respectively (all P<or = 0.05). For quartiles of risk of entry PSA (less than 0.7 ng/mL, 0.7 to 1.1 ng/mL, 1.1 to 1.7 ng/mL, and 1.8 to 3.0 ng/mL), odds ratios increased (smaller treatment effect) as PSA increased: 0.60, 0.62, 0.66, and 0.69, respectively, but remained significant for all strata (each P<0.001). | Finasteride significantly reduced prostate cancer risk regardless of the level of this risk, estimated either by multivariable risk or by PSA stratum; this suggests that finasteride exerts both treatment and preventive effects. All men undergoing PSA screening should be informed of the potential for finasteride to reduce their risk of prostate cancer. | closed_qa |
The fate of prenatally diagnosed primary nonrefluxing megaureter: do we have reliable predictors for spontaneous resolution? | To compare predictive values of current morphologic parameters with congenital renal damage associated with severe megaureter. A retrospective analysis was performed using records of 37 patients (50 megaureters) referred before birth for a primary megaureter. Mean follow-up was 26 months (range, 1 to 8 years). Dilatation resolved spontaneously in 46 of 50 ureters. Only 4 of 37 patients required surgery (10.8%) after a mean follow-up of 58 months (range, 32 to 80 months). Average time to resolution was 24 months (range, 1 to 82 months) and was independent from sex, side, and bilaterality. A weak correlation was found with initial anteroposterior pelvic diameter, ureteral diameter, and separate function at renogram. A significant correlation (P<0.02) was found between megaureter type and time elapsed to spontaneous resolution. As far as differential function was concerned, mean values were significantly lower among type III megaureters, which had the lowest rate of resolution. | The fate of severe megaureter seems strongly influenced by congenital renal damage secondary to a developmental abnormality of the ureteric bud. A poor resolution rate has to be expected in these cases; surgery must be reserved for symptomatic cases but has no influence on pre-existing renal damage. | closed_qa |
Is serum cystatin-C a reliable marker for metabolic syndrome? | Chronic kidney disease and metabolic syndrome are recognized as major cardiovascular risk factors. It has been shown that cystatin C has a stronger association with mortality risk than creatinine-based estimations of glomerular filtration rate. We measured cystatin values in dyslipidemic patients and looked for correlations between renal function, cystatin, and metabolic syndrome. There were 925 dyslipidemic patients prospectively included in this cross-sectional study and evaluated over 10 months. Each visit included clinical and biological assessment. Most patients exhibited cardiovascular risk factors other than dyslipidemia: hypertension in 34%, diabetes in 11%, and smoking in 18%. Mean triglycerides were 149 +/- 136 mg/dL, mean high-density lipoprotein cholesterol 54 +/- 14 mg/dL, and low-density lipoprotein 167 +/- 48 mg/dL. Metabolic syndrome was present in 238 (26%) patients. Plasma creatinine did not differ between control group and metabolic syndrome patients (80 +/- 26 vs 82 +/- 20 micromol/L, respectively, P = .2), but creatinine clearance evaluated by abbreviated Modification of Diet in Renal Disease Study formula was lower in the metabolic syndrome group than in the non-metabolic-syndrome group (83.3 +/- 18.8 mL/min/1.73 m(2) vs 86.8+/-16.9 mL/min/1.73 m(2), respectively, P<.007). Cystatin value was significantly higher in metabolic syndrome patients than in others (0.86 +/- 0.23 vs 0.79 +/- 0.20 mg/L, respectively, P<.0001), independently of serum creatinine level and creatinine clearance. Furthermore, there was a progressive increase in cystatin, as a function of the number of metabolic syndrome components. | Our study shows that cystatin is associated with metabolic syndrome in dyslipidemic patients. Cystatin may be an interesting marker of metabolic syndrome and of increased cardiovascular and renal risk. | closed_qa |
Can we rely on blind endometrial biopsy for detection of focal intrauterine pathology? | To compare the diagnostic power of random endometrial biopsy with hysteroscopy for intrauterine lesions. A retrospective cohort study of 639 women evaluated by diagnostic office hysteroscopy and endometrial biopsy (Novak curette) was carried out between 10/1997-6/2000. Reasons for evaluation were postmenopausal bleeding, abnormal uterine bleeding, ultrasound or hystero-salpingography findings, intrauterine device removal, suspected retained products of conception, infertility, late abortions and recurrent abortions. The women's mean age was 43.4+/-13.3 years (range, 18-88). The most prevalent indication for investigation was abnormal uterine bleeding (n=218, 34.1%), followed by sonographic or hystero-salpingographic findings (n=167, 26.1%). Hysteroscopy revealed a normal uterine cavity in 367 (57.4%) women. Endometrial polyps and submucosal fibroids were the most common hysteroscopic findings (in 151 [23.6%] and 72 [11.3%], respectively). The hysteroscopic findings were compared with the pathology results in 558 cases. The sensitivity of the Novak curette for detection of endometrial polyps and submucosal fibroids was only 8.4% and 1.4%, respectively. The positive predictive value (30.9%) and the negative predictive value (57.9%) for both lesions were likewise low. On the other hand, hysteroscopy was not effective in diagnosing the 27 cases of hyperplasia (26 simple and one complex) all without atypia. | Random endometrial sampling alone is not effective for diagnosing focal lesions of the uterine cavity and should be combined with other modalities, preferably diagnostic hysteroscopy. | closed_qa |
The timing of medical examination following an allegation of sexual abuse: is this an emergency? | A case series of 331 children, who were referred by the police or social services for examination, following an allegation of child sexual abuse or suspicion of this, over a 3(1/2)-year period in a defined geographical area. Two hundred and fifty-seven children alleged penetrative abuse, of whom 114 were seen within 7 days of the abuse. Twenty-three children alleged penetrative anal abuse within the previous 7 days; 13 of these had abnormal findings (56.5%) compared with 9 (18%) of the 50 children seen more than 7 days after anal abuse. Ninety-two girls alleged penetrative vaginal abuse within the previous 7 days and of these 46 (50%) had abnormal findings, compared with 31 (30.7%) of the 101 girls seen more than 7 days after the alleged abuse. In addition 33 girls seen within 7 days had other signs associated with probable assault. Abnormal findings were more common in post-pubertal girls. | Pubertal and post-pubertal girls are more likely to have significant genital signs if they are examined within 7 days of the last episode of sexual abuse. Our findings suggest that abnormal anal signs are more likely to be present in the acute phase. This study indicates that children should be examined as soon as possible following a referral. This will have implications for clinical practice. Regardless of the lack of accurate history it will always be important to examine the child as soon as possible after disclosure. | closed_qa |
Valve failure following homograft aortic valve replacement: does implantation technique have an effect? | Structural valve deterioration (SVD) limits the long-term durability of homograft aortic valve replacement (AVR). Valves are implanted predominantly using two techniques, the free-hand sub-coronary (SC) technique or aortic root replacement (RR). Our objective was to identify risk factors associated with the development of SVD or ascending aortic dilatation. In particular we strived to determine whether the mode of implantation had an independent effect. Demographic and pre-operative clinical data were obtained retrospectively through case-note review. All operations were performed by a single surgeon. Actuarial freedom from>or=2+ AR (aortic regurgitation), elevated trans-valvular gradient (TVG) (>or=25 mmHg) and ascending aortic dilatation (>or=4.0 cm) were assessed using Kaplan-Meier curves and multivariable Cox proportional hazards regression. A propensity analysis was carried out using a non-parsimonius logistic regression model for implantation with SC vs. RR. Between 1 January 1991 and 1 January 2001, 215 patients underwent AVR with a homograft. The SC technique was used in 131 (61%) patients and 84 (39%) patients underwent RR. Technique was not an independent predictor for>or=2+ AR (adjusted hazard ratio 1.9; 95% CI 0.56-6.16, P = 0.31), elevated TVG (adjusted hazard ratio; 0.99; 95% CI 0.15-6.71, P = 0.99) or ascending aortic dilatation (adjusted hazard ratio 2.01; 95% CI 0.50-8.25, P = 0.33). One and 5 year actuarial freedom from>or=2+ AR (log-rank - P = 0.09) and ascending aortic dilatation (log-rank - P = 0.88) were not significantly different between groups. | The incidence of SVD and ascending aortic dilatation is not affected by the method of implantation of the aortic homograft. All homografts are prone to SVD which is responsible for a progressive increase in the prevalence of these changes over time. | closed_qa |
Umbilical hernia in adults: laparoscopic approach with prolene mesh--is it a safe procedure? | The laparoscopic approach for umbilical hernia is more and more used, but few results are reported. The aim is to evaluate the efficacy and safety of using the Prolene mesh placed laparoscopically in umbilical hernia treatment. Between 2004-2006, 21 patients with umbilical hernia, aged of 34 to 77 years, were submitted to intraperitoneal application of a Prolene mesh to cover the umbilical ring. The mesh was sewed by Protack staples or transfascial stitches. Before deflating the patients, the greater omentum was interposed between the mesh and the bowel. It is notice that 8 patients were obese, 6 patients had omental or bowel adhesions to the peritoneal sac and 5 patients had ascites due to liver cirrhosis. The patients were discharged 24 to 48 hours after the operation and followed up for 6 to 12 months. All patients were alive at the end of follow-up, without hernia recurrence or complications due to the Prolene mesh in the abdominal cavity. In 3 patients we registered subcutaneous seromas for 1 to 3 weeks (imposing evacuation by punction) and 5 patients kept a mildly deformed umbilical scar after the cure of large hernias. In the literature are mentioned the techniques using composite or two-layers meshes. Prolene meshes are not agreed by some authors, for the supposed risk of bowel lesions. In our trial were no such complications. | Laparoscopic repair using Prolene intraperitoneal mesh in umbilical hernia is a safe, efficient and rapid method, avoiding infections complications in obese or cirrhotic patients. | closed_qa |
Is insomnia a perpetuating factor for late-life depression in the IMPACT cohort? | Insomnia and depressive disorders are significant health problems in the elderly. Persistent insomnia is a risk factor for the development of new-onset and recurrent major depressive disorder (MDD). Less clear is whether persistent insomnia may perpetuate MDD andlor dysthymia. The present longitudinal study examines the relationship of insomnia to the continuation of depression in the context of an intervention study in elderly subjects. Data were drawn from Project IMPACT, a multisite intervention study, which enrolled 1801 elderly patients with MDD and/or dysthymia. In the current study, subjects were assigned to an insomnia-status group (Persistent, Intermediate, and No Insomnia) based on insomnia scores at both baseline and 3-month time points. Logistic regressions were conducted to determine whether Persistent Insomnia was prospectively associated with increased risk of remaining depressed and/or achieving a less than 50% clinical improvement at 6 and at 12 months compared with the No Insomnia reference group. The Intermediate Insomnia group was compared with the other 2 groups to determine whether a dose-response relationship existed between insomnia type and subsequent depression. Eighteen primary clinics in 5 states. Older adults (60+) with depression. Overall, patients with persistent insomnia were 1.8 to 3.5 times more likely to remain depressed, compared with patients with no insomnia. The findings were more robust in patients receiving usual care for depression than in patients receiving enhanced care. Findings were also more robust in subjects who had MDD as opposed to those with dysthymia alone. | These findings suggest that, in addition to being a risk factor for a depressive episode, persistent insomnia may serve to perpetuate the illness in some elderly patients and especially in those receiving standard care for depression in primary care settings. Enhanced depression care may partially mitigate the perpetuating effects of insomnia on depression. | closed_qa |
Does the prescriptive lifestyle of Seventh-day Adventists provide 'immunity' from the secular effects of changes in BMI? | To examine the effect of Seventh-day Adventist (SDA) membership on 'immunity' to the secular effects of changes in BMI. Three independent, cross-sectional, screening surveys conducted by Sydney Adventist Hospital in 1976, 1986 and 1988 and a survey conducted among residents of Melbourne in 2006. Two hundred and fifty-two SDA and 464 non-SDA in 1976; 166 SDA and 291 non-SDA in 1986; 120 SDA and 300-non SDA in 1988; and 251 SDA and 294 non-SDA in 2006. Height and weight measured by hospital staff in 1976, 1986 and 1988; self-reported by respondents in 2006. The mean BMI of non-SDA men increased between 1986 and 2006 (P<0.001) but did not change for SDA men or non-SDA women. Despite small increases in SDA women's mean BMI (P = 0.030) between 1988 and 2006, this was no different to that of SDA men and non-SDA women in 2006. The diet and eating patterns of SDA men and women were more 'prudent' than those of non-SDA men and women, including more fruit, vegetables, grains, nuts and legumes, and less alcohol, meat, sweetened drinks and coffee. Many of these factors were found to be predictors of lower BMI. | The 'prudent' dietary and lifestyle prescriptions of SDA men appear to have 'immunised' them to the secular effects of changes that occurred among non-SDA men's BMI. The dietary and lifestyle trends of SDA women did not reflect the increase in their BMI observed in 2006. | closed_qa |
Women and men with coronary heart disease in three countries: are they treated differently? | Nonmedical determinants of medical decision making were investigated in an international research project in the United States, the United Kingdom, and Germany. The key question in this paper is whether and to what extent doctors' diagnostic and therapeutic decisions in coronary heart disease (CHD) are influenced by patient gender. A factorial experiment with a videotaped patient consultation was conducted. Professional actors played the role of patients with symptoms of CHD. Several alternative versions were taped featuring the same script with patient-actors of different gender, age, race, and socioeconomic status. The videotapes were presented to a randomly selected sample of 128 primary care physicians in each country. Using an interview with standardized and open-ended questions, physicians were asked how they would diagnose and treat such a patient after they had seen the video. Results show gender differences in the diagnostic strategies of the doctors. Women were asked different questions, CHD was mentioned more often as a possible diagnosis for men than for women, and physicians were less certain about their diagnosis with female patients. Gender differences in management decisions (therapy and lifestyle advice) are less pronounced and less consistent than in diagnostic decisions. Magnitude of gender effect on doctors' decisions varies between countries with smaller influences in the United States. | Although patients with identical symptoms were presented, primary care doctors' behavior differed by patients' gender in all 3 countries under study. These gender differences suggest that women may be less likely to receive an accurate diagnosis and appropriate treatment than men. | closed_qa |
Intravascular volume administration: a contributing risk factor for intracranial hemorrhage during extracorporeal membrane oxygenation? | The objective of this study was to determine the relationship between the frequency and total volume of intravascular volume administration and the development of intracranial hemorrhage during venoarterial extracorporeal membrane oxygenation. In a retrospective, matched, case-control study, 24 newborns who developed an intracranial hemorrhage during venoarterial extracorporeal membrane oxygenation treatment were compared with 40 control subjects. Both groups were analyzed for gestational age, gender, race, Apgar scores at 1 and 5 minutes, birth weight, cardiopulmonary resuscitation before venoarterial extracorporeal membrane oxygenation, age at the start of treatment, duration of treatment, worst arterial blood gas sample preceding treatment, activated clotting time values, need for platelet transfusions, mean blood pressure, and the use of inotropics and steroids before the treatment. For both groups, total number and volume of intravascular infusions of normal saline, pasteurized plasma protein solution, erythrocytes, and platelets during the first 24 hours of treatment were determined. Variables were analyzed in their relationship to intracranial hemorrhage by using univariate and multivariate conditional logistic regression. The only statistically significant difference in patient characteristics between the case patients and control subjects was arterial blood gas values. Newborns who developed intracranial hemorrhage during the treatment received both a statistically significantly higher number and a statistically significantly higher total volume of intravascular volume administrations compared with control patients. After adjustment for pH, Paco(2), and Pao(2) in the multivariate analysis, we found a significant relation between the development of intracranial hemorrhage and>8 infusions or>300 mL of volume infusion in the first 8 hours and>10 infusions in the first 24 hours of treatment. | The number and total volume of intravascular volume administration in the first 8 and 24 hours of venoarterial extracorporeal membrane oxygenation treatment are statistically significantly related to the development of intracranial hemorrhage. | closed_qa |
Is the combination of sulfonylureas and metformin associated with an increased risk of cardiovascular disease or all-cause mortality? | Observational studies assessing the association of combination therapy of metformin and sulfonylurea on all-cause and/or cardiovascular mortality in type 2 diabetes have shown conflicting results. We therefore evaluated the effects of combination therapy of sulfonylureas and metformin on the risk of all-cause mortality and cardiovascular disease (CVD) among people with type 2 diabetes. A MEDLINE search (January 1966-July 2007) was conducted to identify observational studies that examined the association between combination therapy of sulfonylureas and metformin on risk of CVD or all-cause mortality. From 299 relevant reports, 9 were included in the meta-analysis. In these studies, combination therapy of metformin and sulfonylurea was assessed, the risk of CVD and/or mortality was reported, and adjusted relative risk (RR) or equivalent (hazard ratio and odds ratio) and corresponding variance or equivalent was reported. The pooled RRs (95% CIs) of outcomes for individuals with type 2 diabetes prescribed combination therapy of sulfonylureas and metformin were 1.19 (0.88-1.62) for all-cause mortality, 1.29 (0.73-2.27) for CVD mortality, and 1.43 (1.10-1.85) for a composite end point of CVD hospitalizations or mortality (fatal or nonfatal events). | The combination therapy of metformin and sulfonylurea significantly increased the RR of the composite end point of cardiovascular hospitalization or mortality (fatal and nonfatal events) irrespective of the reference group (diet therapy, metformin monotherapy, or sulfonylurea monotherapy); however, there were no significant effects of this combination therapy on either CVD mortality or all-cause mortality alone. | closed_qa |
Amyloid-associated depression: a prodromal depression of Alzheimer disease? | A high ratio of plasma amyloid-beta peptide 40 (Abeta(40)) to Abeta(42), determined by both high Abeta(40) and low Abeta(42) levels, increases the risk of Alzheimer disease. In a previous study, we reported that depression is also associated with low plasma Abeta(42) levels in the elderly population. To characterize plasma Abeta(40):Abeta(42) ratio and cognitive function in elderly individuals with and without depression. Cross-sectional study. Homecare agencies. A total of 995 homebound elderly individuals of whom 348 were defined as depressed by a Center for Epidemiological Studies Depression score of 16 or greater. Cognitive domains of memory, language, executive, and visuospatial functions according to levels of plasma Abeta(40) and Abeta(42) peptides. Subjects with depression had lower plasma Abeta(42) levels (median, 14.1 vs 19.2 pg/mL; P = .006) and a higher plasma Abeta(40):Abeta(42) ratio (median, 8.9 vs 6.4; P<.001) than did those without depression in the absence of cardiovascular disease and antidepressant use. The interaction between depression and plasma Abeta(40):Abeta(42) ratio was associated with lower memory score (beta = -1.9, SE = 0.7, P = .006) after adjusting for potentially confounders. Relative to those without depression, "amyloid-associated depression," defined by presence of depression and a high plasma Abeta(40):Abeta(42) ratio, was associated with greater impairment in memory, visuospatial ability, and executive function; in contrast, nonamyloid depression was not associated with memory impairment but with other cognitive disabilities. | Amyloid-associated depression may define a subtype of depression representing a prodromal manifestation of Alzheimer disease. | closed_qa |
Can we identify those at risk for a nondiagnostic treadmill test in a chest pain observation unit? | Exercise treadmill testing (ETT) is a testing modality that has shown to be a useful chest pain observation unit (CPU). One limitation of this tool is the high rate of nondiagnostic tests. We aim to create a predictive model to discriminate a patient's risk for a nondiagnostic test. This is a retrospective analysis of consecutive subjects admitted to our CPU and undergoing an ETT from January 2001 to December 2006. To account for any variation in physician practice, the training set was those patients admitted January 2004 to December 2006 and the testing set comprised those evaluated January 2001 to December 2003. Recursive partitioning with 10-fold cross validation was used to identify significant variables associated with the outcome measure of a nondiagnostic treadmill test. The beta coefficient from the regression model was used to create a risk score. This risk score was then used stratify patients. A total of 1708 subjects underwent ETT during the study period. The training set comprised 408 subjects with 62 having a nondiagnostic test. Logistic regression identified age, prior history of coronary artery disease, smoking, and diabetes variables used to create a scoring system. The testing set identified 387 (29.7) subjects meeting our criteria as low risk (9.0%) nondiagnostic test and identified 298 (22.9%) at high risk for a nondiagnostic test (32.8%). | Using a simple scoring system to stratify patients undergoing ETT into 3 risk groups, we were able to identify a low-risk group<10% and a high-risk group>30% for having a nondiagnostic ETT. | closed_qa |
Chromosomal alterations in oligodendroglial tumours over multiple surgeries: is tumour progression associated with change in 1p/19q status? | Oligodendroglial neoplasms have morphologic and genotypic heterogeneity. Loss of heterozygosity (LOH) of 1p and/or 19q is associated with increased treatment responsiveness and overall survival. However, the pathogenesis of treatment-resistance is unknown. We sought to determine if tumour progression is due to a proliferating sub-population of tumour cells with intact 1p, or if recurrent tumours retain 1p/19q LOH. 24 patients with oligodendroglial neoplasms, possessing biopsy samples taken at diagnosis and at progression, were identified. 53 tumour specimens were available for LOH analysis of 1p and 19q, using PCR amplification of multiple microsatellite markers. 40 were also tested for 9p and 10q. At diagnosis, the median age was 34 (24-66) years, 14 were male. 19 tumours were WHO Grade II, and 5 were high grade. The most common genomic status was 19q LOH (70%). 13 (54%) tumours were 1p LOH at diagnosis: of these, 12 were 19q LOH, and 1 was 19q uninformative. All 12 patients with 1p/19q LOH primary tumours had persistent co-deletion at progression. 9 (38%) tumours were 1p intact at diagnosis, and 8 remained 1p intact in the progressed tumours. There was little heterogeneity of 9p and 10q between tumours at diagnosis and progression. | 100% of oligodendroglial tumours with 1p/19q LOH, demonstrated persistent 1p/19q LOH in the progressed tumour. Therefore, progression of these tumours is not due to a proliferating sub-population of treatment-resistant, 1p intact tumour cells. We propose that additional mutations contribute to this aggressive phenotype, however, 9p LOH or 10q LOH are unlikely to be involved. | closed_qa |
Can noncontact mapping distinguish between endo- and epicardial foci? | Noncontact mapping has been demonstrated to facilitate RF ablation of ventricular arrhythmias, but the reproducibility in the localization of endocardial exit sites during focal ventricular tachycardia ("VT") originating from defined myocardial layers has not been systematically studied. Furthermore, it remains unclear whether noncontact mapping can distinguish between endo- and epicardial foci. In six dogs, constant pacing was applied through octopolar needle electrodes in the left ventricle to mimic VT of subendocardial, midmyocardial (mid1; mid2) or subepicardial origin. Using noncontact mapping, the site of origin was determined for each of 50 consecutive beats of all "VTs" and the variation between respective exit sites was measured. Exit sites were reconstructed for 50 consecutive beats of each "VT" and the time span between site of origin and exit site was measured as a parameter of intramural conduction. While subendocardial and midmyocardial (mid1, mid2) foci were pinpointed with a variation of<or=2 mm, a variation of 4 mm was encountered for subepicardial foci. A gradual increase in intramural conduction was evident from endocardial towards epicardial foci, with significant differences between subendocardial (4.8 +/- 0.9 ms), midmyocardial (mid1 = 11.1 +/- 4.6 ms; mid2 = 11.8 +/- 3.5 ms) and subepicardial (16.8 +/- 3.6 ms) foci (P<0.005). Systematic differences in the morphology of virtual waveforms depending on the site of origin could not be detected. | Except for subepicardial foci, noncontact mapping localized focal activity in the LV with high reproducibility. In contrast to morphological parameters, the determination of intramural conduction provides a fair estimate of the depth of foci and is proposed as a novel parameter to identify a subepicardial origin. | closed_qa |
Major hepatectomy for colorectal metastases: is preoperative portal occlusion an oncological risk factor? | This study investigates oncological risks and benefits of portal occlusion (PO) in major resection for colorectal liver metastases (CLM). Between 1995 and 2004, 107 patients were scheduled for major hepatectomy for CLM. Of these, 53 patients were selected for PO due to insufficient future liver remnant (FLR), and 54 patients had straightforward hepatectomy. Associations of clinicopathologic factors with resectability, and outcome after PO were analyzed. 21 of 53 patients (39.6%) after PO were unresectable. These patients had a significant smaller volume of the FLR than the 32 resected patients after PO (P = .029). In total, 17 patients (80.9%) did not undergo resection due to cancer progression. Among these, 11 patients (52.4%) exhibited either a progression of known metastases located in the occluded lobes, or new metastases in the nonoccluded portion of the liver. In another 4 individuals (19%), the decision against resection resulted from insufficient hypertrophy of the FLR. Following major hepatectomy, the 5-year survival was 43.66%. Although there was a significantly higher rate of extended hepatectomies versus formal hepatectomies (P<.001), more bilobar distributed metastases versus unilobar manifestations (P = .015), and a smaller resection margin (P = .01) in patients who had PO, no adverse effect on mortality, morbidity, recurrence and survival was observed. | Unresectability after PO is a major problem that warrants multidisciplinary improvements, and randomization to resection with or without PO remains ethically problematic. However, following adequate patient selection, PO may provide a significant survival benefit for patients with prior unresectable CLM. | closed_qa |
Does a history of non-vertebral fracture identify women without osteoporosis for treatment? | Postmenopausal women with a prior fracture have an increased risk for future fracture. Whether a history of non-vertebral fracture defines a group of women with low bone mass but without osteoporosis for whom alendronate would prevent new non-vertebral fracture is not known. Secondary analysis of data from the Fracture Intervention Trial (FIT). Of 2,785 postmenopausal women with a T-score at the femoral neck between -1 and -2.5 and without prevalent radiographic vertebral deformity, 880 (31.6%) reported experiencing a fracture after 45 years of age. Women were randomized to placebo or alendronate (5 mg/day years for the first 2 years and 10 mg/day thereafter) and were followed for an average of 4.2 +/- 0.5 years. Incident non-vertebral fractures were confirmed by x-rays and radiology reports. In the placebo arm, a self-report of prior fracture identified women with a 1.5-fold (hazard ratio [RH] 1.46, 95% C.I. 1.04-2.04) increased risk for incident non-vertebral fracture. However, there was no evidence that the effect of alendronate differed across subgroups of women with (RH 1.26 for alendronate vs placebo, 95% C.I. 0.89-1.79) and without prior fracture (RH 1.02 for alendronate vs placebo, 95% C.I. 0.76-1.38; P = 0.37 for interaction). | Assessing a clinical risk factor, prior non-vertebral fracture, did not identify women with low bone mass for whom alendronate reduced future non-vertebral fracture risk. | closed_qa |
Does the relative silicone content of different syringes affect the stability of foam in sclerotherapy? | Sclerotherapy has become the gold standard in the treatment of varicose veins. Foam sclerosing solution with sodium tetradecyl sulfate (STS) is one of the most popular agents used. This study examined the possibility that relative silicone content of different syringes may affect the overall foam stability. A double-syringe system (DSS) technique to make sclerosing foam (STS 0.5% and air) was applied. Four different brands of syringes were tested. The time required for half of the original volume of sclerosing solution to settle was recorded. The time for the sclerosing solution to settle to half of its initial volume varied with each brand of syringes. | The type of syringe used in the DSS technique to produce foam for sclerotherapy is a determinant of foam stability. Whether this will affect the result of sclerotherapy requires further investigation. | closed_qa |
Does the localisation of tumour at stage I endometrial endometrioid adenocarcinoma have an impact on invasion of the tumour and individualisation of the surgical procedure? | To detect whether the localisation of the tumour has an impact on the dissemination of the tumour and whether or not surgical procedures should be individualized according to the localisation of the tumour. 106 clinically surgically stage I endometrial endometrioid carcinoma cases treated multi-institutionally at Gulhane Military Medical Academy (GATA) and Dr. Zekai Tahir Burak (ZTB) Women's Health Education and Research Hospital Gynecologic Oncology Units in the last five years were evaluated retrospectively. The tumours localised near the internal cervical os and not invading the cervical canal were accepted as lower uterine segment (LUS) localisation and the corporal location as upper uterine segment (UUS) localisation. Tumour localisation was more frequent in the upper segment than LUS (85.9% vs 14.1%). There was no statistically significant difference between only endometrial and only serous invasion rates. Myometrial invasion less than one-half was significantly higher in the UUS group than the LUS group (p<0.05). Lymph vascular space involvement rate was significantly higher in the LUS group (60%, 9/15) than the UUS group (23 %, 21/91), (p<0.01). Positive peritoneal cytology rate was 20% (3/15) in the LUS group and 6.6% (6/91) in the UUS group (p>0.05). | Patients with LUS involvement should be considered as high-risk patients. Thus more expanded surgery must be taken into consideration. In this study a limitation was the low number of patients with LUS involvement. Larger prospective studies are necessary to confirm our results. | closed_qa |
Are grunting respirations a sign of serious bacterial infection in children? | A prospective case-control design was used. Data were collected on all children who were hospitalized with grunting respirations in our department of paediatrics over a 13-month period. The enrolled patients were divided into three groups: previously healthy children aged 3 months or less, previously healthy children aged more than 3 months and children with chronic illness at any age. The findings were compared to matched controls hospitalized for similar symptoms but without grunting respirations. Grunting respirations were documented in 149 of the 3334 admissions (4.5%) during the period of study. The incidence was higher in children aged 3 months or less (7.5%) and lower in children older than 3 months (3.9%). Fever and respiratory symptoms were common (83.9% and 65.1%, respectively). Heart rate was the only vital sign that was significantly different between the study and control groups. Serious bacterial infection occurred more frequently in the study group (31.5% vs. 14.8%, p<0.001, OR 2.14, 95% CI 1.36-3.36). Comparisons between the groups showed that grunting respirations were a sign of serious bacterial infection in previously healthy children older than 3 months (p = 0.007, OR 1.95, 95% CI 1.21-3.13) and in children with a chronic disease of any age (p = 0.033, OR 7.0, 95% CI 1.0-49.7 respectively), but not in previously healthy children younger than 3 months (p = 1). | The incidence and importance of grunting respirations in hospitalized children depend on patient's age and previous medical status. A finding of grunting respirations in a previously healthy child aged over 3 months or in a chronically ill child should alert the physician to seek further evidence of bacterial infection, especially pneumonia. | closed_qa |
Is the "perfect Fontan" operation routinely achievable in the modern era? | In 1990, Fontan, Kirklin, and colleagues published equations for survival after the so-called "Perfect Fontan" operation. After 1988, we evolved a protocol using an internal or external polytetraflouroethylene tube of 16 to 19 millimetres diameter placed from the inferior caval vein to either the right or left pulmonary artery along with a bidirectional cava-pulmonary connection. The objective of this study was to test the hypothesis that a "perfect" outcome is routinely achievable in the current era when using a standardized surgical procedure. Between 1 January, 1988, and 12 December, 2005, 112 patients underwent the Fontan procedure using an internal or external polytetraflouroethylene tube plus a bidirectional cava-pulmonary connection, the latter usually having been constructed as a previous procedure. This constituted 45% of our overall experience in constructing the Fontan circulation between 1988 and 1996, and 96% of the experience between 1996 and 2005. Among all surviving patients, the median follow-up was 7.3 years. We calculated the expected survival for an optimal candidate, given from the initial equations, and compared this to our entire experience in constructing the Fontan circulation. An internal tube was utilized in 61 patients, 97% of whom were operated prior to 1998, and an external tube in 51 patients, the latter accounting for 95% of all operations since 1999. At 1, 5, 10 and 15 years, survival of the entire cohort receiving polytetraflouroethylene tubes is superimposable on the curve calculated for a "perfect" outcome. Freedom from replacement or revision of the tube was 97% at 10 years. | Using a standardized operative procedure, combining a bidirectional cavopulmonary connection with a polytetraflouroethylene tube placed from the inferior caval vein to the pulmonary arteries for nearly all patients with functionally univentricular hearts, early and late survival within the "perfect" outcome as predicted by the initial equations of Fontan and Kirklin is routinely achievable in the current era. The need for late revision or replacement of the tube is rare. | closed_qa |
Use of ocular hypotensive prostaglandin analogues in patients with uveitis: does their use increase anterior uveitis and cystoid macular oedema? | 163 eyes of 84 consecutive patients with uveitis and raised IOP treated with a PG analogue at two tertiary referral uveitis clinics were identified over a 3-month period. Control eyes were selected as those uveitic eyes of the same patients, which were treated with topical IOP-lowering agent(s) other than a PG analogue. Pretreatment IOP was compared with the mean IOP during PG analogue treatment. The frequency of anterior uveitis and CMO during PG analogue treatment was compared with the frequency of these complications in the control eyes during non-PG IOP-lowering treatment. Significant IOP reductions were observed during PG analogue treatment. There was no significant difference in the frequency of anterior uveitis in those eyes treated with PG analogues and those treated with non-PG agents (p = 0.87, Fisher exact test). None of the 69 uveitic eyes without a previous history of CMO developed this complication. There was no increase in the frequency of visually significant CMO during PG treatment compared with that during non-PG treatment (p = 0.19, Fisher exact test). | This study demonstrates that PG analogues are potent topical medications for lowering raised IOP in patients with uveitis and are not associated with increased risk of CMO or anterior uveitis. | closed_qa |
Does orally administered doxycycline reach the tear film? | Orally administered doxycycline, a broad-spectrum antibiotic, is an established treatment for ocular surface diseases, particularly rosacea, meibomian gland dysfunction and recurrent epithelial cell erosion. In recent times, its efficacy in treating these diseases has been ascribed to an ability to inhibit matrix metalloproteinase (MMP) activity and both MMP and interleukin-1 (IL-1) synthesis. Since these functions are concentration-dependent, the aim of this project was to determine whether sufficient doxycycline reached the tear film to fulfil these roles in vivo. Doxycycline was extracted with 1-butanol from tear and blood plasma samples obtained from patients with ocular surface disease and healthy individuals and quantified spectrophotometrically. The MMPs present in the patients tear films before and during doxycycline treatment were analysed zymographically. The quantity of doxycycline detected in the blood plasma samples of patients undergoing treatment ranged from 1.83 to 13.18 microM. Although doxycycline was not detected in their tear samples, the treatment caused the disappearance of the MMPs symptomatic of disease progression. | The inability to detect doxycycline in the tear film of patients undergoing treatment indicates that doxycycline does not directly inhibit MMP activity or the synthesis/secretion of these proteases and IL-1 from corneal epithelial cells. | closed_qa |
Natural history of ventricular premature contractions in children with a structurally normal heart: does origin matter? | Premature ventricular contractions (PVCs) are thought to be innocent in children with normal hearts, especially if they disappear during exercise. The aim of our study was to study the natural history of PVCs in childhood and whether there is a difference between PVCs originating from the right [premature ventricular contraction with left bundle branch block (PVC-LBBB)] or the left ventricle [premature ventricular contraction with right bundle branch block (PVC-RBBB)]. We evaluated children with frequent PVCs and anatomically normal hearts (n= 59; 35M/24F) by 12-lead ECG, echocardiography, Holter recording, and an exercise test. Age at the first visit was 7.1 +/- 4.3 years (mean +/- SD), and follow-up was 3.1 +/- 3.1 years. We could evaluate each child for 2.5 +/- 1.5 times. Premature ventricular contraction with left bundle branch block was seen in 41% of the children; PVC-RBBB in 36%; and undetermined in 23%. Mean percentage PVCs in the Holter recording decreased (14.3 +/- 13.7% in the age group 1-3 years to 4.8 +/- 7.2% in the age group>OR=16 years; P= 0.08). Mean percentage PVC-LBBB did not change (12.3 +/- 21.4 vs. 11.7 +/- 5.5%), whereas PVC-RBBB decreased (16.3 +/- 4.2 to 0.6 +/- 1.4%; P<0.02). | We conclude that there is a difference in the natural history between PVC-LBBB and PVC-RBBB in children with an anatomically normal heart. Premature ventricular contraction with right bundle branch block disappears during childhood. Follow-up of these children seems not necessary. Premature ventricular contraction with left bundle branch block does not disappear and, therefore, it may be necessary to follow these children even during adulthood. | closed_qa |
Is that a lung edge? | We encountered a case whereby an 18-year-old boy presented to the Emergency Department with a stab wound to the left posterior chest. Chest X-ray (CXR) showed what appeared to be a pneumothorax and chest drain insertion was considered. It was confirmed subsequently that this apparent pneumothorax was due to a linear artefactual projection from the edge of the oxygen mask reservoir bag. We set out to investigate whether our colleagues would have misdiagnosed this artefact and what their initial treatment plan would have been. Four clinical scenarios were presented with accompanying radiographs, one of which was the case described above. Doctors were asked to examine the CXRs and accompanying scenarios, describe the radiograph findings and describe initial treatments they would perform. Twenty-three doctors (two consultants, five middle grades, and 16 senior house officers) were recruited. Two (9%) doctors indicated the 'mask sign' as a possible artefact. Nine (39%) reported the CXR as demonstrating a pneumothorax and recommended large bore chest drain insertion. | Our results show that almost half of our colleagues would have carried out tube thoracostomy when no pneumothorax was actually present. In a situation where a pneumothorax is a clinical possibility we would recommend either temporarily removing the oxygen mask if clinically stable, or fixing the reservoir bag outwith the field of the CXR by means of adhesive tape to avoid any misinterpretation of this 'mask sign'. | closed_qa |
Is exercise protective against influenza-associated mortality? | Little is known about the effect of physical exercise on influenza-associated mortality. We collected information about exercise habits and other lifestyles, and socioeconomic and demographic status, the underlying cause of death of 24,656 adults (21% aged 30-64, 79% aged 65 or above) who died in 1998 in Hong Kong, and the weekly proportion of specimens positive for influenza A (H3N1 and H1N1) and B isolations during the same period. We assessed the excess risks (ER) of influenza-associated mortality due to all-natural causes, cardiovascular diseases, or respiratory disease among different levels of exercise: never/seldom (less than once per month), low/moderate (once per month to three times per week), and frequent (four times or more per week) by Poisson regression. We also assessed the differences in ER between exercise groups by case-only logistic regression. For all the mortality outcomes under study in relation to each 10% increase in weekly proportion of specimens positive for influenza A+B, never/seldom exercise (as reference) was associated with 5.8% to 8.5% excess risks (ER) of mortality (P<0.0001), while low/moderate exercise was associated with ER which were 4.2% to 6.4% lower than those of the reference (P<0.001 for all-natural causes; P = 0.001 for cardiovascular; and P = 0.07 for respiratory mortality). Frequent exercise was not different from the reference (change in ER -0.8% to 1.7%, P = 0.30 to 0.73). | When compared with never or seldom exercise, exercising at low to moderate frequency is beneficial with lower influenza-associated mortality. | closed_qa |
Does the placement of a FRECA gastrostomy at the time of laparoscopic fundoplication impact on outcome? | This is retrospective study of a single surgeon's experience of laparoscopic fundoplications over a decade. Patient details were retrieved form a Microsoft Excel database and demographic, operative, and performance measures analysed. Of a series of 67 laparoscopic fundoplications, 20 with neurological compromise underwent FP placement at the time of surgery. Mean age was 3.37 years with a male to female ratio of 1.1:1. A size 9 French FRECA was placed in patients less than 10 kg (12) with larger patients (8) having a size 15 device. A Watson anterior wrap was performed in 16 cases with the rest having a Nissen fundoplication. Seven of these cases had pre-existing FPs which were taken down before replacement post fundoplication. Feeding was resumed the next morning except in three with delayed gastric emptying. Other complications (3) were seen but were not PEG related. The median stay for the series was 4 days (SD 3) and patients were followed up for a mean of 684 days. Over this period four patients relapsed and resumed medical treatment. A single mortality occurred in a syndromic 3-year-old a year later from problems unrelated to surgery. FPs were changed to a button device under general anaesthetic 3-24 months following placement. | FP placement at the time of laparoscopic fundoplication does not appear to compromise the outcome of surgery. Neither the size of patient nor the type of wrap is an impediment to its placement and the device can be used shortly after surgery in the majority allowing for an early discharge. Complications are infrequent; however, change to a button device within 2 years of initial placement requires general anaesthetic. | closed_qa |
Patient-centredness, self-rated health, and patient empowerment: should providers spend more time communicating with their patients? | Patient-centred communication is often employed as a strategy for empowering patients. The purpose of this study was to investigate the relationship between a direct measure of patient empowerment, feeling that one is in control of one's own health and patient satisfaction with communication. A cross-sectional survey of family medicine patients was used to test the theory that, in primary care patients, empowerment is related to satisfaction with several aspects of communication after adjusting for health status, age and gender. Interviews were completed with 680 adult patients for whom complete data were available. Multiple logistic regression analysis revealed that being highly satisfied with overall communication [adjusted odds ratio (AOR)=2.08], explanations (AOR=2.04), listening (AOR=2.63), use of understandable words (AOR=2.41) and involvement in decisions (2.34) were positively associated with empowerment. Self-rated health was more strongly related to empowerment than satisfaction with communication in every model tested (AORs ranged from 2.8 to 3.0). | Reliance solely on patient-centred communication to promote empowerment may be insufficient as well as costly. Instead, improved one-to-one communication between patients and providers should be reserved for clinically complex and urgent situations. For other health matters, referral of patients to community health promotion and education programmes should be considered because this may offer a lower-cost approach to empowerment. | closed_qa |
Is acinic cell carcinoma a variant of secretory carcinoma? | Acinic cell carcinomas (ACCs) and secretory carcinomas (SCs) of the breast are rare, low-grade malignancies that preferentially affect young female patients. Owing to the morphological and immunohistochemical similarities between these lesions, they have been proposed to be two morphological variants of the same entity. It has been demonstrated that SCs of the breast consistently harbour the t(12;15)ETV6-NTRK3 translocation. The aim was to determine whether ACCs also harbour ETV6 gene rearrangements and are thus variants of SCs. Using the ETV6 fluorescence in situ hybridization DNA Probe Split Signal (Dako), the presence of ETV6 rearrangements in three SCs and six ACCs was investigated. Cases were considered as harbouring an ETV6 gene rearrangement if>10% of nuclei displayed 'split apart signals' (i.e. red and green signals were separated by a distance greater than the size of two hybridization signals). Whereas the three SCs displayed ETV6 split apart signals in>10% of the neoplastic cells, no ACC showed any definite evidence of ETV6 gene rearrangement. | Based on the lack of ETV6 rearrangements in ACCs, our results strongly support the concept that SCs and ACCs are distinct entities and should be recorded separately in breast cancer taxonomy schemes. | closed_qa |
Diagnosis of peripheral arterial disease in general practice: can the ankle-brachial index be measured either by pulse palpation or an automatic blood pressure device? | Despite its validity as a screening test for peripheral arterial disease (PAD), and its prognostic value, the ankle-brachial index (ABI) is infrequently used in primary care, probably because a Doppler device is required, along with the requisite skill for its use. We hypothesized that ABI could be accurately measured either by pulse palpation (pABI) or automatic blood pressure devices (autoABI) instead of Doppler method (dABI). In 54 subjects, we compared the results and the intra-observer reproducibility of pABI to dABI, as well as the inter-observer reproducibility of both pABI and autoABI to dABI. Arm and ankle systolic pressures were measured by the three methods by two observers. The first observer repeated pABI and dABI measurements. The results were compared by the Student paired t-test. Reproducibility was assessed by the intra-class correlation coefficient of agreement (R) and the Bland and Altman method. The mean dABI obtained by the first observers was 1.03 +/- 0.26 vs. a pABI of 0.85 +/- 0.44 (p<0.0001) and an autoABI of 1.09 +/- 0.31 (p<0.05). The intra-observer R-coefficient was at 0.89 for dABI vs. 0.60 for pABI (p<0.05). The inter-observer R-coefficients were 0.79 for dABI vs. 0.40 for pABI (p<0.05) and 0.44 for autoABI (p<0.05). | Neither pulse palpation nor automatic oscillometric devices can be recommended as reliable methods for ABI measurement. | closed_qa |
Are we following the European charter? | In 1988, the European Association for Children in Hospital (EACH) established a charter of rights setting out the guiding principles for the treatment of children in hospital. Our aim was to ascertain whether children, parents and staff in a children's hospital believe the European Charter is conformed to. A total of 111 parents (response rate = 90%), 50 children (response rate = 100%), 61 nurses (response rate = 55%) and 41 doctors (response rate = 25%) agreed to participate. Questionnaires based on the 10 rights in the EACH Charter were administered to children, parents and staff. The majority of children and parents were happy with the relationship they had with staff. However, the findings suggest that children, parents and staff are concerned with the lack of facilities in hospital, including parental accommodation, play, education, age-appropriate wards and lack of privacy. Staff felt that many children undergo unnecessary admission and treatment in hospital. Many staff are reluctant to discuss issues such as side effects of medications with patients and do not encourage children to ask questions. Contrary to expectations, clinicians were reluctant to consider children under 16 as capable of giving consent, and most parents and children felt that children should be over 17 and 18 respectively. | This paper highlights patients' and staff's perceptions regarding children's rights in hospital and discusses the changes needed to fully conform to the EACH Charter. | closed_qa |
The Malone Antegrade Continence Enema (MACE) principle in children: is it important if the conduit is implanted in the left or the right colon? | The aim of the study was to determine which was the optimal side for the conduit to be placed (right or left colon) for antegrade continence enema implantation. Between July 1999 and March 2006, 31 patients underwent the construction of a catheterizable conduit using the Malone principle (MACE) In 22 cases the conduit was re-implanted in the right colon and in 9 cases in the left colon. There were 20 male patients and 11 female patients, with a mean age of 10.23 years. The follow-up period varied from 3 from 83 months (average 25 months). Right and left implantation of the conduit in the colon were compared with regards to the presence of complications, volume of the solution utilized, frequency of colonic lavage, time needed for performing the enema, and degree of satisfaction. One patient with the conduit in the right colon, using the appendix, lost the mechanism after two month follow-up. Thirty patients remain clean and are all capable of performing self-catheterization. No statistically significant differences were found between the groups regarding the variables studied: complications (p = 1.000), solution volume (p = 0.996), time required (p = 0.790) and patient's rating (p = 0.670). The lavage frequency required for patients with the conduit in the right colon may be lower. | The MACE principle was considered effective for treating fecal retention and leaks, independent of the implantation site. The success of this surgery appears to be directly related to the patient's motivation and not to the technique utilized. | closed_qa |
Does vaginal anti-incontinence surgery affect sexual satisfaction? | To evaluate the sexual satisfaction rates of women who underwent tension-free vaginal tape (TVT) procedure for stress urinary incontinence and compare it with the results of Burch-colposuspension. A self-administered questionnaire was given to 81 patients who had undergone TVT or Burch-colposuspension at our institution to determine sexual satisfaction rates and reasons for dissatisfaction. Forty-seven patients in TVT group and 22 patients in Burch-colposuspension group were considered eligible for the study. The mean follow-up period and age of patients in TVT and Burch-colposuspension groups were 34 months, 51.5 years and 89 months, 52.9 years, respectively. The difference between the ages in the two groups was not statistically significant, while the difference between mean follow-up periods was significant (p = 0.000). When evaluating sexual satisfaction, 73% in the TVT group and 86% in the Burch-colposuspension group did not report any difference in sexual satisfaction following surgery, while in the TVT group, 23% expressed negative and 4% positive changes, and in the Burch-colposuspension group 9% expressed negative and 5% positive post surgical changes. The differences in sexual satisfaction rates between the two groups were not considered significant. The majority (54%) of those who expressed a negative change suffered from dyspareunia. | Although sexual satisfaction seems to be more adversely affected by TVT compared to Burch-colposuspension, the difference was not statistically significant. Further studies are required concerning different anti-incontinence techniques in order to arrive at more precise conclusions. | closed_qa |
Incorporating the catering sector in nutrition policies of WHO European Region: is there a good recipe? | To review how countries of the WHO European Region address issues related to the catering sector in their nutrition policy plans. Documentary analysis of national nutrition policy documents from the policy database of the WHO Regional Office for Europe by a multidisciplinary research team. Recurring themes were identified and related information extracted in an analysis matrix. Case studies were performed for realistic evaluation. Fifty-three member states of the WHO European Region in September 2007. The catering sector is a formally acknowledged stakeholder in national nutrition policies in about two-thirds of countries of the European region. Strategies developed for the catering sector are directed mainly towards labelling of foods and prepared meals, training of health and catering staff, and advertising. Half of the countries reviewed propose dialogue structures with the catering sector for the implementation of the policy. However, important policy fields remain poorly developed, such as strategies for stimulating and monitoring actual implementation of policies. Others are simply lacking, such as strategies to ensure affordability of healthy out-of-home eating or to enhance accountability of stakeholders. It is also striking that strategies for the private sector are rarely developed. | Important policy issues are still embryonic. As evidence is accumulating on the impact of out-of-home eating on the increase of overweight, member states are advised to urgently develop operational frameworks and instruments for participatory planning and evaluation of stakeholders in public health nutrition policy. | closed_qa |
Antipituitary antibodies after traumatic brain injury: is head trauma-induced pituitary dysfunction associated with autoimmunity? | Traumatic brain injury (TBI) is a devastating public health problem that may result in hypopituitarism. However, the mechanisms responsible for hypothalamic-pituitary dysfunction due to TBI are still unclear. Although the antibodies against neurons have been demonstrated in injured animal studies, investigations regarding the occurrence of antipituitary antibodies (APAs) in patients with TBI are lacking in the literature. In order to investigate whether autoimmune mechanisms could play a role in the pituitary dysfunction after TBI, we have planned this study aimed at investigating the presence of APA at the third year of TBI and association between the TBI-induced hypopituitarism and APA. Twenty-nine (25 males and 4 females; age 36.5+/-2.3 years) patients who had completed a 3-year follow-up after TBI were included in the present study. APA and pituitary function were evaluated in all the patients 3 years after TBI; moreover, APAs were tested also in sera of 60 age-/sex-matched normal controls. The APAs were investigated by an indirect immunofluorescence method. Results APAs were detected in 13 out of the 29 TBI patients (44.8%), but in none of the normal controls. Pituitary dysfunction development ratio was significantly higher in APA-positive patients (46.2%) when compared with APA-negative ones (12.5%; P=0.04). There was a significant association between APA positivity and hypopituitarism due to TBI (odds ratio: 2.25, 95% confidence intervals 1.1-4.6). Moreover, there was a significant positive correlation (r=0.74, P=0.004) between APA titer ratio and peak GH response to GHRH+GH related peptide (GHRP)-6 test, suggesting that high APA titers were associated with low GH response to GHRH+GHRP-6 test. | This study shows for the first time the presence of the APA in TBI patients 3 years after head trauma. Moreover, present investigation indicates preliminary evidence that APA may be associated with the development of TBI-induced pituitary dysfunction, thus suggesting that autoimmunity may contribute in the development of TBI-induced hypopituitarism. The presence of the association between APA and TBI-induced hypopituitarism may provide a new point of view in this field and promote further clinical and experimental studies. | closed_qa |
Does primary immunisation status predict MMR uptake? | To investigate the relationship between primary immunisation status and MMR uptake. Nationally representative Millennium Cohort Study. Children born in the UK, 2000-2002. 14,578 children with immunisation data. MMR status at 3 years, defined as immunised with MMR, immunised with at least one single antigen vaccine or unimmunised. 88.6% of children had been immunised with MMR, 5.2% had received at least one of the single antigen vaccines and 6.1% were unimmunised against measles, mumps and rubella at age 3 years. Children who were unimmunised with the primary vaccines at ages 9 months (1.2%, n = 168) and 3 years (0.4%, n = 67) were 13 (95% CI 10.8 to 14.7) and 17 (95% CI 14.6 to 19.7) times more likely to be unimmunised against measles, mumps and rubella compared with children who were fully immunised. They were also more likely to be immunised with at least one of the single antigen vaccines with risk ratios of 2.8 (95% 1.2 to 6.1) and 4.3 (95% CI 1.8 to 10.1). Similar but smaller associations were observed if children were partially immunised with the primary vaccines at 9 months (3.4%, n = 502) and 3 years (3.6%, n = 522) with risk ratios of 4.0 (95% 3.2 to 4.9) and 5.2 (95% 4.2 to 6.1) for no MMR immunisation, and 2.0 (95% C 1.1 to 3.6) and 1.6 (95% CI 1.1 to 2.5) for single antigen vaccine use. | Children who remain unimmunised with primary vaccines are also more likely not to receive MMR. More work is needed to determine how best to target this group. | closed_qa |
Do gastrointestinal symptoms fluctuate in the short-term perspective? | A representative sample (n = 2,860) of the population (n = 21,610, 20-81 years of age; mean age 50.4 years) in Northern Sweden was studied. The subjects were asked to complete the questionnaire on two occasions [mean 2.5 months (range 1-6)], firstly via mail and secondly at a visit to the clinic. An upper endoscopy was performed after the last assessment of symptoms. 2,122 individuals (74.2%) completed the initial questionnaire; 1,001 of these (mean age 54.1 years, 48.8 males) completed the second questionnaire. On the first occasion, 40% of the subjects were symptom-free (20.2%) or could not be classified according to their symptom pattern, of those with symptoms 39% reported troublesome reflux symptoms, 40% dyspeptic symptoms and 30% irritable bowel symptoms. Symptom overlap occurred in more than two thirds of the subjects. At the second visit 75% of the subjects who had reported dyspeptic complaints still reported such complaints. | In this population-based study, gastrointestinal symptoms were common. Some symptom fluctuation occurred in the shorter term, but troublesome gastrointestinal complaints remained in approximately 90% of subjects over a 1-6-month period. | closed_qa |
Is body mass index associated with asthma in children? | Asthma is a disease with a complex pathogenesis. Obesity seems to be crucial risk factor for the development and worse clinical outcome of the disease. The aim of the study was to assess the relation between the body weight and the severity of asthma and preliminary analysis of factors influencing nutritional status among asthmatic children. Complete data have been available for 101 children with mild persistent, moderate persistent and severe persistent asthma. The questionnaires have been completed according to the physical and spirometric examination, analysis of medical documentation and anamnesis. Weight and height were measured in all children. To estimate the body mass index (BMI) values we used Body Mass Index Percentile Charts for Age. The control group consisted of 45 healthy school children. Mean BMI percentile for age in asthmatic children did not significantly differ from healthy children (53.4 +/- 32.3 and 59.5 +/- 30.5 respectively). Higher BMI percentiles for the age were observed among boys in comparison to girls (p =0.018). We did not find statistically significant relation between values of BMI percentiles and severity of asthma, although higher BMI values in boys with severe persistent asthma were noticed. Body mass index percentiles did not correlate with time of treatment and the doses of inhaled corticosteroids. Food allergy and atopic dermatitis in the past influenced BMI values. | Mean BMI percentile for age in asthmatic children did not significantly differ from healthy children. The correlation between BMI values and severity of asthma and treatment with inhaled corticosteroids were not found. | closed_qa |
Allopurinol hypersensitivity syndrome: a preventable severe cutaneous adverse reaction? | Allopurinol is a widely-prescribed urate-lowering agent. Allopurinol hypersensitivity syndrome, a severe form of cutaneous adverse reaction, is associated with significant mortality and morbidity. The aim of this study was to document the clinical presentation of allopurinol hypersensitivity in a local population, examine the indications for urate-lowering therapy and to identify potential associations with such a syndrome. Retrospective review was done for all patients who were referred to the dermatology unit of a tertiary hospital for allopurinol hypersensitivity syndrome over a four-year period. Over four years, there were 28 patients with allopurinol hypersensitivity syndrome, of which there were 27 (96 percent) Chinese and one (four percent) Malay. The average age was 69 years. At baseline, 24 patients (86 percent) had renal impairment, and 21 patients (75 percent) had higher dosages of allopurinol. The cutaneous manifestation included generalised maculopapular exanthem (22 patients, 79 percent), Stevens Johnson/toxic epidermal necrolysis overlap (two patients, seven percent) and Stevens-Johnson syndrome (two patients, seven percent) and generalised exfoliative dermatitis (one patient, four percent). Mortality rate was 18 percent. Indications for allopurinol therapy were clear in ten patients (36 percent). | Allopurinol hypersensitivit y syndrome is a life-threatening cutaneous adverse reaction. Allopurinol should be initiated under clear indications with appropriate dosages. Potential associations with this syndrome include the Chinese race, the elderly, and patients with underlying renal impairment. | closed_qa |
Distal forearm fracture in the adult: is ORIF of the radius and closed reduction of the ulna a treatment option in distal forearm fracture? | Distal forearm fractures in younger adults are rare injuries resulting from high energy trauma. Treatment options vary from cast fixation, external fixator, percutaneus pinning and open reduction and internal fixation. We retrospectively reviewed 13 patients aged 18-59 from 1996 to 2005 with a distal unstable forearm fracture. All were treated with open reduction and internal fixation of the radius. The ulna was stabilized either by an open reduction and internal fixation or by a closed reduction with or without pin fixation and cast fixation in all cases. At follow-up, we evaluated the radiologic results in terms of forearm fracture retention and functional outcome according to the wrist score by Krimmer. Radial inclination amounted to 24 degrees at the injured side when compared to 27 degrees at the non-injured side, palmar tilt was 3 degrees versus 7 degrees and ulna variance was -2 versus -1 mm. According to the modified wrist score by Krimmer, seven excellent, two good and four fair results were achieved. The range of motion of the injured wrist joint was 149 degrees of rotation, in the sagittal plane 106 degrees , frontal plane 61 degrees and on the non-injured side rotation was 171 degrees , and movement in the sagittal plane was 146 degrees and 79 degrees in the frontal plane. Decreased forearm rotation (107 degrees vs. 162 degrees ) and decreased range of motion in the sagittal plane (77 degrees vs. 114 degrees ) were measured in patient following open reduction and internal fixation of radius and ulna compared to the outcome in patients with open reduction and internal fixation of the radius and closed reduction of the ulna. Grip strength of the injured side averaged 350 N versus 440 N which is 76% of that of the opposite side. All patients stated no pain at rest and some experienced slight pain at work. Three patients had an excellent performance at daily activities, nine patients presented problems with certain activities, and one patient showed severe limitations. | Open reduction and internal fixation of the radius is the keystone in treating distal forearm fracture. In case of stable retention of the ulnar head after closed reduction, cast fixation with or without percutaneus pin fixation is a sufficient method to treat unstable distal forearm fractures. In patients with remaining instability of the distal ulna fracture, ORIF is indicated. | closed_qa |
Are Serbian gynaecologists in line with modern family planning? | In Serbia, gynaecologists could play an important role in achieving the transition from an abortion-based family planning culture to a modern contraception-based one. Exploring their knowledge, attitudes and practice regarding birth control is of particular importance for ensuring the quality of contraceptive counselling. A questionnaire was sent to all the 1,139 members of the Gynaecology and Obstetrics Section of the Serbian Medical Society. The response rate was 27%. Of the respondents, 61.8% reported that either they or their partner had had one or more induced abortions; 37.6% stated that they usually used either coitus interruptus or no contraceptive method at all; 51.0% were unwilling to prescribe combined oral contraceptives (COCs) to girls younger than 18 years, and 76.5% advised women against the use of COCs for more than two years. Irrational concerns about the health risks of contraception were identified. The contraceptive needs of women aged 20 + were particularly hampered by the fact that 75.5% of respondents thought that intrauterine device use was unsafe for women with benign, non infectious cervicitis. | The results indicate that a significant number of Serbian gynaecologists neither use modern methods of contraception themselves nor have adequate knowledge to advise their patients. Thus, education and training of gynaecologists in all methods of available contraception is a priority in Serbia. | closed_qa |
Is bipolar disorder overdiagnosed? | Bipolar disorder, a serious illness resulting in significant psychosocial morbidity and excess mortality, has been reported to be frequently underdiagnosed. However, during the past few years we have observed the emergence of an opposite phenomenon--the overdiagnosis of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we empirically examined whether bipolar disorder is overdiagnosed. Seven hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed a self-administered questionnaire, which asked the patients whether they had been previously diagnosed with bipolar or manic-depressive disorder by a health care professional. Family history information was obtained from the patient regarding first-degree relatives. Diagnoses were blind to the results of the self-administered scale. The study was conducted from May 2001 to March 2005. Fewer than half the patients who reported that they had been previously diagnosed with bipolar disorder received a diagnosis of bipolar disorder based on the SCID. Patients with SCID-diagnosed bipolar disorder had a significantly higher morbid risk of bipolar disorder than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID (p<.02). Patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID did not have a significantly higher morbid risk for bipolar disorder than the patients who were negative for bipolar disorder by self-report and the SCID. | Not only is there a problem with underdiagnosis of bipolar disorder, but also an equal if not greater problem exists with overdiagnosis. | closed_qa |
Management and patient survival in hepatocellular carcinoma: does the physician's level of experience matter? | The prognostic determinants of hepatocellular carcinoma (HCC) depend on tumor stage, liver function reserve, and treatments offered. The clinical impact of the physician's experience on HCC management and the survival outcome is unknown. A total of 103 patients were managed by one high-volume physician and 249 patients by seven low-volume physicians. The experience of high-volume physician in HCC management was five times more than that of low-volume physicians. Patient survival was the single end point for this study. Compared to the low-volume physician group, more of the patients allocated to the high-volume physician had early stage HCC on the date of diagnosis (66/103, 64.1%; vs 119/249, 47.8%; P = 0.008), and they received curative therapies including radiofrequency ablation or liver resection (66/103, 64.1% vs 54/249, 21.7%, P<0.001), and had significantly better survival outcome (median survival of 34 months, 95% confidence interval [CI], 17.6-50.4; vs 6 months, 95% CI, 4.3-7.7; P<0.001) with a multivariable-adjusted hazard ratio (HR) for survival of 1.94 (95%, CI, 1.31-2.87, P<0.001). A multivariate analysis of the pretreatment prognostic factors for these two groups identified alpha-fetoprotein (AFP) level (HR, 1.42; 95% CI, 1.01-1.99; P = 0.042), ascites (HR, 1.68; 95% CI, 1.15-2.46; P = 0.007), maximum tumor diameter (HR, 1.78; 95% CI, 1.16-2.74; P = 0.009), and portal vein thrombosis (PVT) (HR, 2.17; 95% CI, 1.49-3.17; P<0.001) as independent factors for the low-volume physician group. However, only maximum tumor diameter (HR, 4.54; 95% CI, 1.77-11.67; P<0.001) and PVT (HR, 5.73; 95% CI, 2.30-14.22; P = 0.002) were independent factors for the high-volume physician group. | The survival of HCC patients was dependent on the level of experience of the physicians who oversaw these patients. | closed_qa |
Does delayed measurement affect patient reports of provider performance? | We compared two methods of measuring provider performance of tobacco control activities: immediate "exit cards" versus delayed telephone follow-up surveys. Current standards, e.g. HEDIS, use delayed patient measures that may over or under-estimate overall performance. Patients completed exit cards in 60 dental practices immediately after a visit to measure whether the provider "asked" about tobacco use, and "advised" the patient to quit. One to six months later patients were asked the same questions by telephone survey. Using the exit cards as the standard, we quantified performance and calculated sensitivity (agreement of those responding yes on telephone surveys compared with exit cards) and specificity (agreement of those responding no) of the delayed measurement. Among 150 patients, 21% reporting being asked about tobacco use on the exit cards and 30% reporting being asked in the delayed surveys. The sensitivity and specificity were 50% and 75%, respectively. Similarly, among 182 tobacco users, 38% reported being advised to quit on the exit cards and this increased to 51% on the delayed surveys. The sensitivity and specificity were 75% and 64%, respectively. Increasing the delay from the visit to the telephone survey resulted in increasing disagreement. | Patient reports differed considerably in immediate versus delayed measures. These results have important implications because they suggest that our delayed measures may over-estimate performance. The immediate exit cards should be included in the armamentarium of tools for measuring providers' performance of tobacco control, and perhaps other service delivery. | closed_qa |
Does the 'gateway' matter? | The 'gateway' pattern of drug initiation describes a normative sequence, beginning with alcohol and tobacco use, followed by cannabis, then other illicit drugs. Previous work has suggested that 'violations' of this sequence may be predictors of later problems but other determinants were not considered. We have examined the role of pre-existing mental disorders and sociodemographics in explaining the predictive effects of violations using data from the US National Comorbidity Survey Replication (NCS-R). The NCS-R is a nationally representative face-to-face household survey of 9282 English-speaking respondents aged 18 years and older that used the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to assess DSM-IV mental and substance disorders. Drug initiation was estimated using retrospective age-of-onset reports and 'violations' defined as inconsistent with the normative initiation order. Predictors of violations were examined using multivariable logistic regressions. Discrete-time survival analysis was used to see whether violations predicted progression to dependence. Gateway violations were largely unrelated to later dependence risk, with the exception of small increases in risk of alcohol and other illicit drug dependence for those who initiated use of other illicit drugs before cannabis. Early-onset internalizing disorders were predictors of gateway violations, and both internalizing and externalizing disorders increased the risks of dependence among users of all drugs. | Drug use initiation follows a strong normative pattern, deviations from which are not strongly predictive of later problems. By contrast, adolescents who have already developed mental health problems are at risk for deviations from the normative sequence of drug initiation and for the development of dependence. | closed_qa |
Aggressive surgical resection for hilar cholangiocarcinoma: is it justified? | The current study presents our experience with resectional surgery for patients with hilar cholangiocarcinoma (HC). Medical records of 73 HC patients who were referred to our department between 1988 and 2006 were reviewed. Resectability rate, surgical mortality, and factors contributing to survival were investigated. Resectional surgery was performed in 59 patients (80.8%), 51 of whom (86.4%) underwent major hepatic resection. Negative margins were obtained in 35 of 51 patients (68.6%) and were associated with right-sided hepatectomy (80% vs 20%, P = .049). In-hospital mortality and morbidity were 6.8% and 25.4%, respectively. One-, 3- and 5-year survival rates after liver resection were 86%, 48.9%, and 34.9%, respectively. Histologic differentiation, left-sided hepatectomy, and inferior vena cava resection independently predicted survival. Patients undergoing R1 hepatectomy had significantly improved 5-year survival rates compared with patients who were unresectable (P<.01). | Major hepatic resections with concomitant vascular resection and reconstruction, when needed, are justified for patients with Bismuth type III and IV hilar cholangiocarcinoma with negative nodes. Reluctance to incorporate segments V and/or VIII into a left lobectomy often results in tumor-positive margins and unfavorable prognosis. Resections for hilar lesions less than stage IVB, even when resulting in microscopically positive margins, confer prolonged survival compared with untreated patients. The results are further improved for patients with well-differentiated HC. | closed_qa |
Is there unmet need for implantable cardioverter defibrillators? | To establish whether sudden cardiac death (SCD) victims could have been identified prior to their event and considered for an implantable cardioverter defibrillators (ICDs). Consecutive post-mortem cases of adult SCDs presumed to be caused by a ventricular arrhythmia over 12 months (2002-03) from a defined catchment population, Southampton, UK (n = 443 824 adults aged>or=16 years). Pathological data were extracted from the post-mortem reports. Hospital and general practice (GP) notes provided data on previous symptoms, investigations, and cardiac disease history. Two electrophysiologists judged the appropriateness of each case for an ICD against National Guidance. Two hundred and fifteen cases met the inclusion criteria and lived within the catchment area. Agreement between experts on appropriateness for an ICD in those aged<80 years was good (kappa score of 0.64). Only one case (<1%) was considered appropriate for an ICD without requirement for further investigation. Forty-nine per cent of cases were considered to have required further cardiac investigations to determine appropriateness; these were mainly heart failure patients who had suffered a myocardial infarction (MI). Forty per cent of cases had no previous clinical evidence of confirmed or suspected heart disease. However, pathological data showed that 51% of cases had suffered a previous MI. | Two-fifths of SCD victims had no recorded health service contact that would indicate increased risk of SCD within their lifetime. A large number of patients suffered previous cardiac events or symptoms suggestive of increased SCD risk but were not referred for further investigations. There is a need for better care pathways for patients post-MI to identify those requiring an ICD. The impact on the ICD rate of undertaking these extra investigations is uncertain. | closed_qa |
Do medical services personnel who deployed to the Iraq war have worse mental health than other deployed personnel? | Participants' main duty during deployment was identified from responses to a questionnaire and verified from Service databases. Psychological health outcomes included psychological distress, post-traumatic stress disorder, multiple physical symptoms, fatigue and heavy drinking. A total of 479 out of 5824 participants had a medical role. Medics were more likely to report psychological distress (OR 1.30, 95% CI 1.00-1.70), multiple physical symptoms (OR 1.65, 95% CI 1.20-2.27) and, if men, fatigue (1.38, 95% CI 1.05-1.81) than other personnel. Female medics were less likely to report fatigue (0.57 95% CI 0.35-0.92). Neither post-traumatic stress disorder nor heavy drinking symptoms were associated with a medical role. Traumatic medical experiences, lower group cohesion and preparedness, and post-deployment experiences explained the positive associations with psychological ill health. Medics made greater use of medical facilities than other trades. | There is a small excess of psychological ill health in medics, which can be explained by poorer group cohesion, traumatic medical and post-deployment experiences. The association of mental ill health with a medical role was not the consequence of a larger proportion of reservists in this group. | closed_qa |
Do clinical evaluations in a psychiatry clerkship favor students with positive personality characteristics? | The authors examine associations of personality characteristics, National Board of Medical Examiners subject examination performance, and Objective Structured Clinical Examination performance with clinical evaluations of third-year medical students in a psychiatry clerkship. Students completed the Revised NEO Personality Inventory, which measures personality domains of neuroticism, extraversion, openness, agreeableness, and conscientiousness and associated personality traits. At clerkship completion, students completed the National Board of Medical Examiners subject examination and a psychiatry Objective Structured Clinical Examination, and were evaluated by attending physicians (using a standardized evaluation form) regarding their clinical "knowledge and skill" and "interpersonal behavior." Data were analyzed using Pearson correlation and canonical correlation. National Board of Medical Examiners subject examination and Objective Structured Clinical Examination scores were uncorrelated with clinical evaluations of "knowledge and skill" and "interpersonal behavior." Personality variables explained a moderate amount of variance in clinical evaluations. "Knowledge and skill" was positively associated with the domain of conscientiousness, the extraversion trait of warmth, and the conscientiousness traits of competence and achievement striving. "Interpersonal behavior" was negatively associated with the neuroticism trait of angry hostility and positively associated with the domain of agreeableness; the extraversion traits of warmth, gregariousness, and positive emotions; and the agreeableness traits of trust, altruism, compliance, and tender-mindedness. | Clinical evaluations of medical students may favor personality styles that reflect positive elements of extraversion, agreeableness, and conscientiousness. The present findings raise questions regarding the validity of clinical evaluation elements in clerkship performance appraisal. | closed_qa |
Divergent fates of the medical humanities in psychiatry and internal medicine: should psychiatry be rehumanized? | To determine the degree to which the medical humanities have been integrated into the fields of internal medicine and psychiatry, the authors assessed the presence of medical humanities articles in selected psychiatry and internal medicine journals from 1950 to 2000. The journals searched were the three highest-ranking psychiatry and internal medicine journals on the Institute for Scientific Information's Impact Factor rankings that were published in English and aimed at a clinical audience. Operationalized criteria defining the medical humanities allowed the percentage of text in the selected journals constituting medical humanities to be quantified. Journals were hand searched at 10-year intervals from 1950 to 2000. Mixed effects models were used to describe the change in medical humanities over time. The percentage of text within psychiatry journals meeting the criteria for medical humanities declined from a peak of 17% in 1970 to a low of 2% in 2000, while the percentage of humanities articles in internal medicine journals roughly doubled from 5% to 11% over the same time period. A linear model increasing over time best fit the medical humanities in the internal medicine journals, while a cubic model decreasing over time best fit the psychiatry humanities data. Humanities articles in medical journals had a greater breadth and diversity than those in psychiatry journals. | Medical humanities publications dramatically decreased over time in psychiatry journals while they more than doubled in internal medicine journals. These data suggest the need for further empirical research and discussion of the potential roles of the humanities in psychiatry. | closed_qa |
Is arteriovenous shunting involved in the development of varicosities? | Arteriovenous (AV) shunting has been postulated as the underlying cause of varicose veins. The aim of this study was to analyse pressure and oxygen content in primary varicose veins in order to determine evidence of arterial shunting. Thirty-nine patients with varicose veins underwent cannulation of varicosities. The pressure and the blood oxygen content within varicosities were measured in different positions and during exercise. Similar measurements were made in the long saphenous veins of 10 control subjects without venous disease. Mean pressure in varicose veins in the supine position was 12.3 mmHg (Standard deviation [SD] 3.6 mmHg). Control subjects had similar pressures measured in the long saphenous vein. No pulsatile pressure tracings were obtained. Varicosity pressures in the erect position averaged 66 mmHg (SD 9 mmHg). In all cases, the pressure correlated with the distance of the varicosity from the heart. Pressure reduction in varicosities after exercise was significantly less than that in control subjects. Recovery time (RT 90) was also significantly shorter than in the control group. Mean venous pO2 in varicosities was 4.5 kPa (SD 1.0) in the supine position dropping to 3.9 kPa (SD 0.9) on standing; these values were not significantly different to samples from control subjects. | AV shunting is unlikely to be a causative factor in the development of primary varicose veins. | closed_qa |
Glutathione peroxidase 2 and aquaporin 8 as new markers for colonic inflammation in experimental colitis and inflammatory bowel diseases: an important role for H2O2? | Different mouse models of inflammatory bowel diseases (IBD) demonstrate various aspects of the pathophysiology of IBD. We looked for overlapping gene expression profiles in three different mouse models of experimental colitis and analysed whether these overlapping genes are of help to find new genes that could be used as general markers in human IBD. Using Agilent mouse TOX oligonucleotide microarrays, we analysed the gene expression profiles in three widely used models of experimental colitis: 2,4,6-trinitrobenzene sulphonic acid, dextran sodium sulfate and CD4CD45RB transfer and looked for overlapping gene expression in these models. Overlapping genes were analysed using Lightcycler (Roche Diagnostics, Mannheim, Germany) in biopsy materials from human IBD and control tissue. Compared with control mice in dextran sodium sulfate, 2,4,6-trinitrobenzene sulphonic acid and the CD45RB transfer colitis mice five known genes, extracellular proteinase inhibitor (Expi), glutathione peroxidase 2 (Gpx2), mast cell protease 1 (Mcpt1), resistin-like beta (Retnlb) and sulphatase 2 (Sulf2), and two unknown genes were upregulated and the two genes aquaporin 8 (Aqp8) and kallikrein 5 (Klk5) were downregulated in all three models. In human Crohn's disease and ulcerative colitis biopsies, one of the upregulated glutathione peroxidase (Gpx2) and one of the downregulated Aqp8 genes in the mouse models were also differentially expressed in affected colonic tissue of patients with IBD. | Experimental mouse models are suitable models for the search of new markers for human IBD. As both Gpx2 and Aqp8 are involved in H2O2 metabolism (Gpx2 as a radical scavenger whereas Aqp8 facilitates its diffusion), upregulation of Gpx2 and downregulation of Aqp8 could be a mechanism to defend against severe oxidative stress and indicate that H2O2 is a universal mediator in the inflammatory process in the colon. This provides a focus on homeostasis of the antioxidant pathway and its importance in IBD. | closed_qa |
Thromboembolic prophylaxis with intermittent pneumatic compression devices in trauma patients: a false sense of security? | Intermittent pneumatic compression devices provide a safe and attractive means of venous thromboembolism prophylaxis. We hypothesized that intermittent pneumatic compression devices were inadequate prophylaxis secondary to noncompliance. This was a prospective double-blind study evaluating compliance with intermittent pneumatic compression devices in nonambulatory adult trauma patients. Compliance was evaluated for the first 3 days of admission. The study consisted of two 3-month stages (before and after hospital personnel education on the importance of venous thromboembolism prophylaxis). During the first stage, device compliance was 85%, 59%, and 74% in the intensive care unit, surgical ward, and overall, respectively. Following hospital personnel education, device compliance was 82%, 65%, and 77% in the intensive care unit, surgical ward, and overall, respectively. There was no significant difference in compliance between the 2 stages. | With inadequate compliance and the cost attributed with intermittent pneumatic compression devices, other means of venous thromboembolism prophylaxis should be considered first, specifically low-molecular-weight heparin if not contraindicated. | closed_qa |
Does the use of a volatile anesthetic regimen attenuate the incidence of cardiac events after vascular surgery? | To compare the effects of a volatile anesthetic to a non-volatile anesthetic regimen on the incidence of postoperative cardiac events, including the postoperative elevation of troponin I values after arterial vascular surgery in high risk patients. Retrospective analysis of data of a phase II study that compared the Na+/H+ exchanger type II inhibitor, zoniporide to placebo on the occurrence of cardiac events. Multicenter study conducted in 105 sites throughout the United States, South America, Europe and Asia. 784 subjects scheduled for urgent or elective major arterial vascular surgery and a history of at least 3 of the following: age>or = 65 years, hypertension, documented stroke or transient ischemic attack, previous myocardial infarction, active angina pectoris diabetes mellitus, congestive heart failure, or symptomatic cardiac arrhythmia. Type of anesthesia was retrospectively retrieved from the database and patients were subdivided in two groups: inhalational (group A) vs non-inhalational anesthetic regimen (group B). Incidence of postoperative cardiac events was compared between the two groups. The incidence of postoperative cardiac events was not different between the two groups. Maximum postoperative troponin I levels was not different between the two groups in the total population and in the patients undergoing peripheral arterial surgery. In patients undergoing aortic surgery the incidence of elevated troponin levels higher than 1.5 and 4 ng x mL(-1) tended to be lower in group A than in group B in the aortic surgery (28% vs 18% and 30% vs 20% respectively) but this difference did not reach statistical significance. | The results of this hypothesis-generating study suggest that potential beneficial effects on extent of postoperative myocardial damage in high risk patients undergoing arterial surgery will probably be more apparent in abdominal aortic surgery than in peripheral vascular surgery. Further sufficiently powered studies using a standardized protocol should now be performed to definitively address this question. | closed_qa |
Can axillary and supraclavicular radiotherapy be avoided after breast-conserving surgery and axillary dissection in women with multiple involved axillary nodes? | Although some guidelines recommend adjuvant radiotherapy (RT) to the axilla and supraclavicular nodes if 4 or more axillary nodes are involved, the current practice at our Institute is not to irradiate the axilla but to perform complete axillary dissection in which all 3 Berg levels are removed. We performed a retrospective analysis of patients with 4 or more axillary nodes involved and sufficient follow-up to provide indications as to whether our current treatment is adequate. We retrospectively analyzed 287 T1-T3 patients with a median follow-up of 5 years and 4 or more involved nodes treated by quadrantectomy and breast RT but no axillary RT; supraclavicular RT was given only when prognostic factors were unfavorable. A total of 170 (59.2%) patients did not receive supraclavicular RT, while 117 (40.8%) patients received supraclavicular irradiation. No patient received axillary RT. After a median follow-up of 5 years (range, 4-105 months), 4.7% had died and 13.5% had developed distant metastases in the no supraclavicular RT group, compared to 12.0% dead (P = 0.028 log rank) and 24.8% (P = 0.201 log rank) in the supraclavicular RT group. No patients with supraclavicular RT developed supraclavicular metastases compared to 4 in the no supraclavicular RT group. There were no axillary recurrences. | Complete axillary dissection appears adequate treatment in patients with 4 or more involved nodes. The low breast recurrence rate also suggests that breast conservation is adequate treatment in such patients. Supraclavicular RT appears to reduce the number of supraclavicular metastases but confers no survival advantage. Although a small number of cases were examined in this retrospective single-center series, all received highly uniform treatment. | closed_qa |
Does increasing cigarette excise tax improve people's health? | Recently, public health advocates have fervently supported an increase in the cigarette excise tax as a means of reducing smoking. Likewise, political leaders have heavily relied on the cigarette excise tax as a means of encouraging a reduction in the overall rates of cigarette use. However, little is known about whether the cigarette excise tax is a valid tool for reducing the negative effects of smoking on public health. Our objective is to examine whether increasing the cigarette excise tax will reduce the morbidity rates of heart attack and stroke, which have consistently been among the major causes of death and disability in the United States. We used the static and dynamic panel-data model to explore the impact of the US regional cigarette excise tax on morbidity rates of heart attack and stroke. These rates of heart attack and stroke are estimated based on the 1970-2000 National Hospital Discharge Survey (NHDS). Study results show that the causal relationship between cigarette excise tax and morbidity rates of heart attack and stroke is unclear. However, the morbidity rates of non-smoking-related hypertension and high cholesterol-related diseases are positively correlated with the morbidity rates of heart attack and stroke. | We did not find clear empirical evidence to support the hypothesis that raising the cigarette excise tax effects a reduction the morbidities of heart attack and stroke. Therefore, use of the cigarette excise tax may not be an effective means to improve the health of the US population. | closed_qa |
Is total glossectomy for advanced carcinoma of the tongue justified? | Total glossectomy (with or without total laryngectomy) followed by postoperative radiotherapy remains the principal treatment method for advanced base of tongue carcinoma. The procedure remains controversial owing to poor cure rates and the inevitable functional deficits associated with it. However, even though total glossectomy is a major surgical procedure that impacts on speech, deglutition and quality of life, it may offer patients the best chance of cure in many centres, especially in the developing world. We did a retrospective chart review of all patients at Groote Schuur Hospital, Cape Town, who had undergone total glossectomy, with or without total laryngectomy, for stage IV squamous cell carcinoma (SCC) of the tongue between 1998 and 2004. Eight patients had a total glossectomy performed during the study period. At 2, 3 and 5 years 63%, 38% and 25% of patients respectively were alive without disease. No patient required permanent nasogastric or gastrostomy feeding, and all returned to a full oral diet. Three of 5 patients who had laryngeal preservation and could be assessed for speech had intelligible speech. All but 1 patient (88%) reported pain relief following surgical excision. Perineural invasion was present in 75%, and 38% had positive resection margins. Five patients had recurrence, 2 cervical, 1 local, and 2 local and cervical. | Advanced SCC of the tongue is a devastating disease causing severe pain and disorders of speech and swallowing. Total glossectomy (with or without total laryngectomy) and postoperative radiotherapy is a reasonable treatment option, particularly in the developing world setting. It has cure rates superior to primary radiotherapy, and provides motivated patients with excellent pain relief and a reasonable quality of life. | closed_qa |
Is a previous unplanned pregnancy a risk factor for a subsequent unplanned pregnancy? | The objective of the study was to determine whether a history of unplanned pregnancy was a risk factor for a subsequent unplanned pregnancy. We analyzed 542 women aged 14-35 years, enrolled in Project PROTECT, a randomized clinical trial to promote dual-method contraception use to prevent sexually transmitted diseases and unplanned pregnancy. Predictors of unplanned pregnancy were assessed by comparing women with and without a history of unplanned pregnancy. More than 1 in 5 women (22.5%) experienced an unintended pregnancy. History of an unintended pregnancy was a predictor of unintended pregnancy (adjusted odds ratio, 1.91; 95% confidence interval, 1.09-3.34). Other factors that were significantly associated with unplanned pregnancy included young age and low educational status. | Future efforts should focus on bridging the gap between identifying risk factors for unplanned pregnancy and interventions aimed at reducing the incidence in high-risk groups. | closed_qa |
Admission of elderly in intensive care: does age affect access to care? | The life expectancy of the population increasing, contrary to the resources of beds in reanimation, the question of the admission of the old subject in reanimation is increasingly frequent. We will be interested in the role of the age in the medical decision-making. A questionnaire was sent to the intensivists of the same department, then the troop of the subjects refused within an intensive care of the University Hospital of this same department was studied. The age arrives in third place among the factors of refusal of admission quoted. It does not seem to be an appalling criterion for access to intensive care, but rather to lead to a thorough evaluation of the patient. This idea is translated in the open questions as in the clinical settings in situation. The age modulates the recourse to the entry in intensive care. It tends to be integrated in a total process of evaluation of a patient, even if the consensus is not total... The analysis of the troop of the refused subjects showed a first reason for refusal which is the lack of place. The age is not quoted. | The age does not seem a determining element. It cannot solve the question which is to know if the admission in reanimation is relevant or not for the patient proposed. More than the admission or not of a possibly old subject in reanimation, the problem lies in the resolution with accuracy of the acute dilemma which is the decision-making to admit or refuse a patient whatever it is for the benefit of the person. | closed_qa |
HOMA or QUICKI: is it useful to test the reproducibility of formulas? | We used data from a clamp study involving 123 non-diabetic overweight and obese postmenopausal women. Fasting insulin and glucose were measured in two visits 15 and 30 days apart. This allowed us to calculate HOMA as (fasting glucose [mmol/L] x fasting insulin [microU/mL])/22.5 and QUICKI as 1/(log fasting glucose [mg/dL]+log fasting insulin [microU/mL]) twice for subjects who were weight-stable between visits. QUICKI had better reproducibility (CV=3.9%) than either HOMA (CV=26.7%) or log HOMA (CV=22.0%). However, log-transforming HOMA using log (glucose x insulin)/log (22.5) and log-transforming HOMA without transforming the constant denominator improved its CV to 6.5% and 5.7%, respectively. | By modifying the mathematical expression of HOMA, we were able to achieve comparable CVs for QUICKI and HOMA. However, the CV should be used to assess the reproducibility of techniques to measure glucose and insulin, not of mathematical formulas. When evaluating indices for the assessment of insulin sensitivity, the key point is how well they correlate with the 'gold-standard' glucose clamp. | closed_qa |
Does staging computered tomography change management in thick malignant melanoma? | Histological confirmation and assessment of Breslow thickness are essential before embarking on the management plan in Malignant Melanoma (MM). Computerised Tomography (CT) is used in staging of MM in the UK according to BAD/BAPS (British Association of Dermatologists/British Association of Plastic Surgeons). Currently UK guidelines for the management of cutaneous melanoma at intermediate or high risk of recurrent disease (American Joint Cancer Committee) AJCC IIB disease or worse (Breslow 2.01-4.0mm with ulceration or Breslow>4mm) should have the following staging investigations: chest X-ray; liver ultrasonography or computed tomographic (CT) scan with intravenous contrast enhancement of chest, abdomen and pelvis; liver function tests; lactate dehydrogenase and full blood count. It has been the practice at our unit to perform a CT head and neck also as part of our staging. The aim of this study was to determine whether CT staging changed clinical management at the initial presentation scan and follow up scans. Also we aimed to see whether there was a benefit in performing CT head and neck in staging. A retrospective case note review was performed to see whether CT staging actually changed patient clinical management on 132 cases of AJCC IIB melanoma or worse over the past six years at our unit. Clinical management changes were divided into two groups: Initial presentation CT staging and follow up CT staging. In addition numbers of metastases to body regions were recorded. A total of 488 CT scans were performed on 132 patients (3.7 scans per patient). Initial presentation CT staging scans picked up 1/132 (0.7%) patient with an occult metastases that changed their clinical management. Of the 356 follow up CT staging scans imaging (11/127) 8.6% of patients had metastases detected and clinical management changed. All of these patients exhibited symptoms and signs of clinical metastatic disease. Head metastases are at least as common as other regions such as the chest&abdomen and more common than in the pelvis. Neck CT did not change management. | CT staging for cutaneous melanoma is not indicated unless there are signs or symptoms of metastatic disease. If there are symptoms and signs of metastatic disease than patients should be staged and we advocate that staging of AJCC IIB/C should include imaging of the head in addition to chest, abdomen and pelvis. | closed_qa |
Television viewing and abdominal obesity in young adults: is the association mediated by food and beverage consumption during viewing time or reduced leisure-time physical activity? | The behavioral pathways through which television (TV) viewing leads to increased adiposity in adults are unclear. We wanted to determine whether the association between TV viewing and abdominal obesity in young adults is mediated by food and beverage consumption during TV viewing time or by a reduction in overall leisure-time physical activity (LTPA). This study involved a cross-sectional analysis of data from 2001 Australian adults aged 26-36 y. Waist circumference (WC) was measured at study clinics, and TV viewing time, frequency of food and beverage consumption during TV viewing, LTPA, and demographic characteristics were self-reported. Women watching TV>3 h/d had a higher prevalence of severe abdominal obesity (WC:>or = 88 cm) compared with women watching<or = 1 h/d [prevalence ratio (PR): 1.89; 95% CI: 1.32, 2.71]. Moderate abdominal obesity (WC: 94-101.9 cm) was more prevalent in men watching TV>3 h/d than in men watching<or = 1 h/d (PR: 2.16; 95% CI: 1.37, 3.41). Adjustment for LTPA made little difference, but adjustment for food and beverage consumption during TV viewing attenuated the associations (PR: 1.48; 95% CI: 1.01, 2.17 for women; PR: 1.73; 95% CI: 1.06, 2.83 for men). | The association between TV viewing and WC in young adults may be partially explained by food and beverage consumption during TV viewing but was not explained by a reduction in overall LTPA. Other behaviors likely contribute to the association between TV viewing and obesity. | closed_qa |
Are pancreatic autoantibodies associated with azathioprine-induced pancreatitis in Crohn's disease? | Azathioprine is frequently used in the treatment of Crohn's disease. A severe side effect is acute pancreatitis, which is specific for Crohn's disease. Autoantibodies against exocrine pancreas occur in about 30% of Crohn's disease cases but not in other inflammatory diseases. Pancreatic autoantibody positive Crohn's disease patients might have a low grade inflammation of the pancreas which may be aggravated by the introduction of azathioprine, resulting in clinically overt acute pancreatitis. We hypothesized that the presence of pancreatic autoantibodies in Crohn's disease patients is associated with the development of azathioprine-induced pancreatitis. Eight patients with Crohn's disease and azathioprine-induced pancreatitis and 26 patients with Crohn's disease not using azathioprine. Pancreatic autoantibodies were determined by a standardized immunofluorescence method. Two out of 8 patients with azathioprine-induced pancreatitis were positive for pancreatic autoantibodies (25.0%), detectable in serum dilutions of 1:40 and 1:160, respectively. In the control group of Crohn's disease patients, two (7.7%) were positive in serum dilutions of 1:2. All positive samples had an extracellular fluorescence pattern. The difference in the prevalence of pancreatic autoantibodies was not statistically significant (P=0.229). | We could not confirm our hypothesis that most or all patients with azathioprine-induced pancreatitis were pancreatic autoantibody positive. The prevalence of pancreatic autoantibodies in the Crohn's disease patients in our group was lower than in previous reports.This study does not support an association between pancreatic autoantibodies and azathioprine-induced pancreatitis in Crohn's disease. However, this association should not be definitively excluded and larger, preferably prospective, studies are needed. | closed_qa |
Is maternal smoking during early pregnancy a risk factor for all low birth weight infants? | Low birth weight (LBW) infants do not form a homogeneous group; LBW can be caused by prematurity or poor fetal growth manifesting as small for gestational age (SGA) infants or intrauterine growth retardation. We aimed to clarify the relationship of maternal smoking with both SGA and preterm LBW infants. The study population comprised pregnant women who registered at the Koshu City between January 1, 1995, and December 31, 2000, and their children. We performed multivariate analyses using multiple logistic regression models to clarify the relationship of maternal smoking during pregnancy with the SGA outcome and preterm birth in LBW infants. In this study period, 1,329 pregnant women responded to questionnaires, and infant data were collected from 1,100 mothers (follow-up rate: 82.8%). The number of LBW infants was 81 (7.4%). In this cohort, maternal smoking during early pregnancy was associated with LBW and the SGA outcome. Maternal smoking during early pregnancy was a risk factor for LBW with SGA outcome and for LBW with full-term birth. However, it was not a risk factor for LBW with appropriate weight for gestational age (AGA) and LBW with preterm birth. | These results suggested that LBW with AGA and LBW with preterm birth were associated with other risk factors that were not considered in this study, such as periodontal disease. For the prevention of LBW, not only abstinence from smoking during pregnancy but also other methods such as establishing a clinical setting should be adopted. | closed_qa |
Does treadmill training improve lower-extremity tasks in Parkinson disease? | To investigate whether gait training with treadmill improves functional tasks of lower extremities in patients with Parkinson disease (PD). Randomized controlled trial including two groups, the treadmill training group and the nonintervention group. University hospital. Thirty consecutive patients diagnosed with idiopathic PD, who were on stable regimens of antiparkinsonian medication, able to walk independently, and had not participated in a rehabilitation program in the previous 3 months. Patients with severe cognitive impairments or severe musculoskeletal, cardiopulmonary, neurologic, or other systemic disorders were excluded. Twenty-four patients completed the study. Group I attended a training program on a treadmill for 6 weeks, and group II served as the control group. Both groups were instructed in home mobility exercises. The primary study outcome measures were timed functional lower-extremity tasks (walking at a corridor, U-turn, turning around a chair, stairs, standing on one foot, standing from a chair), and secondary outcome measures were exercise test and patient's global assessment. Assessments were performed at baseline and at the end of the study. There were significant improvements in functional lower-extremity tests, exercise test parameters, and patients' global assessment in group I, whereas no significant improvements were observed in group II. | Even though long-term effects remain unknown and the study sample was small, it was concluded that treadmill training in PD patients led to improvements in lower-extremity tasks, thus improving patients' physical well-being in daily life. | closed_qa |
Does work as a nurse increase the risk of adverse pregnancy outcomes? | We conducted a population-based study to assess whether work as a nurse during pregnancy increases the risk of low birth weight, preterm delivery, and small-for-gestational-age. The study population was selected from The Finnish Prenatal Environment and Health Study of 2568 newborns (response 94%) and included 128 (5.0%) newborns of nurses and 559 newborns of office workers (21.8%) as a reference group. The risk of low birth weight (adjusted odds ratio = 1.02; 95% confidence interval = 0.32-3.22) and preterm delivery (0.81; 0.32-2.05) did not differ between newborns of nurses and office workers, but the risk of small-for-gestational-age was substantially higher among newborns of nurses (1.99; 1.10-3.59). This corresponds to a population attributable fraction of 2.5%. | The results indicate that working as a nurse during pregnancy could reduce fetal growth. | closed_qa |
Formyl-methionyl-leucyl-phenylalanine-induced dopaminergic neurotoxicity via microglial activation: a mediator between peripheral infection and neurodegeneration? | Parkinson disease (PD), a chronic neurodegenerative disease, has been proposed to be a multifactorial disorder resulting from a combination of environmental mechanisms (chemical, infectious, and traumatic), aging, and genetic deficits. Microglial activation is important in the pathogenesis of PD. We investigated dopaminergic (DA) neurotoxicity and the underlying mechanisms of formyl-methionyl-leucyl-phenylalanine (fMLP), a bacteria-derived peptide, in relation to PD. We measured DA neurotoxicity using a DA uptake assay and immunocytochemical staining (ICC) in primary mesencephalic cultures from rodents. Microglial activation was observed via ICC, flow cytometry, and superoxide measurement. fMLP can cause selective DA neuronal loss at concentrations as low as 10(-13) M. Further, fMLP (10(-13) M) led to a significant reduction in DA uptake capacity in neuron/glia (N/G) cultures, but not in microglia-depleted cultures, indicating an indispensable role of microglia in fMLP-induced neurotoxicity. Using ICC of a specific microglial marker, OX42, we observed morphologic changes in activated microglia after fMLP treatment. Microglial activation after fMLP treatment was confirmed by flow cytometry analysis of major histocompatibility antigen class II expression on a microglia HAPI cell line. Mechanistic studies revealed that fMLP (10(-13) M)-induced increase in the production of extracellular superoxide from microglia is critical in mediating fMLP-elicited neurotoxicity. Pharmacologic inhibition of NADPH oxidase (PHOX) with diphenylene-iodonium or apocynin abolished the DA neurotoxicity of fMLP. N/G cultures from PHOX-deficient (gp91PHOX-/ -) mice were also insensitive to fMLP-induced DA neurotoxicity. | fMLP (10(-13) M) induces DA neurotoxicity through activation of microglial PHOX and subsequent production of superoxide, suggesting a role of fMLP in the central nervous system inflammatory process. | closed_qa |
Is rectal washout effective for preventing localized recurrence after anterior resection for rectal cancer? | The present study evaluated the effect of rectal washout in reducing local recurrence after resection for rectal cancer. A literature search was performed on studies published since 1989 that compared rectal washout to no washout for rectal cancer resection. Primary end point was local cancer recurrence. Random-effect meta-analysis was used and subgroup analysis was performed. Five studies matched the selection criteria, and reported on 176 patients who underwent rectal washout and 256 who did not undergo washout. Different washout solutions were used in every study, and total mesorectal excision was not universally applied. Overall local recurrence rate was 8 percent (33/432). Local recurrence rate for rectal washout patients was 4.8 percent compared with 10.2 percent for patients who did not undergo rectal washout, a difference that was not statistically significant (odds ratio = 0.64; 95 percent confidence interval = 0.2-2.04). When only studies using total mesorectal excision were considered, there was no significant difference between the two groups (odds ratio = 1.21; 95 percent confidence interval = 0.37-3.92). | Although no definitive conclusions may be drawn because of the nonrandomized nature of the included studies, rectal washout is relatively risk-free and adds little to the operative time. This may be performed until a randomized, controlled trial is undertaken to resolve this contentious issue. | closed_qa |
Diagnostic laparoscopy for patients with potentially resectable pancreatic adenocarcinoma: is it cost-effective in the current era? | For patients with potentially resectable pancreatic cancer, diagnostic laparoscopy may identify liver and peritoneal metastases that are difficult to detect with other staging modalities. The aim of this study was to utilize a population-based pancreatic cancer database to assess the cost effectiveness of preoperative laparoscopy. Data from a state cancer registry were linked with primary medical record data for years 1996-2003. De-identified patient records were reviewed to determine the role and findings of laparoscopic exploration. Average hospital and physician charges for laparotomy, biliary bypass, pancreaticoduodenectomy, and laparoscopy were determined by review of billing data from our institution and Medicare data for fiscal years 2005-2006. Cost-effectiveness was determined by comparing three methods of utilization of laparoscopy: (1) routine (all patients), (2) case-specific, and (3) no utilization. Of 298 potentially resectable patients, 86 underwent laparoscopy. The prevalence of unresectable disease was 14.1% diagnosed at either laparotomy or laparoscopy. The mean charge per patient for routine, case-specific, and no utilization of laparoscopy was $91,805, $90,888, and $93,134, respectively. | Cost analysis indicates that the case-specific or routine use of laparoscopy in pancreatic cancer does not add significantly to the overall expense of treatment and supports the use of laparoscopy in patients with known or suspected pancreatic adenocarcinoma. | closed_qa |
Cumulative operative experience is decreasing during general surgery residency: a worrisome trend for surgical trainees? | The aim of this study was to quantify the changes over time in general surgical residents' operative experience as surgeon, first assistant, and teaching assistant. The introduction of work hour restrictions in July 2003 raised concern that residents' operative experience might decline. Early studies evaluating the mean number of operations performed as surgeon reported no major change. The experiences of residents as first assistant and teaching assistant have not been closely examined. The Accreditation Council for Graduate Medical Education Resident Statistics Summary reports from academic year 1992 to 1993 through the present were reviewed. The mean number of cases reported as total surgeon, surgeon chief, and surgeon junior for academic year 2001 to 2002 through 2005 to 2006 were analyzed for total major operations. The median number of cases reported as total surgeon, first assistant, and teaching assistant for academic year 1992 to 1993 through 2005 to 2006 were analyzed for total major operations. Since the implementation of the 80-hour work duty restrictions, the number of total major operations reported by residents as surgeon decreased from 930 to 909 (2.3% decrease, p<0.0001), surgeon chief operations decreased from 252 to 231 (8.3% decrease, p<0.0001), and surgeon junior operations remained essentially unchanged, from 677 to 678. From academic year 1992 to 1993 through 2005 to 2006, the median number of first assistant and teaching assistant cases declined from 231 to 49 (79% decrease) and from 67 to 23 (66% decrease), respectively. | Since duty hour restrictions were introduced, there have been small but notable declines in the number of total surgeon and surgeon chief operative cases reported by graduating residents. Over a longer time period, operative cases reported by graduating residents in the roles of first assistant and teaching assistant declined dramatically. Although some of these declines were gradual, recent declines may have been accelerated by the 80-hour duty hour restrictions. These trends must be considered as we plan the education of present and future surgical residents. | closed_qa |
Are patients with esophageal cancer who become PET negative after neoadjuvant chemoradiation free of cancer? | Esophageal cancer continues to increase in incidence. Many patients are presenting with stage II or greater disease and proceeding to neoadjuvant chemoradiation therapy before resection. Approximately 30% of patients will achieve a complete response and might not benefit from proceeding to resection. This study will examine the ability of PET to predict patients with a complete pathologic response. A query of our IRB-approved esophageal database revealed 81 patients who underwent a pre- and postchemoradiation PET scan and then proceeded to esophageal resection. Statistical analysis was performed to determine the ability of PET to predict a complete pathologic response. When comparing posttherapy PET with final pathology, it was determined that PET could not consistently differentiate a complete pathologic response from patients who still had persistent disease. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 61.8%, 43.8%, 70%, 35%, and 56%, respectively, for patients with a complete PET response after neoadjuvant therapy. | A complete PET response after neoadjuvant chemoradiation is not substantially predictive of a complete pathologic response. Patients should still be referred for resection unless distant metastases are identified. | closed_qa |
Does race influence outcomes after primary liver transplantation? | Data about the influence of race on survival after liver transplantation (LT) are limited and conflicting. This study was undertaken to evaluate longterm outcomes for LT in African-American (AA) recipients compared with recipients of other races and to determine factors responsible for any observed differences. This was a retrospective case series. Among 2,728 adult patients who underwent primary LT from 1984 to 2007, 1,566 (57%) were Caucasian, 761 (28%) were Hispanic, 290 (11%) were Asian, and 111 (4%) were AA. The primary immunosuppressive agent was cyclosporine from 1984 to 1993 (Era I, n=817) and tacrolimus from 1994 to 2007 (Era II, n=1922). In Era I, the 1-, 5- and 10-year patient and graft survival figures for AA and Asian recipients were considerably lower compared with Caucasian and Hispanic recipients. In Era II, patient and graft survival figures were comparable for all groups. Statistically significant independent predictors of diminished patient survival included LT in Era I; recipient or donor age greater than 55 years; and liver failure secondary to cryptogenic cirrhosis, malignancy, or hepatitis C. Predictors of graft failure included LT in Era I; recipient or donor age greater than 55 years; prolonged cold ischemia time; liver failure secondary to hepatitis C, cryptogenic cirrhosis, or malignancy; and acute rejection. Patient and graft survival were independent of race in both eras. | This is the first study to demonstrate equivalent longterm results after LT for AA and other races. Modern immunosuppression with tacrolimus substantially lowered rejection rates and improved graft and patient survival after LT. | closed_qa |
Is there a role for routine use of MRI in selection of patients for breast-conserving cancer therapy? | The role of preoperative bilateral breast MRI in breast cancer patients being considered for breast-conserving therapy has been controversial. We hypothesized that preoperative MRI, along with an active program in MRI-directed biopsies, would lead to a change in multidisciplinary treatment planning for patients being considered for breast-conserving cancer therapy, and it would be associated with reduced rates of margin-positive partial mastectomies. A retrospective review of a consecutive series of patients who were treated for breast cancer at a single center between January 2005 and July 2007 was conducted. Patients in the study were candidates for breast-conserving cancer therapy based on physical examination, mammography, and ultrasonography. All patients were evaluated by a preoperative breast MRI. Analysis included number and result of MRI-directed biopsies, impact of MRI on treatment planning, and incidence of margin-positive partial mastectomy within the series of patients. Seventy-nine female patients were analyzed. Median age was 57 years. MRI led to the performance of 25 MRI-directed biopsies for previously unrecognized suspicious lesions in 21 patients. Forty-four percent of MRI-directed biopsies were positive for cancer. MRI was associated with a change in management in 15 patients (19%) for multicentric ipsilateral cancer (n = 7), a more extensive primary lesion size (n = 6), or contralateral breast cancer (n = 2). Incidence of margin-positive partial mastectomy requiring additional resective operation was very low in this series (10%). | Bilateral breast MRI, when used in conjunction with MRI-directed biopsy procedures, can be helpful in planning multidisciplinary treatment of candidates for breast-conserving cancer therapy. By allowing more accurate local staging of tumors, MRI is a tool that can be used to help reduce high reexcision rates for margin-positive partial mastectomies. | closed_qa |
Do current outcomes justify more liberal use of revascularization for vasculogenic claudication? | The purpose of this study was to reconsider current recommended treatment guidelines for vasculogenic claudication by examining the contemporary results of surgical intervention. We performed a retrospective review of 1,000 consecutive limbs in 669 patients treated for medically refractory vasculogenic claudication and prospectively followed. Outcomes measured included procedural complication rates, reconstruction patency, limb salvage, maintenance of ambulatory status, maintenance of independent living status, survival, symptom resolution, and symptom recurrence. Of the 1,000 limbs treated, endovascular therapy was used in 64.3% and open surgery in 35.7% of patients; aortoiliac occlusive disease was treated in 70.1% and infrainguinal disease in 29.9% of patients. The overall 30-day periprocedural complication rate was 7.5%, with no notable difference in complication rates when comparing types of treatment or levels of disease. Overall reconstruction primary patency rates were 87.7% and 70.8%; secondary patencies were 97.8% and 93.9%; limb salvage, 100% and 98.8%; and survivals, 95.4% and 76.9%, at 1 and 5 years, respectively. More than 96% of patients maintained independence and ambulatory ability at 5 years. Overall symptom resolution occurred in 78.8%, and symptom recurrence occurred in 18.1% of limbs treated, with slightly higher resolution and recurrence noted in patients treated with endovascular therapy. | Contemporary treatment of vasculogenic claudication is safe, effective, and predominantly endovascular. These data support a more liberal use of revascularization for patients with claudication and suggest that current nonoperative treatment guidelines may be based more on surgical dogma than on achievable outcomes. | closed_qa |
Can urinary excretion rate of malondialdehyde, uric acid and protein predict the severity and impending death in perinatal asphyxia? | Perinatal asphyxia (PA) associated with multi-organ damage is a leading cause of neonatal mortality and morbidity. We evaluated if urinary malondialdehyde:creatinine (UMDA:Cr), uric acid:creatinine (UUA:Cr) and protein:creatinine (UP:Cr) vary with the severity of PA and if these parameters can predict the impending death in PA. Study included 20 asphyxiated and 20 healthy newborn males. Hypoxic-ischemic encephalopathy (HIE) staging, APGAR (activity, pulse, grimace, appearance and respiration) score and urinary protein, uric acid, creatinine and MDA were evaluated. UMDA:Cr, UUA:Cr and UP:Cr were significantly higher and correlated with APGAR and HIE in PA. By regression analysis also, urinary parameters were found to have significant association with HIE stage and APGAR in PA. Receiver operating characteristics (ROC) curve of UP:Cr, UUA:Cr and UMDA:Cr showed area under curve of 0.896 (p=0.003), 0.859 (p=0.008) and 0.849 (p=0.010) with cut-off value of 9.04 mg, 2.34 mg and 3.49 microg/mg of creatinine respectively that can optimally predict the impending death in PA. SDS-PAGE of unconcentrated urine detected both high (73 kDa and 68 kDa) and low molecular weight proteins (52 kDa, 47 kDa, 25 kDa and 20 kDa) in PA but not in controls. | Urinary excretion rate of uric acid, MDA and proteins is higher and has potential to act as biochemical markers for severity evaluation and death prediction in PA. | closed_qa |
AMS 800 artificial urinary sphincter implantation: can the penoscrotal approach constitute an alternative to the perineal approach? | To compare the short-term results of penoscrotal and perineal artificial urinary sphincter implantation. From May 2005 to February 2007, 37 artificial urinary sphincters were implanted successively, via a penoscrotal approach in 16 cases and via a perineal approach in 21 cases. Incontinence was secondary to prostate surgery (n=36) and pelvic trauma (n=1). Seventeen patients had a history of external beam radiotherapy. The times and modalities of activation of the sphincter were identical in the two groups. The mean age of the patients, the mean operating time, the mean catheterization duration, the mean hospital stay and the mean postoperative follow-up were equivalent in the two groups. Six urethral erosions (37.5%) and one scrotal erosion due to the pump (6.6%) were observed in the penoscrotal group and infection of the sphincter in two patients (9.5%) and pump migration in another two patients (9.5%), but no urethral erosions were observed in the perineal group. The success rate without revision was 56% in the penoscrotal group and 71.5% in the perineal group. | The perineal approach is the reference incision, as the penoscrotal approach is associated with a high rate of erosion. The penoscrotal urethral approach can constitute an alternative when the bulbar urethra cannot be used. | closed_qa |
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