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Is saliva as reliable as urine for detection of cytomegalovirus DNA for neonatal screening of congenital CMV infection? | There are no studies on the detection of cytomegalovirus (CMV) DNA by molecular methods in the saliva of newborn infants in large scale screening programs. To evaluate the usefulness of saliva as a sample for the neonatal screening of congenital CMV infection as compared to urine when processed by a PCR. Saliva and urine samples were obtained during the first week of life. Both samples were attempted to be obtained from the first 2816 neonates. Subsequently, only saliva was obtained from other 1623 infants. Urine and saliva were processed by DNA-PCR. Confirmation of positive results was done by PCR and virus isolation by 3 weeks after birth. A urine sample was not obtainable from 893/2816 (31.7%) infants. Both saliva and urine samples were obtained from the remaining 1923 infants. Of these, 28 (1.45%) were CMV-infected. There was 99.7% agreement between the results with both samples. CMV excretion was similar when PCR was applied to urine (1.3%) or to saliva (1.2%) samples. Among the subsequent 1623 infants for whom only a saliva sample was planned for screening, 16 (0.98%) were CMV-infected. | Saliva samples are as useful as urine for the identification of CMV-DNA in large use for screening programs. | closed_qa |
Magnetic resonance imaging of haemorrhage within reperfused myocardial infarcts: possible interference with iron oxide-labelled cell tracking? | Magnetic resonance imaging (MRI) has been proposed as a tool to track iron oxide-labelled cells within myocardial infarction (MI). However, infarct reperfusion aggravates microvascular obstruction (MO) and causes haemorrhage. We hypothesized that haemorrhagic MI causes magnetic susceptibility-induced signal voids that may interfere with iron oxide-labelled cell detection. Pigs (n = 23) underwent 2 h occlusion of the left circumflex artery. Cine, T2*-weighted, perfusion, and delayed enhancement MRI scans were performed at 1 and 5 weeks, followed by ex vivo high-resolution scanning. At 1 week, MO was observed in 17 out of 21 animals. Signal voids were observed on T2*-weighted scans in five out of eight animals, comprising 24 +/- 22% of the infarct area. A linear correlation was found between area of MO and signal voids (R2 = 0.87; P = 0.002). At 5 weeks, MO was observed in two out of 13 animals. Signal voids were identified in three out of seven animals. Ex vivo scanning showed signal voids on T2*-weighted scanning in all animals because of the presence of haemorrhage, as confirmed by histology. Signal voids interfered with the detection of iron oxide-labelled cells ex vivo (n = 21 injections). | Haemorrhage in reperfused MI produces MRI signal voids, which may hamper tracking of iron oxide-labelled cells. | closed_qa |
Does better access to primary care reduce utilization of hospital accident and emergency departments? | Availability of primary care emergency facilities has been improved to help curb heavy growth in the use of Accident and Emergency Departments (A&EDs). The aim of this paper is to analyse the relationship between time series for visits to hospital A&EDs and primary care centres. Using a co-integration time series we analyse the visits to the emergency services of the county hospital and seven healthcare primary centres in the healthcare district of Mieres, Asturias, España, during the period 1992-1999. The main outcome measured is the relationship between the time series for emergency visits to the primary care centres and the hospital A&ED, for groups aged 0-14 years, over 14 years and the total. A total of 506,158 visits to the emergency services of the primary care centres (62.4%) and hospital A&ED (37.6%) have been studied. Emergency visits rose by 40.9% during the period studied (50.3% in primary care centres and 26.5% in the hospital). The gross rise in visits was higher for adults (51.2%) than for 0-14 year olds (6.6%). The co-integration time-series analysis showed that in both age groups and in the total, there was a significant and positive relationship between the primary care and hospital series, indicating that the use of both services had grown simultaneously. The use of the hospital services did not decrease as a result of the increase in primary care services. | The rise in use of primary care emergency services did not reduce use of the hospital A&ED. | closed_qa |
Do snacks of exercise lower blood pressure? | Single blind randomised crossover trial of three 'exercise' regimes in general practice. 35 hypertensive adults without complications. Regimes included 4x10-minute episodes of brisk walking per day, 40 minutes continuous brisk walking per day, and no brisk walking. Each regime lasted 4 days with 10 days of no exercise in between. Change of systolic and diastolic blood pressure. Mean age 53 years and mean baseline blood pressure 166/103 mmHg. Systolic blood pressure changed by: -7.5 mmHg (95%CI: -8.9, -6.0) with 40-minutes regime; -7.3 mmHg (95%CI: -8.7, -5.8) with 4x10-minutes regime; and +1.0 mmHg (95%CI: -0.4, 2.5) with 'no brisk walking' regime (p<0.001). Diastolic blood pressure reduced by -4.0 mmHg (95%CI: -5.0, -3.0) with 40 minutes regime; -5.4 mmHg (95%CI: -6.4, -4.4) with 4x10 minutes regime; and -0.2 mmHg (95%CI: -1.2, 0.8) with 'no brisk walking' regime (p<0.001). | Four 10-minute snacks of brisk walking were as effective as 40 minutes of continuous brisk walking per day at reducing blood pressure. This has implications for public health messages and advice to patients with hypertension. | closed_qa |
Do Ureaplasma urealyticum infections in the genital tract affect semen quality? | To investigate the relationship between Ureaplasma urealyticum (UU) infection and semen quality. From 2001 to 2003, 346 eligible patients aged 20-45 years were invited from two hospitals in Shanghai, China, to participate in an investigation which included questionnaires about general and reproductive health, an external genital tract examination, UU culture and semen analysis. Multiple linear regression models were used to examine whether UU had a significant effect on semen quality after adjustment for confounding factors. Findings suggested that UU infection was associated with higher semen viscosity and lower semen pH value. Sperm concentration was lower in UU positive subjects than that in UU negative subjects (54.04 X 10(6)/mL vs.70.58 X 10(6)/mL). However, UU did not significantly affect other semen quality indexes. | UU infection of the male genital tract could negatively influence semen quality. | closed_qa |
Axillary lymph node metastases in patients with small carcinomas of the breast: is accurate prediction possible? | To find out whether macroscopic classification of the tumour margin is predictive of axillary lymph node metastases and to identify a combination of clinical and pathological findings by which axillary node status can be predicted accurately in small carcinomas (T1) of the breast. Retrospective study. Municipal referral centre, Japan. All 1003 patients with T1 invasive carcinoma of the breast who had axillary lymph node dissection between January 1970 and December 1996 as part of their treatment. The association between the incidence of axillary lymph node metastases and 10 clinical and pathological factors (age, palpability and size of tumour, macroscopic classification of tumour margin, clinical axillary status, radiating spiculation on a mammogram, histological type, lymphatic invasion, oestrogen and progesterone receptor status) were analysed. Clinical axillary node status, macroscopic classification of tumour margin, lymphatic invasion, and age of the patient were significant predictors of axillary lymph node metastases (p<0.01 in each case). Among 47 patients aged 65 or more whose tumours had well-defined margins and with a clinical N0 status in the axillae, the incidence of histological axillary lymph node metastasis was only 6% (n = 3) whereas it was 65% in 57 patients with tumours of ill-defined margins whose axillae were N1 or N2. | Macroscopic classification of tumour margins is an independent predictor of axillary lymph node metastases for patients with small carcinomas of the breast. However, even with combinations of the examined predictors of axillary node metastases, the subgroup of patients at minimal risk of metastasis was less than 5% in T1 breast cancer, whereas three-quarters of the patients had clear axillary lymph nodes. Most patients with T1 breast cancer will need surgical staging of the axillae by methods such as sentinel node biopsy. | closed_qa |
Antibiotic prescribing patterns in primary health care. Do pediatricians use antibiotics rationally? | To determine antibiotic prescribing patterns in the pediatric (infants and children) population attended to at a primary health care centre in the community of Madrid. We also wanted to determine the necessity or otherwise of antibiotic therapy and whether the selected antibiotic drug was appropriate for the pathology diagnosed. Retrospective study of all infectious or respiratory processes diagnosed during 1 year and of the respective antibiotic cycles prescribed in all patients under the age of 4 years. The prescribing physician and the appropriateness of all therapeutic decisions, including those where the decision was not to treat with antibiotic drugs, were analyzed. We evaluated 910 children under the age of 4 years with a total of 3, 847 processes (mean of 4.55 +/-3.6 processes per child per year). Sixty-three percent of the children received at least one cycle of antibiotic drugs per year (mean 1.63+/-1.69 cycles of treatment per child per year). Of all therapeutic decisions, 85.2% were considered appropriate. In 36% of the processes antibiotics were prescribed (1,386 cycles), 46% of which were considered inappropriate either because no antibiotic therapy should have been given (71.6%) or because the chosen drug was not appropriate for the pathology (28.4%). There were significant differences among the evaluated physicians. The most correct decisions were taken by the pediatrician in the outpatient clinic, especially when compared with physicians in the emergency ward (p<0.0001). The most frequently prescribed antibiotic drugs were amoxicillin (41.2%) and amoxicillin combined with clavulanic acid (33%). Cephalosporin accounted only for 6.9% of the prescriptions. | Antibiotic therapy is overprescribed in children, a situation that should be corrected. | closed_qa |
Tuberculous meningitis: a disease in regression in our country? | Our aim was to analyse clinical, diagnostic, therapeutical and evolutionary features in a pediatric population with tuberculous meningitis. The medical records of thirteen children with this diagnosis admitted to Hospital Infantil Virgen del Rocío from Seville (Spain) between 1984 and 1999 were reviewed. The mean age was 2,35 +/- 2,3 years. The symptoms upon admission were: fever in 11 children, anorexia and vomiting in 8, disturbance of the consciousness in 7. Meningeal signs in 6, all of them older than 20 months, the remaining seven showed irritability and four of these ones hypertense fontanelles. Three patients were in the first stage of the disease, 9 in the second and 1 in the third, according to the Medical Research Council. CSF findings were indicative in all the cases. Five children had bacilloscopy positive and Mycobacterium tuberculosis was isolated in 6 patients, sometimes in CSF others in gastric juice. Mantoux skin test was positive in 11. Radiographic studies demonstrated abnormal chest findings in 8 patients (hiliar adenopathy, 1; miliary pattern, 2; and infiltrates, 5). Pathology cranial computed tomography showed in all the cases and the electroencephalogram was slowed down in the initial phases in 11. Two children died and the neurological complications were the most frequent, appearing in 9 patients. Without consequences cured 4 patients, the rest presented cognitive, visual and motor deficits, sensibility skin disturbance and late seizures. No case has been observed during the last 5 years. | Fast diagnosis tests used for M. tuberculosis identification were useful to begin an antituberculous treatment in a high suspicion of meningeal affectation by this German patient. The early treatment will decrease complications and consequences by this disease. A decrease in the incidence looks to be in spite of the VIH infection increase nowadays. | closed_qa |
Treatment of very low birth weight infant: is it evidenced-based? | The management of 80 very low birth weight infants admitted to our neonatal unit during 1998 was retrospectively reviewed. For each clinical diagnosis e.g. respiratory distress syndrome, patent ductus arteriosus or chronic lung disease all interventions were recorder. Each intervention was then categorised according to the level of supporting evidence. Level I was supported by evidence from randomised controlled trials or meta-analysis of multiple trials. Level II included interventions backed by convincing non-experimental evidence where randomised controlled trials would be unnecessary or unethical. Level III were treatments in common use without substantial supporting evidence. These categorizations were made after extensive researching of Medline, The Cochrane Database and the Randomised Controlled Trial Register, detailed hand-searching of the literature as well as using local expertise and knowledge. 943 separate interventions were recorded in the charts of the 80 babies. Overall 91.3% were shown to be evidence-based of which 58.7% were level I, 32.6% were level II and only 8.7% were level III. | 91.3% of interventions for very low birth weight infants in our neonatal intensive care unit were evidence-based and only 8.7% had no substantial supporting evidence. Care of the very low birthweight infants is largely evidence-based. | closed_qa |
Suppression of inflammation in primary systemic vasculitis restores vascular endothelial function: lessons for atherosclerotic disease? | Chronic inflammatory rheumatic disorders are associated with excess cardiovascular mortality. This may result from arteriosclerosis following inflammatory damage to the vessel wall by vasculitis. Our hypothesis that vasculitis results in arteriosclerosis by causing vascular endothelial dysfunction was tested in patients with primary systemic necrotizing vasculitis (SNV). Endothelial function was assessed in cross-sectional and longitudinal studies of patients with primary SNV by measuring flow-mediated, endothelium-dependent brachial artery vasodilatation. These patients exhibited marked endothelial dysfunction compared with controls. Remission induction in patients with active primary SNV restored endothelial function. | Endothelial function is significantly impaired in adults with primary SNV, supporting the hypothesis that premature arteriosclerosis in chronic inflammatory rheumatic disorders results from endothelial dysfunction secondary to vasculitis. Normalization of endothelial function after the treatment of primary SNV suggests that early suppression of disease activity in chronic inflammatory rheumatic disorders may reduce long-term vascular damage. The role of inflammation in atheroma formation is increasingly appreciated; this work raises questions regarding the potential for anti-inflammatory therapy in atherosclerosis itself. | closed_qa |
Is MIB-1 proliferation index a predictor for response to neoadjuvant therapy in patients with esophageal cancer? | The overall survival rate for patients with an esophageal cancer remains poor. As a consequence, preoperative chemoradiation was introduced for patients with tumor stage T>1 M0 regardless of tumor histology or localization. However, factors predicting response to this therapy pretherapeutically are largely unknown. Clinical results of preoperative chemoradiation were investigated. The rates of proliferation and apoptosis were determined in pretherapeutic tumor samples and correlated with tumor response and long-term survival after surgery. A complete tumor response due to chemoradiation (n = 42; cervically localized tumors excluded) was achieved in 11 patients (26%) after resection. Five-year survival rate was significantly improved in these patients compared with those who did not respond to chemoradiation (48% versus 5.5%; P = 0.003). Chemoradiation was performed without benefit in 43%. Perioperative hospital mortality rate was 14.3% in all patients. No correlation of apoptosis with response to chemoradiation or postoperative long-term survival was observed. However, there was a clear correlation between the proliferation rate as determined by MIB-1 immunohistology. Five-year survival rate of patients with a proliferation index (PI)>/=39% was 38% compared with 0% in tumors with a PI<39%. Tumors with a PI>/=39% responded to chemoradiation in 71.4%, but 100% of tumors with a PI<39% did not. Mean survival time of these patients was 33 months and 11 months, respectively (P = 0.015). | The results indicate that the PI may be used for stratification of patients treatment prior surgery. However, these results need further validation in larger patient numbers in the search for factors indicating response pretherapeutically to preoperative chemoradiation in esophageal cancer. | closed_qa |
Do potential patients prefer tissue plasminogen activator (TPA) over streptokinase (SK)? | In patients with acute myocardial infarction, TPA (compared to SK), has been shown to reduce the 30-day mortality rate at the expense of an increased rate of stroke. The assumption in the literature is that were it not for cost issues, all patients presenting with a myocardial infarction would choose TPA. Our hypothesis is that, for many informed individuals, regardless of cost, the increased risk of stroke may deter them from selecting TPA over SK. To assess which thrombolytic drug informed patients would prefer and to explore the clinical and economic implications of such preferences. Prospective survey. Tertiary care hospital. 120 hospitalized patients with cardiac disease who would be "at risk" for a myocardial infarction. Face-to-face interviews utilizing a decision instrument. To minimize bias in soliciting patients' preferences and to standardize the presentation of information we developed a decision instrument which portrays a case scenario of a myocardial infarction, describes treatment outcomes (survival and stroke rate), and displays the likelihood of these outcomes with SK and TPA using three scenarios: a base stroke risk (all patients data), a lower stroke risk (<75 years old data), a higher stroke risk (>75 years old data). Outcome data were derived from the published literature (GUSTO study). When presented the overall results of the GUSTO study, 60/120 (50%) expressed a preference for SK. When presented the outcome data for the subgroups of patients<75 years old (lower stroke rate), 37/120 (31%) preferred SK. When presented the subgroup data for patients>75 years old (higher stroke risk), 67/120 (56%) preferred SK. | Regardless of the scenario that individuals were presented with, a substantial proportion of individuals (31-56%) who could potentially require thrombolytic therapy chose SK over TPA. This study should be repeated in other settings to establish the generalizability of our results. Assuming that these results will be consistent, considering the patient's perspective has significant implications on clinical decision making as well as from an economic perspective. | closed_qa |
Do cerebral potentials to magnetic stimulation of paraspinal muscles reflect changes in palpable muscle spasm, low back pain, and activity scores? | Previous studies have shown that cortical-evoked potentials on magnetic stimulation of muscles are influenced by muscle contraction, vibration, and muscle spasm. This study was carried out to determine whether these potentials correlate with palpatory muscle spasm, patient symptoms, and disability in patients with low back pain. A prospective observational study was performed on 13 subjects with a history of low back pain visiting an orthopedic hospital-based clinic. Patients were screened for serious pathologic conditions by an orthopedic surgeon. The patients were then evaluated for the presence of muscle spasm by one of the investigators who was blinded to the results of the evoked potential studies. Patients were asked to complete a low back pain visual analogue scale (VAS) and a Roland-Morris Activity Scale (RMAS). Cortical-evoked potentials were recorded with a magnetic stimulator placed over the lumbar paraspinal muscles with the patient in the prone position. The palpatory examination, VAS, RMAS, and the cortical potentials were repeated after 2 weeks of therapy commonly used to reduce muscle spasm. The patients demonstrated a significant decrease in low back pain VAS and RMAS scores after treatment compared with before treatment. There was a reduction in the amount of palpatory muscle spasm in 11 of 13 cases. The cortical potentials before treatment were attenuated compared with previously reported controls and showed a significant increase before and after treatment in the amplitude of these potentials with multivariate analysis of variance. There was significant correlation between the changes in cortical potentials after treatment and the changes noted in paraspinal muscle spasm and VAS and RMAS scores. | This study confirms the previous report that the amplitude of cerebral-evoked potentials on magnetic stimulation of paraspinal muscles is depressed in the presence of palpable muscle spasm. The close correlation among these potentials, paraspinal muscle spasm, and clinical symptoms suggests that the measurement of muscle activity may be more important in the assessment of low back pain than is commonly accepted. | closed_qa |
Questionnaires of accident and emergency departments: are they reproducible? | Questionnaires are commonly sent to accident and emergency (A&E) departments to determine common practice and are often extrapolated to best practice. To determine if questionnaire based studies have a defined population of A&E departments and whether studies are reproducible. All questionnaires in the Journal of Accident and Emergency Medicine were reviewed and assessed for inclusion criteria, departments studied and study design. 30 questionnaires were detected, 22 were postal, six telephone and two did not state method of contact. Sample sizes ranged from 15 to 740 and inclusion of A&E departments was highly variable according to geographical area, size of department or consultant status. Seventeen (54.8%) did not state the source of A&E department listings. Response rates ranged from 55-100%. Only three studies undertook subset analysis according to either size or locality. | Questionnaire of studies A&E departments have poor methodology descriptions, which means that many are not reproducible. Inclusion criteria are highly variable and failure to analyse important subsets may mean that individual departments cannot apply recommendations. Questionnaire studies relating to A&E do not use a consistent well defined population of A&E departments. Information in the studies is usually inadequate to allow them to be repeated. | closed_qa |
Does technique of anastomosis play any role in developing late perianal abscess or fistula? | This study examines the risk factors for developing perianal abscess or fistula formation after ileal pouch-anal anastomosis procedure for chronic ulcerative colitis or familial adenomatous polyposis. A total of 1,457 patients with J-pouch, 1,304 (89.5 percent) with chronic ulcerative colitis and 153 (10.5 percent) with familial adenomatous polyposis who had a two-stage procedure without any evidence of previous perianal disease were included in the study. The effect of pouch-to-anal anastomosis type on perianal abscess or fistula formation was evaluated. A total of 108 patients (7.4 percent) had a perianal abscess or fistula after the ileal pouch-anal anastomosis procedure after at least one year of follow-up. No statistically significant difference was identified in fistula formation regarding the age and gender of the patients (P>0.05), nor did the risk of fistula formation differ significantly between the patients with handsewn vs. stapled anastomoses (P>0.05). However, patients with a diagnosis of chronic ulcerative colitis, compared with patients with familial adenomatous polyposis, had a statistically higher risk of developing abscess or fistula (P = 0.012). | The most important risk factor in developing perianal sepsis in long-term patients with ileal pouch-anal anastomosis is the initial disease type. After excluding patients without Crohn's disease, the risk of developing an abscess or fistula was found to be significantly greater in patients with chronic ulcerative colitis compared with patients with familial adenomatous polyposis, and this risk is independent of anastomotic technique. | closed_qa |
Is adjuvant radiotherapy necessary after positive lymph node dissection in head and neck melanomas? | Postoperative radiotherapy (PR) has been recommended in patients with advanced head and neck melanomas to improve regional control. This study examined the incidence of cervical recurrence among patients who did not receive PR after surgical management of node-positive head and neck melanomas. A computerized search of a database listing more than 10,000 patients with melanoma prospectively acquired between 1971 and 1998 identified 217 patients with pathologically positive nodes who had undergone regional lymph node dissection (RLND). Of these patients, 21 had received PR and 196 had not. Median follow-up after RLND was 20 months for nonsurvivors and 32 months for survivors. The overall incidence of cervical recurrence was 14% (27/196). The 5-year cervical recurrence-free survival rate was 83%. Five-year cervical recurrence-free survival rates were 69% vs. 87% for patients with vs. without extranodal disease (P = .004), 96% vs. 81% for patients with nonpalpable vs. palpable nodes (P = .0761), and 82% vs. 91% for patients with one to three positive nodes vs. more than three positive nodes (P = .256). Multivariate analysis, which included the timing of nodal disease presentation and the effect of systemic adjuvant therapy, identified extranodal disease as the only independent predictor of cervical recurrence (P = .034). Cervical recurrence was significantly related to the subsequent occurrence of distant relapse. | The low incidence of cervical recurrence after RLND in patients with node-positive head and neck melanomas does not justify the routine use of PR. The only subset of patients who may benefit from PR are those with extranodal disease. | closed_qa |
Risk classification systems for drug use during pregnancy: are they a reliable source of information? | In several countries, risk classification systems have been set up to summarise the sparse data on drug safety during pregnancy. However, these have resulted in ambiguous statements that are often difficult to interpret and use with accuracy when counselling patients on drug use in pregnancy. The objective of this study was to compare and analyse the consistency between and the criteria for risk classification for medications used during pregnancy included in 3 widely used international risk classification systems. All 3 systems use categories based on risk factors to summarise the degree to which available clinical information has ruled out the risk to unborn offspring, balanced against the drug's potential benefit to the patient. Drugs included in the risk classification systems from the US Food and Drug Administration (FDA), the Australian Drug Evaluation Committee (ADEC) and the Swedish Catalogue of Approved Drugs (FASS), were reviewed and compared on basis of the risk factor category to which they had been assigned. Agreement between the systems was calculated as the number of drugs common to all 3 and assigned to the same risk factor category. In addition, evidence on teratogenicity and adverse effects during pregnancy was retrieved using a MEDLINE search (from 1966 up to 1998) for common drugs classified as teratogenic. Differences in the allocation of drugs to different risk factor categories were found. Risk factor category allocation for 645 drugs classified by the FDA, 446 classified by ADEC and 527 classified by FASS was compared. Only 61 (26%) of the 236 drugs common to all 3 systems were placed in the same risk factor category. Analysis of studies on the safety of common drugs during pregnancy of drugs classified as X by the FDA indicated that the variability in category allocation was not only attributable to the different definitions for the categories, but also depended on how the available scientific literature was handled. | Differences in category allocation for the same drug can be a source of great confusion among users of the classification systems as well as for those who require information regarding risk for drug use during pregnancy, and may limit the usefulness and reliability of risk classification systems. | closed_qa |
Do present damage and health perception in patients with systemic lupus erythematosus predict extent of future damage? | To study whether either initial damage, disease activity, disease duration, age, a drug score, or health status would predict an increase in damage in patients with systemic lupus erythematosus (SLE) within the next three years. A three year prospective longitudinal study of a cohort of 141 consecutive patients with SLE attending a specialist lupus outpatient clinic from their first assessment between July 1994 and February 1995. Disease activity was assessed using the BILAG system, health status by the Medical Outcome Survey Short Form 20 with an extra question about fatigue (SF-20+), and damage by the SLICC/ACR Damage Index (SDI). Damage was reassessed three years later. Statistical analysis was carried out using logistic regression analysis (logXact). 133 female and 8 male patients with SLE (97 white subjects, 16 Afro-Caribbeans, 22 Asians, and 6 others) were included. Their mean (SD) age at inclusion was 41.1 (12.5) years and their disease duration 10.2 (6. 3) years. The mean measures at inclusion were: total BILAG 5.2 (range 0-17), total SDI 1.2 (0-7), drug score 1.2 (0-3); SF-20+: physical 58 (0-100), role 54 (0-100), social functioning 71 (0-100), mental health 64 (16-100), health perception 44 (0-100), pain 53 (0-100), fatigue 59 (0-100). Four patients were lost to follow up because they had moved. At three years in 33 patients the total SDI had increased to a mean of 1.5 (0-7) (n=130). Moreover, seven patients had the maximum damage as they had died during the follow up period. The only variables with an independent and significant contribution in predicting damage at three years were the total damage score (odds ratio (OR)=1.46; 95% CI 1.04 to 2.05), and health perception (OR=0.96; 95% CI 0.93 to 0.99) at inclusion. | Of all the variables at inclusion only the total damage score and SF-20+: health perception, significantly predicted an increase in damage, for patients with SLE, three years later. | closed_qa |
Tobacco use among Massachusetts youth: is tobacco control working? | This paper examines whether the Massachusetts Tobacco Control Program is affecting the rates of smoking and smokeless tobacco use among Massachusetts' youth. School survey data from the Massachusetts Prevalence Study were analyzed to estimate differences between 1993 and 1996 rates of youth cigarette and smokeless tobacco use, attitudes toward smoking, and awareness of cigarette ads and promotions of antismoking messages. Lifetime and Current Smoking rates declined significantly among middle school males, contrasting with stable national trends. Among girls in this age group, Lifetime and Current Smoking did not change significantly. Hispanic middle school students exhibited a significant decline in Lifetime Use. There were no significant changes in Lifetime or Current Smoking rates among high school students. Lifetime use of smokeless tobacco declined among middle school students while Current Use declined among both middle and high school students. Students reported declines in awareness of cigarette ads or promotions and increases in awareness of antismoking messages. | These results provide evidence for cautious optimism regarding the impact of tobacco control, but indicate that these efforts should begin earlier and that additional research is needed to understand and address the problems of tobacco use by girls. | closed_qa |
Ultrastructural and molecular analysis of Bowman's layer corneal dystrophies: an epithelial origin? | Two mutations (R555Q and R124L) in the BIGH3 gene have been described in anterior or Bowman's layer dystrophies (CDB). The clinical, molecular, and ultrastructural findings of five families with CDB was reviewed to determine whether there is a consistent genotype:phenotype correlation. Keratoplasty tissue from each patient was examined by light and electron microscopy (LM and EM). DNA was obtained, and exons 4 and 12 of BIGH3 were analyzed by polymerase chain reaction and single-stranded conformation polymorphism/heteroduplex analysis. Abnormally migrating products were analyzed by direct sequencing. In two families with type I CDB (CDBI), the R124L mutation was defined. There were light and ultrastructural features of superficial granular dystrophy and atypical banding of the "rod-shaped bodies" ultrastructurally. Patients from three families with "honeycomb" dystrophy were found to carry the R555Q mutation and had characteristic features of Bowman's dystrophy type II (CDBII). | There is a strong genotype:phenotype correlation among CBDI (R124L) and CDBII (R555Q). LM and EM findings suggest that epithelial abnormalities may underlie the pathology of both conditions. The findings clarify the confusion over classification of the Bowman's layer dystrophies. | closed_qa |
Multifactorial approach to the prevention of coronary heart disease: from computer to paper and pencil? | In Europe the multifactorial clinical approach to the prevention of coronary heart disease is based on the Framingham equation presented in graphical form including age, sex, level of total serum cholesterol, systolic blood pressure and smoking. To propose a straightforward paper-and-pencil score (Global Coronary Risk Score) including level of high-density lipoprotein cholesterol for the Belgian or more broadly western European population derived from 10-year follow-up mortality of a Belgian national population sample. This score has the same predictive power as the Framingham equation both for men aged 35-74 years and for women aged 50-74 years. It gives a ranking of subjects into four groups according to their relative risks. | Coronary Risk Score is user friendly and probably has pedagogical virtues. | closed_qa |
Hyperlipidaemia and primary prevention of coronary heart disease: are the right patients being treated? | In 1997, the Standing Medical Advisory Committee report suggested that patients with a coronary heart disease risk of 3% per year or greater should be considered appropriate for lipid-lowering medication. The report stated that cholesterol concentration alone is a poor predictor of absolute risk of coronary heart disease and recommended the Sheffield table as a method of estimating the coronary heart disease risk. To assess the impact of the Standing Medical Advisory Committee report on the management of patients with hyperlipidaemia in the primary prevention of coronary heart disease in primary care. A survey questionnaire giving the clinical details of 20 patients with various coronary heart disease risk factors was sent to 200 general practitioners in the West Midlands, UK. Forty-eight percent of the respondents used clinical assessment/perception as the sole means of risk assessment and 26% used the Sheffield table. In patients who did not require treatment, 40.1% of the decisions were inappropriate and, in patients who required treatment, 35.1% of the decisions were inappropriate. Overall, inappropriate decisions were made in 37.9% of the responses. Despite the clear advice in the Standing Medical Advisory Committee report on the importance of incorporating multiple risk factors in estimating absolute coronary heart disease risk, only total cholesterol and triglycerides were significant in influencing treatment decisions. | The Standing Medical Advisory Committee recommendations on the management of hyperlipidaemia in primary prevention of coronary heart disease are not widely used. Large savings could be made by correctly identifying and treating individuals at high risk. We recommend use of the full Framingham risk score in assessment of coronary heart disease risk in primary care. | closed_qa |
Do male sex hormones protect from irritable bowel syndrome? | Irritable bowel syndrome (IBS) is more common in women and it is frequently assumed that being female may predispose to the development of this disorder. Alternatively, being male could offer some degree of protection and if so, this might be mediated by testosterone. The aim of this study was to assess whether male patients with IBS have lower levels of testosterone and related gonadotrophins than their unaffected counterparts and if this relates to rectal sensitivity. Fifty secondary care, male outpatients with IBS (aged 19-71 yr) were compared with 25 controls (aged 22-67 yr). Each subject had serum testosterone, free testosterone, sex hormone-binding globulin, follicle stimulating hormone, and luteinizing hormone (LH) measured, together with rectal sensitivity to balloon distension. Anxiety and depression were also assessed. The only difference in the hormone levels between patients and controls that reached statistical significance was the lower value for LH in the IBS patients (p = 0.014). Although patients were more anxious and depressed than the controls (p<0.001), this could not solely account for the reduced level of LH, as adjusting for these (analysis of variance) still tended to show that LH values were lower in men with rather than without IBS [F(1,70) = 2.74; p = 0.10]. Men with IBS were more sensitive to balloon distension of the rectum, with the distension volumes required for "urgency" (p<0.001) and "discomfort" (p = 0.001) significantly lower than controls. Paradoxically, the patient's sensory thresholds negatively correlated with levels of testosterone (p<0.05) and free testosterone (p<0.002), and positively with levels of sex hormone-binding globulin (p<0.05). Finally, there was a tendency for IBS symptomatology to be inversely related to testosterone levels (p = 0.15). | These results support the need for further exploration of the role of male sex hormones in the pathophysiology of IBS. | closed_qa |
Is urinary drainage necessary during continuous epidural analgesia after colonic resection? | Postoperative urinary retention may occur in between 10% and 60% of patients after major surgery. Continuous lumbar epidural analgesia, in contrast to thoracic epidural analgesia, may inhibit urinary bladder function. Postoperative urinary drainage has been common in patients with continuous epidural analgesia, despite the lack of scientific evidence for its indication after thoracic epidural analgesia. This study describes 100 patients who underwent elective colonic resection with 48 hours of continuous thoracic epidural analgesia and only 24 hours of urinary drainage. This is a prospective, uncontrolled study with well-defined general anesthesia, postoperative analgesia, and nursing care programs in patients with a planned 2-day hospital stay, urinary catheter removal on the first postoperative morning, and epidural catheter removal on the second postoperative morning. Follow-up in the outpatient clinic was on days 8 and 30. Nine patients needed bladder recatheterization, 8 as a single procedure and 1 patient a second recatheterization with removal on day 7. This patient had urinary infection on day 10 and was readmitted for 5 days because of urosepsis and, subsequently, for cystitis and left-sided epididymitis. Three patients had uncomplicated urinary infection. No patients had urological complaints at 30 days follow-up (95% confidence limit, 0% to 3.6%). | The low incidence of urinary retention (9%) and urinary infection (4%) suggests that routine bladder catheterization beyond postoperative day 1 may not be necessary in patients with ongoing continuous low-dose thoracic epidural analgesia. | closed_qa |
Can peer-comparison feedback improve patient functional status? | To determine whether providing physicians with peer-comparison feedback can improve patient functional status. Randomized, controlled, comparative study. Forty-eight primary care physicians at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California, were randomly assigned to an intervention group or a control group. All physicians were informed that their elderly patients (randomly selected patients aged 65 to 75) would be monitored. Physicians in the intervention group received aggregated peer-comparison feedback data (physician "report cards") on the functional status of their elderly patients. Physicians in the control group received only general information that their patients' functional status would be monitored. The effect of the intervention on patients' functional status was determined by comparing responses to surveys completed by the patients at baseline and after the intervention. Patients in both the control and intervention groups had a statistically significant decrease in functional status, including decreases in their ability to complete daily activities and increases in pain. In addition, patients in the control group reported a significant decrease in social activities, physical fitness, and feelings. In the intervention group, patients also experienced a significant decrease in social support. | Educational interventions, including peer-comparison feedback, did not result in improvements in patient functional status. Research is desperately needed to identify interventions that can lead to improved health for elderly patients. | closed_qa |
Is routine use of the intensive care unit after elective infrarenal abdominal aortic aneurysm repair necessary? | Postoperative care after infrarenal abdominal aortic aneurysm (AAA) repair has traditionally involved admission to the intensive care unit (ICU). With the advent of endovascular AAA repair, the management of open procedures has received increased scrutiny. We recently modified our AAA clinical pathway to include selective use of the ICU. Consecutive elective infrarenal AAA repairs performed by members of the vascular surgery division at a university medical center from 1994 to 1999 were analyzed retrospectively with a computerized database, the Medical Archival Retrieval System. Group I consisted of 245 patients who were treated in the ICU for 1 or more days, and Group II included 69 patients admitted directly to the floor. Ruptured, symptomatic, suprarenal, endovascular, and reoperative repairs were excluded. Outcome variables were compared over the 6-year period. Floor admissions increased over the study period with 0%, 0%, 3.3%, 16.3%, 48.6%, and 43.6% of patients admitted directly to the surgery ward from 1994 to 1999. The average ICU length of stay declined from 4.6 to 1.2 days, whereas the hospital length of stay decreased from 12.5 to 6.8 days from 1994 to 1999. The change in ICU use had no effect on death (2.4% in Group I vs 0% in Group II). Major and minor morbidity was comparable. Hospital charges were significantly lower for patients in Group II. | A policy of selective utilization of the ICU after elective infrarenal AAA repair is safe. It can reduce resource use without a negative impact on the quality of care. | closed_qa |
Does the endovascular repair of aortoiliac aneurysms pose a radiation safety hazard to vascular surgeons? | Endovascular aortoiliac aneurysm (EAIA) repair uses substantial fluoroscopic guidance that requires considerable radiation exposure. Doses were determined for a team of three vascular surgeons performing 47 consecutive EAIA repairs over a 1-year period to determine whether this exposure constitutes a radiation hazard. Twenty-nine surgeon-made aortounifemoral devices and 18 bifurcated devices were used. Three surgeons wore dosimeters (1) on the waist, under a lead apron; (2) on the waist, outside a lead apron; (3) on the collar; and (4) on the left ring finger. Dosimeters were also placed around the operating table and room to evaluate the patient, other personnel, and ambient doses. Exposures were compared with standards of the International Commission on Radiological Protection (ICRP). Total fluoroscopy time was 30.9 hours (1852 minutes; mean, 39.4 minutes per case). Yearly total effective body doses for all surgeons (under lead) were below the 20 mSv/y occupational exposure limit of the ICRP. Outside lead doses for two surgeons approximated recommended limits. Lead aprons attenuated 85% to 91% of the dose. Ring doses and calculated eye doses were within the ICRP exposure limits. Patient skin doses averaged 360 mSv per case (range, 120-860 mSv). The ambient (>3 m from the source) operating room dose was 1.06 mSv/y. | Although the total effective body doses under lead fell within established ICRP occupational exposure limits, they are not negligible. Because radiation exposure is cumulative and endovascular procedures are becoming more common, individuals performing these procedures must carefully monitor their exposure. Our results indicate that a team of surgeons can perform 386 hours of fluoroscopy per year or 587 EAIA repairs per year and remain within occupational exposure limits. Individuals who perform these procedures should actively monitor their effective doses and educate personnel in methods for reducing exposure. | closed_qa |
Avascular necrosis of the femoral head in chronic myeloid leukemia patients treated with interferon-alpha: a synergistic correlation? | The objectives of this study were to describe cases of avascular necrosis of the femoral head (ANFH) observed in chronic myeloid leukemia (CML) patients who were treated with interferon-alpha and to review the literature. The authors undertook a case review of the M. D. Anderson experience with ANFH occurring in CML patients who were managed with interferon-alpha-based therapy. MEDLINE (from 1966 to November 1999) and CancerLit (from 1983 to November 1999) searches were conducted to identify cases of avascular necrosis (AVN) associated with either CML or interferon-alpha. Three patients with ANFH were identified from the authors' experience. No common features related to the disease or therapy were seen among them, except for the presence of thrombocytosis and loss of response. A literature review revealed seven cases of ANFH associated with CML with or without interferon-alpha-based therapy. ANFH was not reported in association with interferon-alpha use for indications other than the treatment of patients with CML. | ANFH may be the result of an interaction between CML and interferon-alpha therapy. ANFH that occurs in patients with CML who are treated with interferon-alpha should be recognized for treatment implications. Thrombocytosis with consequent microvascular thrombi and avascular necrosis manifesting in susceptible vascular or weight-bearing areas (e.g., the femoral head) may be an associated finding along with loss of response to interferon-alpha therapy. | closed_qa |
Do new roles contribute to job satisfaction and retention of staff in nursing and professions allied to medicine? | Studies have suggested that job dissatisfaction is a major factor influencing nurses' and occupational therapists' intention to leave their profession. It has also been related to turnover of qualified nurses. However, literature relating to these factors among nurses and professions allied to medicine in innovative roles is scarce. This paper considers the views of 452 nurses and 162 professionals allied to medicine (PAMs) in innovative roles, on job satisfaction, career development, intention to leave the profession and factors seen as hindering and enhancing effective working. A self-completion questionnaire was developed as part of a larger study exploring new roles in practice (The ENRiP Study). Overall there was a high level of job satisfaction in both groups (nurses and PAMs). Job satisfaction was significantly related to feeling integrated within the post-holder's own professional group and with immediate colleagues, feeling that the role had improved their career prospects, feeling adequately prepared and trained for the role, and working to protocol. Sixty-eight percent (n = 415) of respondents felt the role had enhanced their career prospects but over a quarter of respondents (n = 163; 27%) said they would leave their profession if they could. Low job satisfaction was significantly related to intention to leave the profession. | The vast majority of post-holders in innovative roles felt that the role provided them with a sense of job satisfaction. However, it is essential that the post-holders feel adequately prepared to carry out the role and that the boundaries of their practice are well defined. Career progression and professional integration both being associated with job satisfaction. | closed_qa |
Can information technology help ward sisters become ward managers? | Successive governments in the 1990s have provided considerable funds to introduce decision support systems for ward management, but few have been evaluated rigorously. This paper reviews the approaches to systems' evaluation that have been developed. Measuring instruments were designed to define and measure management decisions and those organizational factors which affect decision making. The resulting difficulty index was validated in a before-and-after study of ward decision making. Changes in decision making, after the implementation of a decision support system, were found to relate to the identified organizational factors. | The evaluation methodology described in this paper showed that the potential benefits of a computerized management system would not be realized unless managers, doctors and nurses carried out an organizational review before implementation and then took joint ownership of the system. | closed_qa |
Is access to a standardized neonatal intensive care possible? | This paper aims to determine the factors which impact on the issue of availability and access to a standard quality of neonatal intensive care provision in order to clarify strategies for change. New targets set within the NHS reforms have highlighted quality and fair access to services. Current frameworks for the provision of neonatal services may not be in place to support a standardized quality service provision. The paper examines the historical and political basis for current models of service, giving a grounding for recommendations for change in an attempt to achieve a more standardized, equitable level of care. Changes within health care policy in the late 1980s and 1990s have led to confusion within the service and a lack of the definition needed to provide universally accepted criteria on which to base a regional service provision. | The organization of services will need to be reviewed to include the introduction of national and regional data collection and analysis, and national definitions standardizing service criteria to be used to support variations in regional models of care. In conjunction with these recommendations independent auditing processes must exist to allow for accreditation of services. | closed_qa |
Referral of children with otitis media. Do family physicians and pediatricians agree? | To determine factors influencing family physicians' and pediatricians' decisions to refer children with recurrent acute otitis media (RAOM) and otitis media with effusion (OME) to otolaryngologists for an opinion about tympanostomy tube insertion. Mailed survey. Physicians' practices in Ontario. Random sample of 1459 family physicians and all 775 pediatricians in the province. Physicians' reports of the influence of 17 factors on decisions to refer (more likely, no influence, less likely to refer) and number of episodes of otitis media, months with effusion, level of hearing loss, or months of continuous antibiotics without improvement prompting referral. Physicians agreed (>80% concordance) on six out of 17 factors as indications for referring children with RAOM or OME. Opinions about the importance of other factors varied widely. Family physicians would refer children with otitis media after fewer episodes of illness, fewer months of effusion, lower levels of hearing loss, and fewer months of prophylactic antibiotic therapy than pediatricians (all P<.001). Pediatricians would prescribe continuous antibiotics longer (11.8 weeks) than family physicians (8.9 weeks, P<.0001), which correlated with lower referral thresholds for family physicians. | Family physicians' and pediatricians' self-reported referral practices for surgical opinions on children with otitis media varied considerably. These observations raise questions about the consistency of care for children with otitis media and whether revised clinical guidelines would be helpful. | closed_qa |
Is respite care available for chronically ill seniors? | To determine family physicians' perceptions of how available respite care is and how easy it is to refer chronically ill older people to it, and to examine their opinions of respite care. Mailed survey to family physicians on the Thames Valley Family Practice Research Unit's mailing list. London, Ont, and surrounding area. Of the 448 surveys mailed to eligible physicians, 288 were completed and returned for a response rate of 64.3%. Respondents' perceptions of how available respite care is and how easy it is to refer chronically ill older people to it and their opinions on the effectiveness of respite care. More than half the respondents reported that outpatient respite care is always available, but how available depended on practice location. Inpatient respite care was reported as less available. More than half the respondents found referral to respite care difficult. Respondents were very positive about the role of respite services in long-term care and in lowering caregiver stress. Respondents' perceptions varied according to where they had attended medical school. Their perceptions of respite care's role in long-term care and in helping patients remain at home were influenced by whether they thought respite care was available. | Family physicians need education in the value of respite services for their chronically ill older patients and their families. Physicians also need information on the respite services available and strategies for accessing them. Our findings suggest a need for greater attention to regional discrepancies in availability of services. | closed_qa |
Can continence function after rectal resection be prognostically estimated? | Patients who had undergone rectal resection (n = 65, of whom 24 had had radiochemotherapy) were evaluated by clinical examination, anorectal manometry and orthograde contrast enema before ileostomy closure. Continence was evaluated by clinical findings 91 +/- 52 weeks after stoma closure with the help of standardized questionnaires and classified according to the Wexner continence score. The relationship between findings before stoma closure and continence score was calculated with Pearson's correlation coefficient. Correlations were found to be significant between the continence score and the level of anastomosis (r = -0.58, p<0.001), median resting pressure (r = -0.52, p<0.001), rectal compliance (r = -0.43, p<0.001). Additionally, radiochemotherapy impairs continence (p = 0.0001). Correlations were not significant between continence and functional sphincter length, squeeze pressure, threshold for perception, urge and maximal tolerable volume, and continence for semiliquid contrast medium. | Incontinence after rectum resection is multifactorial: the level of anastomosis, resting pressure, rectal compliance and radiochemotherapy all play a dominant role. Based on these findings, the continence score can be calculated before closure of a diverting ileostomy by applying multivariate analysis with the help of the following formula: Continence score = 18.23 - 0.94 x level of anastomosis - 0.18 x resting pressure + 3.72 x radiochemotherapy. | closed_qa |
Is Na+Ca(2+) exchanger expression altered in the endomyocardium of patients with chronic heart valve diseases parallel to myocardial dysfunction? | Na(+)-Ca2+ exchanger (EXCH) is an important regulator of intracellular calcium homeostasis. To maintain a normal intracellular Ca2+ concentration, EXCH expression may be upregulated before the onset of end-stage heart failure. We tested for a correlation between the EXCH transcription level and the degree of myocardial dysfunction as well as the suitability of EXCH transcription as a molecular marker for early detection of a transition from adequate to inadequate myocardial adaptation to chronic pressure and/or volume overload in valvular heart disease (VHD). The level of EXCH transcription was analyzed in myocardial biopsies from eleven patients with aortic stenosis (AS), five with aortic regurgitation (AR) and six with primary mitral regurgitation (MR) of different hemodynamic severity and myocardial impairment using the quantitative rt-PCR technique. In addition, endomyocardial tissue from thirteen explanted hearts with end-stage heart failure and biopsies from seven individuals without heart disease were investigated. The mean level of EXCH transcription in patients with AS was: 1.8 +/- 1.4 amol/ng total RNA, with AR: 1.9 +/- 0.8 amol/ng and with MR: 2.2 +/- +2.1 amol/ng. This was not from different controls (2.6 +/- 1.2 amol/ng total RNA). However, in myocardium from end-stage heart failure, EXCH transcription was increased fourfold amounting to 8.9 +/- 1.9 amol/ng total RNA. No difference in the EXCH transcription was found in VHD with respect to the degree of myocardial dysfunction: cardiac index (CI)>3.5 l/min/m2 (EXCH 1.4 +/- 1.1 amol/ng total RNA); CI 3.5-2.4 (EXCH 2.5 +/- 1.8); CI<2.4 (EXCH 1.8 +/- 1.0); EF-angio>50% (EXCH 1.9 +/- 1.8); EF-angio<or = 50% (EXCH 1.9 +/- 0.9); EF-RNV>50% (EXCH 2.4 +/- 1.8), EF-RNV<or = 50% (EXCH 1.7 +/- 1.0). | Myocardial EXCH transcription does not change parallel to the degree of myocardial dysfunction in VHD. Consequently, myocardial EXCH transcription does not appear to be suitable as a parameter indicating the transition from adequate to inadequate myocardial adaptation to chronic volume and/or pressure overload. | closed_qa |
Should postmenopausal women with rheumatoid arthritis who are starting corticosteroid treatment be screened for osteoporosis? | To evaluate the cost-effectiveness of different strategies for preventing corticosteroid-induced osteoporosis. Simulated cohorts of postmenopausal women with rheumatoid arthritis (RA) starting corticosteroid treatment were examined. A Markov decision analysis model was developed to compare different management strategies, including watchful waiting, screen and treat, and empirical treatment. Treatment thresholds for the screen and treat strategy were varied from bone mineral density (BMD) T scores<-1.0 to BMD T scores<-4.0. Compared with a watchful waiting approach, the incremental cost-effectiveness ratio for a strategy of screen and treat with alendronate at a BMD T score of<-1.0 was $92,600 per quality-adjusted life year (QALY) gained. This result was sensitive to the cost and efficacy of osteoporosis therapy and, importantly, to the treatment threshold. At a treatment threshold of a BMD T score<-2.5, the incremental cost-effectiveness ratio of screening and treating was $76,100 per QALY. None of these results differed substantially for women taking estrogen replacement therapy. | The incremental cost-effectiveness ratio of a strategy of screening and treating postmenopausal female RA patients with BMD T scores of<-1.0, compared with watchful waiting, was greater than that of other well-accepted medical interventions. The cost-effectiveness ratios were more acceptable when a T score treatment threshold of<-2.5 was used. These conclusions are limited by the lack of data on fracture and treatment efficacy in corticosteroid-treated patients. | closed_qa |
Chlorpromazine induces apoptosis in activated human lymphoblasts: a mechanism supporting the induction of drug-induced lupus erythematosus? | Drug-induced lupus erythematosus is a serious side effect of certain medications, such as procainamide, quinidine, hydralazine, chlorpromazine, and isoniazid, the underlying pathogenesis of which is unresolved. In this study, we examined the influence of these drugs on the regulation of apoptosis, or programmed cell death, in quiescent and activated human lymphocytes. We also discuss the dysregulation of apoptosis as a pathogenetic factor in systemic lupus erythematosus. Peripheral blood mononuclear cells or activated lymphoblasts from normal donors were incubated with different concentrations of each of the above-mentioned drugs. We did not find induction of apoptosis in quiescent cells over a broad concentration range. In contrast, lymphoblasts readily underwent apoptosis when cultured with chlorpromazine, but not any of the other drugs, after stimulation with interleukin-2 (IL-2) in a dose-, time- and cell cycle-dependent manner. By several lines of evidence, toxicity was ruled out. Characteristic features of apoptosis-like incorporation of propidium iodide (PI), such as increased annexin V binding, changes in mitochondrial membrane potential, and induction of DNA breaks (as evidenced by TUNEL techniques), could be induced in lymphoblasts after chlorpromazine treatment. Chlorpromazine did not cause apoptosis by inhibition of cytokine binding or blockade of early intracellular signaling. The protease inhibitor Z-VAD and the ceramide inhibitor sphingosine 1-phosphate effectively blocked chlorpromazine-induced apoptosis (by PI staining and by externalization of phosphatidylserine), in contrast to the caspase 3/CPP32 inhibitor DEVD, which had only minor effects. Western blot analysis revealed IL-2-mediated phosphorylation of extracellular signal-regulated kinase, which was sensitive to chlorpromazine. Using lymphoblasts from a patient with Canale-Smith syndrome, we found that chlorpromazine-mediated apoptosis is Fas/ APO-1 independent. | These data suggest that chlorpromazine mediates apoptosis in human lymphoblasts through specific activation of intracellular proapoptotic signaling cascades. This mechanism might lead to an unsynchronized inflow of apoptotic break-down products and thereby to the induction of (auto)immunity against nuclear components. | closed_qa |
Products of hemolysis in the subarachnoid space inducing spreading ischemia in the cortex and focal necrosis in rats: a model for delayed ischemic neurological deficits after subarachnoid hemorrhage? | The pathogenesis of delayed ischemic neurological deficits after subarachnoid hemorrhage has been related to products of hemolysis. Topical brain superfusion of artificial cerebrospinal fluid (ACSF) containing the hemolysis products K+ and hemoglobin (Hb) was previously shown to induce ischemia in rats. Superimposed on a slow vasospastic reaction, the ischemic events represent spreading depolarizations of the neuronal-glial network that trigger acute vasoconstriction. The purpose of the present study was to investigate whether such spreading ischemias in the cortex lead to brain damage. A cranial window was implanted in 31 rats. Cerebral blood flow (CBF) was measured using laser Doppler flowmetry, and direct current (DC) potentials were recorded. The ACSF was superfused topically over the brain. Rats were assigned to five groups representing different ACSF compositions. Analyses included classic histochemical and immunohistochemical studies (glial fibrillary acidic protein and ionized calcium binding adaptor molecule) as well as a terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling assay. Superfusion of ACSF containing Hb combined with either a high concentration of K+ (35 mmol/L, 16 animals) or a low concentration of glucose (0.8 mmol/L, four animals) reduced CBF gradually. Spreading ischemia in the cortex appeared when CBF reached 40 to 70% compared with baseline (which was deemed 100%). This spreading ischemia was characterized by a sharp negative shift in DC, which preceded a steep CBF decrease that was followed by a slow recovery (average duration 60 minutes). In 12 of the surviving 14 animals widespread cortical infarction was observed at the site of the cranial window and neighboring areas in contrast to findings in the three control groups (11 animals). | The authors conclude that subarachnoid Hb combined with either a high K+ or a low glucose concentration leads to widespread necrosis of the cortex. | closed_qa |
Mild ductal atypia after large-core needle biopsy of the breast: is surgical excision always necessary? | The aim of the current study was to identify a select group of patients with mild atypia who do not need surgical excision after large-core needle biopsy (LCNB) of the breast. Nineteen (70%) of 27 patients with ductal atypia found on LCNB had subsequent surgical excision. These 19 patients were retrospectively assigned to 3 groups according to the severity of the atypia found, which was compared with the final pathologic specimen after surgical biopsy. Cancer was identified through surgical biopsy in 6 (32%) of 19 patients. The severity of atypia seen on the LCNB specimen strongly correlated with subsequent cancer identification (P<.01). Two (33%) of 6 patients in group 2 (true atypical ductal hyperplasia [ADH]) and 4 (80%) of 5 patients in group 3 (severe ADH, borderline ductal carcinoma in situ) had cancer after surgical biopsy. No cancer was found after surgical biopsy in 8 patients in group 1 (mild atypia, not meeting criteria for ADH). | The results of this study suggest that surgical excision can be avoided after LCNB of the breast in patients with only mildly atypical lesions that do not meet criteria for ADH. Patients with true ADH should continue to have surgical excision. | closed_qa |
Can clinical parameters predict fractures in acute pediatric wrist injuries? | Fractures around the wrist are common in pediatric patients presenting to the emergency department (ED). This pilot study was aimed at identifying clinical variables that are most likely to be associated with a fracture. This was a prospective blinded case series of patients 3-18 years of age presenting with an acute (<3 days) wrist injury, without obvious deformity. A team of five investigators blinded to the eventual radiographic findings evaluated patients. Physical examination variables included range of motion (ROM), site of maximal tenderness, and functional deficit. The latter was determined objectively, by recording any difference in grip strength between the injured and noninjured hands. Diagnostic radiographs were obtained for all patients. Univariate analysis using Wilks' log likelihood ratio test was performed to identify clinical variables associated with confirmed wrist fractures. Sample size was determined based on the ability to detect a difference of 15 degrees in the ROM variables, 20% point differences in grip strength, and 30% proportion differences in categorical variables using a power of 0.8 and a two-tailed of 0.05. The ROMs were not significantly different between the fracture (Fx) and nonfracture (NFx) group. There was significant change in the grip strength between the Fx and NFx groups (t = 3.3, p = 0.0019). Tenderness over the distal radius was also associated with a greater likelihood of a fracture (G(2) = 5.0, p = 0.02). Sensitivity of clinical prediction was found to be 79%, and specificity was 63%. The false-negative rate was 0.21 and the false-positive rate was 0.37, while the positive predictive value was found to be 0.68 and negative predictive value 0.75. | Distal radius point tenderness and a 20% or more decrease in grip strength were predictive of fractures. | closed_qa |
Isolated large third-trimester intracranial cyst on fetal ultrasound: fact or fiction? | To distinguish the fact from artifact of an isolated, large, intracranial cyst on prenatal sonography (PSG). The use of PSG is rapidly increasing with most obstetric ultrasounds occurring in general community settings like small hospitals and clinics with personnel who have variable training, experience, and interest levels. In contrast, most PSG articles and books are produced in large subspecialty centers with concentrated referral bases plus both highly-trained and experienced personnel.DESIGN/ We report a series of 2 normal newborn patients who had a large prenatal unilateral intracranial cyst diagnosed by PSG in the 10 years between July of 1989 and 1999 at a rural community hospital. The newborns had imaging studies at birth and their neurodevelopmental progress was followed for several years. Textbook, bibliography and computerized Medline (1966-present) searches including prenatal ultrasound, observer variation, diagnostic errors, reproducibility of results, sensitivity and specificity, accuracy, central nervous system, false-positive, prenatal diagnosis, and brain were examined starting in August 1996 for reports. There were 4079 obstetric ultrasounds performed in 3.5 years, January 1996 through July 1999 at this rural community facility. This rate extrapolates to a total of 11 654 obstetric ultrasounds over the 10-year study period in which the 2 cases of intracranial cyst artifact occurred. Thus, the incidence of 2 intracranial cyst artifacts was estimated as 2/11 654 PSG, a .0002% false-positive rate. | This is the first report of the occurrence of PSG artifacts in a community facility. Artifact is a real problem and needs to be specified in differential diagnoses. There are ways to decrease sonographic artifact-or at least to recognize it-so our estimates at a community hospital for its occurrence are presented with the relevant technical and ethical issues. None of these issues have been previously reported in the pediatric literature. Our false-positive rate for large intracranial cyst compares favorably with other reports. Our estimate may inflate our denominator by reporting scans rather than the number of fetuses scanned, and our numerator may miss cases that moved from the community. Confusion differentiating PSG artifact from reality often occurs when interpreting static or frozen real-time images. The signs that sonogram images may be artifacts include defects that: extend outside the fetal body; change shape, size and echogenecity with different scan planes; are not seen on all examinations; and are isolated in an otherwise normal fetus. Failure to offer quality PSG in clinical settings where it is available restricts access of pregnant women to the diagnosis of fetal anomalies, and therefore restricts access to the options of pregnancy termination, fetal therapy like fetal surgery, and delivery options of timing, setting, and mode. We suggest a multidisciplinary approach to prenatal abnormalities like isolated third trimester unilateral intracranial cyst in both primary and tertiary care settings aids interpretation followed by expectant conservative management without elaborate, risky, or terminal interventions. | closed_qa |
Academic performance of medical students: a predictable result? | Traditionally, medical schools demand their students a high dedication in time, responsibility and integrity.AIM: To assess the predictive capacity of several specific variables, on the academic performance of medical students. All students who entered during 1984-1995 period were studied. The academic performance was assessed using two indices: an overall evaluation of successfulness as determined by the approval rate in different courses and grade-point average obtained during the first three years at the Medical School. The variables used to predict academic performance were year of enrollment, high school grades, university admission test scores, biomedical and demographic characteristics. All these were measured at the time when the student was enrolled. Eight hundred and eight students were studied at the end of the third year. The most important predictive variables selected for both performance indices were: high school grades, admission biology test scores, place were high school studies were done, and previous university studies. In addition verbal and mathematics admission academic performance tests scores were selected for grade-point average index. Although, the overall admission score and high school academic performance were significantly associated with the two outcomes, they were not selected in the final models. | The best predictors of an optimal academic performance in these medical students were high school grades, admission biology test scores, residing in Metropolitan Santiago and previous university studies. | closed_qa |
Are bilateral superior vena cavae a risk factor for single ventricle palliation? | Performing superior vena cava-to-pulmonary artery anastomosis, in the presence of bilateral superior vena cavae, can be technically challenging. Our clinical observation has been that bilateral superior vena cavae are a risk factor for poor outcome in children needing single ventricle palliation. Detailed operative, angiographic, and follow-up data were analyzed in 39 children undergoing bilateral cavopulmonary anastomosis (b-CPA). Overall outcome was compared to 274 children having a unilateral cavopulmonary anastomoses (u-CPA). Nine patients (23%) with bilateral superior vena cavae were found to have thrombus in the cavopulmonary circulation after the b-CPA. Postoperative mean arterial oxygen saturation was significantly lower in those who had thrombus [69%+/-10% versus 82%+/-7%, (p<0.01)]. Thrombus formation was associated with mortality. The indexed superior vena cavae size was not a risk factor for thrombosis. In follow-up studies the connecting pulmonary artery segment between the two cavopulmonary anastomosis was smaller than the pulmonary arteries adjacent to the hilum. Survivors of a b-CPA were less frequently converted to a Fontan circulation at 5 years of follow up (Kaplan-Meier 5-year estimates, 39% for b-CPA versus 74% for u-CPA [p = 0.02]). | Bilateral superior vena cava-to-pulmonary artery anastomosis is associated with an increased risk of thrombus formation and unfavorable growth in the central pulmonary arteries. Modifications of surgical technique may alter flow patterns, thereby optimizing growth and diminishing the risk of thrombus formation. Anticoagulation therapy may be an important adjunct in children undergoing a b-CPA. | closed_qa |
Is low ejection fraction safe for off-pump coronary bypass operation? | Does the manipulation of the heart during off-pump coronary artery bypass (OPCAB) procedure further compromise the hemodynamic stability of a patient with depressed left ventricular function compared with the conventional coronary artery bypass (CCAB) approach? Does this manipulation induce a more dramatic hypoperfused state that may contribute to an increase in the incidence of related complications or mortality? This retrospective review of data attempted to answer the above concern. Between January 1, 1998, and June 30, 1999, 177 patients with ejection fractions of 30% or less underwent full sternotomy coronary artery bypass grafting at our institution. Of these patients, 45 underwent OPCAB procedures and 132 patients underwent CCAB. Pre-, intra-, and postoperative variables as identified by The Society of Thoracic Surgeons National Cardiac Surgery Database were compared using univariate and logistical regression analysis. Despite recognized hemodynamic derangement during cardiac displacement, these groups of OPCAB patients appeared to tolerate the procedure well. Univariate analysis of cardiac enzyme leak and blood loss was statistically significant in the OPCAB patients. Utilizing regression analysis, cardiopulmonary bypass was the only predictor for all postoperative complications. | Multivessel coronary artery bypass utilizing the OPCAB approach in patients with depressed left ventricular function of equal to or less than 30% is appropriate and applicable. Analysis of CCAB and OPCAB variables was nonsignificant except for operative and postoperative blood loss and peak cardiac enzyme leak. Attention to intraoperative detail and hemodynamic management could be credited for the success with OPCAB. | closed_qa |
Is smoking associated with the risk of developing Alzheimer's disease? | To determine whether smoking is associated with Alzheimer's disease (AD). Analyses were conducted using three Canadian data sets: the University of Western Ontario Dementia Study (200 cases, 163 controls), the Canadian Study of Health and Aging (258 cases, 258 controls), and the patient database from the Clinic for Alzheimer Disease and Related Disorders at the Vancouver Hospital and Health Sciences Centre (566 cases, 277 controls). The association between smoking and AD was investigated using bivariate analyses and multiple logistic regression models adjusted for the potential confounders age, sex, educational level, family history of dementia, head injury, and hypertension. The results of bivariate analyses were inconsistent across the three data sets, with smoking status a significant protective factor, a significant risk factor, or not associated with AD. The results of multiple logistic regression models, however, were consistent: any association between smoking status and AD disappeared in all three data sets after adjustment for confounders. | Smoking status was consistently not associated with AD across all three data sets after adjustment for confounders. Failure to adjust for relevant confounders may explain inconsistent reports of the influence of smoking on AD. Any protective effect of smoking may be limited to specific AD subtypes (e.g., early onset AD). | closed_qa |
An Ontario-wide study of vitamin B12, serum folate, and red cell folate levels in relation to plasma homocysteine: is a preventable public health issue on the rise? | Plasma homocysteine has been reported to be useful in the evaluation of patients with suspected vitamin B12 or folate deficiency. In November 1998, Canada began its mandatory fortification of all flour, and some corn and rice products, with folic acid. We evaluated the status of folate and vitamin B12 in Ontario since this fortification program began, and also studied the role of plasma homocysteine in the assessment of vitamin B12 deficiency since that time. A retrospective cross-sectional study design was performed using a community database of all Ontario samples analyzed by MDS Laboratories, a major provider of diagnostic laboratory services in Canada. All consecutive single-patient fasting samples for plasma homocysteine collected between January 1 and September 30, 1999 were included, as well as corresponding red cell folate and serum B12 concentrations. Data for serum folate were included when available. Descriptive statistics included the arithmetic and geometric means for each measure, as well as the lower and upper centile values. After excluding cases with a concomitant serum creatinine>120 micromol/L or red cell folate<215 nmol/L, we established the test properties of a plasma homocyteine level of 15 micromol/L or greater for the diagnosis of "low" (<120 pmol/L) or "indeterminate" (i.e., between 120 and 150 pmol/L) serum vitamin B12 concentrations. The mean age of all subjects was 58.4 years (95% CI 57.4 to 59.4). Plasma homocysteine samples were obtained from 403 males (56.7%) and 308 females. The geometric mean homocysteine concentration for the entire population was 8.3 micromol/L, and was significantly higher among males (9.3 micromol/L) than females (8.3 micromol/L) (unpaired t-test: 2-p<0.0001). The geometric mean serum folate concentration was significantly higher in females (35.8 nmol/L) than males (33.6 nmol/L) (2-p<0.0001), as were the mean red cell folate levels (females 966.8 nmol/L, males 949.3 nmol/L; 2-p<0.0001). Serum vitamin B12 concentrations were available for 692 subjects, with a geometric mean of 322.0 pmol/L. Again, mean vitamin B12 was higher in females (332.5 pmol/L) than males (314.3 pmol/L) (2-p<0.0001). The fifth centile for vitamin B12 was 134.6 pmol/L. A plasma homocysteine concentration>15 micromol/L did not discriminate between cobalamin concentrations below versus above 120 pmol/L (positive and negative predictive values 7.4% and 97.2%, respectively), nor did it discriminate "indeterminate" B12 levels between 120 and 150 pmol/L (positive and negative predictive values 6.3% and 94.0%, respectively). | In a large select group of Ontarians, serum and red cell folate concentrations appear to be higher than expected, possibly due to a recent national folate fortification programme; cobalamin levels are no higher than expected. Given our inability to detect mild B12 deficiency using such indicators as plasma homocysteine, and considering the substantial growth in the elderly segment of the Canadian population, occult cobalamin deficiency could become a common disorder. Accordingly, we recommend either consideration of the addition of vitamin B12 to the current folate fortification programme, and/or the development of better methods for the detection of cobalamin deficiency. | closed_qa |
Does holiday hypoglycaemia exist? | To determine whether an excessive, prolonged and, above all, unusual physical exertion could be associated with episodes of mild hypoglycaemia in non-insulin-dependent diabetes mellitus (NIDDM) patients treated with glibenclamide. 11 months of observation with retrospective analysis of patient personal diaries to determine the hypoglycaemic risk. Diabetic Unit-Department of Medicine and Aging-Chieti University School of Medicine. We enrolled 340 NIDDM outpatients adjusted for sex, age, body mass index, alcohol intake and oral treatment regimen with glibenclamide. PATIENTS were tested monthly for circadian blood glucose profiles and glycosylated hemoglobin. Mild hypoglycaemia was defined on the basis of blood glucose values<2.8 mmol/l associated with mild autonomic symptoms, without requiring external assistance. Each diabetic patient filled personal diary indicating the therapy regimen and the characteristics of eventual hypoglycaemic episodes occurring during the observation period. 21.8% of NIDDM patients experienced one or two episodes of mild hypoglycaemia during the observation period. The analysis of the patients' diaries showed that 60% of the hypoglycaemic episodes was associated with excessive, prolonged and unexpected physical exertions. Within this group, about 70% of the episodes occurred during a holiday ("holiday hypoglycaemia"). After analyzing the socio-demographic and clinical characteristics of the diabetic patients reporting hypoglycaemic events, we found a higher risk for "holiday hypoglycaemia" in patients with a lower educational level, with a sedentary occupation or among the ex-farmers. | As resulted in the present study, unexpected physical exertions may represent a relevant cause of mild hypoglycaemia in diabetic patients receiving oral antidiabetic therapy. However, this hypoglycaemic cause may have been underestimated in the literature. Educational programs conducted by general practitioners or diabetologists could be useful for the patients in reducing the number of mild hypoglycaemic episodes. | closed_qa |
The characteristic pattern of aminoaciduria in patients with aristolochic acid-induced Fanconi syndrome: could iminoaciduria be the hallmark of this syndrome? | In Japan the patients with Chinese herbs nephropathy (CHN), aristolochic acids-(AAs) associated renal failure, often present Fanconi syndrome. The aim of this study was to investigate the pattern of aminoaciduria in patients with AAs-induced Fanconi syndrome and to clarify whether it is different from other Fanconi syndromes reported in the literature. The subjects consisted of 4 patients with Fanconi syndrome due to AAs. We studied biochemical data and urinary excretion of amino acids in the 4 patients. Amino acids in their urine were analyzed by high performance liquid chromatography (HPLC). Three out of 4 patients showed in common very increased excretion ofproline, hydroxyproline and citruline. Last patient showed the very increased levels of proline and valine. Regarding glycine, which is considered to belong to the same group as imino acid and to be shared with high-affinity transport system ofproline, there was not very increased excretion. | These findings suggest that AAs would predominantly affect the low-affinity transport system of proline in the brushborder membrane of proximal tubules because the low-affinity system is considered not to be shared with glycine transport. | closed_qa |
Are vacations good for your health? | The objective of this study was to determine the risk for various causes of posttrial death associated with vacation frequency during the Multiple Risk Factor Intervention Trial (MRFIT). Middle-aged men at high risk for coronary heart disease (CHD) were recruited for the MRFIT. As part of the questionnaires administered during the first five annual visits, men were asked whether they had had a vacation during the past year. For trial survivors (N = 12,338), the frequency of these annual vacations during the trial were used in a prospective analysis of posttrial all-cause and cause-specific mortality during the 9-year follow-up period. The relative risk (RR) associated with more annual vacations during the trial was 0.83 (95% confidence interval [CI], 0.71-0.97) for all-cause mortality during the 9-year follow-up period. For cause of death, the RRs were 0.71 (95% CI, 0.58-0.89) and 0.98 (95% CI, 0.78-1.23) for cardiovascular and noncardiovascular causes, respectively. The RR was 0.68 (95% CI, 0.53-0.88) for CHD (including acute myocardial infarction). These associations remained when statistical adjustments were made for possible confounding variables, including baseline characteristics (eg, income), MRFIT group assignment, and occurrence of a nonfatal cardiovascular event during the trial. | The frequency of annual vacations by middle-aged men at high risk for CHD is associated with a reduced risk of all-cause mortality and, more specifically, mortality attributed to CHD. Vacationing may be good for your health. | closed_qa |
Do panic symptom profiles influence response to a hypoxic challenge in patients with panic disorder? | This study examined how panic symptom profiles affect response to a hypoxic laboratory challenge in patients with panic disorder. Seven patients whose naturally occurring panic attacks were characterized by prominent respiratory symptoms (Resp subgroup) were compared and contrasted with seven patients who did not report respiratory symptoms during panic attacks (NonResp subgroup). All were administered a novel 12% O2 challenge and assessed with measures of tidal volume, respiratory rate, end-tidal CO2, anxiety, and panic symptoms. Although the Resp and NonResp subgroups showed equivalent increases in anxiety and panic symptoms, the Resp subgroup showed greater fluctuation in tidal volume during and after the challenge as well as overall lower levels of end-tidal CO2. | Our results suggest the importance of panic symptom profiles in determining respiratory responses to a hypoxic challenge in patients with panic disorder. These findings are discussed in light of current theories of panic disorder, with particular attention to respiratory disturbances in this disorder. | closed_qa |
Unplanned readmissions of patients with congestive heart failure: do they reflect in-hospital quality of care or patient characteristics? | To determine if early unplanned readmissions of patients hospitalized for heart failure are associated with suboptimal in-hospital care or with the clinical and demographic characteristics of the patient. We performed a case-control study among patients discharged with a principal diagnosis of heart failure. Cases included all patients unexpectedly readmitted within 31 days of discharge; controls were randomly selected from among those not readmitted. Quality of care was measured using explicit criteria reflecting the admission work-up, evaluation and treatment, and readiness for discharge. Ninety-one cases and 351 controls were included. There was no significant association between early unplanned readmissions and the scores for quality of the admission work-up or evaluation and treatment during the stay. There was a significant association between readiness for discharge and subsequent early readmission: for each 10% decrease in the proportion of fulfilled criteria, the odds of readmission increased by 14% (95% confidence interval [CI] 1. 01 to 1.28, P = 0.04) for all-cause readmissions and by 19% (95% CI: 1.04 to 1.36, P = 0.01) for heart-failure-related readmissions. In a multiple logistic regression model, previous diagnosis of heart failure (odds ratio [OR]= 2.9, 95% CI: 1.7 to 4.8, P<0.001), age (OR = 3.3, 95% CI: 1.3 to 8.5, P = 0.01 for patients aged 65 to 79 years and OR = 4.1, 95% CI: 1.6 to 11, P = 0.004 for patients aged 80 years and older), and history of cardiac revascularization (OR = 2.1, 95% CI: 1.2 to 3.9, P = 0.01) showed a stronger association with early unplanned all-cause readmissions than the readiness-for-discharge score (OR = 1.16, 95% CI: 1.02 to 1.31, P = 0.02). Similar findings were seen for heart failure-related readmissions. | Among patients with heart failure, early unplanned readmissions were not associated with suboptimal admission work-up or evaluation and treatment but were weakly associated with readiness for discharge. However, they were strongly associated with the patients' clinical and demographic characteristics. | closed_qa |
Does nimesulide induce gastric mucosal damage? | In this study, it was aimed to examine the effect of nimesulide, a selective inhibitor of cox-2 enzyme, to the gastric mucosa and to correlate its effect with aspirin. This study was planned as double-blind, randomized and placebo-controlled. Mean age of voluntary persons (n = 32) was 42.3 +/- 2.7. Divided into 3 groups of volunteers were given randomized placebo (n = 10), aspirin (n = 10) (500 mg aspirin, Bayer) and nimesulide (n = 12) (100 mg mesulid, Pfizer) with 50 mL of water after 12 hours fasting period at 08.00 am. Gastroduodenoscopy was performed to the volunteers 3 hours after each therapy. Endoscopic scores of groups were; placebo: 0.20 +/- 0.13, aspirin: 2.8 +/- 0.46, nimesulide: 1.41 +/- 0.51. Lesion scores both in the aspirin group when compared with nimesulide and placebo groups (P<0.00002,<0.03), and in the nimesulide group when compared with the placebo group (P<0.01) were significantly high. The positivity of Helicobacter pylori of groups was found; 67% in placebo, 72% in aspirin, 71% in nimesulide and there was no statistically significant difference in the groups. | It was shown that nimesulide causes significantly serious gastric mucosal lesion when compared with placebo. The lesion score of nimesulide was found less than aspirin. According to the findings, nimesulide should be given carefully just as other analgesics due to the probability of causing gastric lesion. | closed_qa |
The use of interprofessional peer examiners in an objective structured clinical examination: can dental students act as examiners? | To assess whether final year dental students could act as reliable examiners within an Objective Structured Clinical Examination (OSCE) by comparison with results obtained by an experienced member of staff. A station testing examination of the mouth was included in the second year medical undergraduate summative OSCE examination. Concurrently run in three different examination venues on the Ninewells Hospital campus. 147 medical students and 3 pairs (A, B, C) of examiners. Each examining pairing consisted of one member of staff and one dental student (blind to each other's marking). A checklist of 13 tasks to be performed was provided to the examiners. One mark awarded for a completed task, no mark for no attempt at the task, and half a mark for attempt at task. Paired results were available for 125 medical students. Using Mann-Witney analysis, the non-parametric 95% confidence intervals for the difference in scores between the 3 paired teams were group A (-0.5, 0), group B (-0.5, 0.5), group C (-0.5, 0). In only 4 students (out of 125) did the difference between the individual pair differ by 2 or more marks. | On the basis of this pilot study final year dental students may be used as examiners in OSCEs where basic technical skills are to be evaluated. This development from peer group teaching provides further evidence supportive of interprofessional education. | closed_qa |
Pancreatic cancer and diabetes: is there a relationship? | There is controversy about whether diabetes mellitus is a risk factor for pancreatic cancer or an epiphenomenon of the cancer. The present study aims to determine if long-term diabetes is a risk factor for pancreatic cancer. The study undertook to determine the prevalence of diabetes among three matched (age/gender) patient groups (pancreatic cancer (PaC), colorectal cancer (CRC), and fracture neck of femur (NOF)) at the date of diagnosis of cancer or fracture as well as 1 and 5 years prior to this. A retrospective review of the medical records of the three groups of patients was undertaken. Patients identified with PaC in the period July 1994 to February 1998 were age (+/- 5 years)- and gender-matched to patients identified in the same time period with NOF and with CRC. The data were then analysed using McNemar's test for discordant pairs. Over a 44-month period 116 patients with PaC were identified of which 24% had diabetes at the time of diagnosis of their malignancy (NOF, 8%; CRC, 9.5%). There was a statistically significant difference (PaC and NOF, P<0.01; PaC and CRC, P<0.01). For a duration of diabetes of>5 years the prevalence of diabetes fell to 7.8% in the PaC group, to 6% in the NOF group and to 6.9% in the CRC group, with no significant difference between the groups. | There is no increase in the prevalence of long-standing diabetes mellitus in patients with PaC compared to age- and gender-matched controls with NOF and CRC. The relationship of PaC and diabetes may be an epiphenomenon, rather than diabetes being a risk factor for pancreatic malignancy. | closed_qa |
Do patients wish to be involved in decision making in the consultation? | To determine patients' preferences for a shared or directed style of consultation in the decision making part of the general practice consultation. Structured interview, with video vignettes of acted consultations. 5 practices in Lothian, Scotland. 410 patients (adults and adults accompanying children) attending surgery appointments. Preference for shared or directed form of video vignette for five different presenting conditions. Patients varied in their preference for involvement in decision making in the consultation. Under multiple regression analysis, patients' preference was found to be independently predicted by the problem viewed (patients presented with physical problems preferred a directed approach), patients' age (patients aged 61 or older were more likely to prefer the directed approach), social class (social classes I and II were more likely to prefer the shared approach), and smoking status (smokers more likely to prefer the shared approach). Those patients who were able to answer (or who thought their doctor's style similar to those in the vignettes) were more likely to describe their own doctor's style as similar to their preferred style. No major association in preference was found with sex, frequency of attendance, or perceived chronic ill health. | Patients may vary in their desire for involvement in decision making in consultations. Although this variation seems to depend on the presenting problem, age, social class, and smoking status, these associations are not absolute, with large minorities in each group. Doctors need the skills, knowledge of their patients, and the time to determine on which occasions, with which illnesses, and at which level their patients wish to be involved in decision making. | closed_qa |
GP job satisfaction in 1987, 1990 and 1998: lessons for the future? | Job satisfaction is an important determinant of physician retention and turnover, and may also affect performance. Objective. Our aim was to investigate changes in GP job satisfaction from 1987 to 1998, covering a period of major change in the organization of British general practice. Postal surveys of random national samples of GPs were carried out by separate groups of investigators in 1987, 1990 and 1998. In each survey, the questionnaire contained a standardized job satisfaction scale and a list of 14 job stressors. The final samples consisted of 1817 GPs in 1987 (response rate 45%), 917 GPs in 1990 (response rate 61%) and 1828 GPs in 1998 (response rate 49%). For both men and women, overall job satisfaction declined from 1987 to 1990 and then improved from 1990 to 1998, although satisfaction in 1998 remained below that in 1987. Women tended to report higher levels of satisfaction than men in all 3 years. Satisfaction with nine specific aspects of work showed dissimilar patterns of change over time. From 1987 to 1990, reported levels of stress increased for eight of 14 job stressors. Of these, three subsequently declined in 1998, two remained unchanged and three continued to increase. Of the six job stressors which showed no change from 1987 to 1990, five subsequently increased as sources of stress. Men and women differed in their sources of stress, but the differences were not consistent over time. | The results suggest that GP job satisfaction has improved significantly from the low point reached following the introduction of the 1990/1991 NHS reforms, although reported levels of stress in relation to many aspects of work have continued to increase. The changes are discussed within the context of wider research into the determinants of GP job satisfaction in order to anticipate the likely effects on GPs of future organizational reforms. | closed_qa |
From analgesic intolerance to analgesic induced asthma: are there some determinants? | Analgesic intolerance (AI) sometimes appear alone and sometimes with bronchial asthma affecting about 10% of asthmatics and sometimes before and the other times after asthma. We investigated the possible clinical risk factors which might be affecting the transition from isolated AI to analgesic induced asthma (AIA). A total of 344 patients admitted to Hacettepe University Hospital Adult Allergy Unit between January 1991 and March 1999 and diagnosed with AI were enrolled in this survey. Patients having AIA (group I) (n = 191) were compared with the patients having AI without asthma (group II) (n = 153). The diagnosis of AI and AIA were made by history and oral provocation tests. A standard questionnaire was filled-in for all the patients. The risk of AIA was increased with nasal polyp, and rhinosinusitis via OR's of 2.75 (95% CI: 1.09, 6.91), and 18.58 (95% CI: 9.86, 35.01), respectively. Having a pet, and ever smoking decreased the risk of AIA in the patients with AI via OR's of 0.53 (95% CI: 0.24, 1.17), and 0.37 (95% CI: 0.17, 0.80), respectively. The association of AIA and smoking was slightly modified by food intolerance (OR for ever smoked and food intolerance: 1.31, 95% CI: 0.40, 4.30). | There may be two different phenotypes of AI with different clinical features: one developing AIA (having nasal polyp and/or rhinosinusitis, and smoking if food allergy/intolerance is present), and the other AI without asthma (having pet, and could smoke). Findings of this study should be confirmed by further investigations. | closed_qa |
Is it permissible to omit mediastinal dissection for peripheral non-small-cell lung cancers with tumor diameters less than 1.5 cm? | Recently the pros and cons of limited surgery for small-sized peripheral non-small-cell lung cancers (PNSCLCs), such as omission of mediastinal dissection, etc., have been vigorously debated. We analyzed whether hilar/mediastinal lymph node metastases were present in 30 small-sized PNSCLCs. In the nine years from 1990 to 1998, 294 lung cancer patients underwent lobectomy or pneumonectomy combined with hilar/mediastinal dissection in the Tokai University Hospital. Thirty of these patients diagnosed as having cT1N0M0 PNSCLC with tumor diameters of 1.5 cm or less by computed tomography, are evaluated in this article. The 30 PNSCLC patients consisted of 14 males and 16 females with a mean age of 61 +/- 9 years. Twenty six patients (87%) had no hilar nor mediastinal lymph node metastases (pN0), one patient (3%) had a hilar lymph node metastasis (pN1), and three patients (10%) had mediastinal lymph node metastases (pN2). | Mediastinal lymph node metastases were histologically observed in 3 (10%) of 30 PNSCLC patients with tumor diameters of 1.5 cm or less. Our results show that mediastinal dissection is still necessary even for small-sized lung cancers. | closed_qa |
Is fasting insulin associated with blood pressure in obese children? | We tested whether fasting insulin levels are associated with blood pressure in a large sample of obese children. Three hundred and fifty obese children (F:M ratio = 1.03) of 10.1 +/- 2.7 y of age (mean +/- SD) were consecutively enrolled at an Outpatient Paediatric Clinic. Obesity was diagnosed on the basis of a relative weight for age>120% and hypertension on the basis of a systolic (SBP) or diastolic (DBP) blood pressure>95th percentile for age after adjustment for height (Ht). Insulin was significantly higher in hypertensive (n = 202, 58%) than normotensive (n = 148, 42%) children (16 vs 14 microU mL(-1), geometric mean, p<0.01, ANOVA) but the difference was not clinically relevant. Moreover, (log-transformed) insulin explained only 7 and 4% of SBP and DBP variance, respectively (p<0.0001 for both) and this contribution disappeared after the confounding effects of age, weight or other anthropometric dimensions were taken into account (p = ns, ANCOVA). | This study does not support the hypothesis of a clinically relevant association between fasting insulin and blood pressure in obese children. | closed_qa |
Is suprapubic cystostomy an optimal urinary management in high quadriplegics? | Long-term outcome of spinal cord injury (SCI) patients was compared between those managed by suprapubic cystostomy (SPC) and clean intermittent catheterization (CIC) with particular emphasis on an incidence of urinary tract complications and patients perception for urinary management. The study comprised 61 SCI patients; 34 patients managed with SPC (group A), while 27 with CIC (group B). After stabilization of their condition, all were followed annually on an outpatient basis with clinical history, urinalysis, urinary imaging and renal function studies. Mean follow-up periods were 8.6 and 9.9 years for groups A and B, respectively. Between groups, a comparative study was performed on the incidence of urinary complications such as renal dysfunction, hydronephrosis, vesicoureteral reflux, symptomatic genitourinary infection and urinary stone. Satisfaction with urinary management was also estimated using the questionnaires during follow-up. Renal dysfunction, hydronephrosis and vesicoureteral reflux were not found in either group. Symptomatic genitourinary infection was seen in 4 (12%) of group A and 7 (26%) of group B, respectively. The incidence of renal stone was 3 (9%) in group A and 1 (4%) in group B. A significant difference was not found between two groups in these urinary complications. On the contrary, bladder stone was seen more frequently in group A (65%) than in group B (30%) with a significant difference (p<0.001). The degrees of incontinence, bother score of daily activities, and overall satisfaction showed no significant difference between the two groups. | Except for bladder stones, SPC is a valuable option of urinary management for quadriplegic patients, the results of which were comparable to paraplegic SCI patients managed with CIC. | closed_qa |
Is systematic sextant biopsy suitable for the detection of clinically significant prostate cancer? | The optimal extent of the prostate biopsy remains controversial. There is a need to avoid detection of insignificant cancer but not to miss significant and curable tumors. In alternative treatments of prostate cancer, repeated sextant biopsies are used to estimate the response. The aim of this study was to investigate the reliability of a repeated systematic sextant biopsy as the standard biopsy technique in patients with significant tumors which are being considered for curative treatment. Systematic sextant biopsy was performed in vitro in 92 radical prostatectomy specimens. Of these patients, 81 (88.0%) had palpable lesions. Of the 92 investigated patients, 70 (76.1%) had potentially curable pT2-3pN0 prostate cancers. In these patients, the cancer was detected only in 72.9% of cases by a repeated in vitro biopsy. In the pT2 tumors, there was a detection rate of only 66.7%. | This study underlines the fact that a considerable number of significant and potentially curable tumors remain undetected by the conventional sextant biopsy. A negative sextant biopsy does not rule out significant prostate cancer. | closed_qa |
Does the chronic prostatitis/pelvic pain syndrome differ from nonbacterial prostatitis and prostatodynia? | The new consensus classification considers the chronic prostatitis/pelvic pain syndrome (CPPS) based on presence or absence of leukocytes in the expressed prostatic secretions, post-massage urine or seminal fluid analysis. We compared classification based on evaluation of these 3 specimens to the traditional classification based on expressed prostatic secretion examination alone. A prospective clinical and laboratory protocol was used to evaluate symptomatic patients who had no evidence of urethritis, acute bacterial prostatitis or chronic bacterial prostatitis. Thorough clinical and microbiological evaluation of 310 patients attending our prostatitis clinic was used to select a population of 140 subjects who provided optimal expressed prostatic secretion, post-massage urine and semen specimens. Inflammation was documented in 111 (26%) of 420 samples, including 39 expressed prostatic secretion samples with 500 or greater leukocytes/mm.3, 32 post-massage urine samples with 1 or greater leukocytes/mm.3 and 40 seminal fluid specimens with 1 or greater million leukocytes/mm.3. Of the 140 subjects 73 (52%) had inflammatory chronic prostatitis/pelvic pain according to the consensus criteria but only 39 (28%) had nonbacterial prostatitis according to traditional expressed prostatic secretion criteria (p<0.001). | The new consensus concept of inflammatory chronic prostatitis/pelvic pain includes almost twice as many patients as the traditional category of nonbacterial prostatitis. | closed_qa |
Prostatic carcinoma: a nutritional disease? | The incidence of prostate cancer in Saudi Arabia has been reported to be low at 1.4 to 2.1/100,000 person-years. We prospectively evaluated the true incidence of this disease and its association with dietary factors. From 1994 to 1997 inclusive Saudi men older than 50 years treated at our institution for various presenting symptoms and diseases were randomly selected from various departments. They were examined prospectively with digital rectal examination, and total and free prostate specific antigen measurement. Transrectal ultrasound and prostatic biopsy were performed when either test was abnormal. Nutrition questionnaires and detailed interviews with a nutritionist were completed to assess the type of diet, and amount of saturated and polyunsaturated fat consumption of patients with prostatic carcinoma and controls. For the 2,270 Saudi men screened we noted an incidence of 3.1/100,000 person-years. Our nutritional survey revealed that recent fat consumption was greater than 120 gm. per person daily, of which about 40% was from meat and dairy products. Saturated fat comprised about 50% of the total fat intake. There was no difference in the amount of fat in the diet of men with and without prostatic carcinoma. | The incidence of prostatic carcinoma in the Kingdom of Saudi Arabia is low despite a high saturated fat diet in recent years. This finding contradicts most western clinical studies, which indicate a positive association of a high fat diet with prostatic carcinoma. | closed_qa |
Perforated peptic ulcer: is there a difference between Eastern Europe and Germany? | Ulcer surgery and the epidemiology of peptic ulcer perforation have changed considerably in recent decades.PATIENTS/ Within two prospective studies, 170 perforated peptic ulcer patients from 12 Eastern European centres and 37 patients from 11 German centres were analysed. The median age of patients was 43 years in the Copernicus study and 49 years in the MEDWIS study (P=n.s.), being higher for MEDWIS female patients (73 vs 53 years, respectively; P<0.05). Female patients made up 17% (29/170) of the Copernicus study and 35% (40/170) of the MEDWIS study (P<0.05). Twenty-three per cent (40/170) of patients in the Copernicus study and 54% (20/37) in the MEDWIS study had gastric ulcer perforation (P<0.001). The proportion of definitive operations was higher in Eastern Europe (41.1%; 67/163) than it was in Germany (16.1%; 5/31) (P<0.01). German patients experienced more general complications than Eastern European patients (35 vs 12%, respectively; P<0.01) and a higher mortality [13% (5/37) vs 2% (4/170), respectively; P<0.01]. Delayed admission>or =12 h and age>or =60 years remained predictors for complications in multivariate logistic regression analysis. | The proportion of both women and gastric ulcers was higher among German patients, while Eastern European patients underwent more definitive operations. German patients experienced more general complications and a higher mortality. Complications were related to high age and delayed admission. | closed_qa |
Are L5 fractures an indicator of metastasis? | To determine whether L5 vertebral body fractures are an indicator of malignancy. A retrospective study of L5 vertebral body fractures was carried out using plain radiographs, CT, and/or MRI. Over a 5-year period, 51 patients with L5 vertebral body fractures were seen at our institution. Since L1 vertebral body fractures are common, 51 age- and gender-matched (20 men, 31 women; mean age 60 years) patients with L fractures were utilized as the control group. The frequency of neoplastic infiltration of the vertebrae was compared between these two populations to determine whether pathologic fracture was more frequent at L5. Twelve (24%) of the L5 fractures were pathologic compared with four (8%) of the L1 fractures (chi-square test, P<0.05). Neoplasm types included multiple myeloma (n=4), prostate (n=3), breast (n=2), lung (n=2), melanoma (n=2), bladder, colon, and leukemia (each n=1). | Although most L5 fractures are not pathologic, there is an increased incidence of pathologic fractures in this location compared with L1. Therefore, a fracture of L5 should raise the suspicion of metastasis. | closed_qa |
Screening for HIV infection in genitourinary medicine clinics: a lost opportunity? | To examine the policy and practice of HIV testing in genitourinary medicine clinics in the United Kingdom. All 176 consultants in charge of genitourinary medicine clinics in the United Kingdom were sent a policy and practice questionnaire. A self selected group of 53 clinics conducted a retrospective case note survey of the first 100 patients seen in each clinic in 1998. Genitourinary medicine clinics in the United Kingdom. Consultants in charge of, and case notes of patients attending, genitourinary medicine clinics. None. Number of patients tested for HIV. Consultants' assessments of their rate of HIV testing often exceeded the actual rates of testing in the clinic as a whole. The majority of patients deemed to be at high risk requested an HIV test. The exception were heterosexuals who had lived in sub-Saharan Africa. Among attenders at high risk of HIV who did not request a test, 57/196 (29%) were not offered one by clinic staff. Two fifths (51/130) of consultants felt the proportion of patients tested in their clinic was too low. The commonest reason given for this was a lack of time, especially that of health advisers. | A substantial minority of people with HIV infection attending genitourinary medicine clinics fail to have their infection diagnosed. Two major reasons were identified. Firstly, a test was not always offered to those at high risk of HIV. Secondly, a lack of resources, mainly staff, which prevents some clinics from increasing their level of testing. | closed_qa |
Is the first post-operative day review necessary following uncomplicated phacoemulsification surgery? | To assess the necessity for first post-operative day review in determining the need for post-operative intervention in patients who had uncomplicated phacoemulsification surgery. A retrospective study was carried out to review the first post-operative day findings in patients who underwent uncomplicated phacoemulsification surgery by a single surgeon between January 1997 and March 1998. The findings analysed were wound integrity, corneal clarity, anterior chamber activity, intraocular pressure and the intraocular lens status. The need for medical or surgical intervention was also analysed. Those eyes that had coexisting ocular pathology such as glaucoma, ocular hypertension, uveitis, trauma or previous intraocular surgery were excluded from the study. Fisher's exact test was used to compare the difference between the groups. Seventy-one eyes of 71 patients who underwent an uncomplicated phacoemulsification procedure were included in the study. Intraocular pressure of 30 mmHg or greater was found in 7 eyes (10%), all of which also had corneal oedema. These patients received acetazolamide SR 250 mg twice daily for 3 days. Another 21 eyes (30%) had corneal oedema for which no specific treatment was given. The intraocular pressure had returned to baseline and corneal oedema resolved by the first clinic follow-up in 1-2 weeks. None of the 71 patients needed surgical intervention in the post-operative period. | First post-operative day review is necessary as it gives an opportunity to manage the post-operative rise in intraocular pressure. | closed_qa |
Oral contraceptives and epithelial ovarian cancer. Does dose matter? | To determine the risk of ovarian cancer among women who use low-estrogen-dose oral contraceptives. The study used data on white women under 70 years of age who had been enrolled in a population-based case-control study conducted between 1986 and 1988 in three western Washington counties. Women with ovarian cancer (n = 276) were ascertained through a population-based cancer registry, and controls (n = 391) were selected by random digit dialing. Unconditional logistic regression was used to estimate the risk of ovarian cancer associated with oral contraceptive use. After adjustment for age and parity, women who took oral contraceptives for at least three months were at decreased risk of ovarian cancer (odds ratio [OR] 0.8, 95% confidence interval [CI]0.5-1.1) relative to women who never used this form of contraception. The reduced risk of ovarian cancer was present among women whose only preparation contained a low (<50 micrograms ethinyl estradiol or<80 micrograms mestranol) (OR 0.6, 95% CI 0.3-1.1) and high (OR 0.8, 95% CI 0.5-1.2) estrogen dose. | While our results are limited in their statistical precision and by the inability of many subjects to recall the brands of oral contraceptives that they took, they suggest that the newer, low-estrogen-dose oral contraceptives confer a benefit regarding ovarian cancer risk similar to that conferred by earlier, high-estrogen-dose formulations. | closed_qa |
Descriptive terms for women attending antenatal clinics: mother knows best? | To determine the noun for 'women who attend antenatal clinics' that is most accepted by the women themselves. Cross sectional study. Consultant-led antenatal clinics in Cornwall. All women attending consultant-led antenatal clinics over a two-month period. The women were surveyed by written questionnaire. The first, second and third choices of descriptions offered to women attending antenatal clinics. Secondary outcome measures include the relation of maternal age, gestation, civil status, occupation and obstetric history to the individual's choice of description. Questionnaires were received from 446 women, constituting 13% of the antenatal population of Cornwall. Their median age was 28 years and median gestation 22 weeks; 255 (57%) had one or more children and 289 (65%) were married. The most popular choice of description was 'patient' (39% of first choices made), whereas the most accepted description was 'pregnant woman' (26% of totalled second and third choices). While women who selected 'patient' as first choice were slightly younger (mean 27.5 years) than the remaining women (mean 28.4 years), the choice of 'pregnant woman' was not related to any of the other recorded characteristics of the respondents. Commercial terms that consistently were selected least included 'client', 'consumer' and 'customer'. | Some professional bodies and government organisations have criticised the use of the term 'patient' to describe antenatal women. In this, the largest study to investigate what the women themselves would choose, 'patient' is the most favoured term. | closed_qa |
Does histological incomplete excision of cervical intraepithelial neoplasia following large loop excision of transformation zone increase recurrence rates? | To determine the risk of recurrent cervical intraepithelial neoplasia (CIN) in women with complete or incomplete excision of cervical intraepithelial neoplasia treated by large loop excision of transformation zone (LLETZ). A retrospective study One consultant-led colposcopy clinic at Leicester Royal Infirmary Three hundred and ninety-four women referred consecutively to the colposcopy clinic between 1991 and 1992. The histological recurrence rate of CIN, length of cytological follow up following treatment related to degree of completeness of excision at initial treatment. Three hundred and twenty-two women had complete cytological or histological follow up. The mean length of follow up was 73 months with a mean number of six smears. Women with incomplete excision of CIN had a significantly higher risk of recurrent CIN (relative risk 8.23) occurring in a significantly shorter time compared with women with complete excision. | This study demonstrates that large loop excision of transformation zone is successful in over 95% of cases. Cytological surveillance is satisfactory for follow up of women who have complete excision of CIN. Women with incomplete excision of CIN at initial LLETZ remain at significant risk of developing further CIN and long term colposcopic and cytological follow up is necessary. | closed_qa |
Mixed venous oxygen saturation during mobilization after cardiac surgery: are reflectance oximetry catheters reliable? | Oximetry catheters immediately reflect changes in mixed venous oxygen saturation (SvO2). We have used the Baxter 2-SAT system to register changes in SvO2 during early mobilizations after cardiac surgery. To assess catheter reliability, readings were compared to blood gases. A total of 352 paired catheter and bench haemoximetry measurements were obtained at the expected highest and lowest levels of SvO2 during the mobilization procedures. The agreement between methods was explored by a Bland-Altman plot. The influence of haemoglobin (Hgb), pH, cardiac output (CO), posture, catheter identity and catheter calibration on agreement was assessed through analysis of covariance. Data included a substantial number of low SvO2 values, 95 paired means of SvO2<or = 50% and 37 paired means<or = 40%. Mean oxygen saturation difference between catheter and haemoximeter readings was -1.6 +/- 5.7% (SD). Agreement between the methods depended upon the level of SvO2. At SvO2 of 65%, the two methods were virtually identical. Below 65%, the catheters increasingly underestimated the corresponding haemoximetric values by 1.5% for every 10% reduction in SvO2. Agreement was to some degree dependent on individual calibrations and catheter identity, but to a lesser extent on Hgb, CO and posture. | The two methods are interchangeable for most clinical purposes. Catheter readings are, however, substantially lower than the corresponding haemoximetric measurements at low SvO2 values. Careful interpretation of the absolute values resulting from catheter measurements is recommended, especially when SvO2 readings are low. | closed_qa |
Is the paternal mononuclear cells' immunization a successful treatment for recurrent spontaneous abortion? | Alloimmunization as a treatment for recurrent spontaneous abortion (RSA) is still controversial due to the lack of enough controls to evaluate its effectiveness. The present study was conducted to compare the live birth rate in the presence or absence of immunotherapy. Ninety-two women with RSA (79 primary [PA] and 13 secondary aborters[SA]) received immunotherapy. Thirty-seven RSA couples not receiving paternal alloimmunization, constituted the "control" group. The pregnancy rate in alloimmunized was 58 vs 46% in the control group. The live birth increased from 71% in the controls to 88% after immunotherapy. The alloimmunization induced mixed lymphocyte reaction blocking factors (MLR BFs) in 79% of women. However, they were also present in 83% of immunized women experiencing a new abortion. | These results indicate that alloimmunization may be useful in the treatment of RSA. | closed_qa |
Anionic PAMAM dendrimers rapidly cross adult rat intestine in vitro: a potential oral delivery system? | To investigate systematically the effect of polyamidoamine (PAMAM) dendrimer size, charge, and concentration on uptake and transport across the adult rat intestine in vitro using the everted rat intestinal sac system. Cationic PAMAM dendrimers (generations 3 and 4) and anionic PAMAM dendrimers (generations 2.5, 3.5, and 5.5) that were modified to include on average a single pendant amino group were radioiodinated using the Bolton and Hunter Reagent. 125I-Labelled dendrimers were incubated with everted sacs in vitro and the transfer of radioactivity into the tissue and serosal fluid was followed with time. The serosal transfer rates seen for all anionic generations were extremely high with Endocytic Indices (EI) in the range 3.4-4.4 microL/mg protein/h. The concentration-dependence of serosal transfer was linear over the dendrimer concentration range 10-100 microg/mL. For 125I-labelled generation 5.5 the rate of tissue uptake was higher (EI = 2.48+/-0.51 microL/mg protein/h) than seen for 125I-labelled generations 2.5 and 3.5 (0.6-0.7 microL/mg protein/h) (p<0.05). The 125I-labelled cationic PAMAM dendrimers (generations 3 and 4) displayed a tissue uptake (EI = 3.3-4.8 microL/mg protein/h) which was higher (p<0.05) than the rate of serosal transfer (EI = 2.3-2.7 microL/mg protein/h), probably due to nonspecific adsorption of cationic dendrimer to the mucosal surface. | As the anionic PAMAM dendrimers displayed serosal transfer rates that were faster than observed for other synthetic and natural macromolecules (including tomato lectin) studied in the everted sac system, these interesting nanoscale structures may have potential for further development as oral drug delivery systems. | closed_qa |
Are oral clefts a consequence of maternal hormone imbalance? | The causes of oral clefts (cleft lip with or without cleft palate, CL/P, and cleft palate alone, CP) have not been established. However, maternal intrauterine hormone profiles have been suspected of being involved. There is now substantial evidence that maternal hormone concentrations around the time of conception partially control the sexes of offspring. It is possible that the hormone profiles that control sex of offspring share features of the profiles suspected of causing clefts. This can be tested by examining the sex ratios (proportions male) of the unaffected sibs of probands. If these sex ratios are skewed in the same direction as that of probands, that suggests, ex hypothesi, maternal hormonal involvement in the causation of clefts. Accordingly, a search was made for data on the sex ratios of the unaffected sibs of probands with clefts. For reasons given in the text, this search was informal rather than based on electronic data retrieval systems. Nine papers were located giving sex ratios of sibs of probands with CL/P and CP. Published data suggest that the sibs of probands with CL/P have a significantly higher sex ratio than the sibs of probands with CP. Thus the sib sex ratios are skewed in the same direction as those of the probands themselves. In other words, parents (mothers) of CL/P patients apparently have a tendency to produce boys, and parents of CP patients to produce girls. | Accordingly, it is suggested that maternal hormone profiles may partially explain the unusual sex ratios (of probands and their sibs), as well as the malformations. | closed_qa |
Third party pharmacy audits: can they be improved? | To discuss issues surrounding the current auditing practices associated with third party insurance prescription claim programs. Audit examples obtained during the last 10 years associated with third party audit methodology. Many unattended issues are associated with third party pharmacy audits. Some issues for discussion are presented in an attempt to produce some possible solutions for the audit inequities. | National professional organizations, insurance companies, and payers need to convene and formulate fair auditing guidelines. | closed_qa |
Elective colonic operation and prosthetic repair of incisional hernia: does contamination contraindicate abdominal wall prosthesis use? | Wound infection and sepsis leading to incisional hernia development are common after emergency colonic operations. Later on, while being operated on to correct an incisional hernia, most of these patients will need colonic resection or bowel continuity reestablishment. Simultaneous treatment of incisional hernias in patients with colostomy or colonic disease remains a difficult challenge, considering the reluctance of most surgeons to treat both conditions at the same time, especially when prosthetic repair is needed. The aim of this study was to analyze the short-term results of patients undergoing colonic resection or bowel continuity reestablishment and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. Over a period of 6 years, 20 patients were operated on for colonic problems associated with incisional hernias, including 8 Hartmanns' colostomies, 6 colostomies or ileostomies with colonic mucous fistulas, 3 postoperative colocutaneous fistulas, a paracolostomic hernia, a Chagas' megacolon, and a pseudotumoral diverticulitis. A "rule of three" statistical analysis was used to estimate the maximum risk of adverse effects, concerning mesh-related morbidity, after 1- and 2-year followup. A major complication occurred in a patient who developed an anastomotic leakage and secondary wound infection; the patient was treated with parenteral nutrition and antibiotics. Other complications included a minor wound infection, a seroma, and a chronic sinus. One patient died from postoperative problems unrelated to the surgical technique. The occurrence of postoperative wound infection did not prevent mesh incorporation. Followup ranging from 1 to 7 years detected no hernia recurrences; 13 patients were followed for 2 years or more. Our results suggest that risk of mesh-related morbidity does not exceed 15.8% (3 of 19) within the first year and 23.1% (3 of 13) for 2 years followup, with 95% confidence. | We concluded that prosthetic repair of incisional hernias associated with simultaneous colonic operations was possible, allowing abdominal wall anatomy reestablishment. There is no reason to believe that abdominal wall prostheses must be avoided in contaminated operations when an adequate surgical technique is used. | closed_qa |
Are antibiotics necessary in the treatment of locally infected ingrown toenails? | A wide variety of generalists and specialists treat locally infected ingrown toenails, with perhaps the most common treatment regimen including resection of the nail border coupled with oral antibiotics. To determine whether oral antibiotic therapy is beneficial as an adjunct to the phenol chemical matrixectomy in the treatment of infected ingrown toenails. We prospectively enrolled healthy patients with infected ingrown toenails. Each patient was randomly assigned to 1 of 3 groups that received either 1 week of antibiotics and a chemical matrixectomy simultaneously (group 1), antibiotics for 1 week and then a matrixectomy (group 2), or a matrixectomy alone (group 3). Institutional ambulatory outpatient clinic. Fifty-four healthy patients with infected ingrown toenails were studied. Patients with immunocompromised states, peripheral vascular disease, or cellulitis proximal to the hallux interphalangeal joint were excluded. Groups were age matched for comparison. Mean healing times for groups 1, 2, and 3 were 1.9, 2.3, and 2.0 weeks, respectively. Subjects receiving antibiotics and a simultaneous chemical matrixectomy (group 1) healed significantly sooner than those receiving a 1-week course of antibiotics followed by a matrixectomy (group 2). There was not a significant difference in healing time between those that received a chemical matrixectomy alone (group 3) and those that received a matrixectomy coupled with a course of oral antibiotics (group 1). | The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity. | closed_qa |
Popliteal artery aneurysms: is endovascular reconstruction durable? | To describe an endovascular method of performing femoropopliteal in situ saphenous vein (SV) bypass and popliteal artery aneurysm (PAA) embolization. Twenty-two patients underwent PAA operations. Twelve patients had conventional SV bypasses with PAA proximal and distal ligation, whereas 10 underwent PAA embolization and an endovascular in situ SV bypass (EISB). The endovascular procedure was performed using an angioscopically guided side branch coil occlusion system. The PAAs were coil embolized under fluoroscopic surveillance. No deaths or wound complications occurred in the EISB group. The mean hospital length of stay (LOS) was 2.1 days. Seven EISB procedures were performed through 2 incisions, whereas 3 operations required an additional incision. One graft occluded at 3 months. All PAAs remained occluded by color-flow ultrasonography at follow-up ranging from 4 to 23 months (mean 13.6); cumulative primary patency was 89%. In the conventional bypass group, no deaths occurred, but 3 (25%) patients had wound complications. The mean LOS was 6.2 days, and 1 graft occluded, giving an 86% cumulative primary patency at 42 months. | This minimally invasive technique obviates an extensive incision to harvest the SV and ligate the PAA proximally and distally. If long-term endovascular bypass graft patency and PAA occlusion rates prove to be similar to open operative results, the benefits of reduced wound complications, decreased hospital LOS, and increased health care savings support further investigation of this endovascular approach for the treatment of PAA. | closed_qa |
Does APO epsilon4 correlate with MRI changes in Alzheimer's disease? | To assess the relation between APO E genotype and MRI white matter changes in Alzheimer's disease. The APO epsilon4 allele is correlated with amyloid angiopathy and other neuropathologies in Alzheimer's disease and could be associated with white matter changes. If so, there should be a dose effect. 104 patients with probable Alzheimer's disease (NINCDS-ADRDA criteria) in this Alzheimer's Disease Research Centre were studied. Patients received MRI and APO E genotyping by standardised protocols. Axial MRI was scored (modified Schelten's scale) for the presence and degree of white matter changes and atrophy in several regions by a neuroradiologist blinded to genotype. Total white matter and total atrophy scores were also generated. Data analysis included Pearson's correlation for regional and total imaging scores and analysis of variance (ANOVA) (or Kruskal-Wallis) and chi(2) for demographic and disease related variables. 30 patients had no epsilon4, 53 patients were heterozygous, and 21 patients were homozygous. The three groups did not differ in sex distribution, age of onset, age at MRI, MMSE, clinical dementia rating, or modified Hachinski ischaemia scores. There were no significant correlations between total or regional white matter scores and APO E genotype (Pearson correlation). | No correlation between total or regional white matter scores and APO E genotype was found. The pathogenesis of white matter changes in Alzheimer's disease may be independent of APO E genotype. | closed_qa |
Is sleep-disordered breathing an independent risk factor for hypertension in the general population (13,057 subjects)? | OBJECTIVES Sleep-disordered breathing has been hypothesized to have a close relationship with hypertension but previous studies have reported mixed results. This is an important health issue that requires further clarification because of the potential impact on the prevention and control of hypertension. The relationship between hypertension and three forms of sleep-disordered breathing (chronic snoring, breathing pauses and obstructive sleep apnea syndrome (OSAS)) was assessed using representative samples of the non-institutionalized population of the UK, Germany and Italy (159 million inhabitants). The samples were comprised of 13,057 individuals aged 15-100 years who were interviewed about their sleeping habits and their sleep symptoms over the telephone using the Sleep-EVAL system. OSAS was found in 1.9% (95% CI: 1.2% to 2.3%) of the UK sample, 1.8% (95% CI: 1.4% to 2.2%) of the German sample and 1.1% (95% CI: 0.8% to 1.4%) of the Italian sample. OSAS was an independent risk factor (odds ratio (OR): 9.7) for hypertension after controlling for possible confounding effects of age, gender, obesity, smoking, alcohol consumption, life stress, and, heart and renal disease. | Results from three of the most populated countries in Western Europe indicate that OSAS is an independent risk factor for hypertension. Snoring and breathing pauses during sleep appeared to be non-significant predictive factors. | closed_qa |
Sentinel lymph node biopsy: is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in-situ with microinvasion? | Axillary lymph node status is the strongest prognostic indicator of survival for women with breast cancer. The purpose of this study was to determine the incidence of sentinel node metastases in patients with high-risk ductal carcinoma-in-situ (DCIS) and DCIS with microinvasion (DCISM). From November 1997 to November 1999, all patients who underwent sentinel node biopsy for high-risk DCIS (n = 76) or DCISM (n = 31) were enrolled prospectively in our database. Patients with DCIS were considered high risk and were selected for sentinel lymph node biopsy if there was concern that an invasive component would be identified in the specimen obtained during the definitive surgery. Patients underwent intraoperative mapping that used both blue dye and radionuclide. Excised sentinel nodes were serially sectioned and were examined by hematoxylin and eosin and by immunohistochemistry. Of 76 patients with high-risk DCIS, 9 (12%) had positive sentinel nodes; 7 of 9 patients were positive for micrometastases only. Of 31 patients with DCISM, 3 (10%) had positive sentinel nodes. 2 of 3 were positive for micrometastases only. Six of nine patients with DCIS and three of three with DCISM and positive sentinel nodes had completion axillary dissection; one patient with DCIS had an additional positive node detected by conventional histological analysis. | This study documents a high incidence of lymph node micrometastases as detected by sentinel node biopsy in patients with high-risk DCIS and DCISM. Although the biological significance of breast cancer micrometastases remains unclear at this time, these findings suggest that sentinel node biopsy should be considered in patients with high-risk DCIS and DCISM. | closed_qa |
Residual area at risk after anterior myocardial infarction: are ST segment changes during coronary angioplasty a reliable indicator? | The aim of this study was to assess whether, after anterior myocardial infarction, ST segment changes during percutaneous transluminal coronary angioplasty (PTCA) of the left anterior descending coronary artery correlated with the amount of ischemic myocardium in the area at risk, measured with 99mTc-labeled sestamibi single-photon emission computed tomography (SPECT) during balloon inflation. Quantitative continuous monitoring of the ST segment was performed during PTCA of the left anterior descending coronary artery in 11 patients, and corresponding SPECT imaging was compared with a rest acquisition performed before PTCA. SPECT was quantified by a bull's-eye analysis according to main criteria: (1) the planimetered defect size during PTCA as an indicator of the size of the area at risk, (2) the change in the pathologic/normal area count ratio in the area at risk as an index of the severity of ischemia, and (3) the difference between the size of the defect during PTCA and at baseline. ST segment changes were correlated to the variation in pathologic/normal area count ratio (19% +/- 14%; r = 0.61; p<0.05) but not to the sizes of the scintigraphic defects. | ST segment changes induced by occlusion of the infarct-related coronary artery during PTCA are related mostly to the severity of ischemia rather than to the size of the area at risk. | closed_qa |
Are retrospective peer-review transfusion monitoring systems effective in reducing red blood cell utilization? | This research used a study-control group design and examined data collected from five hospitals to evaluate the effectiveness of retrospective peer-review systems on reducing utilization of red blood cells (RBCs). The effects of retrospective peer-review systems were studied in three parts: (1) trends of RBC utilization were compared by the slopes of linear regression lines that assessed the effect of time on RBC utilization among four study hospitals and one control hospital, (2) diagnosis-specific RBC utilization was compared between the control hospital and one matched study hospital, and (3) the effect of the retrospective review system of one study hospital was assessed by linear regression using data accumulated 1 year before and 2 years after implementation of the program. Three study hospitals showed no significant changes in RBC utilization during the 10-month study period. One study hospital and the control hospital demonstrated trends of reduced RBC use with negative slopes of regression lines; however, there was no difference in the degree of the two slopes, and the diagnosis-specific RBC utilization was not lower at the study hospital than at the control hospital. Furthermore, implementation of the retrospective peer-review system at one study hospital demonstrated no effect on RBC utilization. | We conclude that the retrospective peer-review systems implemented at these four hospitals had no effect on reducing red blood cell utilization. | closed_qa |
Expenditures on services for persons with acquired immunodeficiency syndrome under a Medicaid home and community-based waiver program. Are selection effects important? | In 1990, the state of Florida implemented an acquired immunodeficiency syndrome (AIDS)-specific Medicaid waiver program to provide home and community-based services to AIDS patients as an alternative to institutional care. The program is available to Medicaid beneficiaries with AIDS who are at risk of institutionalization. This study examines whether the waiver option was effective in reducing Medicaid expenditures per beneficiary during its first 2 years of operation. The authors used Medicaid claims data and county information on the availability of health services to model the selection of the waiver option by AIDS patients and then to estimate the effect of the waiver on expenditures controlling for nonrandom program selection. The results indicate that the selection model is highly significant, but that the influence of nonrandom selection on the estimation of the program effects is negligible. More importantly, the regression results indicate that persons with AIDS who use waiver services incur monthly Medicaid expenditures that are on average 22% to 27% lower than otherwise similar nonparticipants. | These results, based on the first 2 years that Project AIDS Care was operational, suggest that home and community-based care for AIDS patients results in lower expenditures per beneficiary. | closed_qa |
Psychiatry: an impossible profession? | To examine the disconcerting question as to whether psychiatry is a fully-fledged profession or not. A review of pertinent literature regarding the criteria of a profession, the vulnerability of psychiatry to abuse, and potential models for the proper practice of psychiatry. Psychiatry lost its professional anchorage entirely with its misuse to suppress dissent in the former Soviet Union and in the so-called euthanasia program in Nazi Germany. It remains vulnerable to abuse unless psychiatrists recognise the professional criteria they must satisfy. A new symbol, a humble stool, is proposed. Its, three legs represent the three equally significant dimensions of psychiatric practice: science, art and ethics. | Psychiatry just 'scrapes home' in constituting a profession but only subject to three provisos:namely (i) that psychiatrists appreciate the need to achieve a coherent body of special knowledge through a genuine creative process which necessarily results in uncomfortable tension from time to time; (ii) that we promote the art of psychiatry by cultivating an ethos of caring and sensitivity; and (iii) that we function within an articulated ethical framework with respect for codes of ethics as guidelines. | closed_qa |
Seasonal affective disorder in Australia: is photoperiod critical? | Seasonal affective disorder (SAD) is a variant of recurrent depression in which episodes are linked to a particular season, typically winter. SAD is understood as the extreme end of a continuum of seasonality in the general population. Photoperiod (the timing and duration of daylight) has been assumed to be aetiologically critical. The present research used a survey design to investigate the assumed centrality of photoperiod for SAD/seasonality in Australia. Two hypotheses were tested: that self-reported seasonality does not increase further from the equator and that seasonality does not stand alone from non-seasonal neurotic complaints. The sampling frame used was adult females on the Australian Twin Registry roll. A sample of 526 women residing across the latitudes of Australia responded to a survey based around the Seasonal Pattern Assessment Questionnaire (SPAQ). The SPAQ asks respondents to retrospectively report on season-related changes in mood and behaviour. The survey also contained three questionnaire measures of neurotic symptoms of anxiety and depression: the General Health Questionnaire (GHQ), the Community Epidemiological Survey for Depression (CES-D) and the State-Trait Anxiety Inventory-Trait (STAI-T). Self-reported seasonality did not correlated with latitude (r = 0.01, NS). On the other hand, a substantial relationship was found between seasonality and each of the measures of non-seasonal complaints: GHQ (r = 0.35, p<0.001); CES-D (r = 0.35, p<0.001); and STAI-T (r = 0.30, p<0.001). | Within the limitations of a design based on retrospective self-report, the findings of the present study suggest that the diathesis for SAD/seasonality may not be photoperiod-specific. At least in Australia, there is provisional support for the proposal that human seasonality may have a broader psychological component. The findings are discussed in terms of established research into normal mood, trait personality and non-seasonal depression. | closed_qa |
Is there an adult form of separation anxiety disorder? | The aim of this clinical report is to investigate whether symptoms of separation anxiety disorder can occur in adulthood. Three cases are described to illustrate that adults may experience: wide-ranging separation anxiety symptoms, such as extreme anxiety and fear, when separated from major attachment figures; avoidance of being alone; and fears that harm will befall those close to them. Symptoms of panic appeared to be secondary to separation anxiety, and none of the patients fulfilled criteria for dependent personality disorder. Group cognitive behavioural treatment focusing on preventing panic attacks and generalised anxiety did not appear to have an impact on core separation anxiety symptoms. Exacerbations of separation anxiety appeared to be closely linked to actual or threatened ruptures to primary bonds. | Separation anxiety disorder may be a neglected diagnosis in adulthood. Formal nosological systems such as the DSM may need to be revised to incorporate adult manifestations of the disorder. | closed_qa |
Is reperfusion injury an important cause of mucosal damage after porcine intestinal ischemia? | Intestinal ischemic injury is exacerbated by reperfusion in rodent and feline models because of xanthine oxidase-initiated reactive oxygen metabolite formation and neutrophil infiltration. Studies were conducted to determine the relevance of reperfusion injury in the juvenile pig, whose low levels of xanthine oxidase are similar to those of the human being. Ischemia was induced by means of complete mesenteric arterial occlusion, volvulus, or hemorrhagic shock. Injury was assessed by means of histologic examination and measurement of lipid peroxidation. In addition, myeloperoxidase, as a marker of neutrophil infiltration, and xanthine oxidase-xanthine dehydrogenase were measured. Significant ischemic injury was evident after 0.5 to 3 hours of complete mesenteric occlusion or 2 hours of shock or volvulus. In none of these models was the ischemic injury worsened by reperfusion. To maximize superoxide production, pigs were ventilated on 100% O2, but only limited reperfusion injury (1.2-fold increase in histologic grade) was noted. Xanthine oxidase-xanthine dehydrogenase levels were negligible (0.4 +/- 0.4 mU/gm). | Reperfusion injury may not play an important role in intestinal injury under conditions of complete mesenteric ischemia and low-flow states in the pig. This may result from low xanthine oxidase-xanthine dehydrogenase levels, which are similar to those found in the human being. | closed_qa |
Cutaneous nasal malignancies: is primary reconstruction safe? | The nose is particularly vulnerable to cutaneous malignancies, making it the most common location for presentation. Recurrence of these cutaneous lesions is not uncommon, often compromising the timing of nasal restoration. It is the purpose of this report to reexamine the safety of primary nasal reconstruction in selected patients. Seventy-one patients who underwent nasal reconstruction at The University of Texas M. D. Anderson Cancer Center between 1987 and 1995 were retrospectively reviewed. There were 35 men and 36 women with an average age of 60 years. All nasal reconstructions were performed for defects secondary to malignancies. Basal cell carcinoma was the most common lesion (n = 49), followed by squamous cell carcinoma (n = 10) and melanoma (n = 7), with five additional variable malignancies. The most common location of the cutaneous lesions was the nasal dorsum, and the forehead flap was the most common adjacent tissue used for reconstruction. Immediate reconstruction was performed for 42 of the basal cell carcinomas, 6 of the squamous cell carcinomas, 6 melanomas, and 3 other lesions. Delayed restoration was performed for 7 basal cell carcinomas, 4 squamous cell carcinomas, 1 melanoma, and 2 additional lesions. The average time between surgical extirpation and the start of nasal reconstruction was 8.2 months for basal cell carcinoma, 29 months for squamous cell carcinoma, and 10 months for melanoma. Twenty-six recurrent lesions were identified at an average of 36 months after extirpation. Despite these numbers, only three recurred after nasal reconstruction at our institution. Follow-up averaged 41 months, with none less than 1 year. Seventy patients are still alive with no evidence of disease. | Primary reconstruction is safe in selected patients. Surgical delay in reconstruction should be considered if margins are questionable, the pathology is determined to be aggressive, if there is perineural or deep bony invasion, or if postoperative radiotherapy is to be initiated. Nasal reconstruction ultimately is based upon a complex series of issues but can be performed with few complications in an effort to restore self-image. | closed_qa |
Cognitive impairment in medical inpatients. I: Screening for dementia--is history better than mental state? | evaluation of the short version of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and the Abbreviated Mental Test (AMT) as screening tools for dementia in medical inpatients. 201 patients over 65 were assessed. Assessment included administration of the AMT, a delirium screening instrument and a brief psychiatric interview. Relatives were interviewed and the IQCODE administered. Diagnostic and Statistical Manual (DSM) IIIR diagnoses of various causes of cognitive impairment were made. Sensitivity and specificity values of the screening tests for a DSM IIIR diagnosis of dementia were calculated. our study suggests that the IQCODE is more accurate than the AMT as a screening instrument for dementia. Using a cut-off point of>3.44, sensitivity and specificity of the IQCODE for diagnosing dementia were 100 and 86% respectively. Equivalent values for the AMT (cut-off point<8) were 96 and 73%. It was possible to use the IQCODE in eight of the 10 patients unable to complete the AMT. | using both the IQCODE and a brief cognitive function test when screening for dementia in medical inpatients will maximize the number of patients who can be screened. | closed_qa |
Are physicians less likely to recommend preventive services to low-SES patients? | Do low-SES adult patients visiting private primary care clinics differ from higher SES adult patients in their need for eight preventive services or in receiving either a recommendation for or the needed services? Randomly identified adult patients were surveyed within 2 weeks of a visit to 22 clinics in the Minneapolis-St. Paul area. Questions assessed patient recollection of the latest receipt of eight services and whether needed services had been recommended during the visit or received then soon after. Of those surveyed, 4,245 patients (1,650 low SES) responded (84.3%), showing that low SES patients were less likely to be up to date for cholesterol measurement, Pap smear, mammography, breast exam, and flu or pneumonia shots (P<0.004), but not for blood pressure measurement. Low-SES patients needing services received recommendations to have them and actually received them at the same rate as higher SES patients. | The 22 primary care clinics studied appear to be recommending and providing needed preventive services to visiting patients at the same rate regardless of income or insurance status. The reasons for differences in prevention status by SES are complex but the low proportion of all patients receiving recommendations for needed services suggests the need to take advantage of all visits for updating prevention needs. | closed_qa |
Does lateral lymph node dissection improve survival in rectal carcinoma? | The treatment of rectal carcinoma by lateral lymph node dissection has risks and benefits. Therefore, we investigated the therapeutic efficacy of lateral lymph node dissection. We studied 198 patients with rectal carcinoma who underwent lateral lymph node dissection. Metastases to the lymph nodes were examined by the clearing method. The incidence of urinary and male sexual dysfunction was determined by measuring the residual urine volume and individual interview 1 year after operation. The rate of metastasis to lateral lymph nodes was 11.1 percent, and metastasis to the lateral lymph nodes occurred more frequently with lower rectal carcinoma classified as pT3 or pT4 in the TNM system. The rate of local recurrence was 12.5 percent and the 5-year survival rate after curative resection was 70.1 percent. The 5-year survival rate in patients with metastasis to the lateral lymph nodes was 25.1 percent, and this rate was significantly lower than the 5-year survival rate of 74.3 percent in patients without metastasis to the lateral lymph nodes. Urinary dysfunction was observed in 67.5 percent of patients, and male sexual dysfunction was found in 97.4 percent of men younger than 60 years of age with prior sexual ability. | The prognosis for patients with metastasis to the lateral lymph nodes is poor, and the improvement in survival rate from lateral lymph node dissection is minimal. | closed_qa |
Axillary lymph node dissection: is it required in T1a breast cancer? | Several authors have questioned the need for axillary lymph node dissection in T1a breast cancer (primary tumors 5 mm or less in diameter), although current practice typically includes routine axillary lymph node dissection. We retrospectively reviewed the records of 2,242 breast cancers in our tumor registries from 1987 to 1994. The incidence of axillary lymph node metastases was determined according to primary breast cancer size. The objective was to determine the need for axillary lymph node dissection in T1a breast cancers, and our data included 74 T1a cancers. Axillary lymph node dissection was performed in 66 of these patients. Axillary lymph node metastases were found in 3 of 66 cases (4.5 percent). We also reviewed several other institutional series of T1a breast cancers and found no statistical difference in the reported axillary lymph node metastases and our data (p<.10). The combined single-institution data included 256 T1a breast cancers and had a 3.9 percent incidence of axillary lymph node metastases. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute published data statistically different from ours. From 1977 to 1982, 339 T1a lesions had a 21 percent incidence of axillary lymph node metastases (p<.005), and from 1983 to 1987, 1,491 T1a lesions had an 11 percent metastatic rate (p<.001). We believe that the SEER data is flawed, because SEER results do not require histologic confirmation of axillary lymph node status. | We believe the single-institution rate of 3.9 percent axillary lymph node metastases in T1a breast tumors results from state-of-the-art breast cancer screening and detection of earlier and smaller lesions. Our data support abandoning routine axillary lymph node dissection in T1a breast cancer. | closed_qa |
Pain treatment after thoracotomy: is it a special problem? | Although it is frequently stated in the literature that thoracotomy is one of the most painful operative incisions, few data supporting this view are available. Patients' postoperative pain experience can be assessed on the basis of their usage of patient-controlled analgesia. In a prospective trial the daily self-administered doses of analgesics in 55 patients within the first 4 days after posterolateral thoractomy were compared with those in 30 patients for the same number of days after median laparotomy. The visual analog scale was used as a second measure to evaluate postoperative pain. On the basis of patient-controlled analgesia usage on the first postoperative day and the visual analog scale score for the first 2 days, a small but significant difference between the two patient groups was found which showed that thoracotomy is less painful than median laparotomy. | The common belief that posterolateral thoracotomy is a very painful operative access is not true. Therefore it is not necessary to use special techniques for postthoracotomy pain relief in these patients. Patient-controlled analgesia is sufficient for pain relief after major thoracic or abdominal incisions. | closed_qa |
Do general practitioners act consistently in real practice when they meet the same patient twice? | To assess the variation within individual general practitioners facing the same problem twice in actual practice under unbiased conditions. General practitioners were consulted during normal surgery hours by a standardised patient portraying a patient with angina pectoris. Six weeks later the same general practitioners were consulted again by a similar standardised patient portraying a similar case. The patients reported on the consultations. Trondheim, Norway. Of 87 general practitioners invited by letter, 28 (32%) agreed to participate without hesitation; nine others (10%) wanted more information before consenting. From these 24 were selected and visited. Number of actions undertaken from a guideline in both rounds of consultations. Duration of consultations. The mean (range, interquartile range) guideline score, total score, and duration of consultation were not significantly different between the first and second patient encounters for the group as a whole. For individual doctors the mean (SD) difference was -0.09 (3.36) for the guideline score, 0.30 (8.1) for the total score, and -0.87 (9.01) for consultation time. | The study shows that assessment of performance in real practice for a group of general practitioners is consistent from the first round of consultations to the second round. However, significant variation occurs in performance of individual physicians. | closed_qa |
Can androgen deprivation with leuprolide be predicted from histology alone? | Androgen deprivation therapy with analogues of luteinizing hormone-releasing hormone produces distinctive histological changes in neoplastic and nonneoplastic prostate tissue. Others have described these features in cases in which treatment status was known. To our knowledge the specificity and sensitivity of luteinizing hormone-releasing hormone effects based only on histology and possible reasons for interobserver variation have not been addressed previously. Slides from 97 prostatectomies performed in a 3-year period were reviewed by 2 observers blinded to knowledge of previous hormonal treatment. The observers evaluated each case, recording the presence or absence of 14 features associated with androgen deprivation therapy, and then made an overall assessment regarding treatment status. Of the 97 patients 31 had received androgen deprivation therapy with the luteinizing hormone-releasing hormone agonist leuprolide. A luteinizing hormone-releasing hormone effect was identified by the 2 observers in 26 and 28, respectively, of the 31 cases (83.9 versus 90.3% sensitivity and 92.4 versus 80.3% specificity). Including focal changes as consistent with androgen deprivation therapy increased sensitivity but decreased specificity. Of the 14 features 12 had a significant association for predicting treatment status. | Interobserver variations in interpretation occurred although both examiners were experienced in the evaluation of luteinizing hormone-releasing hormone effects and they used exactly the same criteria. These variations were apparently due to differences in the value (mental weight) given by each observer to the features assessed in each case. Predicting treatment status was optimized by noting a luteinizing hormone-releasing hormone effect only when changes were diffuse, improving specificity significantly with only a modest decrease in sensitivity. | closed_qa |
On-site HIV testing in resource-poor settings: is one rapid test enough? | To determine the feasibility, accuracy and cost-effectiveness of a rapid, on-site, HIV testing strategy in a rural hospital, and to assess its impact on test turnaround time and the proportion of patients post-test counselled. Prospective comparison of two testing strategies [double rapid test on-site versus central enzyme-linked immunosorbent assay (ELISA)-based testing], and an economic evaluation. Hlabisa Hospital, a rural South African district hospital. A total of 454 consecutive adult inpatients requiring and consenting to HIV testing as part of their clinical management. Concordance between rapid tests, and between the rapid and ELISA strategies, test turnaround time, proportion of patients post-test counselled, and cost-effectiveness. HIV seroprevalence was 49.6%. Both rapid tests were concordant in all patients [one-sided 95% confidence interval (CI) of probability, 99.3-100]. The rapid strategy was 100% sensitive (95% CI, 97.9-100) and 99.6% specific (95% CI, 97.2-100) compared with the ELISA strategy. The mean interval between ordering a test and post-test counselling fell from 21 days prior to the introduction of the rapid test strategy to 4.6 days after its introduction (P<0.00001). The proportion of patients post-test counselled increased to 96% from 17% after the introduction of the rapid test strategy (P<0.00001). By using a double rapid test strategy the cost per patient post-test counselled was almost halved to US$ 11. Accuracy of the rapid strategy was not substantially increased by performing two tests. | In high prevalence, resource-poor settings, rapid, on-site HIV testing is feasible, accurate and highly cost-effective, substantially increasing the number of patients post-test counselled. A single rapid test may be sufficient. | closed_qa |
Experimental free muscle transplantation. Is autologous graft on the distal esophagus viable? | Experimental free muscle transplantation has resulted in some successful clinical applications.AIM: The possibility that this type of transplantation could act as a sphincteric mechanism motivated us to start by assessing the viability of autologous skeletal grafts on the distal esophagus of laboratory animals. Twenty transplants of previously denervated free plantaris muscle grafted on the distal esophagus of Sprague-Dawley rats were evaluated at the 1st, 2nd, 4th, 8th and 16th posttransplant week. Histological and histochemical studies were performed to evaluate general features of the grafts and the muscle fibers condition. One and two weeks after transplant the grafts show large areas of necrosis with inflammatory infiltrate. Between the 2nd and the 4th week, as revascularization and motor endplates become significant, the areas of necrosis begin to regress and they almost disappear by the 8th week. Since the 4th week after transplant, regenerated muscle fibers demonstrate morphological and biochemical features similar to normal. | Experimental free plantaris muscle transplantation on the distal esophagus is viable and shows revascularized and reinnervated muscle fibers from the 8th week after transplant on, and at least until the 16th. These fibers have the structural and metabolic properties enabling contractile function. This original model may allow further investigation of some features related to pathophysiology and therapy of gastroesophageal reflux. | closed_qa |
Do physicians' strikes influence the utilization profile of hospital emergency services? | To assess the differences in appropriateness of consultations and demographic outline of people attended in a hospital emergency facility (HEP) along the hospital physicians strike period in spring 1995. Observational cross-sectional study in Health Area 1 in the province of Badajoz. 8964 patients assisted along the strike period were compared with 8024 attended in the same period of 1994 (no strike). The patients average was 169.13 (SD 27.35) a day in the strike period, during the control period this mean was 151.39 (SD 19.78) patients a day (p<0.001). Demographic variables of patients were similar in both groups, with similar mean ages and gender proportion in all age and residence site groups. Most of patients went to the HEF self-promoted (70.1% and 65.8%) and without ambulance (92% and 90.8%) in both periods (strike and control). The outcome of medical care was home discharge in 85.35% during the strike period and 83.81% in the control period, with admission rates of 13.1% and 14.15% (p<0.01). | There are no significant differences in the HEF use features completely explained by the physicians strike. | closed_qa |
Does immunoglobulin interfere with the immunogenicity to Pasteur Mérieux inactivated hepatitis A vaccine? | The aim of this study was to compare the immunogenicity of Pasteur Mérieux (P.M. s.v.) inactivated hepatitis A vaccine when given alone with its immunogenicity when given in combination with immunoglobulin. We enrolled 80 healthy volunteers who were seronegative for anti-HAV. Forty subjects (group A) were given two doses of vaccine at 0 and 6 months plus 4 ml of immunoglobulin given simultaneously with the first vaccine injection; and 40 subjects (group B) were given vaccine alone. The population characteristics (age, sex, height and weight) of the two groups were comparable. Anti-HAV antibody was detectable at week 1 in 100% of group A and in 5.7% of group B, and in 100% of both groups at 4 and 8 weeks. Seroconversion rates (>or = 20 mIU/ml) were 97.4% in group A and 100% in group B at week 24 and were 100% in both groups 4 weeks after a booster injection at 6 months. The antibody response level was lower after concomitant administration of vaccine with immunoglobulin. The antibody geometric mean titer was higher at week 1 in subjects who had been given vaccine and immunoglobulin, but nearly 50% lower at week 4 and thereafter, indicating inhibition of the vaccine-induced immune response by immunoglobulin. At week 28, i.e. 4 weeks after the booster injection, geometric mean titers had increased about 13-15 times in both groups, reaching highly protective antibody levels (3351 mIU/ml in group A and 5843 mIU/ml in group B). No serious adverse effects were observed during the follow-up. | These data indicate that P.M. s.v. hepatitis A vaccine is highly immunogenic and safe, even when given simultaneously with immunoglobulin. Despite the interference of the immunoglobulin with the active immune response, individuals who were immunized passively plus actively also developed high titers of anti-HAV antibody. It is therefore reasonable to expect that this inhibition will not affect the overall protection conferred by the vaccine. | closed_qa |
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