instruction
stringlengths 10
664
| context
stringlengths 1
5.66k
| response
stringlengths 1
3.34k
| category
stringclasses 1
value |
|---|---|---|---|
Does pretreatment with omeprazole decrease the chance of eradication of Helicobacter pylori in peptic ulcer patients? | It has been reported that pretreatment with omeprazole could decrease the efficacy of Helicobacter pylori eradication. Our aim was to compare the efficacy, safety, and tolerability of the eradicating regimen, omeprazole/amoxicillin/metronidazole. The two antibiotics were scheduled either during the first or during the last 2 wk of omeprazole administration. In this prospective controlled study conducted in a single center, 78 symptomatic peptic ulcer patients were treated for 4 wk with omeprazole 40 mg o.m.; the patients were randomly assigned to receive amoxicillin 1 g t.i.d. postprandially and metronidazole 250 mg t.i.d. postprandially, either during the first 2 wk (group A, n = 40) or the last 2 wk of therapy with omeprazole (group B, n = 38). H. pylori status was assessed by culture, histology, urease test, and IgG antibodies. Each patient's course was followed for 1 yr. H. pylori infection was cured in 97.4% of group A (95% CI: 0.84-0.99) and in 89% of group B (95% CI: 0.73-0.96, p = 0.28). Healing was achieved in 80% of the patients in group A (95% CI: 0.63-0.90) and in 75.7% of patients in group B (95% CI: 0.60-0.90, p = 0.60) At 12-month follow-up, 72 patients were evaluated: 37/38 (97%) of patients in group A and 33/33 (100%) in group B were confirmed as cured of the infection (NS). Peptic ulcer healing rate reached 100% in the two groups. Furthermore, between the two groups, there were no significant differences in symptom relief or improvement. Both regimens were well tolerated, and no patient had to be withdrawn from therapy because of an adverse event. Minor side-effects appeared to be similar in the two groups (40% vs. 38%). | This randomized study clearly indicates that omeprazole pretreatment does not significantly reduce the efficacy of eradicating therapy for H. pylori in peptic ulcer patients. | closed_qa |
Is atelectasis following aortocoronary bypass related to temperature? | To determine the frequency of acute postoperative atelectasis in patients undergoing aortocoronary bypass with either normothermic (warm) or hypothermic (cold) technique. Prospective, randomized study comparing two groups. University-affiliated hospital. Three hundred thirty-one patients (166 cold and 165 warm) undergoing isolated aortocoronary bypass. Chest radiographs were obtained preoperatively, on the day of surgery, and subsequently as clinically indicated until discharge from the hospital. Radiologist (blinded to the patient allocation into warm or cold group) scored the atelectasis from 0 to 3 based on its severity. Regression analysis was used to determine if there was any difference in the atelectasis scores between the two groups. Mean daily postoperative atelectasis scores were not different between the cold and warm groups. The number of patients requiring chest radiographs was similar in both groups. The percent of patients with abnormal chest radiographs was similar in both groups. | The temperature of cardioplegia has no effect on the development of atelectasis following aortocoronary bypass, and therefore temperature-related cold injury is not a major cause of atelectasis following this type of surgery. | closed_qa |
Clinically recognized cardiac dysfunction: an independent determinant of mortality among critically ill patients. Is there a role for serial measurement of cardiac troponin I? | To determine the relative importance of clinically recognized cardiac dysfunction and unrecognized cardiac injury to hospital mortality. Prospective, blinded, single-center study. Medical ICU of Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. Two hundred sixty adult patients requiring admission to the medical ICU. Daily blood collection. The presence of cardiac dysfunction (myocardial infarction, unstable angina, cardiac arrest, or congestive heart failure) as determined by the physicians responsible for the care of the patient. Daily measurement of levels of cardiac troponin I, a sensitive, highly specific, and long-lived marker of myocardial injury. Fifty-five (21.2%) patients had clinical evidence of cardiac dysfunction, among whom 22 (40%) had an elevated level of cardiac troponin I. A total of 41 (15.8%) patients had evidence of acute myocardial injury based on elevated levels of cardiac troponin I. Patients with clinically recognized cardiac dysfunction had a significantly greater hospital mortality rate compared to patients without clinically recognized cardiac dysfunction (45.5% vs 10.2%; p<0.001). Similarly, patients with elevated blood levels of cardiac troponin I had a greater hospital mortality rate compared to patients without elevated blood levels of cardiac troponin I (26.8% vs 16.0%; p = 0.095). Multiple logistic-regression analysis controlling for potential confounding variables demonstrated that the presence of clinically recognized cardiac dysfunction was independently associated with hospital mortality (adjusted odds ratio = 3.0; 95% confidence interval = 1.9 to 4.8; p = 0.016). However, having an elevated blood level of cardiac troponin I was not found to be an independent determinant of hospital mortality. | Among critically ill medical patients, clinically recognized cardiac dysfunction is an independent determinant of hospital mortality. The identification of unrecognized cardiac injury, using serial measurements of cardiac troponin I, did not independently contribute to the prediction of hospital mortality. | closed_qa |
Immunosuppressive therapy: a potential alternative to bone marrow transplantation as initial therapy for acquired severe aplastic anemia in childhood? | Currently bone marrow transplantation (BMT) with an HLA-identical sibling donor is recommended as optimal therapy for children with acquired severe aplastic anemia (SAA). Immunosuppressive therapy (IST) has become a very successful initial therapy for SAA in children lacking a related bone marrow donor. We wished to evaluate whether current IST regimens may be as efficacious as BMT. A retrospective review identified children treated for SAA over a 12-year period. Children with a related donor received a BMT. Children lacking a donor were treated with IST followed by a "rescue" BMT if IST was ineffective. IST consisted of anti-thymocyte globulin and steroid +/- cyclosporine A. Transfusion independence and survival rates were compared between the two groups. Twenty-seven children were identified. Nine received a related BMT; seven of these survive and are transfusion independent (median follow-up 54 months). Sixteen of 18 patients who received IST are transfusion-independent survivors, including three of four patients who received a rescue BMT (median follow-up 33.5 months). Actuarial survival is 75% (95% CI = 45%, 105%) and 92% (95% CI = 78%, 107%) for the BMT and IST groups, respectively (p = 0.15). Severe toxicity was not experienced by any patient as a result of IST. | Equivalent rates of transfusion independence and survival were experienced by patients receiving BMT and IST. We propose that a prospective trial be undertaken to evaluate IST as initial therapy in all children with SAA, to be followed by BMT if there is inadequate response. | closed_qa |
Postsclerotherapy pigmentation. Is serum ferritin level an accurate indicator? | Human beings have suffered and sought treatment for disease of veins as early as the recordings of the old testament. The use of irritating sclerosing agents have been and are widely used today to treat varicose veins and telangiectasia. One of the most common and cosmetically significant side effects of sclerosing agents is varying degrees of hyperpigmentation. It has been reported that elevated serum ferritin level plays a role in this postsclerotherapy pigmentation. To support or negate the possibility of a direct correlation between serum ferritin levels and pigmentation postsclerotherapy using for our investigation a patient with hemochromatosis. A patient with hemochromatosis having a serum ferritin level of 1200 was treated for spider veins. Clinical and histologic studies were performed pretreatment and posttreatment. There was no clinically apparent hyperpigmentation noted on the patient after sclerotherapy over a 6-month period. Histology reports revealed macrophagic pigmentation both pretreatment and posttreatment. | Our results do not confirm the theory that lab values of elevated serum ferritin correlate with pigmentation postsclerotherapy. Further study of the correlation between postsclerotic pigmentation and serum ferritin levels are needed. One would anticipate that if a true correlation existed, then an extreme case such as this would clearly support this theory. | closed_qa |
Development of tympanosclerosis: can predicting factors be identified? | The etiological hypothesis is that there might be factors triggering an immunological chain reaction that eventually leads to tympanosclerosis formation. Tympanosclerosis is a condition leading to a calcification process in the middle ear and, occasionally, also to the lining of the inner ear. This sometimes leads to hearing loss due to fixation of the middle ear ossicles. In severe cases. deafness may occur as a result of the inner ear impairment. Surgery is the treatment offered, often with poor long-term results, and, alternatively, prescription of hearing aids. Some patients develop tympanosclerosis after mild inflammatory otitis media processes whereas some heal without tympanosclerosis after more aggressive infections. This difference may be due to individual variations in the inflammatory response. The biological mechanism of calcification in tympanosclerosis is probably similar to that occurring in other calcifying tissues due to diseases. The present investigation was performed to develop methods for immunohistochemical analyses of this delicate tissue consisting of both hard bone and the very thin tympanic membrane. Sprague-Dawley rats were inoculated with a suspension of Streptococcus pneumoniae, type 3, into the middle ear and sacrificed after 1 week up to 6 months. A new technique was elaborated where the whole specimen was prefixed briefly and then en bloc incubated with the primary antibodies and after that decalcified in edetic acid (EDTA). Primary antibodies against macrophages were used for the immunohistochemical staining. Acute otitis media was successfully induced in the rats and myringosclerosis was seen in 30% of the animals, often localized close to the bony frame where macrophages could also be detected. | Acute otitis media and myringosclerosis were introduced in the animals. Conventional immunological techniques were tested on this delicate tissue. A new method for immunohistochemical staining was elaborated in which specimens were stained en bloc before decalcification and sectioning were performed. Expression of macrophages was demonstrated in the tympanic membrane. | closed_qa |
Can final EMG baseline be used as a reference to calculate neuromuscular recovery? | Investigations recording recovery times of muscle relaxants have used initial or final baseline of a neuromuscular trace, or both, as a reference for data analysis. We evaluated the use of final baseline of EMG traces as a reliable reference to calculate recovery times. We analyzed EMG traces from 82 children who had full spontaneous neuromuscular recovery following a single dose of mivacurium. Times from administration of mivacurium to 25, 50, 75, and 90% EMG recoveries were measured using both initial and final baselines as a reference. EMG traces with final baseline of 100 +/- 10% of the initial baseline were regarded as optimal. Recovery times from all other traces were compared to the times obtained from these optimal traces. Poor final baseline was defined as that of<80% of initial baseline. Inter-group comparisons were made using Kruskal-Wallis test followed by Mann-Whitney U tests. EMG recovery times were similar for optimal traces whether the reference was the initial or the final baseline of the EMG trace. If the final baseline was used as the reference, then traces with poor final EMG baseline also showed similar neuromuscular recovery times. If the initial baseline was used as the reference for EMG traces with poor final baseline, then neuromuscular recovery times became 24-55% longer (P<0.05). | We conclude that the final baseline of an EMG trace can be used as a reference for calculations of neuromuscular recovery times following a bolus injection of mivacurium. | closed_qa |
Surgery of the thoracic aorta using deep hypothermic total circulatory arrest. Are there neurological consequences other than frank cerebral defects? | Deep hypothermic total circulatory arrest has reduced primary morbidity and mortality in thoracic aortic surgery. Although frank neurological deficits have been proven to be a rare complication of this technique, the rate of subtle but irreversible neuropsychological disorders remains unknown. A total of 23 patients (15 male, 8 female) who had undergone surgery for dissection or aneurysm of the thoracic aorta using deep hypothermic total circulatory arrest (mean 25.5 min, range 10-75 min) were studied retrospectively. The mean follow-up was 17 months. The following psychometric tests were conducted: a computer-based test battery to assess tonic alertness and sustained attention, the trail making test (TMT part A and B), the Münchner Gedächtnistest and a verbal learning test. In addition, a cerebral dopamine D2 receptor scintigraphy (using the SPECT technique) was performed. For comparison, 10 healthy subjects were studied. With regard to tonic alertness, 69.6 and 30.4% were below the 50th and 10th centiles, respectively, according to age- and education-corrected standard values. The impairment in sustained attention correlated significantly with the duration of the circulatory arrest. On the tests assessing short-term memory, the patients scored 30% below their age- and education-corrected peers. In terms of long-term memory, 60.9 and 39.1% of the patients were below one and two standard deviations, respectively. Concerning speed of information processing whilst 78.3% of the patients were below the 50th and 21.7% below the 10th centile. Indicative of some persistent and functional brain alteration, the dopamine D2 receptor binding was significantly reduced when compared with healthy subjects. | These data prove a substantial and chronic reduction of higher cognitive function in some of the patients who underwent cardiac surgery using deep hypothermic total circulatory arrest; this was accompanied by a depression of the cerebral dopamine D2 receptor binding. | closed_qa |
Are pulmonary homografts subjected to pulmonary hypertension more appropriate for aortic valve replacement than normal pulmonary homografts? | To compare the function in aortic position of cryopreserved pulmonary homografts subjected to pulmonary hypertension with that of normal cryopreserved pulmonary homografts. Pulmonary valves (52) were implanted in aortic position in different cardiothoracic centres. The valves were classified as follows: Group I-pulmonary hypertension (procured from recipients of heart/heart-lung transplantation, 31 valves), Group II-normal pulmonary pressure (procured from cadavers and multiorgan donors, 21 valves). Regular echocardiographic follow-up was obtained by the implanting centers. Significant echo changes were defined as insufficiency>2+ and/or stenosis producing a delta P>30 mm Hg. Pulmonary homografts showed the following significant echo changes: in the Pulmonary Hypertension Group, 7, 27 and 33% at 12, 24 and 36 months, respectively; in the normal PA Group 10, 37.5 and 80% at 12, 24 and 36 months, respectively. In both groups the most common echocardiographic alteration was homograft insufficiency rather than stenosis. Thus, pulmonary homografts subjected to long-term pulmonary hypertension have significantly less echo changes than normal pulmonary homografts, especially after 12 months (chi 2: P<0.036). | These findings suggest that pulmonary valves subjected to pulmonary hypertension might be more appropriate than normal pulmonary homograft for aortic valve replacement, constituting a possible alternative in case of lack of aortic valve homografts. However, the failure of two out of five valves in the longer term must dictate caution while waiting further long-term results. | closed_qa |
Is the arterial switch operation still a challenge in small centers? | In the last years, major changes as regards timing for operation, surgical technique, and perioperative care determined a great improvement in the arterial switch operation (ASO) allowing excellent mid-term results in a few leading centers. This stimulated the widespread adoption of ASO as procedure of choice for transposition of the great arteries (TGA), even in small institutions. We reviewed our early experience with ASO in an attempt to evaluate its safety in a small center. Since April 1992, 39 consecutive patients underwent TGA repair by ASO in our department. There were 27 patients with simple TGA, 8 with TGA and VSD and 4 with Taussig-Bing heart and aortic coarctation. Median age and weight at operation were 7 days and 3.5 kg, respectively. Neonatal repair was performed in 34 patients. In accordance with the Planché coronary classification, type I was encountered in 21 patients, type II in 4 and type III in 14. Several modifications of the original technique were used, mainly regarding coronary relocation, pulmonary artery reconstruction and approaches for associated VSD closure and aortic arch repair. Early mortality was 2.6% (n = 1), the only operative death being related to unsatisfactory coronary relocation. Since modified ultrafiltration was adopted, mean ICU stay decreased from 5 +/- 4 days (n = 21) to 2 +/- 1 days (n = 17) (P<0.05). Three patients required reoperation for residual ASD and/or VSD closure. There were no late deaths. After a mean follow-up of 26 +/- 15 months all survivors are thriving and are currently asymptomatic. | Although this series is rather small, most of the major coronary anomalies and complex anatomic associations were encountered. This experience suggests that neonatal repair of TGA by ASO can be safely accomplished even in small centers. Modified ultrafiltration appears to improve the early outcome of neonates undergoing ASO. | closed_qa |
Phosphatidylcholine coated chest drains: are they better than conventional drains after open heart surgery? | Inadequate thoracic drainage after open heart surgery has serious deleterious consequences. Thrombus formation within the chest drains is primarily responsible for the occlusion of chest drains. Chest drains coated with derivatives of phosphatidylcholine (PC), commonest phospholipid on cell membranes, potentially have a less thrombogenic surface. In a prospective randomised double blind study, we compared PC-coated drains (Group I, n = 25) with non coated drains (Group II, n = 26) after open heart surgery. Drain performance, post-operative complications and clinical course were compared. PC-coated drains had a significantly shorter period of drainage, 20.4 +/- 1.0 versus 28.9 +/- 3.7 h (P<0.05). Otherwise, mean volume drained, number clots removed from drain and the ease of drainage of the two types of drains were similar. There were no significant differences in the incidence of post-operative pericardial effusions, dysrhythmias, ambulation time and hospital stay. | We conclude that the PC coated drains may be of importance in cases where prolonged drainage is anticipated otherwise they have no significant advantage. | closed_qa |
Does modification of the Innsbruck and the Glasgow Coma Scales improve their ability to predict functional outcome? | The accurate prediction of functional outcome requires the development of multivariate models. To enhance their contribution to such models, the predictive power of each component must be optimized. To improve the predictive power of coma scales as the first step in building more sophisticated multivariate models to predict specific levels of functional outcome. Prospective descriptive study. Neurology and neurosurgery intensive care unit (NNICU) in a tertiary care academic center. Eighty-four patients with acute traumatic brain injury, intracerebral hemorrhage, subarachnoid hemorrhage, or ischemic stroke. None. The Glasgow Coma Scale (GCS) and Innsbruck Coma Scale (ICS) were administered within 24 hours of admission to the NNICU and then at 48-hour intervals until discharge of the patient from the NNICU. The assessments were performed by 3 occupational therapy graduate students working under the supervision of the medical director of the NNICU. The functional outcome at 3 months after discharge from the hospital was assessed by telephone by the same nurse using the following categories: (1) dead, (2) receiving nursing home or custodial care, (3) home with help, or (4) independent. Cronbach's alpha estimates of reliability for each scale were computed using all scores obtained during the study. The analyses indicated that the verbal response item of the GCS and the oral automatisms item of the ICS were less reliable in this patient population. The scales were modified by deleting those items, and predictive validity for the original and modified scales was computed using a discriminant function of the admission scores. Before modification, both scales were best at predicting independence (GCS and ICS, 71% correct) and mortality (GCS, 60% correct; ICS, 56% correct). The modifications produced a modest improvement in the ability of both scales to better predict levels of outcome (modified GCS: home with help, 33% correct, independent, 71% correct; modified ICS: home with help, 0% correct, independent, 74% correct). | By deleting items with low reliability from the ICS and the GCS we achieved improved reliability and predictive validity. The improvement in predictive power, however, was inadequate to accurately predict functional outcome. Combining clinical scales with other demographic, physiological, functional, and radiographic data will be needed to achieve useful predictions of functional outcome. | closed_qa |
Is parathyroid hormone-related protein a sensitive serum marker in advanced breast cancer? | To compare already used serum markers in advanced breast cancer, namely erythrocyte sedimentation rate (ESR), carcino-embryonic antigen (CEA), and polymorphic epithelial mucins (e.g. CA15-3) with a newer potential marker: parathyroid hormone related protein (PTHrP). A study group of 33 patients of proven advanced breast cancer was compared with 11 patients with benign breast lumps who were undergoing surgery, and eight patients with humoral hypercalcaemia of malignancy of non-breast origin. ESR, CA15-3, CEA, PTHrP, parathormone (PTH), liver and renal function were measured using commercially available kits. Using given reference ranges, results were classified into normal versus abnormal, and univariate statistical comparisons were made using Fisher's exact test. For multivariate analysis, absolute serum levels were used, and multivariate logistic regression models were employed. By univariate analysis, only CA15-3 (P = 0.007), and CEA (P = 0.004), were significant markers of metastatic disease. By multivariate analysis the only independently significant serum marker was CA15-3 (P = 0.043). PTHrP was neither a sensitive (22%) nor specific (90.1%) serum marker when compared to CEA or CA15-3. ESR was the most sensitive single serum marker (93%). An incidental finding of elevations of serum parathormone was found in as many patients as in the study group as there were elevations of PTHrP. | PTHrP would not have revealed any patients with metastatic disease that would not have been predicted by any existing tumour markers including CA15-3, CEA and ESR. The finding of elevated PTH in as many patients as PTHrP indicates the possible need for a study inclusive of other polypeptide hormones as markers in advanced breast cancer. | closed_qa |
Defensive testing in Dutch family practice. Is the grass greener on the other side of the ocean? | Ordering laboratory tests and diagnostic imaging can be part of the defensive behavior of the physician. How often does this occur in family practice in the Netherlands? Defensive behavior is defined as a clear deviation from the family physician's usual behavior and from what is considered to be good practice in order to prevent complaints or criticism by the patient or the patient's family. Over a 1-year period, 1989-1990, 16 family physicians in 11 practices with 31,343 patients recorded all episodes of care involving an order for laboratory tests or diagnostic imaging or both (n = 8897). The physicians selected one or more reasons to order each test from a fixed list of clinical considerations. In addition, they recorded whether they acted defensively for every test order. The participating physicians reported that some degree of defensive medicine was associated with 27% of all test orders. Defensive testing varied with the clinical reasons to order a test: the wish to exclude a disease or to reassure the patient was a much stronger motive for defensive testing than the intention to confirm a diagnosis or to screen. Defensive tests generally resulted in fewer abnormal findings. | Defensive testing is an important phenomenon in Dutch family practice: it forms a well-defined element of practice despite the variations implicit in the different clinical reasons to order a test. Defensive testing is associated with a lower probability of finding an abnormal test result. The analysis of family physicians' clinical reasons for ordering tests becomes more meaningful when defensive testing is included. | closed_qa |
Is screening of Australian blood donors for HTLV-I necessary? | To re-examine the 1992 decision by Australian Red Cross for its blood banks to screen blood donors for antibody to human T-cell lymphotropic virus type I (HTLV-I) by determining the risk of its transmission by blood transfusion. Data on patterns of return behaviour by repeat blood donors in Victoria were modelled to deduce the number of donors giving repeat donations in Australia from March 1993 to December 1995. Data on annual donor and issued cellular blood products from 1992 to 1995 were obtained from national Red Cross statistics. From the numbers of donations given by repeat donors, together with the number of new donors, the number tested for HTLV-I was deduced. The number and characteristics of donors screened positive for HTLV-I antibody were collated. The crude prevalence of HTLV-I was calculated by dividing the number of donors with HTLV-I by the total number of donors (repeat donors and new donors). The incidence of HTLV-I was calculated by dividing the number of seroconversions in repeat donors by the cumulative period of donor exposure. Sixteen homologous and five autologous donors were found to be positive for HTLV-I; none seroconverted and no clear risk factors for HTLV-I were identified. The prevalence of HTLV-I in Australian donors is 1 in 100,000 and the incidence less than 1 in 1 million person-years. In the absence of HTLV-I screening, the calculated risk of a transfused patient developing HTLV-I infection is 1 in 370,000, with a risk of developing HTLV-I disease of 1 in 9 to 15 million. | Three possible future courses of action for screening for HTLV-I are to screen every donation, to screen only new donors or to discontinue screening altogether. Using the information in this study, public discussion should be encouraged to assist stakeholders to agree on an acceptable level of risk and an appropriate level of screening for HTLV-I in Australia. | closed_qa |
Could a satellite-based navigation system (GPS) be used to assess the physical activity of individuals on earth? | To test whether the Global Positioning System (GPS) could be potentially useful to assess the velocity of walking and running in humans. A young man was equipped with a GPS receptor while walking running and cycling at various velocity on an athletic track. The speed of displacement assessed by GPS, was compared to that directly measured by chronometry (76 tests). In walking and running conditions (from 2-20 km/h) as well as cycling conditions (from 20-40 km/h), there was a significant relationship between the speed assessed by GPS and that actually measured (r = 0.99, P<0.0001) with little bias in the prediction of velocity. The overall error of prediction (s.d. of difference) averaged +/-0.8 km/h. | The GPS technique appears very promising for speed assessment although the relative accuracy at walking speed is still insufficient for research purposes. It may be improved by using differential GPS measurement. | closed_qa |
Can frontotemporal dementia and Alzheimer's disease be differentiated using a brief battery of tests? | To compare the performance of patients with frontotemporal dementia (FTD) and Alzheimer's disease (AD) on a range of simple neuropsychological tests. A battery of neuropsychological tests easily applied at the bedside, consisting of traditional tests of memory, attention and executive function, were given together with tests of motor sequencing and examination of frontal release signs. In addition, we devised a theoretically motivated test of dual attention-a story with distraction which also contained a 'social dilemma'. Specialist memory and cognitive disorders clinic. 12 patients with FTD and 12 patients with AD, matched for overall level of dementia on the Mini-Mental State Examination, were selected. In general, the difference in results between FTD and AD patients was small. However, a composite score derived from the presence of a grasp and pout reflex, the number of perseverations during category fluency for animals and response to the social dilemma within the two stories produced a sensitivity of 83.3% and specificity of 91.6%. There was also a highly significant difference between patients with FTD and AD in scores achieved on the Clinical Dementia Rating Scale reflecting the marked change in behaviour that patients with FTD suffer, even at a stage when memory functions are well preserved. | Traditional neuropsychological tests were poor at differentiating cases of FTD and AD; however, a composite (SIFTD) score appears potentially useful but requires prospective validation. Better methods of assessing the changes in comportment that characterize the early stages of FTD are required. | closed_qa |
Physical activity and body composition in 10 year old French children: linkages with nutritional intake? | To investigate the relationships between physical activity, dietary intake and body composition in children. A cross-sectional study on physical activity, nutritional intakes and body composition conducted in 86 healthy 10 y old French children. In addition, growth parameters and nutritional intakes were available from the age of 10 months. Physical activity level (using a validated activity questionnaire over the past year), nutritional intake (dietary history method), anthropometric measurements (body weight, height, arm circumference, triceps and subscapular skinfolds, Body Mass Index (BMI), arm muscle and arm fat areas calculated from these measurements) at the age of 10 y. Anthropometric measurements and nutritional intakes were recorded in the same children at the age of 10 months and every 2 y from the age of 2 y. At the age of 10 y, active children ingested significantly more energy than less active children, mostly due to higher energy intake at breakfast and in the afternoon. This higher energy intake was accounted for by increased consumption of carbohydrates (281 g vs 246 g; 49.6% vs 47.4% of total energy). Even if the amounts of fat consumed were similar in both groups (90 g vs 84 g; P = 0.09), the percentage of fat intake was lower in active children (35.4% vs 37.4%; P = 0.04). The percentage of protein was not different (14.9% vs 15.3%; P = 0.33). In spite of a higher energy intake in the active group, active and less active children had similar BMI at the age of 10 y. However, their body composition differed significantly: active children had a higher proportion of fat-free mass, a lower proportion of fat-mass as measured in the arm and they had a later adiposity rebound. Fatness was significantly and positively associated with the time spent watching television and video games. | Physical activity was associated with improved body composition and growth pattern. This association may be related to nutritional changes: active children consumed more energy by increasing carbohydrate, thus reducing the relative fat content of their diet. These results provide support to encourage physical activity during childhood. | closed_qa |
Is walking for exercise too exhausting for obese women? | As exhaustion and pain during walking seem to be common problems among obese women, we decided to analyse the relative oxygen cost (% VO2max) in obese women during level walking. Fifty-seven obese female outpatients, 44.1 +/- 10.7 y, BMI 37.1 +/- 3.4 kg.m-2. Walking tests at a self-selected, comfortable speed were performed indoors. Speed was measured with a speedometer, oxygen consumption (VO2) with the argon-dilution method and oxygen cost was estimated. Heart rate was measured; perceived exertion and pain were assessed with Borg's Category Ratio scale, CR10. Maximum oxygen uptake (VO2max/kg) was predicted from a submaximum bicycle ergometry test. The women walked more slowly, 70.9 +/- 5.6 m.min-1 (P<0.0001), and had higher VO2, 1.2 +/- 0.2 l.min-1 (P<0.001), than normals. A majority experienced exertion and some experienced pain. Their VO2max/kg, 21.2 +/- 5.0 ml.kg-1.min-1, was less than for normals (P<0.0001). The mean % VO2max during walking was 56%, which was higher than in normal subjects 36% (P<0.0001). Significant correlations between % VO2max and VO2max/kg (P<0.0001), heart rate during walking (P = 0.0009) and age (P = 0.0081), respectively, were found. | Very low VO2max/kg in obese women, rather than severe obesity per se, seems the most important factor to cause high % VO2max during walking. This might explain why many obese women perceive the exertion to be excessive and cannot follow the advice of their clinicians to exercise through long and brisk walks. | closed_qa |
Abnormal cholangiograms during laparoscopic cholecystectomy. Is treatment always necessary? | Laparoscopic common bile duct exploration (LCBDE) is more expensive and time consuming than its conventional counterpart. Therefore, it should only be performed when there is near certainty that stones are present. The purpose of this study was to identify patients who should be spared LCBDE despite an abnormal intraoperative cholangiogram. Of 700 consecutive laparoscopic cholecystectomies performed between 1989 and 1994 by a single surgeon (R.J.F.), 41 had abnormal intraoperative cholangiograms (6%). All 41 patients were treated by either immediate CBDE (19) (conventional or laparoscopic) or had postoperative follow-up cholangiograms (22). The patients were retrospectively assigned to one of three groups. Group I patients had a single "soft" indicator of choledocholithiasis. Group II patients had one or more of the following: (1) a highly suspicious abnormal intraoperative cholangiogram, (2) two or more "soft" indicators of choledocholithiasis, or (3) preoperative clinical findings such as elevated liver function studies or positive preoperative radiological studies. Group III patients had proven choledocholithiasis. In group I, there were 11 patients, none of whom underwent immediate CBDE. Eight of the 11 (73%) had normal follow-up cholangiograms due to either spontaneous stone passage or a false-positive intraoperative cholangiogram. There were 27 patients in group II; 19 underwent immediate CBDE with 100% stone recovery. The remaining 8 had delayed treatment and in five stones were recovered, while three had normal postoperative cholangiograms suggesting spontaneous stone passage. In group III, all three had negative follow-up cholangiograms despite proven choledocholithiasis. Spontaneous stone passage in this group seemed highly likely. | The finding of a single soft indicator results in a low rate of stone recovery postoperatively, and these patients should not undergo LCBDE. In this series, spontaneous stone passage seemed highly likely in at least 3/22 (14%) and possibly as high as 14/22 (64%). | closed_qa |
Does routine follow up after head injury help? | To evaluate the Medical Disability Society's 1988 recommendation that "every patient attending hospital after a head injury should be registered and offered an outpatient follow up appointment" by determining whether offering a routine follow up service to patients presenting to hospital with a head injury of any severity affects outcome six months later. A randomised controlled trial design with masked assessment of outcome. A mixed rural and urban health district with a population of about 560000. 1156 consecutive patients resident in Oxfordshire aged between 16 and 65 years presenting over 13 months to accident and emergency departments or admitted to hospital and diagnosed as having a head injury of any severity, including those with other injuries. Patients were registered and randomised to one of two groups. Both groups continued to receive the standard service offered by the hospitals. The early follow up group were approached at 7-10 days after injury and offered additional information, advice, support, and further intervention as needed. All randomised patients were approached for follow up assessment six months after injury by independent clinicians blind to their group. Validated questionnaires were used to elicit ratings of post-concussion symptoms (the Rivermead postconcussion symptoms questionnaire), and changes in work, relationships, leisure, social, and domestic activities (the Rivermead head injury follow up questionnaire). The two groups were comparable at randomisation. Data was obtained at six months on 226 of 577 "control" patients and 252 of 579 "trial" patients (59% were lost to follow up). There were no significant differences overall between the trial and control groups at follow up, but subgroup analysis of the patients with moderate or severe head injuries (posttraumatic amnesia>or = one hour, or admitted to hospital), showed that those in the early intervention group had significantly fewer difficulties with everyday activities (P = 0.03). | The results from the 41% of patients followed up do not support the recommendation of offering a routine follow up to all patients with head injury, but they do suggest that routine follow up is most likely to be beneficial to patients with moderate or severe head injuries. Some of those with less severe injuries do continue to experience difficulties and need access to services. A further trial is under way to test these conclusions. | closed_qa |
Is there a specific trauma precipitating anorexia nervosa? | The aims of this study were to explore the role of life events and difficulties in the onset of anorexia nervosa and bulimia nervosa and to find out whether events and difficulties with a specific meaning, i.e. those of a certain sexual nature, are important in the onset of anorexia nervosa. Seventy-two patients with anorexia nervosa (AN) and 29 with bulimia nervosa (BN) were assessed with the life events and difficulties schedule (Brown&Harris, 1978), the year before onset was studied. A new dimension to measure specific meaning of life events and difficulties called 'pudicity' was developed. Subjects from two community cohorts were used as comparison groups (Brown&Harris, 1978; Andrews et al. 1990). Anorexic patients, bulimic patients and community controls did not differ in proportion of patients with at least one severe event; however, significantly more AN and BN patients than community controls had experienced a major difficulty. Sixty-seven per cent of anorexics and 76% of bulimia nervosa patients had either a severe event or a marked difficulty during the year before onset. In AN and BN the most common serious life stresses before onset concerned close relationships with family and friends with BN patients being significantly more often than AN patients directly involved in the problem (interpersonal events). Patients with anorexia nervosa had significantly more pudicity events before onset than BN patients or community controls. | While serious life stresses commonly precede the onset of anorexia nervosa and bulimia nervosa, problems with sexuality seem to be specific in triggering the onset of anorexia nervosa. | closed_qa |
Stressful life events and genetic liability to major depression: genetic control of exposure to the environment? | Although overwhelming evidence suggests that genetic and environmental risk factors both contribute to the aetiology of major depression (MD), we know little of how these two risk factor domains inter-relate. In particular, can the genetic liability to MD increase the risk of experiencing stressful life events (SLEs)? Using discrete time survival analysis in a population-based sample of 2164 female twins, we examined whether the risks for nine personal and three aggregate network SLEs were predicted by the level of genetic liability to MD, indexed by the lifetime history of MD in monozygotic and dizygotic co-twins. Genetic liability to MD was associated with a significantly increased risk for six personal SLEs (assault, serious marital problems, divorce/breakup, job loss, serious illness and major financial problems) and one network SLE (trouble getting along with relatives/friends). This effect was not due to SLEs occurring during depressive episodes. Similar results were found using structural equation twin modelling. In contrast to the pattern observed with MD, the genetic liability to alcoholism impacted on the risk for being robbed and having trouble with the law. | In women, genetic risk factors for MD increase the probability of experiencing SLEs in the interpersonal and occupational/financial domains. Genes can probably impact on the risk for psychiatric illness by causing individuals to select themselves into high risk environments. | closed_qa |
Is the clinical course of HIV-1 changing? | To assess whether the clinical course of HIV infection has changed from 1985 to 1995. Cohort Study. Infectious disease clinic. 285 patients recruited from September 1985 to January 1995 with<or = 12 months between the dates of their last seronegative and first seropositive test result and with first follow up visit in the six months after seroconversion and at least 12 months' follow up. Patients were grouped according to the date of seroconversion. Time to CD4 cell count of<500, 400, and 200 x 10(6) cells/l, and clinical outcome defining AIDS; variation in cell count per day between consecutive visits, and ratio between this variation and time from estimated date of seroconversion at each visit. The groups were similar in age, number with acute primary HIV infection, CD4 cell count at intake, and cell count at the beginning of antiretroviral treatment; they differed in sex ratio, risk factors for HIV, probability of CD4 cell decline to<500, 400, and 200 x 10(6) cells/l. and risk of developing AIDS. Acute infection, seroconversion after December 1989, and serum beta 2 microglobulin>296 nmol/l were independent predictors of poor clinical course. The speed of CD4 cell decline, expressed as cell variation divided by the number of days between consecutive visits, increased with more recent seroconversion (P = 0.02). Ratio between the speed of CD4 cell decline and time from estimated date of seroconversion at each visit was also higher in the patients who seroconverted after December 1989. | The faster disease progression and the higher speed of CD4 cell decline at early stages in the patients with recently acquired HIV infection suggest changes in the clinical course of HIV infection. | closed_qa |
Twenty years of childhood coeliac disease in The Netherlands: a rapidly increasing incidence? | The incidence of coeliac disease varies internationally. To assess the incidence of childhood coeliac disease in The Netherlands and to study the clinical features and the presence of associated disorders. Identified cases of childhood coeliac disease in The Netherlands in 1993-4 by means of the Dutch Paediatric Surveillance Unit. Inclusion criteria were born in The Netherlands, diagnosed with at least one biopsy of the small bowel in 1993-4 and age at diagnosis 0-14 years. The data were cross checked by the Dutch Network and National Database of Pathology and compared with data from a previous study on childhood coeliac disease, 1975-90. A total of 193 coeliac patients were identified by means of the Surveillance Unit, another 20 through the National Database of Pathology. The mean crude incidence rate of diagnosed childhood coeliac disease was 0.54/1000 live births, which is in the range of rates found in other western European countries and significantly higher than the mean crude incidence rate of 0.18/1000 live births found in The Netherlands in 1975-90. The clinical presentation was classic: chronic diarrhoea, abdominal distension, and growth failure. Associated disorders were present in 11.7% of the cases. | The incidence of diagnosed childhood coeliac disease in The Netherlands seems to have increased significantly during the past few years. In a period of 20 years no significant changes could be found in the clinical picture at preentation of coeliac disease in Dutch children. | closed_qa |
Glucocorticoid replacement therapy: are patients over treated and does it matter? | Adequate assessment of patients on glucocorticoid replacement therapy is of great importance to avoid the consequences of under or over treatment, but no simple test is available for this. The aims of this study were (1) to assess adequacy of glucocorticoid replacement in hypoadrenal patients, (2) to correlate serum cortisol levels (cortisol day curve) with 24-hour urine free cortisol excretion and (3) to assess the impact of glucocorticoid dose optimization on markers of bone formation and bone resorption. Cross-sectional study of current replacement therapy and a prospective study of the effect of dose alteration on bone turnover markers. Thirty-two consecutive patients on replacement glucocorticoid therapy (12 Addison's disease, 20 hypopituitarism) from a University teaching hospital out-patient department. Serum and urinary cortisol, osteocalcin, N-telopeptide of type I collagen (NTX) and bone mineral density. 28/32 (88%) patients required a change of therapy; 24/32 (75%) a total reduction in dose, 18/32 (56%) a change in replacement therapy regimen or drug and 14/32 (44%) both changes. The mean daily dose of hydrocortisone was reduced from 29.5 +/- 1.2 to 20.8 +/- 1.0 mg. A significant correlation was found between peak cortisol and 24-hour urine free cortisol/ creatinine (Spearman correlation r = 0.60, P<0.0001; n = 51). Following hydrocortisone dose reduction, median osteocalcin increased from 16.7 micrograms/l (range 8.2-65.7) to 19.9 micrograms/l (8.2-56.3); P<0.01, with no change in the NTX/creatinine ratio. | A high proportion of patients on conventional corticosteroid replacement therapy are over treated or on inappropriate replacement regimens. To reduce the long term risk of osteoporosis, corticosteroid replacement therapy should be individually assessed and over replacement avoided. | closed_qa |
Do school-based health centers improve adolescents' access to health care, health status, and risk-taking behavior? | The purpose of this investigation was to assess the School-Based Adolescent Health Care Program, which provided comprehensive health-related services in 24 school-based health centers. The outcomes evaluation compared a cohort of students attending 19 participating schools and a national sample of urban youths, using logit models to control for observed differences between the two groups of youths. Outcome measures included self-reports concerning health center utilization, use of other health care providers, knowledge of key health facts, substance use, sexual activity, contraceptive use, pregnancies and births, and health status. The health centers increased students' access to health care and improved their health knowledge. However, the estimated impacts on health status and risky behaviors were inconsistent, and most were small and not statistically significant. | School-based health centers can increase students' health knowledge and access to health-related services, but more intensive or different services are needed if they are to significantly reduce risk-taking behaviors. | closed_qa |
Dislocated multiple fragment fractures of the head of the humerus. Does dislocation of the humeral head fragment signify a worse prognosis? | The vascularity of the articular fragment is of key importance for the final outcome in three- and four-part fractures of the humeral head. Displacement of the articular segment may compromise the arterial blood supply to the humeral head and result in avascular necrosis. There is still controversy as to whether three-and four-part fracture dislocations (articular fragment outside the glenoid) have an even worse prognosis than displaced three- and four-part fractures. Between January 1985 and May 1993, 102 patients with three- and four-part fractures of the humeral head were treated by ORIF (mostly tension band wiring) at our institution. In a retrospective study we analysed the functional (Constant 100 point score) and radiological outcome of 67 (66%) of these patients. There were 21 patients with fracture dislocations (FD), n = 5 type B2X, n = 5 type B3X, n = 3 type C2X, n = 8 type C3X, according to the classification of Habermeyer [7]. The "X" represents the dislocation of the articular fragment, whereas the classification to each type is done after reduction of the head. The remaining 46 patients presented with displaced, but not dislocated, three- and four-part fractures (DF), n = 24 type B2, n = 7 type B3, n = 3 type C2, n = 12 type C3. Average follow-up was 25 months (7-72 months). Patients with FD were significantly younger (average age 50 years) than patients with DF (average age 63 years, P<0.05) and showed a significantly higher incidence of traumatic nerve or plexus lesions (FD 19%, DF 2%, P<0.05). Concerning the functional results, there was no statistically significant difference between the two groups. The FD patients even showed a slight tendency to better results than patients with DF. This was true for the three-part fractures (average Constant score 78 versus 67 points), as well as for the four-part fractures (average Constant score 62 versus 55 points). The significantly younger age of the FD patients may explain their better results. The entire group of patients with three-part fractures showed a significantly better functional outcome (average Constant score 68 points) than patients with four-part fractures (average Constant score 55 points, P<0.05). The rate of partial and total avascular necrosis of the humeral head was strongly correlated to the fracture type (number of fragments, fracture of the anatomical or surgical neck, according to the classification of Habermeyer),but again there was no difference between the FD and DF group (B2X: 20%, B3X: 20%, C2X: 33%, C3X: 63%; B2: 25%, B3: 29%, C2: 33%, C3: 67%). Astonishingly, the FD were not associated with an increased rate of avascular necrosis of the humeral head. Three (axillary nerve) out of the five observed primary nerve and plexus lesions had a full neurological recovery after 6-12 months; the two patients with alterations of the brachial plexus showed a slow tendency of improvement at follow-up (12 and 18 months), but still had gross muscular atrophy and impaired sensory function. | In displaced three-and four-part fractures of the humeral head the dislocation of the articular segment does not seem to increase the risk of avascular necrosis, if treated by timely and careful ORIF with respect to the vascularity. Even with the increased risk of primary nerve and plexus lesions in fracture dislocations, good functional results can be achieved by early operative nerve decompression and fracture stabilization in this middle-aged patient group. However, older patients with displaced or dislocated four-fragment fractures through the anatomical neck (type C3) have a poor chance of a favourable outcome, and therefore primary prosthetic replacement should be considered. | closed_qa |
Is there a relationship between vaccination coverage and pediatric health care? | The aims of this study were to evaluate the relationship between pediatric health care visits and immunization coverage. The study was made in a rural health care center. All of the children between 3 months and 14 years old were included. The data were obtained directly from their clinical histories. The quality of the health care visits was evaluated according to the fulfillment of A.E.P. patterns of health care. We observed that 87% of infants, 74% of preschool children and 74% of school children were correctly vaccinated. We observed a significantly lower (p<0.05) coverage of the MMR vaccine in respect to the first three doses of DPT and OPV vaccines; and the coverage of OPV and DT at 6 years old was even lower. The quality of health care visits was good in 67% of infants, 10% of preschool children and 12% of school children. There was a relationship between incomplete vaccinations and missed visits (p<0.001) and also with low quality health care visits (p<0.001). | We conclude that there is a significant relationship between missed visits and low quality health care visits with delayed immunization. | closed_qa |
Is hyperglycaemia an independent predictor of poor outcome after acute stroke? | To determine whether raised plasma glucose concentration independently influences outcome after acute stroke or is a stress response reflecting increased stroke severity. Long-term follow up study of patients admitted to an acute stroke unit. Western Infirmary, Glasgow. 811 patients with acute stroke confirmed by computed tomography. Analysis was restricted to the 750 non-diabetic patients. Survival time and placement three months after stroke. 645 patients (86%) had ischaemic stroke and 105 patients (14%) haemorrhagic stroke. Cox's proportional hazards modelling with stratification according to Oxfordshire Community Stroke Project categories identified increased age (relative hazard 1.36 per decade; 95% confidence interval 1.21 to 1.53), haemorrhagic stroke (relative hazard 1.67; 1.22 to 2.28), time to resolution of symptoms>72 hours (relative hazard 2.15; 1.15 to 4.05), and hyperglycaemia (relative hazard 1.87; 1.43 to 2.45) as predictors of mortality. The effect of glucose concentration on survival was greatest in the first month. | Plasma glucose concentration above 8 mmol/l after acute stroke predicts a poor prognosis after correcting for age, stroke severity, and stroke subtype. Raised plasma glucose concentration is therefore unlikely to be solely a stress response and should arguably be treated actively. A randomised trial is warranted. | closed_qa |
Multiple frequent recurrences in superficial transitional cell carcinoma of the bladder: is survival compromised by a conservative management strategy? | To examine whether a strategy of bladder conservation is reasonable in patients with multiple frequent superficial recurrences of transitional cell carcinoma (TCC) of the bladder. Fifty-four patients with pTa/pT1. G1/G2 tumours at diagnosis, with five or more recurrences at two or more cystoscopies within 2 years of diagnosis and a minimum follow-up of 4 years were identified. The patients were categorized according to outcome, i.e. disease settled, continuing high-activity disease and disease progression. Forty-four patients did not progress, of whom 16 continued to have high-activity disease and 28 settled to a lower disease activity. One patient had a cystectomy for superficial disease. Nine patients progressed, six with muscle invasion in the bladder and three elsewhere in the urinary tract. Neither grade nor stage were predictive of recurrence. All but one of the patients with progression had both multicentric tumours at diagnosis and a positive cystoscopy at 3 months. Three patients died from their bladder cancer. | A policy of endoscopic resections and intravesical chemotherapy or bacille-Calmette-Guèrin, with cystectomy reserved until muscle-invasive disease develops, does not significantly compromise survival in patients with high-activity superficial TCC. Cystectomy for superficial disease is rarely necessary. | closed_qa |
Acute epididymitis in boys: are antibiotics indicated? | To report the results of using supportive therapy only, rather than antibiotics, in managing boys with acute sterile epididymitis. From 1991 to 1995, 48 boys presented with acute epididymitis. The diagnosis was confirmed by radionuclide scan in 43 cases, ultrasonography in one, surgical exploration in one and physical examination in three. Urine was collected for microscopy and culture: if pyuria was detected, antibiotics were prescribed. If the urine analysis was normal, the patient was advised to minimize physical activity and analgesics were prescribed. Of the 48 boys, five (10%) had pyuria; seven patients with either no urine tested or negative urine culture were given antibiotics. The remaining 36 were managed with supportive therapy only. The mean follow-up was 87 days (with three patients lost to follow-up). No boys showed any evidence of testicular atrophy or other complications. | Only a minority of boys with acute epididymitis, as defined by increased flow on radionuclide scanning of the scrotum, have a bacterial aetiology. For those without pyuria or positive urine culture, the condition is self-limiting and does not lead to testicular atrophy. We recommend that for boys with acute epididymitis who have no urinary abnormalities, antibiotics are not indicated. The aetiology of acute sterile epididymitis in boys remains obscure. | closed_qa |
Does aging mean a better life for women? | To study 10-year changes in selected quality of life dimensions in a cohort of aging Eastern Finnish women. Ten-year follow-up of a representative population sample. The county of Kuopio in Eastern Finland. In 1982, a representative sample (n = 296) of 50 to 60-year-old women was examined in the FIN-MONICA study. Ten years later, 241 of the participants were re-examined. Self-administered questionnaires were used to collect the data. Self-rated health, self-rated physical fitness, frequency of leisure time physical activity, functional capacity, reported symptoms, occurrence of diseases, and satisfaction with family life and economic situation were measured. In 1992, total life satisfaction at that moment and 5 years earlier were also assessed. The self-rated health assessment remained unchanged. During the 10 years from 1982 to 1992, the proportion of women who reported diagnosed cardiopulmonary diseases increased; angina pectoris, in particular, increased from 6% to 20%. However, even though their running ability had decreased, the number of women rating their physical fitness as good or fairly good increased from 23% to 32%. The participants reported significantly less headache and feelings of exhaustion than they had 10 years earlier. Average satisfaction with their economic situation increased, and satisfaction with family life remained the same. Thirty-seven percent of the women rated their current life situation as better than 5 years previously, 29% felt that it had remained the same, and 34% indicated that it had become worse during the past 5 years. | These data suggest that some quality of life dimensions may improve during aging in postmenopausal women. | closed_qa |
Postpemphigus acanthomata: a sign of clinical activity? | Pemphigus is a group of vesiculobullous disorders in which the blisters usually heal with hyper or hypopigmentation. The appearance of acanthomata at sites of previous blisters has been noted in some cases. All cases of pemphigus admitted to the Madras Medical College hospitals during a 2-year period from March 1993 to March 1995 were taken into the study and screened for the presence of acanthomata. Fifty-two cases of pemphigus were identified, 47 of pemphigus vulgaris and five of pemphigus foliaceus; and of these 13 developed acanthomata when the blisters healed. Ten of these cases were of pemphigus vulgaris and three were of pemphigus foliaceus; biopsy of these lesions showed hyperkeratosis, acanthosis, papillomatosis, and intraepidermal clefting. Immunofluorescence carried out in two of these acanthomata also showed intercellular fluorescence. | The occurrence of acanthomata in healed lesions of pemphigus is not uncommon; because histopathologic and immunofluorescence evidence of disease activity is present, cases of this sort require careful follow-up. | closed_qa |
Does arterial hypotension due to cardiogenic shock in older patients lead to functional oliguria or to acute renal failure? | Reports indicate some differences in the outcome of prolonged arterial hypotension due to cardiogenic shock: acute renal failure in older and more often functional oliguria in younger patients. The aim of the study is to analyze prolonged hypotension due to acute myocardial infarction in older and younger patients and to answer the question: does prolonged hypotension, due to acute myocardial infarction, lead to acute renal failure or to functional oliguria in older patients. During a 10-year observation, a study of 11 older (>65 years) and 7 younger patients (<65 years), suffering from acute myocardial infarction and cardiogenic shock, is presented: clinical data and laboratory: diuresis, sodium in urine, creatinine urine/plasma ratio, urine osmolality, osmolality urine/plasma ratio, renal failure index and fractional excretion of filtered sodium. In 7 older and 5 younger patients, natriuresis indicated acute renal failure. The ratio of creatinine in urine and plasma in 3 older and 5 younger indicated functional oliguria; in 3 older and 1 younger, acute renal failure; and in 5 older and 1 younger, borderline values. In 7 older and 2 younger, the values of urine osmolality were in the range of functional oliguria and, in 4 older and 5 younger, borderline values between those two parameters, as the osmolality quotient in urine and plasma. The values of the renal failure index in all older and younger patients was lower than 3.0 (in 6 older and 3 younger, lower than 1.0) indicated functional oliguria, as the fractional excretion of filtered sodium Of 9 older patients who died, 5 were examined by autopsy, and 3 out of 4 younger who died. All had myocardial fibrosis and scars, apart from recent myocardial infarction and coronary atherosclerosis. In 2 older, acute tubular necrosis was found while in 2 no renal changes were found. In 2 younger, no renal changes were found and in 1 showed disseminated intravascular coagulation. | Acute renal failure due to cardiogenic shock in older patients is functional, or is rare renal. | closed_qa |
Do patient preferences contribute to racial differences in cardiovascular procedure use? | To determine whether patient preferences for the use of coronary revascularization procedures differ between white and black Americans. Cross-sectional survey. Tertiary care Department of Veterans Affairs hospital. Outpatients with and without known coronary artery disease were interviewed while awaiting appointments (n = 272). Inpatients awaiting catheterization were approached the day before the scheduled procedure (n = 80). Overall, 118 blacks and 234 whites were included in the study. Patient responses to questions regarding (1) willingness to undergo angioplasty or coronary artery bypass surgery if recommended by their physician and (2) whether they would elect bypass surgery if they were in either of two hypothetical scenarios, one in which bypass surgery would improve symptoms but not survival and one in which it would improve both symptoms and survival. Blacks were less likely to say they would undergo revascularization procedures than whites. However, questions dealing with familiarity with the procedure were much stronger predictors of a positive attitude toward the procedure use. Patients who were not working or over 65 years of age were also less interested in procedure use. In multivariable analysis race was not a significant predictor of attitudes toward revascularization except for angioplasty recommended by their physician. | Racial differences in revascularization rates may be due in part to differences in patient preferences. However, preferences were more closely related to questions assessing various aspects of familiarity with the procedure. Patients of all races may benefit from improved communication regarding proposed revascularization. Further research should address this issue in patients contemplating actual revascularization. | closed_qa |
Is esophagectomy following upfront chemoradiotherapy safe and necessary? | To examine the safety and necessity of esophagectomy following upfront chemoradiotherapy (CRT) in patients with potentially resectable esophageal cancer. Cohort analytic study during a 4-year period. Tertiary referral center. Thirty-seven patients who completed CRT and underwent esophagectomy as compared with 30 patients who underwent esophagectomy alone without pretreatment during the same period. Resection-related events, perioperative morbidity and mortality, response to CRT, site of residual disease following CRT, and survival of partial responders. Patients receiving CRT followed by esophagectomy were similar to patients who underwent esophagectomy alone for operative characteristics, postoperative course, and perioperative morbidity and mortality. Of the 33 patients who achieved an objective response to CRT, 23 had residual tumor in the resection specimen. Of the 18 patients alive with no evidence of disease at a median follow-up of 30 months, 50% had residual tumor following CRT. | Upfront CRT did not adversely affect resection-related outcome and may facilitate resection by downstaging disease. A considerable number of patients had prolonged survival after esophageal resection despite having residual tumor present following treatment with upfront CRT. Therefore, esophagectomy following upfront CRT can improve locoregional control of disease and should remain a critical component of any multimodality regimen. | closed_qa |
Does the method of payment affect anaesthetic practice? | To test the null hypothesis that the method of physician payment does not influence the practice of anaesthesia. Retrospective cohort study of anaesthetists before (Jan-June, 1994) and after (Jan-June, 1995) departure from fee-for-service practice into an alternate funding arrangement (AFP). Another group of physicians was studied as a concurrent control. Case numbers, induction times, cancellation rates, and operating hours for the department, recorded by third parties, were compared before and after AFP implementation. Using index procedures, details of individual patient decisions made by anaesthetists were compared for the two study periods, and between subscribing and non-subscribing physicians. Implementation of AFP resulted in a modest reduction in case numbers (7.2%) offset by an increase (5.7%) in the average case duration. Net change in time dedicated to clinical service (2% per physician) is inconsequential to the academic mission of the department. There was no change in cancellation rate and the use of invasive monitors was unchanged. An increase in the use of regional anaesthesia occurred but, since a similar increase occurred in the practice of those still on fee-for-service, it cannot be ascribed to the AFP. With respect to hip arthroplasty, the case was prolonged (P = 0.001) if the surgeon was paid via the AFP. | Payment of physicians by non-fee-for-service techniques did not have a constructive influence on measures of anaesthetic practice. The goal of alternate payment arrangements, to liberate time for academic pursuits, could not be achieved in this experimental model. | closed_qa |
Do enflurane and isoflurane interfere with the release, action, or stability of endothelium-derived relaxing factors? | The volatile anaesthetics enflurane and isoflurane inhibit the endothelium dependent-relaxation in some in vitro preparations. To determine their site of action on the endothelium-derived relaxing factor/nitric oxide (EDRF/NO) pathway, experiments were conducted in a bioassay system. Continuously perfused cultured bovine aortic endothelial cells (BAEC) were the source of EDRF/NO while a phenylephrine-precontracted denuded rabbit aortic ring, directly superfused by the BAEC effluent served to detect EDRF/NO. The effect of basal and bradykinin (Bk)-stimulated EDRF/NO release on vascular tension was measured. The effect of 4% enflurane or 2% isoflurane on EDRF/NO-induced relaxation was determined. Enflurane added to the perfusate either upstream or downstream in relation to BAEC attenuated the relaxation induced by Bk at low concentrations. On the other hand, isoflurane, added either upstream or down-stream to BAEC, potentiated the relaxation induced by the basal release of EDRF but attenuated the relaxation induced by the Bk stimulated release of EDRF. Neither enflurane nor isoflurane attenuated the relaxation induced by sodium nitroprusside (SNP), an NO donor. | Enflurane decreases the stability of EDRF/NO released after Bk stimulation while isoflurane can have opposite effects depending on whether the relaxation results from basal or Bk-stimulated release of endothelial derived relaxing factor(s). Isoflurane increases the stability or action of the basal relaxing factor, decreases the stability of the Bk-stimulated relaxing factor (which is probably NO). | closed_qa |
Introduction of a computerised protocol in clinical practice: is there anything to gain? | To assess the potential benefit of a protocol for the diagnostic work-up and management of patients with obstructive jaundice, by comparing its recommendations with the policies actually followed in patients and to compare local expertise with diagnostic and therapeutic procedures with that described in published reports. A retrospective analysis of patients' records. University hospital, The Netherlands. 49 consecutive patients who presented to the departments of internal medicine and surgery between June 1990 and June 1992 with serum alkaline phosphatase activities>125 mumol/L, and serum bilirubin concentrations>17 mumol/L. The proportions of diagnostic and therapeutic decisions that deviated from the recommendations, and the success rates of diagnostic and therapeutic procedures. In patients with bile duct stones the treatment strategies did not deviate from those recommended in the protocol. In patients with cancer 38 (30%) of the 128 diagnostic decisions and 4 (11%) of the 37 therapeutic decisions deviated from the protocol. Success rates of all diagnostic investigations were comparable with those reported, and success rates of endoscopic biliary drainage tended to be lower than those reported. | The introduction of a protocol for the diagnostic work-up of patients with obstructive jaundice may reduce unnecessary investigations and diagnostic omissions by half. Because local expertise of some of the procedures seems to be significantly less than reported elsewhere it may be necessary to modify the protocol to better fit local circumstances. | closed_qa |
Poorly differentiated carcinoma and poorly differentiated adenocarcinoma of unknown origin: favorable subsets of patients with unknown-primary carcinoma? | The objectives of this study were to assess clinical outcomes and prognostic factors in unselected, consecutive patients with poorly differentiated carcinoma (PDC) or poorly differentiated adenocarcinoma (PDA). The 1,400 patients analyzed were referred to our unknown-primary tumor (UPT) clinic from January 1, 1987 through July 31, 1994. Clinical data from these patients were entered into a computerized data base for storage, retrieval, and analysis. Survival was measured from the time of diagnosis; survival distribution was estimated using the product-limit method. Multivariate survival analyses were performed using proportional hazards regression and by recursive partitioning. Nine hundred seventy-seven patients were diagnosed with unknown-primary carcinoma (UPC) and 337 of these patients had PDC or PDA. No clinical differences were identified among patients with PDC, PDA, or UPC patients with other carcinoma or adenocarcinoma subtypes. PDC patients enjoyed better survival than PDA patients. Poor cellular differentiation was not an important prognostic variable. Variables predictive of survival included lymph node metastases, sex, number of metastatic sites, histology (PDC v PDA), and age. Although chemotherapy did not appear to influence survival for the entire group of PDC or PDA patients, a subset of patients with good prognostic features experienced median survival durations of up to 40 months. | The long median survival and chemotherapy responsiveness of UPC patients with PDC and PDA could not be confirmed. However, subpopulations with prolonged median survival durations could be defined, and the value of chemotherapy in this group remains to be determined. Identification and exclusion of treatable or slow-growing malignancies may account for the poor survival of the PDC and PDA patients reported in this study. | closed_qa |
Does a long pre-operative hospital stay before hepatectomy improve liver dysfunction in HCC patients with chronic liver disease? | We retrospectively evaluated whether or not hepatic dysfunction improved in patients with chronic liver disease who had been waiting to undergo a hepatectomy after admission. Fifty-two hepatocellular carcinoma patients had been admitted for more than 2 weeks prior to undergoing a hepatectomy. They had a liver function test twice, at admission and just before surgery, during the hospitalization period. Twenty-six of them were histologically diagnosed as having chronic hepatitis while the remainder had liver cirrhosis. In the liver function test, the serum levels of albumin, total bilirubin, glutamic pyrubic transaminase (alanine transaminase), total cholesterol and the Child grade were examined. First, including the pre-operative treatment cases for small tumors under angiography, the total bilirubin and transaminase levels improved in the chronic hepatitis patients with a statistically significant difference, but no difference was observed in the Child grade. In the examined cirrhotic patients, no significant difference was shown in the tests. Second, after excluding the pre-operative treatment cases, we performed the same investigation as that for chronic liver disease cases and only the transaminase level significantly improved. | A long pre-operative hospital stay might only by justified in patients with a high level of transaminase corresponding to chronic active hepatitis. | closed_qa |
Simultaneous hepatic resection with pancreato-duodenectomy for metastatic pancreatic head carcinoma: does it improve survival? | To determine whether aggressive surgery, consisting of a simultaneous pancreatic and partial hepatic resection, for patients with an invasive metastatic ductal adenocarcinoma of the pancreatic head improves the postoperative outcome. A total of 109 patients with adenocarcinoma of the pancreatic head were divided into two groups. Group 1 consisted of 33 patients with liver metastasis and Group 2 consisted of 76 patients without liver metastasis. Group 1 was further subdivided into 11 patients(Group 1-A) to aggressive surgery, consisting of pancreatoduodenectomy and partial liver resection, and 22 patients to palliative bypass surgery(group 1-B). Group 2 was subdivided into 37 patients to pancreatoduodenectomy(group 2-A), and 39 patients to bypass surgery(group 2-B). No significant statistical differences were seen in the outcomes between Group 1-A (median survival period: 6 months) and Group 1-B (median survival period: 4 months). Further, all Group 1-A patients died from multiple recurrent liver metastasis within a year. In addition, the outcomes of Group 1-A were significantly poorer than that of 2-A patients(median survival period: 24 months). | Patients who underwent an aggressive simultaneous resection of primary and metastatic hepatic lesion did not exhibit any improvement. However, it is anticipated that these findings will provide insights into developing an effective adjuvant therapy to impede or destroy macroscopic/occult liver metastasis. | closed_qa |
Is the volume of distribution of digoxin reduced in patients with renal dysfunction? | To determine digoxin pharmacokinetics in subjects with different degrees of renal function using fluorescence polarization immunoassay (FPIA), which is associated with less interference from digoxin-like immunoreactive substances (DLIS) than radioimmunoassay. University hospital clinical research center. Eighteen subjects (mean age 44 yrs) with different degrees of renal function: group 1, creatinine clearance (Clcr) below 10 ml/minute; group 2, Clcr 10-50 ml/minute; and group 3, Clcr greater than 50 ml/minute (6 patients in each group). Over 5-7 days, 15 serum samples were collected after a single intravenous dose of digoxin 7 or 10 micrograms/kg actual body weight (WT) for serum concentration measurements by FPIA. Two-compartment pharmacokinetic parameters (zero-time intercept of the concentration-time curve of the initial distribution phase [A], zero-time intercept of the concentration-time curve of the terminal elimination phase [B], initial distribution phase constant [alpha], terminal elimination rate constant [beta], volume of distribution in the central compartment [Vc] and at steady state [Vss], total body clearance [Cl], mean residence time [MRT], area under the concentration-time curve [AUC]) were determined using a nonlinear least squares regression program. No significant differences were found among groups for A, B, alpha, beta, beta-half-life Vc/WT, MRT, AUC, and Cl/WT. Significant differences were observed in Vss/WT (4.8 +/- 1.0, 6.6 +/- 0.5, 6.4 +/- 0.7 L/kg) between group 1 versus group 2 and group 1 versus group 3 (p<0.01). Measured Clcr was correlated with Cl (r2 = 0.40, p<0.01), Cl/WT (r2 = 0.29, p<0.05), Vss (r2 = 0.35, p = 0.01), and Vss/WT (r2 = 0.24, p<0.05). | This study confirmed that Vss is smaller in patients with chronic renal failure (Clcr<10 ml/min) than those without chronic renal failure. Therefore, previous recommendations that lower digoxin loading doses should be administered in patients with renal failure are applicable to digoxin serum concentration monitoring using FPIA. | closed_qa |
Are aluminium potroom workers at increased risk of neurological disorders? | To determine whether long term potroom workers in an aluminium smelter are at increased risk of neurological disorders. Cross sectional study of 63 current and former aluminium potroom workers first employed before 1970 and with at least 10 years of service. A group of 37 cast house and carbon plant workers with similar durations of employment and starting dates in the same smelter were used as controls. The prevalence of neurological symptoms was ascertained by questionnaire. Objective tests of tremor in both upper and lower limbs, postural stability, reaction time, and vocabulary were conducted. All subjects were examined by a neurologist. No significant differences in age, race, or education were found between the two groups. Although the potroom group had higher prevalences for all but one of the neurological symptoms, only three odds ratios (ORs) were significantly increased; for incoordination (OR 10.6), difficulty buttoning (OR 6.2), and depression (OR 6.2). Tests of arm or hand and leg tremor in both the visible and non-visible frequencies did not show any significant differences between the two groups. Testing of postural stability showed no definitive pattern of neurologically meaningful differences between the groups. There were no significant differences between the two groups in reaction time, vocabulary score, or clinical neurological assessment. | The objective measures of neurological function provided little support for the finding of increased neurological symptom prevalences in the potroom workers, although increased symptoms may be an indicator of early, subtle neurological changes. The results provide no firm basis for concluding that neurological effects among long term potroom workers are related to the working environment, in particular aluminium exposure, in potrooms. These findings should be treated with caution due to the low participation of former workers and the possibility of information bias in the potroom group. | closed_qa |
Does the BJGP need more fizz and pop? | The British Journal of General Practice (BJGP) is the leading primary care journal in the world. By impact factor, it ranks 24th of all medical journals. However, despite major changes in the journal since its inception in 1954, there have been no published readership surveys since a limited report in 1969.AIM: To canvass members of the Midland Faculty and to add to the debate about the future of the BJGP. A postal questionnaire was sent to a random sample of 299 members, fellows and associates of the Midland Faculty asking for their views about the BJGP. Two hundred replies were received (a response rate of 67%). The median year of qualification of responders was 1981, and 32 (16%) held academic posts. Ninety-nine (49%) disagreed with the present format of the BJGP, which compared poorly with the British Medical Journal (BMJ) in simple rank order of importance. Readership was equal to that of the BMJ (93% reading it within 28 days of arrival), but fewer people read it within a week of receiving it. The most popular sections were the editorials, original articles and letters; least popular were the book reviews and the pull-out magazine, Connection. All sections were rated excellent to average. Readers wished for an expansion of the BJGP to include clinical reviews, medical politics and humorous pieces. Most responders felt that Connection should remain separate. There was dissatisfaction with the delay between submission and publication of original articles, particularly among the academic general practitioners (GPs). Academics and fundholders did not differ from other readers in their views of the content or style of the BJGP. Half of the responders stated that the BJGP should be self-financing and should be open to more advertising. Responders' free comments largely related to improving the style of articles and expanding the BJGP. | There is a view that the present BJGP is not relevant to the non-academic GP. This is probably due to style rather than content. Simple comparisons with a weekly multi-disciplinary journal may not be valid. The style could be updated to improve retention of information and to highlight areas of particular relevance. Readers are satisfied with the core content of the BJGP but want it to expand to include humour, clinical reviews and medical politics, for example. There is no evidence that the BJGP is more appealing to the academic GP. This study supports an expanded BJGP with an improved style. | closed_qa |
Does risperidone improve verbal working memory in treatment-resistant schizophrenia? | Treatment efficacy in schizophrenia is typically defined in terms of symptom reduction. However, new antipsychotic medications could potentially have an impact on aspects of disability, such as neurocognitive deficits. The authors evaluated the effects of risperidone on verbal working memory, a memory component of theoretical interest because of its link to prefrontal activity and of practical interest because of its link to psychosocial rehabilitation. Verbal working memory of 59 treatment-resistant schizophrenic patients was assessed as part of a randomized, double-blind comparison of treatment with risperidone and haloperidol. Verbal working memory was measured under both distracting and nondistracting conditions at baseline and after 4 weeks of both fixed- and flexible-dose pharmacotherapy. Risperidone treatment had a greater beneficial effect on verbal working memory than haloperidol treatment across testing conditions (with and without distraction) and study phases (fixed and flexible dose). The treatment effect remained significant after the effects of benztropine cotreatment, change in psychotic symptoms, and change in negative symptoms were controlled. Neither benztropine status nor symptom changes were significantly related to memory performance. | Treatment with risperidone appears to exert a more favorable effect on verbal working memory than treatment with a conventional neuroleptic. The beneficial effect appears to be due, at least partially, to a direct effect of the drug, possibly through antagonism of the 5-HT2A receptor. Results from this study suggest that pharmacotherapeutic efficacy in schizophrenia treatment could be broadened to include impact on neurocognitive abilities. | closed_qa |
Diagnosis from thyroid aspirates. Is the cytopathologist handicapped if not fully informed about the patient? | When fine needle aspiration cytology (FNA) of the thyroid is performed as a first-line test, the cytopathologist cannot be fully informed about the patient's data. The authors investigated whether this decreases the accuracy of FNA and results in consequences for the patient. FNA smears of 202 patients, 190 with benign and 12 with malignant thyroid disease, were reevaluated, supplying the cytopathologist first with only information from the case history known already at the initial admission, and subsequently with full data. The FNA diagnoses were corrected in 13 cases; in 8/13 they showed a more serious finding. The therapeutic modality was changed in only one case. No corrections were made in the ultimately malignant cases. | In several cases the cytopathologist may be handicapped by receiving only partial information about the patient, but in our patients this had no demonstrable adverse consequences. Thus, FNA can be performed upon patient's admission. | closed_qa |
Use of microvascular flap technique in older adults with head and neck cancer: a persisting dilemma in reconstructive surgery? | To compare perioperative problems and outcomes of reconstructive surgery with microvascular flaps of a group of older (≥ 70) and younger adults (20-69). Prospective clinical cohort study. Maxillofacial surgical unit of a university teaching hospital in Munich, Germany. Two hundred fifteen people with head and neck carcinoma (older: n = 54, mean age 75.8, range 70-96; younger: n = 161, mean age 55.5, range 20-69) who underwent surgery between 2007 and 2009. Participant characteristics: age, sex, American Society of Anesthesiologists (ASA) status, tumor type, preoperative radiation or chemotherapy, medical comorbidities. Surgical variables: flap type, type of reconstruction (primary/secondary), length of operation (minutes). Postoperative variables: length of stay (minutes) on intensive care unit (ICU), reasons for ICU stay longer than 1,500 minutes (surgical or medical), length of hospitalization (days), and reasons for hospitalization longer than 20 days (surgical or /medical). Short-term outcome within 30 days: revisions, flap success, overall complication rate, mortality. Older adults had a higher ASA class (P<.001) and shorter duration of surgery (P = .02). Age as an independent factor prolonged stay on ICU (P = .008) and was associated with a higher complication rate (P = .003) but had no influence on length of hospitalization, flap success, need for revisions, or mortality. | Although higher rates of peri- and postoperative difficulties must be expected when microvascular reconstructive surgery is considered for older adults, careful surgical technique, adequate postoperative surveillance, and immediate management of complications can facilitate outcomes comparable with those for younger adults. | closed_qa |
Nonsurgical treatment of lumbar disk herniation: are outcomes different in older adults? | To determine whether older adults (aged ≥ 60) experience less improvement in disability and pain with nonsurgical treatment of lumbar disk herniation (LDH) than younger adults (<60). Prospective longitudinal comparative cohort study. Outpatient specialty spine clinic. One hundred thirty-three consecutive patients with radicular pain and magnetic resonance-confirmed acute LDH (89 younger, 44 older). Nonsurgical treatment customized for the individual patient. Patient-reported disability on the Oswestry Disability Index (ODI), leg pain intensity, and back pain intensity were recorded at baseline and 1, 3, and 6 months. The primary outcome was the ODI change score at 6 months. Secondary longitudinal analyses examined rates of change over the follow-up period. Older adults demonstrated improvements in ODI (range 0-100) and pain intensity (range 0-10) with nonsurgical treatment that were not significantly different from those seen in younger adults at 6 month follow-up, with or without adjustment for potential confounders. Adjusted mean improvement in older and younger adults were 31 versus 33 (P = .63) for ODI, 4.5 versus 4.5 (P = .99) for leg pain, and 2.4 versus 2.7 for back pain (P = .69). A greater amount of the total improvement in leg pain and back pain in older adults was noted in the first month of follow-up than in younger adults. | These preliminary findings suggest that the outcomes of LDH with nonsurgical treatment were not worse in older adults (≥ 60) than in younger adults (<60). Future research is warranted to examine nonsurgical treatment for LDH in older adults. | closed_qa |
Is there evidence of recent hepatitis E virus infection in English and North Welsh blood donors? | The risk of hepatitis E virus (HEV) to blood safety remains unknown in England. Reports of persistent HEV infection with serious disease sequelae indicate that transfusion transmitted HEV is not a trivial disease in immunosuppressed patients. Samples from unselected blood donors and donors with a history of jaundice were tested for HEV antibody and RNA. Overall, 10% of the donor sera were anti-HEV IgG reactive. Four of the donor samples were anti-HEV IgM reactive but HEV RNA negative. | There is evidence of probable recent HEV infections in donors with a predicted attack rate of 2.8%. | closed_qa |
Is there a prostate-specific antigen upper limit for radical prostatectomy? | • To assess the feasibility of radical prostatectomy (RP) in a series of patients with prostate cancer with very high prostate-specific antigen (PSA) levels by comparing the clinical outcomes of different PSA thresholds (20.1-50 ng/mL, 50.1-100 ng/mL and>100 ng/mL, respectively). • Within a multicentre European retrospective database of 712 RP in patients with a baseline PSA level>20 ng/mL, we identified 48 patients with prostate cancer with a preoperative PSA level>100 ng/mL, 137 with a PSA level between 50.1 and 100 ng/mL and 527 with PSA values between 20.1 and 50 ng/mL. • Comparisons between groups were performed using chi-square test, analysis of variance and Kaplan-Meier analysis with log-rank test. • Ten-year projected cancer-specific survival (79.8% in the PSA>100 ng/mL group vs 85.4% in the PSA 50.1-99 ng/mL group vs 90.9% in the PSA 20.1-50 ng/mL interval; P = 0.037) but not overall survival (59.6% in the PSA>100 ng/mL group vs 71.8% in the PSA 50.1-99 ng/mL group vs 75.3% in the PSA 20.1-50 ng/mL interval; P = 0.087) appeared significantly affected by the different PSA thresholds. • At a median follow-up of 78.7 months, 25.8%, 6.6% and 8.3% of patients in the PSA level groups for 20.1-50 ng/mL, 50.1-100 ng/mL and>100 ng/mL respectively, were cured by surgery alone. | • Ten-year cancer-specific survival, while showing significant reduction with increasing PSA values intervals, remain relatively high even for PSA levels>100 ng/mL. • As part of a multimodal treatment strategy, RP may therefore be an option, even in selected patients with prostate cancer whose PSA level is>100 ng/mL. | closed_qa |
Do wind and brass players snore less? | To determine whether playing a wind or brass musical instrument is associated with reduced snoring or daytime fatigue. Cross-sectional, controlled, anonymous, questionnaire-based observational study. Rehearsal and performance halls. Three hundred and forty musicians from Scotland's five professional orchestras. Snore Outcomes Survey questionnaire and the Epworth Sleepiness Score. Hierarchical linear regression analysis. No significant difference was found between the snoring severity (Snore Outcomes Survey score) or daytime sleepiness (Epworth score) of wind/brass and other professional musicians. A regression model with snoring severity (Snore Outcomes Survey score) as the dependent variable and the three covariates of gender, age and body mass index as independent variables was significant [F(3, 206) = 28.77, P<0.01, adjusted r(2) = 0.285]. Increasing age, body mass index and male gender were all significantly associated with lower Snore Outcomes Survey scores (i.e. worse snoring).The addition of instrument type did not significantly increase the fit of the model, and the regression coefficient for instrument type was not significant. There were similar results when the Epworth Sleepiness Score was used as the dependent variable. | This study demonstrated no significant difference between the snoring severity or daytime sleepiness of brass/wind players and other professional orchestral musicians. This result may have been attributed to comparatively low levels of snoring/daytime sleepiness in the population studied. The findings contrast with previous studies examining the effects of singing and didgeridoo playing but concur with a recent similar study of orchestral musicians. A prospective interventional study would be required to determine whether playing a wind or brass instrument improves these variables in patients complaining of disruptive snoring. | closed_qa |
Depression, anxiety, and history of substance abuse among Norwegian inmates in preventive detention: reasons to worry? | Inmates on preventive detention are a small and select group sentenced to an indefinite term of imprisonment. Mood disorders and substance abuse are risk factors for inmate violence and recidivism, so the prevalence of depression, anxiety, and substance abuse was examined in this cohort using psychometric tests. Completion of self-report questionnaires was followed by face-to-face clinical interviews with 26 of the 56 male inmates on preventive detention in Norway's Ila Prison. Substance abuse histories and information about the type of psychiatric treatment received were compiled. To assess anxiety and depression, the Hospital Anxiety and Depression Scale (HADS), the Clinical Anxiety Scale (CAS), and the Montgomery Asberg Depression Rating Scale (MADRS) were used. Scores on the MADRS revealed that 46.1% of inmates had symptoms of mild depression. The HADS depression subscale showed that 19.2% scored above the cut-off for depression (κ = 0.57). The CAS anxiety score was above the cut-off for 30.7% of the subjects, while 34.6% also scored above the cut-off on the HADS anxiety subscale (κ = 0.61). Almost 70% of all these inmates, and more than 80% of those convicted of sex crimes, had a history of alcohol and/or drug abuse. | Mild anxiety and depression was found frequently among inmates on preventive detention. Likewise, the majority of the inmates had a history of alcohol and drug abuse. Mood disorders and substance abuse may enhance recidivism, so rehabilitation programs should be tailored to address these problems. | closed_qa |
Does CBT facilitate emotional processing? | Cognitive Behavioural Therapy (CBT) is not primarily conceptualized as operating via affective processes. However, there is growing recognition that emotional processing plays an important role during the course of therapy. The Emotional Processing Scale was developed as a clinical and research tool to measure emotional processing deficits and the process of emotional change during therapy. Fifty-five patients receiving CBT were given measures of emotional functioning (Toronto Alexithymia Scale [TAS-20]; Emotional Processing Scale [EPS-38]) and psychological symptoms (Brief Symptom Inventory [BSI]) pre- and post-therapy. In addition, the EPS-38 was administered to a sample of 173 healthy individuals. Initially, the patient group exhibited elevated emotional processing scores compared to the healthy group, but after therapy, these scores decreased and approached those of the healthy group. | This suggests that therapy ostensibly designed to reduce psychiatric symptoms via cognitive processes may also facilitate emotional processing. The Emotional Processing Scale demonstrated sensitivity to changes in alexithymia and psychiatric symptom severity, and may provide a valid and reliable means of assessing change during therapy. | closed_qa |
Can differences in corrected coronary opacification measured with computed tomography predict resting coronary artery flow? | A proof-of-concept study was undertaken to determine whether differences in corrected coronary opacification (CCO) within coronary lumen can identify arteries with abnormal resting coronary flow. Although computed tomographic coronary angiography can be used for the detection of obstructive coronary artery disease, it cannot reliably differentiate between anatomical and functional stenoses. Computed tomographic coronary angiography patients (without history of revascularization, cardiac transplantation, and congenital heart disease) who underwent invasive coronary angiography were enrolled. Attenuation values of coronary lumen were measured before and after stenoses and normalized to the aorta. Changes in CCO were calculated, and CCO differences were compared with severity of coronary stenosis and Thrombolysis In Myocardial Infarction (TIMI) flow at the time of invasive coronary angiography. One hundred four coronary arteries (n = 52, mean age = 60.0 ± 9.5 years; men = 71.2%) were assessed. Compared with normal arteries, the CCO differences were greater in arteries with computed tomographic coronary angiography diameter stenoses ≥ 50%. Similarly, CCO differences were greater in arteries with TIMI flow grade<3 (0.406 ± 0.226) compared with those with normal flow (TIMI flow grade 3) (0.078 ± 0.078, p<0.001). With CCO differences, abnormal coronary flow (TIMI flow grade<3) was identified with a sensitivity and specificity, positive predictive value, and negative predictive value of 83.3% (95% confidence interval [CI]: 57.7 to 95.6%), 91.2% (95% CI: 75.2% to 97.7%), 83.3% (95% CI: 57.7% to 95.6%), and 91.2% (95% CI: 75.2% to 97.7%), respectively. Accuracy of this method was 88.5% with very good agreement (kappa = 0.75, 95% CI: 0.55 to 0.94). | Changes in CCO across coronary stenoses seem to predict abnormal (TIMI flow grade<3) resting coronary blood flow. Further studies are needed to understand its incremental diagnostic value and its potential to measure stress coronary blood flow. | closed_qa |
Do long-term changes in relative maxillary arch width affect buccal-corridor ratios in extraction and nonextraction treatment? | Our aims were to evaluate long-term maxillary arch width changes in orthodontic patients treated with and without premolar extractions and to provide a potential link to the buccal-corridor ratios. Dental casts of 34 extraction and 32 nonextraction orthodontic patients with Class I malocclusions were digitized and evaluated before treatment (T1), at posttreatment (T2), and at postretention (T3). The mean postretention times for the extraction and the nonextraction groups were 5 years 2 months and 4 years 10 months, respectively. Specific arch width measurements were made on the anatomic y-axis of the casts between the most labial aspects of the anatomic dental arch immediately distal to the incisive papilla, the farthest point posteriorly of the conjunction of the third lateral and medial rugae on the midpalatal raphe and at an individually constant distance from the incisive papilla. Arch width changes were calculated and compared statistically to determine whether the dental arches were narrower after extraction treatment and at postretention. All maxillary arch width measurements remained virtually stable after extraction therapy and at the postretention follow-up. Significant increases were recorded for all maxillary arch width measurements in the nonextraction group after treatment (mean changes, 1.37-2.05 mm). Posterior arch width measurements decreased significantly between T2 and T3 (mean change, 0.5 mm). Mean changes between T1 and T2 were significant between the 2 groups for all measurements (P <0.05). Only the mean change in posterior arch width was significant between the 2 groups in the postretention period (P <0.05). | Extraction treatment did not result in narrower maxillary dental arches, whereas nonextraction treatment slightly expanded the dental arch. | closed_qa |
Does psychological well-being influence oral-health-related quality of life reports in children receiving orthodontic treatment? | Although the associations between oral biologic variables such as malocclusion and oral-health-related quality of life (OHRQOL) have been explored, little research has been done to address the influence of psychological characteristics on perceived OHRQOL. The aim of this study was to assess OHRQOL outcomes in orthodontics while controlling for individual psychological characteristics. We postulated that children with better psychological well-being (PWB) would experience fewer negative OHRQOL impacts, regardless of their orthodontic treatment status. One hundred eighteen children (74 treatment and 44 on the waiting list), aged 11 to 14 years, seeking treatment at the orthodontic clinics at the University of Toronto, participated in this study. The child perception questionnaire (CPQ11-14) and the PWB subscale of the child health questionnaire were administered at baseline and follow-up. Occlusal changes were assessed by using the dental aesthetic index. A waiting-list comparison group was used to account for age-related effects. Although the treatment subjects had significantly better OHRQOL scores at follow-up, the results were significantly modified by each subject's PWB status (P <0.01). Furthermore, multivariate analysis showed that PWB contributed significantly to the variance in CPQ11-14 scores (26%). In contrast, the amount of variance explained by the treatment status alone was relatively small (9%). | The results of this study support the postulated mediator role of PWB when evaluating OHRQOL outcomes in children undergoing orthodontic treatment. Children with better PWB are, in general, more likely to report better OHRQOL regardless of their orthodontic treatment status. On the other hand, children with low PWB, who did not receive orthodontic treatment, experienced worse OHRQOL compared with those who received treatment. This suggests that children with low PWB can benefit from orthodontic treatment. Nonetheless, further work, with larger samples and longer follow-ups, is needed to confirm this finding and to improve our understanding of how other psychological factors relate to patients' OHRQOL. | closed_qa |
Comparative prognostic utility of conventional and novel lipid parameters for cardiovascular disease risk prediction: do novel lipid parameters offer an advantage? | Comparative data on the prognostic utility of novel lipid parameters vs. conventional lipid parameters in predicting coronary events are scant. We sought to compare the predictive value of various lipid measures for coronary events and to further examine the incremental value of novel lipid parameters over traditional cardiovascular risk factors in estimating cardiac risk. We performed a post-hoc analysis of the National Heart Lung and Blood Institute limited access dataset of Multi-Ethnic Study of Atherosclerosis subjects (n = 6693). The lipid measures considered in the estimation of coronary risk were conventional and novel lipid parameters, the latter included total low-density lipoprotein (LDL), high-density lipoprotein (HDL) and very low-density lipoprotein (VLDL)-particle concentrations (LDL-p, HDL-p and VLDL-p), LDL-p/HDL-p ratio, and LDL-p subfractions. The outcome measured was occurrence of any coronary event (CE) that included myocardial infarction, resuscitated cardiac arrest, cardiac death, and angina. During an average follow up of 4.5 years, 228 patients developed coronary events. In the multivariate Cox proportional hazards model, TC/HDL-c (HR: 3.27; 95% CI: 1.95 to 5.47, P<.0001) was a stronger predictor of CE. Among the novel lipid parameters, LDL-p/HDL-p (hazard ratio 2.84; 95% confidence interval 1.89 to 4.26; P<.0001) was a powerful independent predictor of CE. The c-statistics were similar for both LDL-p/HDL-p and TC/HDL-c ratios (0.60). The addition of LDL-p/HDL-p ratio to the Framingham risk score components resulted in a very small increase in the overall C statistic. | In our large study cohort, a predictive model for future coronary events incorporating the best-available novel lipid parameter (LDL-p/HDL-p ratio) was comparable with the same model that incorporated conventional lipid ratios such as the TC/HDL-c ratio . The use of LDL-p/HDL-p ratio did not appear to offer incremental value over more traditional risk prediction models. | closed_qa |
Infants with single ventricle physiology in the emergency department: are physicians prepared? | To assess emergency department (ED) utilization and physician preparedness for infants with single ventricle (SV) physiology between stage 1 and stage 2 surgical palliation. Records of infants with SV physiology discharged after stage I palliation between July 2006 and June 2009 were retrospectively reviewed. Next, a cross-sectional survey of registered ED physicians in Michigan was performed. Thirty-three of 42 patients (79%) required 65 ED visits, most commonly presenting with respiratory distress (35%). Six patients died in the ED; 35 other visits resulted in hospital admission, 4 requiring urgent surgery or catheterization. Median initial hospital stay in those with ED visits was significantly longer (21 days; IQR, 17-45 days) than those without (12 days; IQR, 5.5-24 days) (P = .032). Three hundred seventy-six of 915 surveyed ED physicians responded. Most (72%) were unsure of the acceptable range of arterial oxygen saturation for these infants, and 58% felt "uncomfortable" or "worried" about their treatment. Despite these concerns, 59% deemed education in SV physiology as low priority. | Between stages I and II, infants with SV physiology utilized the ED frequently, often with high disease acuity. Most ED physicians surveyed appeared underprepared for these infants. These findings underscore the need for educational efforts aimed at increasing ED preparedness. | closed_qa |
Can dual-energy CT evaluate contrast enhancement of ground-glass attenuation? | Evaluation of contrast enhancement of pulmonary lesions with ground-glass attenuation (GGA) is difficult with conventional techniques but might be possible using contrast-mapping images (CMIs) obtained by dual-energy computed tomography. To address this issue, a phantom study was conducted, and this technique was then applied to clinical cases. Phantoms made of agarose gel and those made of hollow resin clay, containing various concentrations of iodine or calcium, were used to simulate soft tissue and GGA, respectively. They were scanned using a dual-energy computed tomographic scanner, and the relationship between iodine concentration and calculated iodine value on CMIs was examined. The influence of calcium was also evaluated. In addition, contrast enhancement of 24 GGA lesions was evaluated on CMIs. There was a good correlation between iodine value and iodine concentration in the soft-tissue models (r(2) = 0.996). In the GGA models, the former tended to exceed the latter when default parameters for calculating CMIs were used, but this could be corrected by modifying the parameters (r(2) = 0.998). The iodine value increased with calcium concentration in both models. On CMIs, contrast enhancement was visible in 22 adenocarcinomas but not in a pulmonary hemorrhage and an inflammatory change. | Dual-energy computed tomography can evaluate contrast enhancement of GGA lesions. | closed_qa |
Can phylogenetic type predict resistance development? | To determine whether phylogenetic type is associated with the development of multidrug resistance to antibiotics. Urinary tract infection (UTI) isolates from three hospitals in Pakistan were collected over a period of 10 months, and analysed in terms of causative bacterial species and drug susceptibility. Multidrug resistance was widespread and resistance frequencies were>50% for several of the most commonly used antibiotics, including ciprofloxacin and third-generation cephalosporins for Escherichia coli isolates. The great majority of E. coli isolates remained susceptible to meropenem and fosfomycin. Sixty E. coli isolates were analysed in detail to determine correlations between resistance phenotypes and genotypes, mutation rates and phylogenetic group. Most isolates had elevated mutation rates, suggesting this was being selected. The majority of ciprofloxacin-resistant isolates carried a specific set of mutations in the quinolone resistance-determining region of gyrA and parC (S83L, D87N, S80I and E84V). In addition, 67% of the ciprofloxacin-resistant E. coli isolates carried one or more horizontally transmissible determinants of resistance to ciprofloxacin, including aac(6')-Ib-cr, qepA, qnrA and qnrB. There was a significant correlation between resistance to third-generation cephalosporins, being an extended-spectrum β-lactamase producer, being resistant to ciprofloxacin and belonging to phylogenetic group B2. | The data suggest that features of the bacterial genotype might facilitate the development of multidrug resistance in particular lineages. Better understanding of the mechanistic basis for correlations between drug resistance and genotype could potentially be exploited to develop molecular tools for the prediction of resistance development. | closed_qa |
Do sex and atopy influence cough outcome measurements in children? | Despite the commonality of cough and its burden, there are no published data on the relationship between atopy or sex on objectively measured cough frequency or subjective cough scores in children. In 202 children with and without cough, we determined the effect of sex and atopy on validated cough outcome measurements (cough receptor sensitivity [CRS], objective cough counts, and cough scores). We hypothesized that in contrast to adult data, sex does not influence cough outcome measures, and atopy is not a determinant of these cough measurements. We combined data from four previous studies. Atopy (skin prick test), the concentration of capsaicin causing two and five or more coughs (C2 and C5, respectively), objectively measured cough frequency, and cough scores were determined and their relationship explored. The children's (93 girls, 109 boys) mean age was 10.6 years (SD 2.9), and 56% had atopy. In multivariate analysis, CRS was influenced by age (C2 coefficient, 5.9; P = .034; C5 coefficient, 29.1; P = .0001). Atopy and sex did not significantly influence any of the cough outcomes (cough counts, C2, C5, cough score) in control subjects and children with cough. | Atopy does not influence important cough outcome measures in children with and without chronic cough. However, age, but not sex, influences CRS in children. Unlike adult data, sex does not affect objective counts or cough score in children with and without chronic cough. Studies on cough in children should be age matched, but matching for atopic status and sex is less important. | closed_qa |
Isolation of bacteriophages to multi-drug resistant Enterococci obtained from diabetic foot: a novel antimicrobial agent waiting in the shelf? | While foot infections in persons with diabetes are initially treated empirically, therapy directed at known causative organisms may improve the outcome. Many studies have reported on the bacteriology of diabetic foot infections (DFIs), but the results have varied and have often been contradictory. The purpose of the research work is to call attention to a frightening twist in the antibiotic-resistant Enterococci problem in diabetic foot that has not received adequate attention from the medical fraternity and also the pharmaceutical pipeline for new antibiotics is drying up. Adult diabetic patients admitted for lower extremity infections from July 2008 to December 2009 in the medical wards and intensive care unit of medical teaching hospitals were included in the study. The extent of the lower extremity infection on admission was assessed based on Wagner's classification from grades I to V. Specimens were collected from the lesions upon admission prior to the initiation of antibiotic therapy or within the first 48 h of admission. During the 18-month prospective study, 32 strains of Enterococcus spp. (26 Enterococcus faecalis and 06 E. faecium) were recovered. Antibiotic sensitivity testing was done by Kirby-Bauer's disk diffusion method. Isolates were screened for high-level aminoglycoside resistance (HLAR). A total of 65.6% of Enterococcus species showed HLAR. Multidrug resistance and concomitant resistance of HLAR strains to other antibiotics were quite high. None of the Enterococcus species was resistant to vancomycin. | Multidrug-resistant Enterococci are a real problem and continuous surveillance is necessary. Today, resistance has rendered most of the original antibiotics obsolete for many infections, mandating the development of alternative anti-infection modalities. One of such alternatives stemming up from an old idea is the bacteriophage therapy. In the present study, we could able to demonstrate the viable phages against MDR E. faecalis. | closed_qa |
Laparoscopic versus open left pancreatectomy: can preoperative factors indicate the safer technique? | Laparoscopic left pancreatectomy (LLP) is associated with favorable outcomes compared with open left pancreatectomy (OLP). However, it is unclear if the risk factors associated with operative morbidity differ between these two techniques. Guidelines for determining which patients should undergo OLP versus LLP do not exist. A multi-institutional analysis of OLP and LLP performed in 9 academic medical centers was undertaken. LLP cases were defined in an intent-to-treat manner. Perioperative variables were analyzed to identify factors associated with complications and pancreatic fistulae after OLP and LLP. In addition, complication and fistula rates for patients undergoing OLP and LLP were compared in matched cohorts to determine if one approach resulted in superior outcomes over the other. Six hundred and ninety-three left pancreatectomy cases (439 OLP, 254 LLP) were analyzed. OLP and LLP cases were similar with respect to patient age and American Society of Anesthesiologists score. Body mass index (BMI) was higher in patients undergoing LLP. OLP was more often performed for adenocarcinoma and larger tumors, resulted in longer resected specimen lengths, and more commonly involved concomitant splenectomy. Estimated blood loss was higher and operative times were longer during OLP. On multivariate analysis, variables associated with major complications and clinically significant fistulae differed between OLP and LLP. Patients with body mass index ≤27, without adenocarcinoma, and with pancreatic specimen length ≤8.5 cm had significantly higher rates of significant fistulae after OLP than after LLP; in contrast, no preoperatively evaluable variables were associated with a higher likelihood of significant fistula after LLP versus OLP. | Risk factors for complications and pancreatic fistulae after left pancreatectomy differ when open versus laparoscopic techniques are employed. Preoperative characteristics may identify cohorts of patients who will benefit more from LLP, and no patient cohorts had higher postoperative complication rates after LLP than OLP. These observations suggest that LLP may be the operative procedure of choice for most patients with left-sided pancreatic lesions; a more definitive prospective and randomized comparison may be warranted. | closed_qa |
Does 23-gauge sutureless vitrectomy modify the risk of postoperative retinal detachment after macular surgery? | To compare the cumulative risk of retinal detachment (RD) after macular surgery with 23-gauge sutureless vitrectomy and with 20-gauge vitrectomy. A single-center retrospective comparative study was conducted, comparing eyes operated for epiretinal membrane, macular hole, vitreomacular traction, and internal limiting membrane peeling. The 23-gauge group included 349 eyes operated consecutively between June 2007 and December 2008. The 20-gauge group included 346 eyes operated between October 2003 and September 2007. After a 6-month follow-up, the cumulative probability of RD was 1.1% in the 23-gauge group and 3.5% in the 20-gauge group (P = 0.04). With a median follow-up of 14 months (range, 6-30 months) in the 23-gauge group and 30 months (range, 6-72 months) in the 20-gauge group, the cumulative probability of RD was, respectively, 1.1% and 4.9% (P = 0.04; log-rank test). Overall, RD was observed in 7 of 96 cases after macular hole surgery (7.3%), in 11 of 478 cases after epiretinal membrane surgery (2.3%), and in 3 of 70 cases after vitreomacular traction surgery (4.3%) (P = 0.14; log-rank test). | After a short-term follow-up, a lower rate of postoperative RD was observed in the 23-gauge group. Sutureless 23-gauge vitrectomy appears safe when considering the risk of postoperative RD. Prospective and long-term studies are still needed to confirm these results. | closed_qa |
Is primary care providers' trust in socially marginalized patients affected by race? | Interpersonal trust plays an important role in the clinic visit. Clinician trust in the patient may be especially important when prescribing opioid analgesics because of concerns about misuse. Previous studies have found that non-white patients are perceived negatively by clinicians. To examine whether clinicians' trust in patients differed by patients' race/ethnicity in a socially marginalized cohort. Cross-sectional study of patient-clinician dyads. 169 HIV infected indigent patients recruited from the community and their 61 primary care providers (PCPs.) The Physician Trust in Patients Scale (PTPS), a validated scale that measures PCPs' trust in patients. The mean PTPS score was 43.2 (SD 10.8) out of a possible 60. Reported current illicit drug use and prescription opioid misuse were similar across patients' race or ethnicity. However, both patient illicit drug use and patient non-white race/ethnicity were associated with lower PTPS scores. In a multivariate model, non-white race/ethnicity was independently associated with PTPS scores 6.3 points lower than whites (95% CI: -9.9, -2.7). Current illicit drug use was associated with PTSP scores 5.5 lower than no drug use (95% CI -8.5, -2.5). | In a socially marginalized cohort, non-white patients were trusted less than white patients by their PCPs, despite similar rates of illicit drug use and opioid analgesic misuse. The effect was independent of illicit drug use. This finding may reflect unconscious stereotypes by PCPs and may underlie disparities in chronic pain management. | closed_qa |
Is total ankle arthroplasty a cost-effective alternative to ankle fusion? | Total ankle arthroplasty (TAA) implantation is increasing, as the potential for pain relief and restoration of function and risks are compared with those for ankle fusion. A previous analysis with a simple decision tree suggested TAA was cost-effective compared with ankle fusion. However, reevaluation is warranted with the availability of newer, more costly implants and longer-term patient followup data.QUESTIONS/ Considering all direct medical costs regardless of the payer, we determined if TAA remains a cost-effective alternative to ankle fusion when updated evidence is considered. Using a Markov model, we evaluated expected costs and quality-adjusted life years (QALY) for a 60-year-old hypothetical cohort with end-stage ankle arthritis treated with either TAA or ankle fusion. Costs were estimated from 2007 diagnosis-related group (DRG) and current procedural terminology (CPT) codes for each procedure. Rates were extracted from the literature. The incremental cost-effectiveness ratio (ICER), a measure of added cost divided by QALY gained for TAA relative to ankle fusion, was estimated. To identify factors affecting the value of TAA, sensitivity analyses were performed on all variables. TAA costs $20,200 more than ankle fusion and resulted in 1.7 additional QALY, with an ICER of $11,800/QALY gained. Few variables in the sensitivity analyses resulted in TAA no longer being cost-effective. | Despite more costly implants and longer followup, TAA remains a cost-effective alternative to ankle fusion in a 60-year-old cohort with end-stage ankle arthritis. | closed_qa |
Anterior construct location following vertebral body metastasis reconstruction through a posterolateral transpedicular approach: does it matter? | The posterolateral transpedicular approach (PTA) is a widely used method for the surgical treatment of vertebral body metastases. It is crucial to understand the optimal location of the anterior graft in terms of sound and durable reconstruction following PTA. The purpose of this study was to investigate whether postoperative construct stability is related to the location of anterior grafts. The authors conducted a retrospective review of 45 cases of metastatic spine disease with epidural tumor extension in which patients underwent circumferential decompression and fusion by means of PTA. Mechanical (anterior construct stability), pain (visual analog scale score), and neurological (American Spinal Injury Association scale) outcomes were evaluated and correlated with the anterior graft location (lateral or central) and surgical approach (unilateral or bilateral), number of decompressed levels, types of anterior graft, screw density of posterior fixation (number of screws used divided by the number of pedicles spanned), and kyphotic angle change from the immediate postoperative period to the most recent follow-up. Seven of 45 constructs were judged unstable--5 with a lateral location of the anterior graft and 2 with a central location. The anterior graft was located laterally in 31 cases (69%), centrally in 11 (24%), and bilaterally in 3 (7%). A unilateral approach was used in 33 cases and a bilateral approach in 12. Neither the location of the anterior graft nor the approach had a significant effect on the stability of the reconstructed spine (p>0.05). There was a significant difference in construct stability between the single-level decompression group (33 patients) and the multiple-level decompression group (12 patients) (p = 0.0001). The types of anterior graft, screw density, and kyphotic angle change were not correlated to the mechanical outcome. | The anterior graft location showed no significant relationship to the final mechanical, pain, and neurological outcomes. | closed_qa |
Symphysiotomy: Is it obsolete? | This was a prospective comparative cohort study. Symphysiotomy was performed in 25 women who presented with obstructed labor. The controls were 50 women on whom CS was performed due to obstructed labor. Maternal mortality and morbidity due to postpartum hemorrhage (PPH), sepsis, genitourinary trauma, pelvic pain and gait problems were analyzed and compared between cases and controls. Neonatal mortality and morbidity due to birth asphyxia, intracranial hemorrhage, cephalohematoma and hypoxic ischemic encephalopathy were also compared following the two procedures. Maternal mortality was similar in both the cesarean section group (CSG) and symphysiotomy group (SG), but SYM has less morbidity than CS, and also preserves the uterus from scars. Transient pelvic pain was the most common maternal morbidity following SYM, whereas PPH and wound sepsis were the most common complications after CS. Neonatal mortality and morbidity were similar in both cases and controls. Lastly, SYM is a simple, low-cost and quicker procedure than CS. | Symphysiotomy is an alternative management in women with obstructed labor. It has a role in low-resource settings, where CS is unaffordable, unavailable or unsafe. For the vast majority of the poor population, who may not have even have one proper meal a day, it can be of benefit to have a woman's pelvis made permanently adequate so that traditional birth attendants can conduct her subsequent labors. | closed_qa |
Medical bankruptcy in Massachusetts: has health reform made a difference? | Massachusetts' recent health reform has decreased the number of uninsured, but no study has examined medical bankruptcy rates before and after the reform was implemented. In 2009, we surveyed 199 Massachusetts bankruptcy filers regarding medical antecedents of their financial collapse using the same questions as in a 2007 survey of 2314 debtors nationwide, including 44 in Massachusetts. We designated bankruptcies as "medical" based on debtors' stated reasons for filing, income loss due to illness, and the magnitude of their medical debts. In 2009, illness and medical bills contributed to 52.9% of Massachusetts bankruptcies, versus 59.3% of the bankruptcies in the state in 2007 (P=.44) and 62.1% nationally in 2007 (P<.02). Between 2007 and 2009, total bankruptcy filings in Massachusetts increased 51%, an increase that was somewhat less than the national norm. (The Massachusetts increase was lower than in 54 of the 93 other bankruptcy districts.) Overall, the total number of medical bankruptcies in Massachusetts increased by more than one third during that period. In 2009, 89% of debtors and all their dependents had health insurance at the time of filing, whereas one quarter of bankrupt families had experienced a recent lapse in coverage. | Massachusetts' health reform has not decreased the number of medical bankruptcies, although the medical bankruptcy rate in the state was lower than the national rate both before and after the reform. | closed_qa |
Suctioning via the tube during endotracheal intubation in a model of severe upper airway haemorrhage: is there an advantage vs. suctioning with a separate catheter? | In a model of severe simulated upper airway haemorrhage, we compared two techniques of performing endotracheal intubation: (1) suctioning via the endotracheal tube during laryngoscopy with subsequently advancing the endotracheal tube, and (2) the standard intubation strategy with performing laryngoscopy, and performing suction with subsequently advancing the endotracheal tube. Forty-one emergency medical technicians intubated the trachea of a manikin with severe simulated airway haemorrhage using each technique in random order. There was no significant difference in the number of oesophageal intubations between suctioning via the tube and the standard intubation strategy [8/41 (20%) vs. 6/41 (15%); P = 0.688], but suctioning via the endotracheal tube needed significantly more time [median (IQR, CI 95%): 42 (20, 39-60) vs. 33 (15, 35-48)s; P = 0.015]. | Suctioning via the endotracheal tube showed no benefit regarding the number of oesophageal intubations and needed more time when compared to the standard intubation strategy. | closed_qa |
Is there a role for partial nephrectomy in patients with metastatic renal cell carcinoma? | The incidence of metastatic disease in patients with renal cell carcinoma (RCC) correlates with tumor size. We sought to determine the incidence of metastatic disease by tumor size, and the utilization and impact of nephron-sparing surgery on survival in those with metastatic disease. Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, we identified 56,011 patients between 1988 and 2005 diagnosed with RCC. Patients were initially separated into two groups--those with and without metastatic disease--and stratified by tumor size. Cox proportional hazard modeling and Kaplan-Meier analyses were then utilized to evaluate the role of gender, age, grade, histology, tumor size, and type of surgery (radical vs. partial nephrectomy) on overall- and cancer-specific survival in patients with metastatic disease. Eight thousand four hundred ninety-eight patients (15%) had metastatic disease. Four percent of patients with tumors less than 2 cm and 5% of patients with tumors between 2 and 3 cm presented with metastatic disease. Two thousand nine hundred fifty patients (35%) with metastatic disease underwent surgery (radical or partial nephrectomy). Seventy patients (2% of those undergoing surgery) had a partial nephrectomy. Those who underwent partial nephrectomy were 0.49 times less likely to die of RCC than those who underwent radical nephrectomy (95% CI 0.35-0.69, P<0.001). | Albeit small, the risk of metastases in patients with small kidney tumors is distinct and should be considered in management discussions. Partial nephrectomy, when able to be done, should be utilized in the setting of metastatic disease. | closed_qa |
Is repeat use of emergency contraception common among pharmacy clients? | As emergency contraception (EC) becomes more widely available in African pharmacies, public concern in many countries has emerged over perceived "repeat use" of the method. This study examines issues of repeat use in Kenya, a country where women almost exclusively obtain EC from pharmacies. Interviews were conducted with all clients who purchased EC from private pharmacies located in five urban areas across Kenya. Over a period of 5 days, a total of 182 male and female EC purchasers were interviewed. χ(2) tests were used to determine the statistical significance of differences between repeat and nonrepeat users. The majority (58%) of respondents had purchased EC at least twice in the past 1 month. All women interviewed reported purchasing EC a mean of 3.8 times in the 6 months prior to the survey. Those who purchased EC at least twice in the past 1 month were significantly more likely to hold misperceptions about EC's efficacy or side effects. Two thirds of all users reported having a chance to ask questions at the pharmacy, although one quarter felt that they did not receive adequate information. | This study indicates that many of the women surveyed, particularly those who had sex on an infrequent basis, chose to use EC as a regular family planning method. Among these women, it also indicates the need for better information on EC's efficacy and side effects. Such information-sharing could take place within pharmacies, although interventions must not undermine the core benefits of pharmacy access: convenience and confidentiality. | closed_qa |
Is right-sided laparoendoscopic single-site donor nephrectomy feasible? | To present our initial experience with right-sided laparoendoscopic single-site donor nephrectomy (LESS-RDN). Laparoendoscopic single-site (LESS) donor nephrectomy, although in its infancy, represents a potential exciting advancement over conventional laparoscopic donor nephrectomy (LDN). Almost all of the reported cases thus far have been left-sided kidneys. Between August 2009 and June 2010, a total of 85 consecutive LESS DN were performed. Of these, 6 (7%) were LESS-RDN. Donor outcomes analyzed included operative time, estimated blood loss, complications, visual analog pain scores, and recovery time. Renal vein lengths were measured on preoperative computed tomography scans. Recipient outcomes analyzed included recipient creatinine at discharge and at 1 and 3 months. All data were prospectively accrued in an institutional review board-approved database. Five LESS-RDN were successfully performed. One case was converted to hand-assisted laparoscopy to optimize hilar dissection. The mean (± SE) operative time until allograft extraction was 89 ± 5.1 minutes, total operative time was 146 ± 12.8 minutes, warm ischemia time was 3.9 ± 0.2 minutes, and estimated blood loss was 92 ± 27 mL. The mean renal vein length was 2.7 ± 0.3 cm. There were no perioperative complications. All allografts functioned after transplantation. When compared with a matched cohort of LESS-LDN, there was no difference in allograft function at discharge and at 1 and 3 months. | Although technically challenging, LESS-RDN in experienced hands can be performed safely and should be considered as an alternative if it is the preferred kidney for transplantation. | closed_qa |
Does lead use the intestinal absorptive pathways of iron? | Human isotope studies and epidemiological trials are controversial as to whether lead absorption shares the absorptive pathways of iron and whether body lead content can be reduced by iron supplementation.AIM: To compare the impact of iron-deficiency on ⁵⁹Fe- and ²¹⁰Pb-absorption rates in duodenal and ileal segments. ⁵⁹Fe- and ²¹⁰Pb-absorption was determined in ligated duodenal and ileal segments from juvenile and adult iron-deficient and iron-adequate C57Bl6 wild-type mice (n=6) in vivo at luminal concentrations corresponding to human exposure (Fe: 1 and 100 μmol/L; Pb: 1 μmol/L). ⁵⁹Fe-absorption increased 10-15-fold in iron-deficient duodena from adult and adolescent mice. Ileal ⁵⁹Fe-absorption was 4-6 times lower than in iron-adequate duodena showing no adaptation to iron-deficiency. This in accordance to expectation as the divalent metal transport 1 (DMT1) shows low ileal expression levels. Juvenile ⁵⁹Fe-absorption was about twice as high as in adult mice. In contrast, duodenal ²¹⁰Pb-absorption was increased only 1.5-1.8-fold in iron-deficiency in juvenile and adult mice and, again in contrast to ⁵⁹Fe, ileal ²¹⁰Pb-absorption was as high as in iron-adequate duodena. | The findings suggest a DMT1-independent pathway to mediate lead absorption along the entire small intestine in addition to DMT1-mediated duodenal uptake. Ileal lead absorption appears substantial, due the much longer residence of ingesta in the distal small intestine. Differences in lead-solubility and -binding to luminal ligands can, thus, explain the conflicting findings regarding the impact of iron-status on lead absorption. They need to be considered in future studies. | closed_qa |
Should ureteral catheterization be systematically used in kidney transplants? | To assess if the systematic use of double J ureteral catheters in ureteroneocystostomies of kidney transplants reduces the rate of complications. Non-randomized prospective, comparative study of parallel groups in 194 kidney transplants. We established two equal groups, 111 patients with double J catheter and another of 83 catheter-free patients. We studied the incidence of complications between both groups by means of a univariate comparative study (X2 test)and a multivariate analysis (logistic regression). In the catheter group, the overall complications appeared in 22.2% as opposed to 43.3% of the catheter-free group (p=0.04). Depending on the ureteral transplant, complications appeared in 38.12% of the Paquin type reimplantation as opposed to the 20.3% in Lich-Gregoir (p=0.09). There was evidence of 1 (0.9%) urinary fistula in the catheter group as opposed to 5 (6%) in the catheter-free group (p=0.08), and 3 (2.7%) ureterovesical anastomosis stricture in the group with catheter against 7 (8.4%) of the catheter-free group (p=0.13). The multivariate analysis showed that not using the catheter increases the risk of suffering complications related to reimplantation (OR: 2.55; IC 95%, 1.37-4.75). The risk of fistula increased significantly when a catheter was not placed (OR 9.19, IC 95%, 1.01-84.7). There were no differences between the two groups as regards urinary tract infections; there were 3 (2.7%) in the catheter group and 1 (1.2%) in the catheter-free group (p=0,63). | The placement of a double J catheter reduces complications related to ureteral reimplantation without increasing the morbidity associated with their use. | closed_qa |
Does skeletal facial profile influence preoperative motives and postoperative satisfaction? | The aim of the present prospective study was to assess whether patients' pretreatment facial profile influenced their motives for wanting a change in their appearance. We also assessed whether their post-treatment facial profile influenced their overall satisfaction with surgical-orthodontic treatment, the perceived change in facial profile, and general appearance. Finally, we assessed whether their degree of satisfaction was influenced by the specific change in their facial profile. The gender differences in these variables were also analyzed. A total of 66 orthognathic surgery patients were examined. The skeletal facial profile was analyzed on the lateral head films. Using the sagittal relationship between the maxilla and mandible, all patients were classified into 1 of 9 facial profile types before and after treatment. The influence of the patients' appearance on their motives before treatment and their satisfaction after treatment were evaluated using questionnaires. The preoperative facial profile type had no influence on the strength of the appearance motives; however, men had stronger appearance motives than did women. Treatment was associated with a high degree of satisfaction with both the overall result of the treatment and the perceived change in profile and general appearance. Of those patients who obtained a relative prognathic mandibula after treatment, the men voiced more outspoken satisfaction with their general appearance than did the women. The overall treatment satisfaction was not related to any specific changes in the facial profile. | Most of the patients expressed strong appearance motives before treatment and high degrees of satisfaction with the treatment afterward. The facial profile types had little influence on these parameters. | closed_qa |
Does tranexamic acid in an irrigating fluid reduce intraoperative blood loss in orthognathic surgery? | The aim of this study was to investigate the efficacy of tranexamic acid in an irrigant fluid in decreasing intraoperative blood loss during orthognathic surgery. This was a prospective, randomized, double-blind, placebo-controlled trial of elective bimaxillary osteotomy. Forty patients were included in the study and 20 were randomly assigned to each group. Drawing of random lots determined whether 0.05% tranexamic acid in normal saline solution or normal saline was used as an irrigant fluid during surgery. All patients underwent hypotensive anesthesia and surgery according to standard protocol. Intraoperative blood loss, operative and hypotensive times, preoperative and postoperative hematocrit levels, transfusion of blood product, and amount of irrigant fluid were recorded. Parametric data were reported as mean ± standard deviation and nonparametric data were counted. Changes in parametric variables were analyzed using unpaired Student t test. Two-sided significance tests were used. P<.05 was accepted as statistically significant. Blood loss during bimaxillary surgery was not decreased significantly in the tranexamic acid group compared with the control group (832.5 ± 315.5 vs 917.5 ± 424.0 mL, respectively, P = .47). | Tranexamic acid in an irrigant fluid does not significantly decrease intraoperative blood loss compared with placebo during orthognathic surgery. | closed_qa |
Is routine coagulation testing necessary in patients presenting to the emergency department with chest pain? | Driven by the need for rapid assessment, treatment and appropriate disposition of patients in the emergency department (ED), blood tests are often performed in a protocolised fashion before full clinical assessment. The cardiologists at this institution currently insist upon a coagulation profile in each patient referred with a possible acute coronary syndrome. A retrospective cohort of 1000 consecutive patients presenting to the ED with chest pain was identified. If performed, the international normalised ratio (INR) and the activated partial thromboplastin time ratio (APTR) were retrieved for each patient. If no coagulation sample was sent from the ED, a search was performed to determine whether a sample was sent within the subsequent 24-h period by the admitting hospital team. A cause of a raised INR or APTR that could have been identified easily at initial patient assessment in the ED was sought. 640 patients were identified who had coagulation tests sent from the ED as part of their assessment. Of the 592 coagulation samples successfully processed 79 were abnormal. All of these abnormal tests could have been predicted on the basis of a history of warfarin or heparin use or a history of liver disease, or were trivial enough to not preclude coronary angiography or the therapeutic use of heparin. | Routine coagulation testing in adults presenting to ED with chest pain is unnecessary. This practice should be replaced by a coagulation testing policy based on an increased risk of coagulopathy due to warfarin or heparin use or a history of liver disease. | closed_qa |
Does laboratory antibiotic susceptibility reporting influence primary care prescribing in urinary tract infection and other infections? | Using a prospective interrupted time series design, our goal was to determine whether a change in urine antibiotic susceptibility reporting from co-amoxiclav to cefalexin to community clinicians served by Southmead General Hospital led to a change in antibiotic prescribing. We used longitudinal data on antibiotic prescribing using a clinician questionnaire to identify prescribing for urinary tract infections (UTIs) when a urine specimen was submitted to microbiology; MIQUEST computer search in general practices for prescribing for all UTIs in the community; and Prescribing Analysis and Cost (PACT) data to determine antibiotic prescribing for all infections. Cefalexin and cephalosporin prescribing increased when cefalexin was reported and co-amoxiclav prescribing decreased when co-amoxiclav was not reported by the laboratory. This was seen for episodes of UTI in which a general practitioner (GP) sent a specimen as determined with: the questionnaire results (9-fold rise in cephalosporins, 70% fall in co-amoxiclav); episodes of UTI identified by MIQUEST searches in the practice (50% increase in cefalexin, 25% reduction in co-amoxiclav); and overall antibiotic prescribing in the practice determined with PACT data (20% increase in cefalexin, 8% reduction in co-amoxiclav). MIQUEST data indicated that prescribing reverted to pre-intervention levels once the change in antibiotic reporting had stopped. | Our data provide more evidence that changing laboratory antibiotic susceptibility reporting has a direct effect on antibiotic prescribing by GPs. Our data indicate that much of the change in prescribing was attributable to the use of cefalexin and co-amoxiclav for persistent or recurrent infections. Microbiology laboratories can influence antibiotic use by selectively reporting antibiotics they would prefer GPs to prescribe. | closed_qa |
Is subclinical adrenal failure in adrenoleukodystrophy/adrenomyeloneuropathy reversible? | X-linked adrenoleukodystrophy/adrenomieloneuropathy (ALD/AMN) is a progressive neurodegenerative disorder due to mutations in the ABCD1 gene encoding the ABC transporter ALDP. Mutations in ALDP impair peroxisomal β-oxidation of very long chain fatty acids (VLCFA), resulting in elevated levels of VLCFA in plasma, nervous system, and adrenals. Lorenzo's oil, combined with VLCFA- poor diet, normalizes plasma VLCFA within 1 month, but it does not prevent the progression of pre-existing neurological symptoms. No previous study analyzed the effect of Lorenzo's oil therapy on adrenal function.AIM: To investigate short-term effects of Lorenzo's oil, combined with VLCFA- poor diet, on adrenal function of AMN patients with early subclinical signs of adrenal failure. Seven AMN subjects underwent VLCFA-restricted diet combined with Lorenzo's oil (45 ml/day po), without steroid therapy, for 6 months. All patients had elevated ACTH at baseline, and a significant reduction was evident after 6 months (median ACTH at baseline: 1300 pg/ml, range: 720- 2100; median ACTH at 6 months: 186 pg/ml, range: 109-320, p: 0.0156). Cortisol was normal both at baseline and after 6 months. VLCFA dropped in all patients during the 6- month follow-up, and no patient required glucocorticoid replacement therapy. | Adrenal insufficiency in ALD/AMN is probably due to a defective adrenal response to ACTH, related to VLCFA accumulation with progressive disruption of the adrenal cell membrane functions. In an early phase, Lorenzo's oil therapy may be able to improve VLCFA clearance and restore a normal ACTH receptor activity, and hypoadrenalism may be potentially reversible. | closed_qa |
Is there a standard trochanteric entry site for nailing of subtrochanteric femur fractures? | To evaluate the variability of the ideal trochanteric starting point as a possible cause for malreduction of subtrochanteric fractures and to analyze the accuracy of contralateral templating to predict correct entry site. Standardized anteroposterior pelvis radiographs of 50 patients were evaluated by two independent reviewers. Patients with advanced osteoarthritis, severe hip deformity, and radiographs with asymmetric hip rotation were excluded. Ideal nail entry site was established using a template for a trochanteric nail with a 6° proximal bend. The distance from the greater trochanteric tip to the ideal nail entry site was measured. Additionally, offset of the greater trochanter tip from the femoral longitudinal axis was measured. Interobserver reliability and accuracy of contralateral templating were evaluated. The ideal entry point ranged from 16 mm medial to 8 mm lateral to the trochanteric tip (mean, 3 mm medial; standard deviation, 5 mm). In 70% of patients, the ideal entry point was medial to and in 23% lateral to the tip of the greater trochanter. Ideal entry points were located within 2 mm of the trochanteric tip in 29% and within 4 mm in 44% of patients. The location of the ideal entry point relative to the trochanteric tip had a weak correlation with patient height and neck shaft angle (r: -0.23 and r: -0.35, respectively). Interobserver reliability and agreement between left and right side measurements were strong (intraclass correlation coefficient:>0.94 and>0.88, P<0.001, respectively). The mean measurement differences between sides was 0 mm (95% confidence interval: -1 to 1). Greater trochanter offset averaged 15 mm (range, 5-26 mm; standard deviation: 5) on the right and 15 mm (range, 5-25 mm; standard deviation: 5.1) on the left (P = 0.95). | A high degree of variability exists for the ideal trochanteric entry site. The trochanteric tip represents the ideal starting point in only the minority of cases. Preoperative contralateral templating provides an accurate means for establishing a patient-specific entry point to minimize fracture malreduction. | closed_qa |
Slowed EEG rhythmicity in patients with chronic pancreatitis: evidence of abnormal cerebral pain processing? | Intractable pain usually dominates the clinical presentation of chronic pancreatitis (CP). Slowing of electroencephalogram (EEG) rhythmicity has been associated with abnormal cortical pain processing in other chronic pain disorders. The aim of this study was to investigate the spectral distribution of EEG rhythmicity in patients with CP. Thirty-one patients with painful CP (mean age 52 years, 19 male) and 15 healthy volunteers (mean age 49, nine male) were included. A multichannel EEG was recorded from 62 surface electrodes. Amplitude strengths of the resting EEG were retrieved based on wavelet frequency analysis and summarized in frequency bands with corresponding topographic mapping. Patients with CP had slowed EEG rhythmicity compared with healthy volunteers. This was evident as increased activity in the lower frequency bands δ (1-3.5 Hz) (P=0.05), θ (3.5-7.5 Hz) (P<0.001) and α (7.5-13.5 Hz) (P<0.001). Due to normalization a reciprocal relationship was observed for the high frequency band β (13.5-32 Hz). In a sub-analysis, δ band activity was modified by diabetes, opioid treatment and alcohol aetiology of CP. However, no effect modification was seen for the θ or α bands. Differences in θ activity were located over centro-frontal brain regions, whereas differences in δ, α and β band activity were located in frontal regions. | Slowed EEG rhythmicity was evident in patients with CP. This possibly mirrors abnormal central pain processing and may serve as a clinically useful biomarker of abnormal central pain processing. | closed_qa |
Can partial coherence interferometry be used to determine retinal shape? | To determine likely errors in estimating retinal shape using partial coherence interferometric instruments when no allowance is made for optical distortion. Errors were estimated using Gullstrand no. 1 schematic eye and variants which included a 10 diopter (D) axial myopic eye, an emmetropic eye with a gradient-index lens, and a 10.9 D accommodating eye with a gradient-index lens. Performance was simulated for two commercial instruments, the IOLMaster (Carl Zeiss Meditec) and the Lenstar LS 900 (Haag-Streit AG). The incident beam was directed toward either the center of curvature of the anterior cornea (corneal-direction method) or the center of the entrance pupil (pupil-direction method). Simple trigonometry was used with the corneal intercept and the incident beam angle to estimate retinal contour. Conics were fitted to the estimated contours. The pupil-direction method gave estimates of retinal contour that were much too flat. The cornea-direction method gave similar results for IOLMaster and Lenstar approaches. The steepness of the retinal contour was slightly overestimated, the exact effects varying with the refractive error, gradient index, and accommodation. | These theoretical results suggest that, for field angles ≤30°, partial coherence interferometric instruments are of use in estimating retinal shape by the corneal-direction method with the assumptions of a regular retinal shape and no optical distortion. It may be possible to improve on these estimates out to larger field angles by using optical modeling to correct for distortion. | closed_qa |
Immediate free flap reconstruction for advanced-stage breast cancer: is it safe? | Numerous studies have demonstrated that immediate breast reconstruction following mastectomy is associated with improvements in quality of life and body image. However, immediate breast reconstruction for advanced-stage breast cancer remains controversial. This study evaluates its safety in patients with advanced-stage breast cancer. Over a 10-year period, patients diagnosed with stage IIB or greater breast cancer treated with mastectomy followed by immediate breast reconstruction were identified and analyzed. Complication rates and reconstructive aesthetics were determined. One hundred seventy patients were identified who underwent 157 unilateral and 13 bilateral reconstructions (183 flaps) predominantly by means of free transverse rectus abdominis musculocutaneous flaps (n = 162). The average age was 47 years and the average hospital stay was 5.1 days. There were 15 major complications (8.8 percent), but adjuvant postoperative therapy was delayed in only eight patients (4.7 percent), with the maximum delay lasting 3 weeks in one patient. Although some degree of flap shrinkage was noted in 30 percent of patients treated with postoperative radiotherapy, only 10 percent of patients experienced severe breast distortion. Importantly, the overall cosmetic outcome in patients who underwent postoperative irradiation was comparable to that of those who did not. | The authors have shown that immediate breast reconstruction in the setting of advanced-stage breast cancer is safe and well tolerated by patients, and is not associated with significant delays in adjuvant therapy. These findings make a strong argument for immediate reconstruction regardless of cancer stage. The authors found the changes caused by radiation to the reconstructed breast to be less significant than previously reported and readily addressed to complete an ultimate reconstruction that is aesthetically acceptable to both surgeon and patient.CLINICAL QUESTION/ | closed_qa |
Analysis of adjacent fracture after percutaneous vertebroplasty: does intradiscal cement leakage really increase the risk of adjacent vertebral fracture? | The purpose of this study was to evaluate the incidence and risk factors associated with adjacent vertebral fracture after percutaneous vertebroplasty (PVP) to treat osteoporotic vertebral compression fractures. We also investigated the effect of intradiscal cement leakage on adjacent vertebral fracture formation after PVP. From January 2003 to March 2009, 188 patients (163 women, 25 men; mean age, 70.9 years; range, 42-92 years) who underwent 214 PVP sessions at 351 levels for osteoporotic vertebral compression fractures were retrospectively enrolled in this study. The effect of intradiscal cement leakage on new adjacent vertebral fracture formation after PVP was evaluated. Possible other risk factors were also analyzed using univariate and multivariate methods. The risk factors included age, gender, mean bone mineral density (BMD), the vertebral level treated, presence of an intravertebral cleft or cyst before treatment, kyphosis angle, wedge angle, and the injected cement volumes. During the follow-up periods, new adjacent vertebral fractures developed in 36 (10.3%) of 351 treated levels. For 91 (25.9%) levels, intradiscal cement leakage was detected on procedural fluoroscopic radiographs. There was no statistically significant association between intradiscal cement leakage and new adjacent vertebral compression fracture (p = 0.789). Among the other risk factors, only the vertebral levels treated, especially the thoracolumbar junction, showed a significant relationship to new adjacent vertebral fractures (univariate analysis, p = 0.037; multivariate analysis, p = 0.043). | Intradiscal cement leakage does not seem to be related to subsequent adjacent vertebral compression fracture in patients who underwent PVP for treatment of an osteoporotic compression fracture. The thoracolumbar location of the initial compression fracture is the only factor correlated with an adjacent vertebral fracture after PVP. | closed_qa |
Is para-aortic lymph node metastasis a contraindication for radical resection in biliary carcinoma? | Para-aortic nodal dissection in patients with biliary carcinoma has not been performed routinely worldwide. Therefore, the prognostic impact of para-aortic lymph node metastasis in biliary carcinoma has not yet been evaluated. The aim of this study was to clarify the prognostic impact of para-aortic lymph node metastasis in biliary carcinoma. Of 113 patients with biliary adenocarcinoma who underwent surgical resection with regional and para-aortic lymph node dissection, para-aortic lymph node metastasis was found in 17 patients (15%) by final pathological examination. Relationships between clinicopathological factors, including para-aortic lymph node metastasis, and survival were analyzed by univariate and multivariate analyses. Overall survival rates for the 113 patients were 82% at 1 year, 65% at 2 years, 58% at 3 years, and 52% at 5 years. Univariate analysis revealed that better tumor differentiation (P=0.044), negative lymph node metastasis (P<0.001), negative para-aortic lymph node metastasis (P=0.007), negative surgical margin status (P<0.001), lower UICC pT factor (P=0.009), and earlier UICC stage (P<0.001) were associated significantly with longer survival. Lymph node metastasis (P=0.004) but not para-aortic lymph node metastasis (P=0.323) remained associated independently with longer survival by multivariate analysis. Five-year survival rates for node-negative patients, node-positive patients without para-aortic lymph node metastasis, and node-positive patients with para-aortic lymph node metastasis were 72, 31, and 24%, respectively. | Radical resection should not be abandoned for patients with para-aortic lymph node metastasis in biliary adenocarcinoma. | closed_qa |
Does the small farm exemption cost lives? | Congress has exempted farms with fewer than 11 employees from enforcement of the Occupational Safety and Health Act. Three states (California, Oregon, and Washington) do not observe the exemption. We compared rates of fatal occupational injury in agriculture, by year, in 1993-2007, in California, Oregon, and Washington (aggregated), and the remaining states (as two aggregated groups): those with, and those without, state-designed occupational safety and health programs. Fatality rates were approximately 1.6 to 3 times as high in both groups of states observing the small farm exemption as in the group of three states not observing it. Comparisons excluding the agriculture industry showed weaker differences. | The three states' opting out of the small farm exemption may have had substantial direct effects. They may also reflect and/or encourage a generally more effective approach to occupational health and safety. Although alternative explanations must be considered, the stakes are high in terms of injury and loss of life; further investigation seems urgently indicated. | closed_qa |
Is walking endurance associated with activity and participation late after stroke? | After stroke, impaired walking ability may affect activity and participation. The aim was to investigate whether self-reported activity and participation were associated with walking endurance late after stroke. A non-randomised sample of 31 persons with a mean age of 59.7 years and time since stroke of 7-10 years was studied. Walking endurance was measured by the 6-minute walk test (6MWT). Self-reported activity and participation were measured by the Physical Activity Scale for the Elderly and the Stroke Impact Scale. Relationships were analysed with linear regression. A regression model including activities of daily living and 6MWT explained 44%, mobility and 6MWT explained 25% and a model including physical activity level and 6MWT explained 21% of the variation in activity. Regarding participation, the explanatory level of the model of participation and 6MWT was 30%. | Walking distance several years after stroke was partly associated with self-reported difficulties in activity and participation. | closed_qa |
Does hydrophobicity always enhance antioxidant drugs? | Phenolic antioxidants are currently attracting a growing interest as potential therapeutic agents to counteract diseases associated with oxidative stress. However, their high hydrophilicity results in a poor bioavailability hindering the development of efficient antioxidant strategies. A promising way to overcome this is to increase their hydrophobicity by lipophilic moiety grafting to form the newly coined 'phenolipids'. Although hydrophobicity is generally considered as advantageous regarding antioxidant properties, it is nevertheless worth investigating whether increasing hydrophobicity necessarily leads to a more efficient antioxidant drug. To answer this question, the antioxidant capacity of a homologous series of phenolics (chlorogenic acid and its methyl, butyl, octyl, dodecyl and hexadecyl esters) toward mitochondrial reactive oxygen species (ROS) generated in a ROS-overexpressing fibroblast cell line was investigated using 2',7'-dichlorodihydrofluorescein. Overall, the long chain esters (dodecyl and hexadecyl esters) were more active than the short ones (methyl, butyl, and octyl esters), with an optimal activity for dodecyl chlorogenate. Moreover, dodecyl chlorogenate exerted a strong antioxidant capacity, for concentration and incubation time below the cytotoxicity threshold, making it a promising candidate for further in-vivo studies. More importantly, we found that the elongation of the chain length from 12 to 16 carbons led unexpectedly to a 45% decrease of antioxidant capacity. | The understanding of this sudden collapse of the antioxidant capacity through the cut-off theory will be discussed in this article, and may contribute towards development of a rational approach to design novel amphiphilic antioxidant drugs, especially phenolipids with medium fatty chain. | closed_qa |
'Is that normal? | Context has been recognised as a key variable in studies of medical student professionalism, yet the effect of students' stage of training has not been well explored, despite growing recognition that medical students begin to form their professional ethos from their earliest medical school experiences. The purpose of this study, which builds on previous research involving clinical clerks, was to explore the decision-making processes of pre-clerkship medical students in the face of standardised professional dilemmas. Structured interviews were conducted with 30 pre-clerkship (Years 1 and 2) medical students at one institution. During the interviews, students were asked to respond to five videotaped scenarios, each of which depicted a student facing a professional dilemma. Transcripts were analysed using an existing theoretical framework based on a constructivist grounded theory approach. Pre-clerkship students' approaches to professional dilemmas were largely similar to those of clerks, despite their limited clinical experience, with several notable exceptions. For example, reliance on instincts and emotions was not as pervasive, but concerns with systems-associated issues were more recurrent. These findings were explored in the context of theory on professional identity formation. | As the novice student constructs a professional identity, he or she may feel the need to take on the role of doctor and shed that of student, a process that involves the suppressing of emotions, but this may be misguided. Educators should be aware of these stages of identity formation and tailor their teaching and evaluation of professionalism accordingly. | closed_qa |
Can diabetes management be safely transferred to practice nurses in a primary care setting? | To determine whether the management of type 2 diabetes mellitus in a primary care setting can be safely transferred to practice nurses. Because of the increasing prevalence of type 2 diabetes mellitus and the burden of caring for individual patients, the demand type 2 diabetes mellitus patients place on primary health care resources has become overwhelming. Randomised controlled trial. The patients in the intervention group were cared for by practice nurses who treated glucose levels, blood pressure and lipid profile according to a specified protocol. The control group received conventional care from a general practitioner. The primary outcome measure was the mean decrease seen in glycated haemoglobin (HbA1c) levels at the end of the follow-up period (14 months). A total of 230 patients was randomised with 206 completing the study. The between-group differences with respect to reduction in HbA1c, blood pressure and lipid profile were not significant. Blood pressure decreased significantly in both groups; 7.4/3.2 mm Hg in the intervention group and 5.6/1.0 mm Hg in the control group. In both groups, more patients met the target values goals for lipid profile compared to baseline. In the intervention group, there was some deterioration in the health-related quality of life and an increase in diabetes-related symptoms. Patients being treated by a practice nurse were more satisfied with their treatment than those being treated by a general practitioner. | Practice nurses achieved results, which were comparable to those achieved by a general practitioner with respect to clinical parameters with better patient satisfaction. | closed_qa |
Intention to leave of Asian nurses in US hospitals: does cultural orientation matter? | To measure the predictability of cultural orientation on organisational commitment, perception of practice environment and intention to leave amongst Asian nurses working in US hospitals. To alleviate the nursing shortage, healthcare institutions have increased recruitment of nurses internationally, with Asian nurses representing the largest proportion of international nurses working in the US. Whilst organisational commitment and perception of practice environment were related to intention to leave, few studies have been done on the predictability of intention to leave amongst Asian nurses. A cross-sectional postal survey design. One hundred and ninety-five Asian nurses working at least six months in US hospitals completed the survey. Most participants were Filipinos or Chinese, married and worked full-time. The Organisational Commitment Questionnaire, Practice Environment Scale of the Nursing Work Index, Anticipated Turnover Scale and Collectivist Orientation Scale with satisfactory reliability were used. Perception of practice environment was correlated with intention to leave and organisational commitment, which was correlated with intention to leave. Cultural orientation showed positive predictable effects on organisational commitment and perception of practice environment, but had negative predictability for intention to leave. The mediating effect of organisational commitment on practice environment and intention to leave was 93·98%, when cultural orientation was not controlled for. It increased slightly to 96·54% when cultural orientation was controlled for. | Asian nurses who are more collectivist-oriented are more willing to accept the goals and values of the organisation, exert effort on behalf of the organisation, are more satisfied with their current practice environment and have less intention to leave their current job. Organisational commitment is a key predictor of Asian nurses' intention to leave. | closed_qa |
Fetal blood sampling in early labour: is there an increased risk of operative delivery and fetal morbidity? | To determine whether the rate of caesarean section was increased in women undergoing fetal blood sampling (FBS) in early labour. Retrospective study. Secondary and tertiary obstetric units in the UK. A cohort of 381 women undergoing FBS. Data relating to demographics, labour and delivery characteristics, and neonatal outcomes were collected on women undergoing FBS in labour. Odds ratios (ORs) for caesarean section compared with vaginal delivery for women who had their first FBS in early labour (≤ 3 cm cervical dilatation) and for women who required multiple samples were calculated. Mode of delivery. Forty-eight percent of women who required their first FBS at a cervical dilatation of ≤ 3 cm achieved a vaginal delivery; these women were at modestly increased risk of caesarean section (adjusted OR 1.80; 95% CI 1.04-3.13) compared with women who had their first FBS at a cervical dilatation of ≥ 4 cm. The odds ratio for caesarean section in women who required two or more FBS was 1.71 (95% CI 1.37-2.13) compared with those requiring a single sample. There were no differences in instrumental delivery. Infants undergoing three or more FBS were more likely to be admitted to a neonatal intensive care unit (NICU; OR 2.69; 95% CI 1.09-6.64), although this was not associated with increased acidaemia. | Women who require FBS in early labour or multiple FBS are at a modestly increased risk of caesarean section compared with those in established labour. When contemplating FBS at ≤ 3-cm cervical dilatation, practitioners should not be put off by the perceived low chance of vaginal delivery, but repeating FBS on more than three occasions should be considered carefully. | closed_qa |
Is vaccination coverage a good indicator of age-appropriate vaccination? | Timely vaccination is important to protect children from common infectious diseases. We assessed vaccination timeliness and vaccination coverage as well as coverage of vitamin A supplementation in a Ugandan setting. This study used vaccination information gathered during a cluster-randomized trial promoting exclusive breastfeeding in Eastern Uganda between 2006 and 2008 (ClinicalTrials.gov no. NCT00397150). Five visits were carried out from birth up to 2 years of age (median follow-up time 1.5 years), and 765 children were included in the analysis. We used Kaplan-Meier time-to-event analysis to describe vaccination coverage and timeliness. Vaccination coverage at the end of follow-up was above 90% for all vaccines assessed individually that were part of the Expanded Program on Immunization (EPI), except for the measles vaccine which had 80% coverage (95%CI 76-83). In total, 75% (95%CI 71-79) had received all the recommended vaccines at the end of follow-up. Timely vaccination according to the recommendations of the Ugandan EPI was less common, ranging from 56% for the measles vaccine (95%CI 54-57) to 89% for the Bacillus Calmette-Guérin (BCG) vaccine (95%CI 86-91). Only 18% of the children received all vaccines within the recommended time ranges (95%CI 15-22). The children of mothers with higher education had more timely vaccination. The coverage for vitamin A supplementation at end of follow-up was 84% (95%CI 81-87). | Vaccination coverage was reasonably high, but often not timely. Many children were unprotected for several months despite being vaccinated at the end of follow-up. There is a need for continued efforts to optimise vaccination timeliness. | closed_qa |
Does intraperitoneal chemotherapy benefit optimally debulked epithelial ovarian cancer patients after neoadjuvant chemotherapy? | To compare survival of ovarian cancer patients treated with neoadjuvant chemotherapy followed by intraperitoneal (IP) versus intravenous (IV) chemotherapy after optimal interval debulking. Optimally debulked patients after neoadjuvant IV platinum paclitaxel based chemotherapy followed by postoperative IP chemotherapy were reviewed. A similar cohort of patients treated postoperatively with IV platinum paclitaxel based chemotherapy was chosen as control. Patient and disease-related demographics were abstracted from electronic hospital medical records. Associations between categorical variables were determined using Chi square test. Cox regression and Kaplan-Meier method estimated progression-free and overall survival. Fifty-four IV and 17 IP treated patients after interval debulking were studied. The majority of patients had serous histology and grade 3 tumours. There was no significant difference between the two groups with respect to age and proportion of microscopic residual disease. Patients with macroscopic residual disease had a significantly worse prognosis (HR=2.17, 95% CI=1.23-3.85, p=0.008). Clinical complete response after primary treatment was 67% and 88% in the IV and IP group, respectively (p=0.36). Estimated mean progression-free survival was 18 months in the IV group and 14.1 months in the IP group (p=0.42). IP chemotherapy was not predictive of progression-free survival in the Cox model adjusted for age and residual disease status (HR=1.22, 95% CI=0.62-2.4, p=0.56). Estimated mean survival was 68.9 months in the IV group and 37.5 months in the IP group (p=0.85). | Survival benefit associated with IP chemotherapy after optimal upfront surgery may not translate to the neoadjuvant setting. | closed_qa |
Can a pharmacist reduce annual costs for Medicare Part D enrollees? | To determine the ability of a community pharmacist to reduce the annual drug expenditures for Medicare Part D enrollees. Independent community pharmacy. Located in rural North Carolina, one pharmacist and two technicians, 900 prescriptions per week, open 56 hours per week; and median income of $14,500 in 2009. Drug regimen reviews for 50 Medicare Part D enrollees were performed using the Medicare.gov Web site to determine the potential annual savings available to patients by selecting the lowest-cost prescription drug plan and requesting therapeutic alternatives to expensive medications. The impact of this intervention on the patient's entry into the coverage gap was also explored. Annual prescription drug plan cost (in dollars/year), number of patients in coverage gap, number of months to reach coverage gap (MTG) in the Medicare Part D drug program. 48/50 patients had not selected the lowest-cost prescription plan and had a potential to save $456 per year, 27/50 patients had an opportunity for therapeutic substitution with a potential savings of $1,303 per year, 25 enrollees would reach the coverage gap without an intervention, 16 could be kept out of the gap with an average improvement of 3.02 months' coverage. | Pharmacists can use the Medicare.gov Web site to assist Medicare Part D plan enrollees in reducing their out-of-pocket annual expenditures. | closed_qa |
Is there a difference between the effects of single and triple indirect moxibustion stimulations on skin temperature changes of the posterior trunk surface? | To determine whether any difference exists in responses to indirect moxibustion (IM) relative to thermal stimulation duration. In experiment 1, 9 subjects attended two experimental sessions consisting of single stimulation with IM or triple stimulation with IM, using a crossover design. A K-type thermocouple temperature probe was fixed on the skin surface at the GV14 acupuncture point. IM stimulation was administered to the top of the probe in order to measure the temperature curve. In addition, each subject evaluated his or her subjective feeling of heat on a visual analogue scale after each stimulation. Experiment 2 was conducted on 42 participants, divided into three groups according to the envelope allocation method: single stimulation with IM (n=20), triple stimulation with IM (n=11) and a control group (n=11). A thermograph was used to obtain the skin temperature on the posterior trunk of the participant. To analyse skin temperature, four arbitrary frames (the scapular, interscapular, lumbar and vertebral regions) were made on the posterior trunk. In experiment 1, no significant difference in maximum temperature was found in IM and subjective feeling of heat intensity between single and triple stimulation with IM. In experiment 2, increases in skin temperature occurred on the posterior trunk, but no differences in skin temperature occurred between the groups receiving single and triple stimulation with IM. | No difference exists in the skin temperature response to moxibustion between the single and triple stimulation with IM. | closed_qa |
Does an intervention that improves infant sleep also improve overweight at age 6? | Short sleep duration may contribute to childhood obesity. Amenable to intervention, sleep thus provides a potential path for prevention. The authors aimed to determine the impact of a behavioural intervention that successfully reduced parent-reported infant sleep problems on adiposity at age 6. 5-year follow-up of a previously reported population-based cluster randomised trial. Participant allocation was concealed to researchers and data collection blinded. Recruitment from well-child centres in Melbourne, Australia. 328 children (174 intervention) with parent-reported sleep problems at age 7-8 months drawn from 49 centres (clusters). Behavioural sleep strategies delivered over one to three structured individual nurse consultations from 8 to 10 months, versus usual care. MAIN OUTCOMES AT AGE 6 Body mass index (BMI) z-score, percentage overweight/obese and waist circumference. Intention-to-treat regression analyses adjusted for potential confounders. Anthropometric data were available for 193 children (59% retention) at age 6. There was no evidence of a difference between intervention (N=101) and control (N=92) children for BMI z-score (adjusted mean difference 0.2, 95% CI -0.1 to 0.4), overweight/obese status (20% vs 17%; adjusted OR 1.4, 95% CI 0.7 to 2.8) and waist circumference (adjusted mean difference -0.3, 95% CI -1.6 to 1.1). In posthoc analyses, neither infant nor childhood sleep duration were associated with anthropometric outcomes. | A brief infant sleep intervention did not reduce overweight/obesity at 6 years. Population-based primary care sleep services seem unlikely to reduce the early childhood obesity epidemic. | closed_qa |
Subsets and Splits