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Are airborne refractory ceramic fibers similar to asbestos in their carcinogenicity? | Animal studies on refractory ceramic fiber (RCF) have led to the suggestion that RCF might resemble asbestos in carcinogenicity. Human data are available to test this hypothesis. We compared the occurrence of lung cancer and mesothelioma in 605 men engaged in the manufacture of RCF and followed since 1987 to cancer rates that would have been anticipated if airborne RCF were carcinogenic to the same degree as are crocidolite, amosite or chrysotile asbestos. We integrated the results of workplace exposure monitoring with mortality follow-up using formulas presented by Hodgson and Darnton (2000) to estimate hypothesized risks under different asbestos scenarios. During 15,281 person-years of observation, there were 12 deaths from lung cancer. General population rates predicted 11.8 cases expected for an observed/expected (O/E) ratio of 1.0. Anticipated numbers of deaths from lung cancer under hypotheses of carcinogenicity similar to that of amphiboles and chrysotile were 62 and 17, allowing for rejection of amphibole-like effects (p<10(-5)) but not chrysotile-like carcinogenicity (p = 0.15). There were no cases of mesothelioma, as compared to 4.9 anticipated under a crocidolite-like hypothesis (p = 0.007 to reject), 1.0 for amosite (p = 0.38) and 0.05 for chrysotile (p = 0.95). | There was no increase in lung cancer or mesothelioma in these workers exposed to RCF. If the cohort had the same exposure to crocidolite asbestos the number of lung cancer and mesothelioma cases would have been significantly greater than observed. The data do not yet permit a similar conclusion with respect to chrysotile asbestos. | closed_qa |
Do apolipoprotein E genotype and educational attainment predict the rate of cognitive decline in normal aging? | We investigated suspected longitudinal interaction effects of apolipoprotein E (APOE) genotype and educational attainment on cognitive decline in normal aging. Our sample consisted of 571 healthy, nondemented adults aged between 49 and 82 years. Linear mixed-models analyses were performed with four measurement time points: baseline, 3-year, 6-year, and 12-year follow-up. Covariates included age at baseline, sex, and self-perceived physical and mental health. Dependent measures were global cognitive functioning (Mini-Mental State Examination; Folstein, Folstein,&McHugh, 1975), Stroop performance (Stroop Color-Word Test; Van der Elst, Van Boxtel, Van Breukelen,&Jolles, 2006a), set-shifting performance (Concept Shifting Test; Van der Elst, Van Boxtel, Van Breukelen,&Jolles, 2006b), cognitive speed (Letter-Digit Substitution Test; Van der Elst, Van Boxtel, Van Breukelen,&Jolles, 2006c), verbal learning (Verbal Learning Test: Sum of five trials; Van der Elst, Van Boxtel, Van Breukelen,&Jolles, 2005), and long-term memory (Verbal Learning Test: Delayed recall). We found only faint evidence that older, high-educated carriers of the APOE-ε4 allele (irrespective of zygosity) show a more pronounced decline than younger, low-educated carriers and noncarriers (irrespective of educational attainment). Moreover, this outcome was confined to concept-shifting performance and was especially observable between 6- and 12-year follow-ups. No protective effects of higher education were found on any of the six cognitive measures. | We conclude that the combination of APOE-ε4 allele and high educational attainment may be a risk factor for accelerated cognitive decline in older age, as has been reported before, but only to a very limited extent. Moreover, we conclude that, within the cognitive reserve framework, education does not have significant protective power against age-related cognitive decline. | closed_qa |
Are obstetrical, perinatal, and infantile difficulties associated with pediatric bipolar disorder? | Despite increasing acknowledgement of bipolar disorder (BD) in childhood, there is a paucity of literature that has investigated obstetrical, perinatal, and infantile difficulties and their potential link with BD. To this end, we examined difficulties during delivery, immediate post-birth, and infancy and the association with BD in childhood. From two similarly designed, ongoing, longitudinal, case-control family studies of pediatric BD (N = 327 families), we analyzed 338 children and adolescents [mean (± standard deviation) age: 12.00 ± 3.37 years]. We stratified them into three groups: healthy controls (N = 98), BD probands (N = 120), and their non-affected siblings (N = 120). All families were comprehensively assessed with a structured psychiatric diagnostic interview for psychopathology and substance use. Mothers were directly questioned regarding the pregnancy, delivery, and infancy difficulties that occurred with each child using a module from the Diagnostic Interview for Children and Adolescents-Parent Version (DICA-P). Mothers of BD subjects were more likely to report difficulties during infancy than mothers of controls [odds ratio (95% confidence interval) = 6.6 (3.0, 14.6)]. Specifically, children with BD were more likely to have been reported as a stiffened infant [7.2 (1.1, 47.1)]and more likely to have experienced 'other' infantile difficulties [including acting colicky; 4.9 (1.3, 18.8)] compared to controls. We found no significant differences between groups in regards to obstetrical or perinatal difficulties (all p values>0.05). | While our results add to previous literature on obstetrical and perinatal difficulties and BD, they also highlight characteristics in infancy that may be prognostic indicators for pediatric BD. | closed_qa |
Can targeted early intervention improve functional recovery in psychosis? | This paper assesses the impact of different models of early intervention (EI) service provision on functional recovery and inpatient hospital admission. The study compares the outcome of a comprehensive EI team with a partial model (community mental health team (CMHT) plus specialist support) and traditional care (generic CMHT) over a 10-year period. The design is in comparison with historical control. The study compares the functional recovery outcomes of three cohorts from the same geographical area over the period 1998-2007. The primary outcomes were partial and full functional recovery defined with respect to readily identifiable UK benefit system thresholds and psychiatric inpatient admission days at 1 and 2 years post-referral. Only 15% of individuals made a full or partial functional recovery at 2 years under the care of a traditional generic CMHT in 1998. In 2007, 52% of the cases were making a full or partial functional recovery under the care of the comprehensive EI team. A large reduction in inpatient admissions was associated with the EI strategy. | The implementation of comprehensive EI teams can have a major impact in improving functional recovery outcomes in psychosis and reducing inpatient admissions. Partial implementation using limited funding of specialist workers in collaboration with traditional care appeared to have a more limited effect on these recovery dimensions. The implementation of targeted EI in psychosis strategies can result in substantive functional benefits. | closed_qa |
Dissatisfaction with residency: a discrepancy between preferences and expectations? | Medical residents play two roles that enter into conflict during their educational period: trainees and workers. This dual role can lead to dissatisfaction among residents that can affect both the quality of the services they provide to citizens and the proper functioning of the health services model itself.AIM: To analyse discrepancies between the preferences and expectations of first-year medical residents and whether these differences affect satisfaction with the residency. A questionnaire was administered on-line to the entire population of first-year medical residents of the Autonomous Community of Andalusia (Spain) in 2008. We performed a means contrast test between the indicator discrepancy (difference between preferences and expectations during the residency as a training or a working period), overall satisfaction with the residency and their relationship to other expectations of medical residents. Respondents showing greater discrepancy have a more negative opinion about the residency. | There is a gap between what residents prefer and what they expect from the residency, giving rise to dissatisfaction. This gap must be bridged to improve the quality of training received by these new physicians, their satisfaction and hence the delivery of health services to citizens. | closed_qa |
Tracheostomy and laryngectomy survey: do front-line emergency staff appreciate the difference? | In an emergency scenario, it is vital to appreciate the difference between a laryngectomy and a tracheostomy so that oxygen can be administered in an appropriate manner. This survey aimed to ascertain the level of emergency healthcare personnel's knowledge with regards to distinguishing between a tracheostomy and a laryngectomy patient, and the emergency management of such patients. Forty-four accident and emergency staff (28 doctors, nine nurses and seven paramedics) within one Foundation Trust were invited to complete a questionnaire to ascertain (1) their confidence at differentiating between a laryngectomy and tracheostomy stoma; (2) knowledge of the appropriate site for oxygen delivery if needed; and (3) overall level of training on this subject. There were significant gaps in knowledge, particularly with regards to fundamental differences between a tracheostomy and a laryngectomy; less than 5 per cent were able to describe the anatomical difference. Only 41 per cent correctly identified the route of oxygen administration in laryngectomy patients. | In this cohort of emergency staff, the fundamental difference between a laryngectomy and a tracheostomy was poorly understood. This lack of awareness of front-line emergency staff needs to be addressed in order to maximise patient safety. | closed_qa |
Is home management of fevers a cost-effective way of reducing under-five mortality in Africa? | To assess the cost-effectiveness of two strategies of home management of under-five fevers in Ghana - treatment using antimalarials only (artesunate-amodiaquine - AAQ) and combined treatment using antimalarials and antibiotics (artesunate-amodiaquine plus amoxicillin - AAQ + AMX). We assessed the costs and cost-effectiveness of AAQ and AAQ + AMX compared with a control receiving standard care. Data were collected as part of a cluster randomised controlled trial with a step-wedged design. Approximately, 12,000 children aged 2-59 months in Dangme West District in southern Ghana were covered. Community health workers delivered the interventions. Costs were analysed from societal perspective, using anaemia cases averted, under-five deaths averted and disability-adjusted life years (DALYs) averted as effectiveness measures. Total economic costs for the interventions were US$ 204,394.72 (AAQ) and US$ 260,931.49 (AAQ + AMX). Recurrent costs constituted 89% and 90% of the total direct costs of AAQ and AAQ + AMX, respectively. Deaths averted were 79.1 (AAQ) and 79.9 (AAQ + AMX), with DALYs averted being 2264.79 (AAQ) and 2284.57 (AAQ + AMX). The results show that cost per anaemia case averted were US$ 150.18 (AAQ) and US$ 227.49 (AAQ + AMX) and cost per death averted was US$ 2585.58 for AAQ and US$ 3272.20 for AAQ + AMX. Cost per DALY averted were US$ 90.25 (AAQ) and US$ 114.21 (AAQ + AMX). | Both AAQ and AAQ + AMX approaches were cost-effective, each averting one DALY at less than the standard US$ 150 threshold recommended by the World Health Organisation. However, AAQ was more cost-effective. Home management of under-five fevers in rural settings is cost-effective in reducing under-five mortality. | closed_qa |
Does the epidemiologic paradox hold in the presence of risk factors for low birth weight infants among Mexican-born women in Colorado? | To test whether foreign-born status confers a protective effect against low birth weight (LBW) outcomes among Mexican-origin women in Colorado. Retrospective cohort study utilizing Colorado birth records from 1989-2004 for multivariate logistic regression analysis. The study population was 66,422 U.S.-born women of Mexican origin (USB) and 85,000 Mexican-born (MB) women with singleton births. Mexican-born women had 24.9% lower odds of LBW (OR 0.751 95% CI 0.782) than USB women. Mexican-born women had a higher prevalence of risk factors for LBW than their USB counterparts (anemia, cardiac disease, hypertension, inadequate prenatal care, less than high school education). After adjusting for these risk factors, MB women had 22.5% lower odds of having LBW infants than USB women (OR 0.775, 95% CI 0.73-0.81). | This study supports the epidemiologic paradox of LBW; despite higher prevalence of risk factors, foreign-born status confers an overall protective effect against low birth weight outcomes. | closed_qa |
Racial disparities in intensity of care at the end-of-life: are trauma patients the same as the rest? | Medicare data show Blacks and Hispanics use more health care resources in the last six months of life than Whites. We sought to determine if similar differences exist in trauma patients who died following moderate to severe injury. We analyzed data from a prospective cohort study of 18 Level 1 and 51 non-trauma centers in 12 states to examine racial/ethnic variation in intensity of care and hospital costs. Blacks were more likely than Whites to receive critical care consultation RR=1.67 (95% CI, 1.22, 2.30), specialty assessments RR=1.44 (95% CI, 1.12, 1.86) and procedures RR=1.22 (95% CI, 1.00, 150). Hispanics were less likely than Whites to have withdrawal-of-care orders, RR=0.72 (95% CI, 0.53, 0.98). | Among patients who die after trauma, Blacks receive higher intensity of care and Hispanics were less likely to have withdrawal of care orders than others. This suggests racial disparities in patient preferences and provider treatment. | closed_qa |
Is a positive nasal lysine-aspirin challenge test associated with a more severe phenotype of chronic rhinosinusitis and asthma? | Current guidelines recommend a greater use of aspirin challenge testing in the diagnosis of aspirin-intolerant rhinosinusitis and asthma, a disorder with high burden of illness and resistance to treatment. The indications for these tests and their clinical significance remain unclear. This study was designed to characterize the phenotype of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) with or without asthma undergoing a nasal lysine-aspirin (L-ASA) challenge to evaluate which factors strongly predict a positive test. Seventy-five patients with CRSwNP underwent nasal challenge with 16 mg (total) of L-ASA after 30 minutes of acclimatization and diluent challenge. A positive challenge was defined as a 25% drop in total nasal volume measured by acoustic rhinometry. Twenty-three (31%) participants gave a history of aspirin intolerance and 38 (51%) had a positive nasal L-ASA challenge. Upper airway measures (CT scan score, olfaction, polyp grading, peak nasal inspiratory flow, nasal symptoms, etc.) and lower airway measures (methacholine provocative concentration required to produce a 20% drop in forced expiratory volume in 1 second, effective special airway resistance, and spirometry) were not significantly worse in patients with a positive aspirin challenge. Test sensitivity was 48%, specificity was 52%, positive predictive value was 29%, and negative predictive value was 68%. A regression analysis identified forced expiratory flow at 25-75% (FEF(25-75)), history of aspirin intolerance, and duration of rhinosinusitis as significant predictors of a positive aspirin challenge. | A positive response to nasal L-ASA challenge is not associated with a more severe phenotype of CRSwNP with or without asthma. A history of aspirin intolerance, duration of rhinosinusitis, and FEF(25-75) predict a greater response to aspirin. | closed_qa |
Work burden with remote monitoring of implantable cardioverter defibrillator: is it time for reimbursement policies? | The efficacy and accuracy, as well as patients' satisfaction, of device remote monitoring are well demonstrated. However, the workload of remote monitoring management has not been estimated and reimbursement schemes are currently unavailable in most European countries. This study evaluates the workload associated with remote monitoring systems. A total of 154 consecutive implantable cardioverter defibrillator patients (age 66±12 years; 86.5% men) with a remote monitoring system were enrolled. Data on the clinician's workload required for the management of the patients were analyzed. A total of 1744 transmissions were received during a mean follow-up of 15.3±12.4 months. Median number of transmissions per patient was 11.3. There were 993 event-free transmissions, whereas 638 transmissions regarded one or more events (113 missed transmissions, 141 atrial events, 132 ventricular episodes, 299 heart failure-related transmissions, 14 transmissions regarding lead malfunction and 164 transmissions related to other events). In 402 cases telephonic contact was necessary, whereas in 68 cases an in-clinic visit was necessary and in 23 of them an in-clinic visit was prompted by the manufacturer due to technical issues of the transmitter. During follow-up, 316 work hours were required to manage the enrolled patients. Each month, a total of 14.9 h were spent on the remote monitoring of 154 patients (9.7 h for 100 patients monthly) with approximately 1.1±0.15 h per year for each patient. | The clinician's work burden is high in patients with remote monitoring. In order to expand remote monitoring in all patients, reimbursement policies should be considered. | closed_qa |
2011 Mid-America Orthopaedic Association Dallas B. Phemister Physician in Training Award: Can musculoskeletal tumors be diagnosed with ultrasound fusion-guided biopsy? | Percutaneous biopsy for musculoskeletal tumors commonly relies on imaging adjuncts including ultrasound (US), CT, or MRI. These modalities however have disadvantages (US) or are cumbersome, not universally available, and costly (CT and MRI). US fusion is a novel technique that fuses previously obtained CT or MRI data with real-time US, which allows biopsies to be performed in an US suite. It has proven useful in various body systems but musculoskeletal applications remain scarce. Our goal is to evaluate the fusion technology and determine its ability to diagnose musculoskeletal tumors.QUESTIONS/ We determined whether biopsies performed via US fusion compared with CT guidance provide equivalent diagnostic yield and accuracy and allow quicker biopsy scheduling and procedure times. Forty-seven patients were assigned to undergo either US fusion (with MR, n = 16 or CT, n = 15) or CT-guided biopsies (n = 16). We evaluated adequacy of the histologic specimen (diagnostic yield) and correlation with surgical pathology (diagnostic accuracy). We determined scheduling times and lengths of the biopsy. US fusion and CT-guided biopsy groups had comparable diagnostic yields (CT = 94%; US/MRI = 94%; US/CT = 93%) and accuracy (CT = 83%; US/MRI = 90%; US/CT = 100%). US fusion biopsies were faster to schedule and perform. All procedures were safe with minimal complications. | US fusion provides a high diagnostic yield and accuracy comparable to CT-guided biopsy while performed in the convenience of an US suite. This may have resulted in the observed faster scheduling and biopsy times. | closed_qa |
Is serum alpha-fetoprotein useful for predicting recurrence and mortality specific to hepatocellular carcinoma after hepatectomy? | Serum alpha-fetoprotein (AFP) is frequently used to predict posthepatectomy outcomes in patients with hepatocellular carcinoma (HCC), but its predictive value is still not established. Therefore, we assessed the prognostic significance of AFP status. Of 525 patients undergoing curative hepatectomy for HCC, 290 had preoperative AFP levels of ≥20 ng/mL (AFP-positive group) and 235 had AFP levels of<20 ng/mL (AFP-negative group). We compared the 2 groups with respect to time-to-recurrence, using the inverse probability of treatment weighted (IPTW) for the entire cohort and propensity score matching, and the cumulative incidence of HCC-specific mortality using competing risks regression. During follow-up (median duration 64 months, range 2-137 months), HCC recurred in 54.9 % of the AFP-negative group and 52.4 % of the AFP-positive group; there was no death without recurrence. After IPTW adjustment, time-to-recurrence did not differ in the 2 groups (hazard ratio [HR] 0.86, 95 % confidence interval [95 % CI]0.66-1.12; P = 0.28). In a propensity-score matched cohort (152 pairs), time-to-recurrence data were similar to those obtained by IPTW adjustment (HR 0.91, 95 % CI 0.65-1.25; P = 0.55). There was no difference in recurrence pattern (site and stage) or treatment between the 2 groups even after propensity-score matching. The adjusted HR evaluating the impact of AFP positivity on the risk of HCC-specific mortality was 0.77 (95 % CI 0.54-1.08; P = 0.13) A multivariable competing risks analysis also failed to reveal a significant correlation between baseline AFP level and HCC-specific mortality in the AFP-positive group. | Preoperative AFP levels are not useful for predicting recurrence or survival endpoints following curative hepatectomy for HCC. | closed_qa |
CCR7 and VEGF-C: molecular indicator of lymphatic metastatic recurrence in pN0 esophageal squamous cell carcinoma after Ivor-Lewis esophagectomy? | Esophageal squamous cell carcinoma (ESCC) is a malignant tumor with a high incidence of lymph node metastasis. This study was undertaken to investigate the expression of CCR7 and VEGF-C in pN0 ESCC and its relationship with lymphatic metastatic recurrence. The expression of CCR7 and VEGF-C was examined by RT-PCR and immunohistochemistry. The recurrence rates were calculated by the Kaplan-Meier method and their difference was determined by log rank analysis. Cox regression analysis was performed to determine the independent risk factors. In 99 patients, CCR7 mRNA expression was observed in 42 patients with a 3 year recurrence rate of 57.1%; VEGF-C mRNA expression was observed in 52 patients with a 3 year recurrence rate of 53.8%; and coexpression of CCR7 mRNA and VEGF-C mRNA was observed in 22 patients with a 3 year recurrence of 63.6%. Neither CCR7 mRNA nor VEGF-C mRNA expression was observed in 27 patients with a 3 year recurrence rate of 22.2%. The recurrence rates of patients with positive expression of CCR7 mRNA and/or VEGF-C mRNA were significantly higher than in patients without expression of both CCR7 mRNA and VEGF-C mRNA. We achieved better concordance between RT-PCR and immunohistochemistry detection of both markers. The Cox regression analysis showed tumor T classification, positive expression of CCR7/VEGF-C mRNA, and positive expression of CCR7/VEGF-C protein in tumor tissues to be independent risk factors for 3 year recurrence. | Patients with positive expression of CCR7 and/or VEGF-C have a higher recurrence rate than patients without expression of both CCR7 and VEGF-C. CCR7 and VEGF-C may become molecular indicators of disease in patients vulnerable to lymphatic metastatic recurrence. | closed_qa |
Persistence of mitral regurgitation following ring annuloplasty: is the papillary muscle outside or inside the ring? | Ischemic mitral regurgitation (IMR) often persists, despite annular ring reduction. It has been hypothesized that persistent IMR following ring annuloplasty was related to a continued tethering of the mitral leaflets, as defined by the distance by which the papillary muscles (PMs) were displaced outside the mitral annular ring. Seven sheep (four acute, three chronic) with persistent mitral regurgitation (MR) following ring annuloplasty for IMR were studied using three-dimensional (3D) echocardiography to examine the mitral valve geometry. The three stages examined were: Stage 1, baseline; Stage 2, post myocardial infarction (via ligation of the obtuse marginal branches); and Stage 3, post undersized ring annuloplasty. The 3D echocardiography measurements included mitral annular area, tethering distance from the ischemic PM to the anterior annulus, and the outside displacement of the PM relative to ring PM displacement. Persistent moderate MR remained in these seven sheep following undersized ring annuloplasty (MR vena contracta change (pre versus post ring): 7.0 versus 5.8 +/- 2.4 mm, p = NS), despite a reduction in the mitral annular area of 50 +/- 18% (10.3 +/- 6.3 versus 4.7 +/- 1.3 cm2). Ring annuloplasty shifted the posterior annulus towards the anterior annulus, such that the infarcted PM became displaced outside the mitral annulus. The projected displacement distance of the PM outside versus inside the annular ring was 8.4 +/- 2.4 mm outside mitral annulus post ring versus 3.6 +/- 2.5 mm within mitral annulus pre ring, p<0001). The displacement distance from the infarcted PM to the mitral annulus restricted the ability of the posterior leaflet to move anteriorly, preventing effective coaptation. By multivariate analysis, this displacement distance was an important determinant of residual MR (p<0.02). | Persistent MR following ring annuloplasty for IMR relates to persistently abnormal leaflet tethering, with restricted posterior leaflet motion due to PM displacement outside of the mitral annulus. | closed_qa |
Does thinking and doing the same thing amount to involved participation? | Participation as involvement in a situation includes two dimensions; doing the activity and the experience of involvement. The ICF-CY only measures doing using the capacity and performance qualifiers, a dimension measuring the experience is needed; a third qualifier. The experienced involvement of pupils in school activities is higher when thinking and doing coincided. By comparing self-reported experiences of involvement of children, data about what children were thinking and doing during activities were gathered from 21 children with and 19 without disabilities in inclusive classrooms. A relationship exists between an index of the subjective experience of involvement and whether children were thinking and doing the same things. | This index can be constructed using measures of concentration, control, involvement, and motivation. Choice is influential, as knowledge about why an activity is undertaken affects involvement. Additionally, increased subjective experience of involvement gives better psychological health and well-being. | closed_qa |
Can simulation replace part of clinical time? | Education in simulated learning environments (SLEs) has grown rapidly across health care professions, yet no substantive randomised controlled trial (RCT) has investigated whether SLEs can, in part, substitute for traditional clinical education. Participants were physiotherapy students (RCT 1, n = 192; RCT 2, n = 178) from six Australian universities undertaking clinical education in an ambulatory care setting with patients with musculoskeletal disorders. A simulated learning programme was developed as a replica for clinical education in musculoskeletal practice to replace 1 week of a 4-week clinical education placement. Two SLE models were designed. Model 1 provided 1 week in the SLE, followed by 3 weeks in clinical immersion; Model 2 offered training in the SLE in parallel with clinical immersion during the first 2 weeks of the 4-week placement. Two single-blind, multicentre RCTs (RCT 1, Model 1; RCT 2, Model 2) were conducted using a non-inferiority design to determine if the clinical competencies of students part-educated in SLEs would be any worse than those of students educated fully in traditional clinical immersion. The RCTs were conducted simultaneously, but independently. Within each RCT, students were stratified on academic score and randomised to either the SLE group or the control ('Traditional') group, which undertook 4 weeks of traditional clinical immersion. The primary outcome measure was a blinded assessment of student competency conducted over two clinical examinations at week 4 using the Assessment of Physiotherapy Practice (APP) tool. Students' achievement of clinical competencies was no worse in the SLE groups than in the Traditional groups in either RCT (Margin [Δ] ≥ 0.4 difference on APP score; RCT 1: 95% CI - 0.07 to 0.17; RCT 2: 95% CI - 0.11 to 0.16). | These RCTs provide evidence that clinical education in an SLE can in part (25%) replace clinical time with real patients without compromising students' attainment of the professional competencies required to practise. | closed_qa |
Top-down and bottom-up approaches to motor skill assessment of children: are child-report and parent-report perceptions predictive of children's performance-based assessment results? | BACKGROUND/ AIM: Therapists use different types of tests, scales, and instruments to assess children's motor skills, including those classified as being top-down and bottom-up. The aim of the study was to investigate the ability of measures of children's motor skill performance from the perspectives of children and parents (a type of top-down assessment) to predict children's performance-based motor ability test results (a type of bottom-up assessment). A convenience sample of 38 children and parents was recruited from Victoria, Australia. Motor skill performance was evaluated from a top-down perspective using the Physical Self-Description Questionnaire (PSDQ) and the Movement Assessment Battery for Children--Second Edition (MABC-2) Checklist to measure children's and parents' perspectives respectively. Motor skill performance was also evaluated from a bottom-up approach using the Bruininks-Oseretsky Test of Motor Proficiency--Second Edition (BOT-2). Data were analyzed using multiple linear regression analysis to determine whether the PSDQ or MABC-2 Checklist was predictive of the children's BOT-2 performance results. Two predictive relationships were identified based on parents' perspectives, where the total score of the MABC-2 Checklist was found to be a significant predictor of the BOT-2 Manual Coordination motor composite score, accounting for 8.35% of its variance, and the BOT-2 Strength and Agility motor composite score, accounting for 11.6% of its variance. No predictive relationships were identified between the children's self-report PSDQ perspectives and the BOT-2 performance scores. | Therapists are encouraged to utilize a combination of top-down and bottom-up approaches and purposefully to seek parents' and children's perspectives when evaluating children's motor skill performance. | closed_qa |
Functional neuroimaging in craniopharyngioma: a useful tool to better understand hypothalamic obesity? | To use functional magnetic resonance imaging (fMRI) in craniopharyngioma (CP) patients to examine the hypothesis that hypothalamic damage due to CP and its treatment results in enhanced perception of food reward and/or impaired central satiety processing. Pre- and post-meal responses to visual food cues in brain regions of interest (ROI; bilateral nucleus accumbens, bilateral insula, and medial orbitofrontal cortex) were assessed in 4 CP patients versus 4 age- and weight-matched controls. Stimuli consisted of images of high- ('fattening') and low-calorie ('non-fattening') foods in blocks, alternating with non-food object blocks. After the first fMRI scan, subjects drank a high-calorie test meal to suppress appetite, then completed a second fMRI scan. Within each ROI, we calculated mean z-scores for activation by fattening as compared to non-fattening food images. Following the test meal, controls showed suppression of activation by food cues while CP patients showed trends towards higher activation. | These data, albeit in a small group of patients, support our hypothesis that perception of food cues may be altered in hypothalamic obesity (HO), especially after eating, i.e. in the satiated state. The fMRI approach is encouraging for performing future mechanistic studies of the brain response to food cues and satiety in patients with hypothalamic or other forms of childhood obesity. | closed_qa |
Is peripheral neuron degeneration involved in multiple system atrophy? | Lower motor neuron lesions are not among the characteristic features of multiple system atrophy (MSA), although electromyography (EMG) and autopsy studies revealed peripheral neuron abnormalities in some cases of MSA. The aim of the study was to evaluate subclinical involvement of the peripheral neuron in MSA using EMG and electroneurography (ENG). 48 patients with clinically probable MSA (mean age 60.6 years; 67% males) were included in the study and divided into subgroups, with predominant cerebellar (MSA-C) and parkinsonian signs (MSA-P). ENG in ulnar, peroneal and sural nerves and EMG of the first interosseus dorsal and tibial anterior muscles were performed. Abnormal ENG in one nerve was recorded in 20.8% of patients, and in two nerves in another 20.8% of patients. The most frequent and significant findings were decreased compound motor action potential amplitudes in the ulnar nerve in the overall MSA group as well as in the MSA-P type as compared to controls. Abnormalities suggesting reinnervation was observed in 43 of 96 examined muscles (44.7%). In individual cases, neurogenic features were recorded in one muscle in 31.2% of patients and in two muscles in 29.1% of patients. | Subclinical axonopathy in MSA is not frequent and is more pronounced in MSA with predominant parkinsonian signs. In MSA, neurogenic EMG abnormalities in muscles are more frequent than peripheral nerve lesions and as evidenced by increased motor unit potential amplitudes, could be considered a sign of anterior horn cell involvement and a hallmark of the "continuum" of neurodegeneration in MSA. | closed_qa |
Cardiac findings in routine fetal autopsies: more than meets the eye? | The main objective of this study was to evaluate the spectrum of cardiac anomalies found in routinely performed fetal autopsies and to establish the correlation between prenatal and postmortem diagnosis. A retrospective study of fetal autopsies was performed. Cases with cardiac anomalies were analyzed. Seven main categories were established and each case was assigned to a single group. Cardiac defects were also classified as isolated or with associated anomalies. In the cases with prenatal diagnosis, we performed a correlation between prenatal and postmortem findings. Abnormal cardiac findings were identified in 99 fetuses (13.6%). The two most common categories were septal defects and complex anomalies, each occurring in 21 fetuses (21.2%). Sixty-seven (67.7%) had associated anomalies. Septal anomalies were more frequent in cases with associated anomalies (p=0.012). Prenatal diagnosis had been performed in 50 cases. There was complete agreement between prenatal and postmortem diagnosis in 36 cases (72%), and major agreement with additional information in ten (20%). When the echocardiogram was not performed by a specialist, the number of cases classified with complete disagreement was higher (33.3% vs 2.4%) (p=0.002). | The high prevalence of cardiac defects in lost pregnancies, some of them lacking prenatal diagnosis, highlights the importance of examining the heart in all cases. | closed_qa |
Radical resection of gallbladder cancer: could it be robotic? | The only potentially curative option for patients with gallbladder cancer is radical resection. This is the first report that describes the successful application of a minimally invasive, robot-assisted radical resection, including lymphadenectomy, in five gallbladder cancer patients. Medical records of patients who underwent radical resection of gallbladder cancer via the da Vinci robotic surgical system in the Hepato-Bilio-Pancreatic Surgical Department of the Shanghai Ruijin Hospital, China, between March 2010 and July 2011 were reviewed and analyzed. Robot-assisted radical resection was successful in all five patients. The mean number of excised lymph nodes was 9 (range = 3-11), mean operative time was 200 min (range = 120-300 min), mean intraoperative blood loss was 210 ml (range = 50-400 ml), and mean length of hospital stay was 7.4 days (range = 7-8 days). All patients were discharged with no reported complications. Mean postoperative follow-up was 11 months (range = 1-17 months). One patient died due to tumor recurrence 10 months postsurgically, but there was no recurrence in the remaining four patients during the follow-up period. | Robot-assisted radical resection for gallbladder cancer is both feasible and safe. Compared to laparoscopic surgery, the robotic surgery system is better suited for subtle dissection in a narrow, deep space. This is advantageous for both the removal of lymph nodes near the pancreas and hepatoduodenal ligament and the skeletonization of the hepatoduodenal ligament, the hepatic artery, and the celiac axis. The long-term outcome and direct comparisons to laparotomy in a larger patient cohort are needed to provide more clinical data supporting the superiority of this approach. | closed_qa |
Can early laparoscopic cholecystectomy be the optimal management of cholecystitis with gallbladder perforation? | Gallbladder perforation is a rare but serious complication of cholecystitis. It was usually managed by percutaneous gallbladder drainage (PTGBD) followed by elective cholecystectomy. However, evidences are emerging that early laparoscopic cholecystectomy (LC) is still feasible under these conditions. We hypothesized that early LC may have comparable surgical results as to those of PTGBD + elective LC. From January 2005 to October 2011, patients admitted to China Medical University Hospital with a diagnosis of perforated cholecystitis were retrospectively reviewed. The diagnosis of gallbladder perforation was made by image and/or intraoperative findings. Those patients who had unstable hemodynamics that were not fitted for general anesthesia or those who had concomitant major operations were excluded. Patients were divided into three groups: early open cholecystectomy (group 1), early LC (group 2), and PTGBD followed by elective LC (group 3). The demographic features, surgical results, and patient outcome were analyzed and compared between groups. A total of 74 patients were included. All patients had similar demographic features except that patients in group 2 were younger (62 vs. 72 and 73.5 years) compared with group 1 and group 3 (p = 0.016). There were no differences in terms of operative time, blood loss, conversion, and complication rate between three groups. The length of hospital stay (LOS) was significant shorter in group 2 patients compared with that of groups 1 and 3. | Although PTGBD followed by elective LC was still the mainstay for the treatment of gallbladder perforation, early LC had comparable surgical outcomes as that of PTGBD + LC but with a significantly shorter LOS. Early LC should be considered the optimal treatment for gallbladder perforation, and PTGBD + LC can be preserved for those who carried a high risk of operation. | closed_qa |
Does fellow participation in laparoscopic Roux-en-Y gastric bypass affect perioperative outcomes? | Laparoscopic Roux-en-Y gastric bypass (LRYGB) requires specialized training commonly acquired during a fellowship. We hypothesized that fellows affect patient outcomes and this effect varies during training. We included all LRYGB from the 2005 to 2009 American College of Surgeons-National Surgical Quality Improvement Program database. Cases without trainees (attending) were compared to those with trainees of ≥6 years (fellow). Outcomes were pulmonary, infectious, and wound complications and deep venous thrombosis (DVT). Multivariable regression controlled for age, BMI, and comorbidities. Of the 18,333 LRYGB performed, 4,349 (24%) were fellow cases. Fellow patients had a higher BMI (46.1 vs. 45.7, p<0.001) and fewer comorbidities. Mortality was 0.2 and 0.1% and overall morbidity was 4.8 and 6.0% for attending and fellow groups, respectively. On adjusted analysis, mortality was similar, but fellow cases had 30% more morbidity (p = 0.001). Specifically, fellows increased the odds of superficial surgical site infections (SSSIs) [odds ratio (OR) = 1.4, p = 0.01], urinary infections (UTIs) (OR = 1.7, p = 0.002), and sepsis (OR = 1.5, p = 0.05). During the first 6 months, fellows increased the odds of DVT (OR = 4.7, p = 0.01), SSIs (OR = 1.5, p = 0.001), UTIs (OR = 1.8, p = 0.004), and sepsis (OR = 1.9, p = 0.008). By the second half of training, fellow cases demonstrated outcomes equivalent to attending cases. | Involving fellows in LRYGB may increase DVT, SSIs, UTIs, and sepsis, especially early in training. By completion of their training, cases involving fellows exhibited outcomes similar to cases without trainees. This supports both the need for fellowship training in bariatric surgery and the success of training to optimize patient outcomes. | closed_qa |
Is laparoscopic surgery for recurrent Crohn's disease beneficial in patients with previous primary resection through midline laparotomy? | Patients undergoing abdominal surgery for Crohn's disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic versus open resection in patients with previous intestinal resection for Crohn's through midline laparotomy is controversial. Patients with previous open resection for intestinal Crohn's disease undergoing elective laparoscopic surgery for recurrent bowel disease from 1997 to 2011 were case-matched with open counterparts based on age (±5 years), gender, body mass index (±2 kg/m(2)), American Society of Anesthesiologists (ASA) score, surgical procedure, and year of surgery (±3 years). Groups were compared using Chi-square or Fisher exact tests for categorical and the Wilcoxon rank-sum test for quantitative data. 26 patients undergoing laparoscopic ileocolectomy (n = 14), proctocolectomy (n = 5), small bowel resection (n = 4), abdominoperineal resection (n = 1), extended right colectomy (n = 1), and strictureplasty (n = 1) were well matched to 26 patients undergoing open surgery. The number of previous operations, disease phenotypes, steroid use, and comorbidities were comparable in the two groups. There were no deaths, and three patients (12%) required conversion because of adhesions. Laparoscopic and open groups had statistically similar operating times (169 versus 158 min, p = 0.94), estimated blood loss (222 versus 427 ml, p = 0.32), overall morbidity (39 versus 69%, p = 0.051), reoperation rates (8 versus 0%, p = 0.5), postoperative return of bowel function (3.5 ± 1.4 versus 3.9 ± 1.7 days, p = 0.3), mean length of hospital stay (6.4 ± 6.2 versus 6.9 ± 3.5 days, p = 0.12), and readmission rates (8 versus 12%, p = 0.64). Wound infection rate was decreased after laparoscopic surgery (0 versus 27%, p = 0.01). | Surgery for recurrent Crohn's disease in patients with previous primary resection through laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced, but the recovery advantages of a minimally invasive approach are not maintained when compared with open surgery. The decision to operate laparoscopically should therefore be carefully calibrated. | closed_qa |
Chemotherapy in patients with advanced pancreatic cancer: too close to death? | We evaluated the attitude in using chemotherapy near the end of life in advanced pancreatic adenocarcinoma (PAC). Clinical and laboratory parameters recorded at last chemotherapy administration were analyzed, in order to identify risk factors for imminent death. Retrospective analysis of patients who underwent at least one line of palliative chemotherapy was made. Data concerning chemotherapy (regimens, lines, and date of last administration) were collected. Clinical and laboratory factors recorded at last chemotherapy administration were: performance status, presence of ascites, hemoglobin, white blood cell (WBC), platelets, total bilirubin, albumin, LDH, C-reactive protein (C-rp), and Ca 19.9. We analyzed 231 patients: males/females, 53/47 %; metastatic/locally advanced disease, 80/20 %; and median age, 66 years (range 32-85). All patients died due to disease progression. Median overall survival was 6.1 months (95 % CI 5.1-7.2). At the last chemotherapy delivery, performance status was 0-1 in 37 % and 2 in 63 %. Fifty-nine percent of patients received one chemotherapy line, while 32, 8, and 1 % had second-, third-, and fourth line, respectively. The interval between last chemotherapy administration and death was<4 weeks in 24 %, ≥4-12 in 47 %, and>12 in 29 %. Median survival from last chemotherapy to death was 7.5 weeks (95 % CI 6.7-8.4). In a univariate analysis, ascites, elevated WBC, bilirubin, LDH, C-rp and Ca 19.9, and reduced albumin were found to predict shorter survival; however, none of them remained significant in a multivariate analysis. | A significant proportion of patients with advanced PAC received chemotherapy within the last month of life. The clinical and laboratory parameters recorded at last chemotherapy delivery did not predict shorter survival. | closed_qa |
Do immigrants from Turkey, Pakistan and Ex-Yugoslavia with newly diagnosed type 2 diabetes initiate recommended statin therapy to the same extent as Danish-born residents? | To explore whether newly diagnosed type 2 diabetes patients without previous cardiovascular disease (CVD) initiate preventive statin therapy regardless of ethnic background. Using nationwide individual-level registers, we followed a cohort of Danish-born residents and immigrants from Turkey, Pakistan and Ex-Yugoslavia, all without previous diabetes or CVD, during the period 2000-2008 for first dispensing of oral glucose-lowering medication (GLM), first dispensing of statins and register-markers of CVD (N = 3,764,620). Logistic regression analyses were used to test whether the odds ratios (ORs) of early statin therapy initiation (within 180 days after first GLM dispensing) are the same regardless of ethnic background. While age and gender were included as confounders in the basic model, income was included in the second model as a potential mediating variable. Compared to native Danes, the ORs for early statin therapy were 0.68 (95 % confidence interval 0.50-0.92], 0.67 (0.56-0.81) and 0.56 (0.44-0.71) for Ex-Yugoslavians, Turks and Pakistanis, respectively. The differences remained largely unchanged after adjusting for income and tended to be accentuated when the threshold period was extended. The ORs of women initiating therapy (compared to native Danes) were 0.56 (0.35-0.90), 0.60 (0.46-0.78) and 0.48 (0.32-0.72) for Ex-Yugoslavians, Turks and Pakistanis, respectively, and those for men were 0.78 (0.52-1.17), 0.74 (0.58-0.95) and 0.60 (0.44-0.83), respectively. | Immigrants from Turkey, Pakistan and Ex-Yugoslavia with type 2 diabetes were less likely to initiate statin therapy than Danish-born residents-despite a similar or even higher risk of CVD. The treatment inequities associated with ethnicity were more pronounced in women than men. | closed_qa |
Does health information exchange reduce unnecessary neuroimaging and improve quality of headache care in the emergency department? | Health information exchange (HIE) is advocated as an approach to reduce unnecessary testing and improve quality of emergency department (ED) care, but little evidence supports its use. Headache is a specific condition for which HIE has theoretical benefits. To determine whether health information exchange (HIE) reduces potentially unnecessary neuroimaging, increases adherence with evidence-based guidelines, and decreases costs in the emergency department (ED) evaluation of headache. Longitudinal data analysis All repeat patient-visits (N = 2,102) by all 1,252 adults presenting with headache to a Memphis metropolitan area ED two or more times between August 1, 2007 and July 31, 2009. Use of a regional HIE connecting the 15 major adult hospitals and two regional clinic systems by authorized ED personnel to access the patient's record during the time period in which the patient was being seen in the ED. Diagnostic neuroimaging (CT, CT angiography, MRI or MRI angiography), evidence-based guideline adherence, and total patient-visit estimated cost. HIE data were accessed for 21.8 % of ED patient-visits for headache. 69.8 % received neuroimaging. HIE was associated with decreased odds of diagnostic neuroimaging (odds ratio [OR] 0.38, confidence interval [CI]0.29-0.50) and increased adherence with evidence-based guidelines (OR 1.33, CI 1.02-1.73). Administrative/nursing staff HIE use (OR 0.24, CI 0.17-0.34) was also associated with decreased neuroimaging after adjustment for confounding factors. Overall HIE use was not associated with significant changes in costs. | HIE is associated with decreased diagnostic imaging and increased evidence-based guideline adherence in the emergency evaluation of headache, but was not associated with improvements in overall costs. Controlled trials are needed to test whether specific HIE enhancements to increase HIE use can further reduce potentially unnecessary diagnostic imaging and improve adherence with guidelines while decreasing costs of care. | closed_qa |
Do children eat less at meals when allowed to serve themselves? | The effect of self-serving on young children's energy intake is not well understood. The objective was to examine individual differences in the effects of plated and self-served entrée portions on children's energy intake. Two within-subjects experiments were used to examine ad libitum intake at meals in 63 children aged 3-5 y when 400 g of a pasta entrée was either plated or available for children to self-serve. Child age, sex, BMI, and responsiveness to increasing portion size (defined as individual slope estimates relating ad libitum intake of the entrée across a range of entrée portions) were evaluated as predictors of self-served portions. Children's entrée and meal intakes did not differ between the self-served and plated conditions for the total sample or by child weight status. However, larger self-served entrée portions were associated with greater entrée and meal intakes. Children who served themselves larger entrée portions tended to be overweight and more responsive to portion size (ie, greater increases in entrée intake as plated portion size increased). Last, self-served portion predicted both entrée and meal intake over and above BMI z score and responsiveness to portion. | Contrary to our hypothesis, relative to plated portions, allowing children to self-serve the entrée portion did not reduce energy intake. Children who were more responsive to portion-size effects were likely to self-serve and eat larger entrée portions. Self-serving is not a one-size-fits-all approach; some children may need guidance and rules to learn how to self-select appropriate portion sizes. | closed_qa |
Does levator trauma 'heal'? | To evaluate if pregnancy- and delivery-related changes to levator morphology and distensibility regress with time. 488 nulliparous pregnant women, recruited between 36 and 38 weeks' gestation, were invited for assessment at 3-6 months and again at 2-3 years postpartum. All underwent an interview and four-dimensional translabial ultrasound examination. Hiatal morphometry and bladder neck descent (BND) were determined and compared between the two postpartum visits. 367 participants returned for assessment at 4.1 (interquartile range (IQR), 3.7-5.0) months and 161 returned at 2.6 (IQR, 2.0-3.1) years, allowing a groupwise comparison. There was no significant difference in hiatal area (22 vs 22 cm(2), P = 0.95) or BND on Valsalva maneuver (26.3 vs 25.5 mm, P = 0.49). Pairwise comparison in women who had attended both postpartum appointments without second births (n = 77), separately for those who had a cesarean section (n = 24) and those who had a vaginal delivery (n = 53) originally, showed no significant changes, except a reduction in BND (31.2 vs 28.3 mm, P = 0.025) in those who had delivered vaginally. Two women out of 12 diagnosed with a levator avulsion at 3-6 months showed obvious anatomical improvement on translabial ultrasound at 2-3 years. | We found no evidence of regression or healing of pregnancy- and delivery-related changes to levator distensibility on comparing imaging data obtained at 3-6 months and 2-3 years postpartum. However, we documented anatomical improvement on translabial ultrasound at the second postpartum visit in two women diagnosed with levator avulsion at 3-6 months postpartum. | closed_qa |
Should LSIL-H be a distinct cytology category? | The 2001 Bethesda System for gynecologic cervical cytology reporting classifies squamous intraepithelial lesions into low-grade (LSIL) and high-grade (HSIL) lesions. An intermediate term, "low-grade squamous intraepithelial lesion, cannot exclude high-grade squamous intraepithelial lesion (LSIL-H)," has been used in a small percentage of LSIL cases. To the authors' knowledge, little is known regarding the human papillomavirus (HPV) status in patients with LSIL-H. A total of 808 SurePath specimens obtained between December 2009 and April 2011 were tested for 40 HPV genotypes using DNA microarray, followed by a confirmatory DNA sequencing assay. The infection rate for high-risk HPV in women with LSIL-H (92%) was strikingly close to that for women with HSIL (91%), which was higher than that for those with LSIL (74%); atypical squamous cells, cannot rule out high-grade lesion (ASC-H) (78%); or LSIL and ASC-H combined (74%). HPV type 16, the most common carcinogenic HPV genotype, was detected in 36% of women with LSIL-H, which was significantly higher than that in women with LSIL and ASC-H combined (13.8%), but less than that in women with HSIL (44.6%). Patients with LSIL-H and HSIL had similar infection rates for low-risk/intermediate-risk HPV genotypes, which were lower than those in LSIL or LSIL and ASC-H combined. | Women found to have LSIL-H on a Papanicolaou test appear to have a unique HPV distribution pattern that clearly differs from LSIL and is comparable to that for HSIL, suggesting an increased risk of high-grade lesions over that of women with LSIL. Recognizing LSIL-H as an independent diagnostic category may help in the early identification of the high-risk subgroup that may require a management algorithm comparable to that for patients with HSIL. Cancer (Cancer Cytopathol) 2012. © 2012 American Cancer Society. | closed_qa |
Retinopathy of prematurity: are we missing any infant with retinopathy of prematurity? | To evaluate incidence of retinopathy of prematurity (ROP) and validity of current ROP screening criteria adopted in the Armed Forces Hospitals. A retrospective study of ROP indices was carried out in infants admitted to the neonatal intensive care unit in Khamis Mushait, Saudi Arabia, from January 2009 to December 2011. All infants who had birth weight (BW) of 1500 g or less and/or gestational age (GA) of 32 weeks or less had their data reviewed for ROP diagnosis and related indices. Some heavier or older infants were also included in the study. 386 infants were screened and ROP was diagnosed in 90 infants (23.31%). 25 infants (6.47%) had type 1 or worse ROP and were treated with cryopexy or laser. For patients having ROP, the mean GA was 27.8 ± 2 weeks and mean BW was 961.8 ± 237.4 g. Infants who needed treatment for ROP had a mean BW of 828.8 ± 192.8 g and mean GA of 27 ± 1.8 weeks. All infants who developed ROP fulfilled both or one criterion of ROP screening. No infant greater than 1350 g BW or more than 31 weeks GA was treated for ROP. | Current ROP screening criteria of BW of 1500 g or less and/or GA of 32 weeks or less seems reasonable in our set up as no infant having ROP was missed by using these criteria. We do not recommend lowering or using only one index for ROP screening. | closed_qa |
Are physicians underestimating the challenges of hypertension management? | The Supporting Hypertension Awareness and Research Europe-wide (SHARE) survey aimed to qualify the key challenges that physicians face when trying to get patients to recommended blood pressure (BP) goals. The survey was open to physicians involved in the treatment of hypertension, was anonymous, and included 45 questions covering: physicians' demographic information, familiarity with BP treatment guidelines, views on the BP targets recommended by the 2007 European Society of Hypertension and European Society of Cardiology (ESH-ESC) guidelines, and perceptions on the proportion of 'challenging patients' in hypertension management (defined as patients not achieving the BP goal, where the BP goal is at least<140/90 mm Hg, and<130/80 mm Hg for patients with co-morbidities or high CV risk). Physicians significantly underestimated the proportions of their 'challenging patients' with hypertension compared with their perceptions of the proportions achieving 2007 ESH-ESC BP targets (p<0.0001). The majority of cardiologists (75.5%) and general/family practitioners (GPs) (81.3%) as well as internists (59.3%) (p<0.05 for cardiologists and GPs vs internists) felt that it was a challenge to get their patients to target BP, stating that only 43.2%, 57.4% and 38.2% of their patients, respectively, achieved these targets in practice (p<0.05 for GPs vs cardiologists and internists). | Physicians may underestimate the proportion of 'challenging patients' with hypertension and there is a need to improve their BP control. Increasing physicians' awareness about the risks of uncontrolled BP and improving compliance are two possible ways to improve management of hypertension. | closed_qa |
The pattern, clinical characteristics and outcome of ESRD in Ile-Ife, Nigeria: is there a change in trend? | The prevalence of chronic renal failure and End Stage Renal Disease (ESRD) has remained high worldwide and the epidemiology has changed significantly in the last decade in industrialised countries. While there have been significant improvements in these patient's outcomes in developed countries, their state and survival is still appalling in developing countries. To determine the clinical pattern, presentation and management outcomes in our ESRD population over a 19-year period (1989-2007). Seven hundred and sixty patients' records were reviewed. Data on major causes, clinical presentation, management and survival were retrieved and collated. Data was analysed using SPSS package version 16. Their ages ranged between 15-90 years (mean ± SD; 39.9±1.67years) with male preponderance (70.3%). Major presenting complaints were body swelling and uraemic symptoms in most studied patients. The predisposing conditions included chronic glomerulonephritis, hypertension, obstructive uropathy and diabetes mellitus. Renal replacement therapy offered included HD in 556(73.2%), Continous Ambulatory Peritoneal Dialysis (CAPD) in only 9(1.2%) patients and renal transplantation in only 7(0.9%). Only 38(6.8%) survived on HD for longer than three months while 7(77.8%) CAPD patients and all transplanted patients survived for between six months and four years (p<0.00001). Median duration of survival after diagnosis for all the patients was 2 weeks (range 0-50 months). | End stage renal disease is still prevalent with chronic glomerulonephritis and hypertension being the common causes. Prognosis is still grave hence subsidized renal replacement therapy and preventive nephrology should be targeted in such underserved populations. | closed_qa |
Does transrectal color Doppler ultrasound improve the diagnosis of prostate cancer? | To prospectively evaluate whether TRUS guided biopsy associated with Color Doppler (CD) imaging improves the detection of PCa. From January 2008 to December 2010, 144 subjects, with an increased PSA value or with a suspect digital rectal examination, were enrolled. Transrectal grey-scale Ultrasound (US) and CD examination were performed in all patients. CD US was considered positive or negative on the basis of the presence or absence of vascular abnormality. Prostate biopsy was performed immediately after grey-scale and Doppler evaluation, with a mean of 10 core-biopsy for each patient as well as a selective biopsy of all US abnormal areas (hypoechoic lesion or CD abnormality areas). PCa has been detected in 71 (49.3%) patients. 58 of the 71 patients had a hypoechoic area at US scan and 27 had a CD abnormality. The PSA value was<4 ng/ml in 11 patients (Group 1), in 63 patients PSA ranged between 4 and 10 ng/ml (Group 2) and in 70 patients PSA was greater than 10 ng/ml (Group 3). The detection rate was 36.7, 36.5 and 62.8% respectively. In Group 1 we detected 5 hypoechoic areas and 4 CD abnormal areas. Moreover 6 of 11 patients had a positive DRE. In the Group 2, 20 patients were positive to DRE; we visualized 21 hypoechoic areas and 7 CD abnormality. In the Group 3, 38 patients had a positive DRE, with 32 hypoechoic areas and 16 CD abnormalities found. We obtained 1537 total bioptic cores, 1440 randomly from peripheral gland, 70 from hypoechoic areas and 27 from abnormal CD flow areas. The detection rate was 17.1, 65.7 and 22.2% respectively. | CD US showed to be a complement to grey-scale imaging of prostate unless insufficiently sensitive to replace the standard systematic 8-12 core random peripherally biopsy. Furthermore it should be associated routinely to TRUS to easily focus suspect areas. | closed_qa |
Paradox of schizophrenia genetics: is a paradigm shift occurring? | Genetic research of schizophrenia (SCZ) based on the nuclear genome model (NGM) has been one of the most active areas in psychiatry for the past two decades. Although this effort is ongoing, the current situation of the molecular genetics of SCZ seems disappointing or rather perplexing. Furthermore, a prominent discrepancy between persistence of the disease at a relatively high prevalence and a low reproductive fitness of patients creates a paradox. Heterozygote advantage works to sustain the frequency of a putative susceptibility gene in the mitochondrial genome model (MGM) but not in the NGM. We deduced a criterion that every nuclear susceptibility gene for SCZ should fulfill for the persistence of the disease under general assumptions of the multifactorial threshold model. SCZ-associated variants listed in the top 45 in the SZGene Database (the version of the 23rd December, 2011) were selected, and the distribution of the genes that could meet or do not meet the criterion was surveyed. 19 SCZ-associated variants that do not meet the criterion are located outside the regions where the SCZ-associated variants that could meet the criterion are located. Since a SCZ-associated variant that does not meet the criterion cannot be a susceptibility gene, but instead must be a protective gene, it should be linked to a susceptibility gene in the NGM, which is contrary to these results. On the other hand, every protective gene on any chromosome can be associated with SCZ in the MGM. Based on the MGM we propose a new hypothesis that assumes brain-specific antioxidant defenses in which trans-synaptic activations of dopamine- and N-methyl-d-aspartate-receptors are involved. Most of the ten predictions of this hypothesis seem to accord with the major epidemiological facts and the results of association studies to date. | The central paradox of SCZ genetics and the results of association studies to date argue against the NGM, and in its place the MGM is emerging as a viable option to account for genomic and pathophysiological research findings involving SCZ. | closed_qa |
Decreased gray matter diffusivity: a potential early Alzheimer's disease biomarker? | Gray matter atrophy, an important biomarker for early Alzheimer's disease, might be due to white matter changes within gray matter. Twenty older participants with significant memory decline over a 12-year period (T12) were matched to 20 nondeclining participants. All participants were magnetic resonance imaging scanned at T12. Cortical thickness and diffusion tensor imaging analyses were performed. Lower cortical thickness values were associated with lower diffusion values in frontal and parietal gray matter areas. This association was only present in the memory decline group. The cortical thickness-diffusion tensor imaging correlations showed significant group differences in the posterior cingulate gyrus, precuneus, and superior frontal gyrus. | Decreased gray matter diffusivity in the posterior cingulate/precuneus area might be a disease-specific process and a potential new biomarker for early Alzheimer's disease. Future studies should validate its potential as a biomarker and focus on cellular changes underlying diffusivity changes in gray matter. | closed_qa |
Can virtual reality simulation be used for advanced bariatric surgical training? | Laparoscopic bariatric surgery is a safe and effective way of treating morbid obesity. However, the operations are technically challenging and training opportunities for junior surgeons are limited. This study aims to assess whether virtual reality (VR) simulation is an effective adjunct for training and assessment of laparoscopic bariatric technical skills. Twenty bariatric surgeons of varying experience (Five experienced, five intermediate, and ten novice) were recruited to perform a jejuno-jejunostomy on both cadaveric tissue and on the bariatric module of the Lapmentor VR simulator (Simbionix Corporation, Cleveland, OH). Surgical performance was assessed using validated global rating scales (GRS) and procedure specific video rating scales (PSRS). Subjects were also questioned about the appropriateness of VR as a training tool for surgeons. Construct validity of the VR bariatric module was demonstrated with a significant difference in performance between novice and experienced surgeons on the VR jejuno-jejunostomy module GRS (median 11-15.5; P = .017) and PSRS (median 11-13; P = .003). Content validity was demonstrated with surgeons describing the VR bariatric module as useful and appropriate for training (mean Likert score 4.45/7) and they would highly recommend VR simulation to others for bariatric training (mean Likert score 5/7). Face and concurrent validity were not established. | This study shows that the bariatric module on a VR simulator demonstrates construct and content validity. VR simulation appears to be an effective method for training of advanced bariatric technical skills for surgeons at the start of their bariatric training. However, assessment of technical skills should still take place on cadaveric tissue. | closed_qa |
Can skills coaches be used to assess resident performance in the skills laboratory? | The purpose of this study was to compare faculty ratings between live versus video-recorded resident performances and faculty versus skills coaches' ratings of video-recorded resident performances. PGY1 residents were observed, video-recorded, and rated during a Verification of Proficiency examination on 4 stations (ie, suturing, laparotomy, central line, and cricothyroidotomy). One surgeon and 2 trained skills coaches independently rated each video-recorded performance (N = 25). The chi-square test was used to compare checklist ratings. Analysis of variance was used to compare global ratings. Intraclass correlations were used to evaluate inter-rater agreement. There were no statistical differences in faculty checklist ratings for live versus video-recorded performances (P>.05), and we found a nearly perfect interrater agreement, intraclass correlation coefficient (ICC) = 0.99 (P<.001). When comparing faculty versus skills coaches' ratings on video-recorded performances, we found no differences for the global or checklist ratings. Inter-rater agreement was moderately high for the global ratings, ICC = 0.71 (P<. 0.01, 95% confidence interval 0.23-0.96), and nearly perfect for the checklist ratings, ICC = 0.99 (P<.001, 95% confidence interval 0.94-1.00). | When assessing residents' performances, use of video-recorded performance ratings and skills coaches may be viable alternatives to live ratings performed by surgical faculty. | closed_qa |
Is a closed bladder neck on preoperative videourodynamic studies an important factor for continence following augmentation ileocystoplasty in myelodysplastic patients? | The aim of this study is to evaluate the importance of a closed bladder neck during videourodynamic (VUDE) studies in relation to urinary continence following augmentation ileocystoplasty in myelodysplastic patients. We retrospectively reviewed the records of 24 myelodysplastic patients who underwent augmentation ileocystoplasty, using a standard technique. All patients had a closed bladder neck during preoperative VUDE studies. Their charts, imaging studies and VUDE data before and after surgery were analyzed. The mean follow-up after augmentation ileocystoplasty was 8.4 years. The overall incidence of urinary incontinence following the augmentation ileocystoplasty was 12.5%. Continence was achieved in 21 of 24 (87.5%) patients without additional outlet procedures. No significant upper tract changes developed. A clinically apparent tethered cord significantly hindered the achievement of continence. No significant correlation was found between the other videourodynamic parameters and obtaining continence. | Our study provides evidence that a coexisting cord tethering in this myelodysplastic group can affect bladder neck morphology and function, and subsequent continence. | closed_qa |
Is ultrasound follow-up necessary in humero-axillary prosthetic arteriovenous fistulas for haemodialysis? | Retrospective study. Between January 2005 and December 2009, 108 Hax-AVF were implanted. From June 2007 a T-AVF was established. A preoperative duplex was performed and a follow-up control carried out a month after the intervention and subsequently every 3 months. An analysis was made of the permeability of 57 Hax-AVF carried out between June 2007 and December 2009 (T-AVF Group), in comparison to 51 interventions performed during the previous 30 months (Control Group). No differences in the permeability achieved were found at 12 and 24 months, with a secondary permeability at 12 months of 49% in the T-AVF Group and 52% in the Control Group. The percentage of patients needing to be re-operated was inferior in the T-AVF Group (35%) than in the Control Group (67%) p=0.02. The re-operation per patient average was lower in the T-AVF Group than in the Control Group (0.49 vs. 1.18 p=0.01). The patients of the TAVF Group underwent a lesser number of re-operations for obstruction as opposed to the Control Group (0.42 vs 1.04 p=0.01). | In our experience, the intensive follow-up controls did not improve the permeability of the Hax-AVF, although re-operations due to obstruction did diminish. The follow-up of these access fistulas should be clinical based on hemodialysis data, leaving ultrasonographic evaluation for those cases where a malfunction is suspected. | closed_qa |
Does aggressive phototherapy increase mortality while decreasing profound impairment among the smallest and sickest newborns? | Aggressive phototherapy (AgPT) is widely used and assumed to be safe and effective for even the most immature infants. We assessed whether the benefits and hazards for the smallest and sickest infants differed from those for other extremely low-birth-weight (ELBW; ≤ 1000 g) infants in our Neonatal Research Network trial, the only large trial of AgPT. ELBW infants (n=1974) were randomized to AgPT or conservative phototherapy at age 12 to 36 h. The effect of AgPT on outcomes (death, impairment, profound impairment, death or impairment (primary outcome), and death or profound impairment) at 18 to 22 months of corrected age was related to BW stratum (501 to 750 g; 751 to 1000 g) and baseline severity of illness using multilevel regression equations. The probability of benefit and of harm was directly assessed with Bayesian analyses. Baseline illness severity was well characterized using mechanical ventilation and FiO(2) at 24 h age. Among mechanically ventilated infants ≤ 750 g BW (n=684), a reduction in impairment and in profound impairment was offset by higher mortality (P for interaction<0.05) with no significant effect on composite outcomes. Conservative Bayesian analyses of this subgroup identified a 99% (posterior) probability that AgPT increased mortality, a 97% probability that AgPT reduced impairment, and a 99% probability that AgPT reduced profound impairment. | Findings from the only large trial of AgPT suggest that AgPT may increase mortality while reducing impairment and profound impairment among the smallest and sickest infants. New approaches to reduce their serum bilirubin need development and rigorous testing. | closed_qa |
Diagnostic implications of informant disagreement about rage outbursts: bipolar disorder or another condition? | Modest agreement between parent- and teacher-reports of child behavior is a common finding. This study examines diagnoses made when significant disparity occurs in parent- and teacher-reports of rage behaviors. Parents and teachers of 911 5-18 year-olds referred for psychiatric outpatient services completed rating scales and received a psychiatric evaluation blind to parent- and teacher-ratings. Children with rage outbursts (n=431, 47.2%) were assessed for diagnosis, family history, and clinical variables. Children were 12.0 (3.6) years; 26.5% were female. Bipolar disorder was rare (11.2%) in this sample; however, in children with parent- and teacher-reported rages, severe mood dysregulation was the most common condition (54.4%). In parent only reported rages, anxiety disorders were most common (40.6%) diagnoses, and in teacher only reported rages, learning/language disorders were the most common (46.0%) diagnoses. | The context in which a rage outburst occurs may impact the diagnosis; however, diagnosis alone does not explain this difficult and impairing behavior. | closed_qa |
Does the new standard for eugenol designed to protect against contact sensitization protect those sensitized from elicitation of the reaction? | Potential fragrance allergens used in daily products should have a concentration limited to levels that are at, or below, acceptable exposure levels based on the quantitative risk assessment for the induction of dermal sensitization. To date, there are insufficient data to discern any quantitative relationship between induction and elicitation concentrations for fragrance ingredients that have a potential for dermal sensitization. When available, these data should be used to confirm the effectiveness of quantitative risk assessment-based risk management procedures. In this study, the relationship between the allergen concentration and the time to elicit allergic contact dermatitis in eugenol-sensitized patients was studied. The products used to elicit allergic contact dermatitis had a concentration of eugenol that was equal to, or below, the International Fragrance Association standard. Volunteers with and without known sensitization to eugenol were patch tested with various concentrations of eugenol (dilution series) and also underwent repeated open application tests (ROATs). This study model has previously been successfully used with stronger sensitizers. In this study, allergic contact dermatitis, as evidenced by a positive ROAT, could not be elicited by any of the concentrations studied, including in those patients where the patch tests were positive. | When tested in a 3-week ROAT at, or below, its current International Fragrance Association Standard, eugenol did not induce reactions even in those known to be sensitized. Whether this represents a false-negative result for a weak allergen is unknown. | closed_qa |
Is quaternium-15 a formaldehyde releaser? | The question of whether quaternium-15 is a formaldehyde releaser is controversial. Understanding this relationship is critical because of the widespread use of quaternium-15 and the need to properly advise formaldehyde-allergic individuals. This study aimed to look for an association between allergy to quaternium-15 and formaldehyde by correlating reactions to both and to correlate the intensity of positive patch test results to formaldehyde with reactivity to quaternium-15. This is a retrospective analysis of 1905 patients who underwent patch testing for allergic contact dermatitis. Associations were analyzed by χ testing. Of all patients, 9.5% reacted to quaternium-15, 7.2% reacted to formaldehyde, and 5.4% reacted to both (P<0.001). Of 137, 86 had strong (2 or 3+) and 51 had weak (1+ or +/-) formaldehyde reactions; there was no relationship between the severity of formaldehyde reactivity and responsiveness to quaternium-15 (P = 0.229). Sex analysis did not change these findings. This study is limited by its retrospective analysis and small sample size. | A statistically significant relationship exists between reactivity to quaternium-15 and formaldehyde; however, the severity of the formaldehyde reaction does not predict reactivity to quaternium-15. Despite coreactivity with formaldehyde, quaternium-15 may not be a significant formaldehyde releaser. The coreactivity between quaternium-15 and formaldehyde requires further studies. | closed_qa |
Erythema papulosa semicircularis recidivans: a new reactive dermatitis? | Nine patients with recrudescent and centrifugally expanded papuloerythematous eruptions were observed in our outpatient department during the recent 8 years. The patients were all young and middle-aged men presenting with characteristic skin lesions and relapsing each year in the warm humid season. Such an observation has not yet been described in the English literature. The objective of this study was to describe the clinical characteristics and explore the possible etiologies of our cases. In addition, differential diagnosis with other common figurate erythemas was also reviewed and discussed. In 5 of the patients, skin-prick testing was performed with common airborne and food allergens, and skin patch testing with the Chinese baseline series of contact allergens was performed, along with histopathologic examinations. The skin findings in our patients were conspicuous in their papular characteristics of the borders, semicircular arrangement, male predominance, and yearly crescendo of recurrence in warm seasons. Histopathologic examination showed superficial perivascular dermatitis, whereas skin-prick testing and patch testing showed negative results. | Although the etiology of our cases remains unclear at present, the clinical characteristics make them distinct from other well-described figurate erythemas characterized by annular erythematous lesions. We propose the term erythema papulosa semicircularis recidivans to depict a special form of recurrent papuloerythematous figurate erythema of unknown etiology. | closed_qa |
Is there any relationship between pulmonary function tests and post-transplant complications of allogeneic hematopoetic stem cell transplantation? | One hundred and fifty one patients who had undergone allogeneic HSCT between years 2003 through 2008, and had the records of PFTs prior to and at 1, 3, 6, 9 and 12 months after transplantation were included in the study. Prospectively collected data of these patients were analysed retrospectively. Although no significant difference was identified in other PFT parameters, a significant decrease in DLCOadj was determined after 1st and 3rd months of HSCT. A significant correlation was found between pretransplant DLCOadj value<%70 and sinusoidal obstruction syndrome (SOS) (P=0.001, r=0.323), but in multivariate analysis pretransplant DLCOadj was not an independent predictor of SOS; only total body irradiation (TBI) (OR: 3.673, %95 CI: 0.880-15.804), the day of platelet engraftment (OR=1.093, %95 CI: 1.029-1.161) and serum ferritin (OR=1.001, %95 CI: 1.000-1.001) were significant. Advancing age and serum ferritin levels>600 ng/mL were the independent risk factors for pretransplant DLCOadj<%70 (OR: 0.970, %95 CI: 0.941-0.999 and OR: 2.355, %95 CI: 1.058-5.241 respectively). | Although a significant correlation exists between pretransplant DLCOadj values and post-transplant SOS development, pretransplant DLCOadj was not an independent predictor of SOS. Increased serum ferritin levels were common both for pretransplant DLCO decrease and post-transplant SOS development. Iron induced endothelial damage may be the common pathophysiologic mechanism causing lung and liver vulnerability, and DLCOadj may be a non-invasive method of demonstrating this vulnerability. | closed_qa |
Is the carotid intima-media thickness really a good surrogate marker of atherosclerosis? | To evaluate the relationship between carotid IMT and atherosclerosis, postmortem specimens of the distal segments of the left common carotid artery (CCA) from 133 Korean men aged from 20 to 78 years were used for histopathology and computer-assisted morphometry. Blood lipids and atherosclerosis-associated collagen and elastin were quantitatively analyzed. Correlation coefficients of IMT were smaller than those of intima thickness but IMT was well associated with age (r= 0.55, p<0.00001), atherosclerosis score (or grade, AS, r= 0.73, p<0.00001), plaque area (PA, r= 0.72, p<0.00001), total cholesterol (TC, r= 0.69, p<0.00001), low-density lipoprotein cholesterol (LDL-c, r= 0.72, p<0.00001) and triglyceride (TG, r= 0.38, p<0.001). Coronary artery stenosis (CAS) and coronary calcification were also well associated with age (p<0.00001), IMT (p<0.005) and PA (p<0.00001). When IMT was thicker than 1 mm, the possibility of carotid atherosclerosis accompanied with CAS and coronary calcification, TC, LDL-c and TG was much higher (CAS with coronary calcification,p<0.005; TC, p<0.00001; LDL-c, p<0.00005; TG, p<0.00001). Collagen tended to increase while elastin tended to decrease as AS increased (p<0.005); collagen increased and elastin decreased (p<0.00001) when comparing plaque to the plaque-free area in the same segment. | These results support that the carotid IMT in association with TC, LDL-c and TG can be used as a good surrogate marker of atherosclerosis and predictor of coronary heart disease. Plaque formation may influence significant quantitative changes in collagen and elastin. | closed_qa |
Is Doppler ultrasonography essential for hemorrhoidal artery ligation? | Doppler ultrasonography enables accurate identification of the terminal branches of the superior rectal artery prior to hemorrhoidal artery ligation (HAL). However, since the positions of these branches have been found to be relatively constant, the question arises as to the necessity of ultrasonography for their identification. The aim of the current study was to examine the positions of all arteries identified and ligated during the HAL procedure. We recorded the position of all arteries located and ligated in 135 consecutive patients who underwent the HAL procedure during the years 2003 to 2006. In all patients, 6-8 terminal arterial branches were located above the dentate line. In 102 (76 %) patients, terminal branches were located in all 6 of the odd-numbered clock positions around the anus (1, 3, 5, 7, 9, and 11 o'clock in the lithotomy position). If we had ligated arteries only at these odd-numbered clock positions, without using Doppler ultrasonography, we would have located all the arteries in 96 (71 %) of our patients. | The number and location of arterial branches of the superior rectal artery are relatively constant. Nevertheless, if, Doppler ultrasonography had not been performed and, ligation in the HAL procedure had been at the odd-numbered clock positions only, then at least one artery would have been missed in 29 % of our patients. | closed_qa |
Could chemical enhancement of gold nanoparticle penetration be extrapolated from established approaches for drug permeation? | Investigations on chemical enhancement of skin penetration of gold nanoparticles are considered crucial to have a deeper insight into the main barrier of particle penetration. In this study, penetration of gold nanoparticles in the presence of several chemical enhancers - urea, sodium lauryl sulphate, polysorbate 80 and dimethyl sulfoxide (DMSO) - through human skin was studied. Among the tested chemical enhancers, DMSO could induce the penetration of hydrophilic (citrate-stabilized) gold colloid of no intrinsic penetration ability in a concentration-dependent manner. Pretreatment of the skin with DMSO however reduced the penetration of hydrophobic (cetrimide-coated) gold nanoparticles as a result of aggregation in the top layers of the stratum corneum limiting penetration into the deeper skin layers. In addition, nanoparticles-vehicle interaction and the stability of the nanoparticles in the applied vehicle were found important determinants of skin penetration. | Our results demonstrate that the already established approaches for chemical permeation enhancement of drug molecules and their postulated mechanisms could be used as preliminary guidelines for enhancing the penetration of nanoparticles. At this size range of 15 nm, intercellular lipids provide the main barrier to particle penetration through the stratum corneum. | closed_qa |
Tetrasomy 15q26: a distinct syndrome or Shprintzen-Goldberg syndrome phenocopy? | The aim of this study was to characterize the clinical phenotype of patients with tetrasomy of the distal 15q chromosome in the form of a neocentric marker chromosome and to evaluate whether the phenotype represents a new clinical syndrome or is a phenocopy of Shprintzen-Goldberg syndrome. We carried out comprehensive clinical evaluation of four patients who were identified with a supernumerary marker chromosome. The marker chromosome was characterized by G-banding, fluorescence in situ hybridization, single nucleotide polymorphism oligonucleotide microarray analysis, and immunofluorescence with antibodies to centromere protein C. The marker chromosomes were categorized as being neocentric with all showing tetrasomy for regions distal to 15q25 and the common region of overlap being 15q26→qter. | Tetrasomy of 15q26 likely results in a distinct syndrome as the patients with tetrasomy 15q26 share a strikingly more consistent phenotype than do the patients with Shprintzen-Goldberg syndrome, who show remarkable clinical variation. | closed_qa |
ADHD predominantly inattentive subtype with high sluggish cognitive tempo: a new clinical entity? | The authors investigate differences in the neuropsychological and behavioral profiles of two groups of children with ADHD, one with predominantly inattentive subtype of ADHD (PI) and high sluggish cognitive tempo (SCT; n = 19) and another formed by the rest of the sample (children with ADHD combined subtype and children with PI and low SCT scores; n = 68). Instruments included Wechsler Intelligence Scale for Children and subtests from Developmental Neuropsychological Assessment, Conners' Continuous Performance Test, Behavior Rating Inventory of Executive Function, and Achenbach's Child Behavior Checklist for ages 6 to 18. PI with high SCT had fewer problems with sustained attention, and more internalizing problems, anxiety/depression, and withdrawn/depressed behavior, and more executive problems with self-monitoring than the rest of the ADHD sample. | This study supports revising subtype's criteria and further studying the hypothesis that ADHD with high SCT constitutes a separate clinical entity. | closed_qa |
The production of social discourse on Hansen' disease and health education materials in Brazil: a skin patch as something harmless or a serious disease? | Hansen's disease is endemic in Brazil and government control programmes promote publicity campaigns to increase the detection of new cases through the production and distribution of educative material. This study analyses a set of 276 educational materials produced by governmental and non-governmental organisations that work to control Hansen's disease in Brazil. It describes the content of the materials and the way the issues were approached. It is a qualitative study that adopts the theoretical and methodological framework of the semiology of social discourse. Analysis reveals that the relations between the enunciator and recipient of the materials are asymmetrical as a result of the technical and educational language employed. Biomedical information forms the basis for social representations an practices of Hansen's disease, as opposed to historical collective knowledge of 'leprosy'. The prioritised topics are: signs and symptoms of the disease, treatment stigma, cure and surveillance. | The institutionalisation of public education on Hansen's disease in Brazil was not limited simply to the change of terminology from 'leprosy' to 'Hansen's disease,' but was shaped also by new educational practices. It is recommended that the evaluation and production of new materials be incorporated into the set of activities already carried out in health centres so as to expand the discussion on content, language and the best way to address the disease in the materials. | closed_qa |
Mini-sternotomy aortic valve replacement: is it safe and effective? | Mini-sternotomy aortic valve replacement (MSAVR) has been increasingly performed at the authors' institution since October 2003. The study aim was to compare results obtained with MSAVR to those following AVR with conventional sternotomy (SAVR). Between 1998 and 2008, a total of 143 consecutive patients (mean age: 67 +/- 12.5 years) underwent AVR at the authors' institution. Of these patients, 82 underwent SAVR, and 61 underwent MSAVR performed through a reversed-L-shaped median sternotomy with a transverse limb at the right fourth intercostal space. Ascending aortic and right atrial cannulation through the mini-sternotomy were employed for cardiopulmonary bypass (CPB). Typically, the MSAVR patients were slightly younger than SAVR patients (mean age: 67 +/- 16 years and 70 +/- 15 years, respectively; p = 0.037), had a lower incidence of diabetes (3% versus 18%, p = 0.008), and a slightly higher left ventricular ejection fraction (74.5 +/- 12% versus 71 +/- 12%, p = 0.019). There were no other inter-group preoperative differences. As expected, MSAVR required a slightly longer aortic cross-clamp time (49 +/- 19 min) compared to SAVR (44.5 +/- 16 min; p = 0.019), and longer CPB times (77 +/- 31 min versus 60 +/- 26 min; p<0.0001), though the overall operating times were similar (p = 0.38). Postoperatively, MSAVR patients were extubated at 3 +/- 5 h, similar to SAVR patients (4 +/- 5 h) (p = 0.13). The median intensive therapy unit stay was 1 +/- 1 days in both groups. The median hospital stay was comparable between groups (MSAVR, 7 +/- 5 days; SAVR, 8 +/- 4 days; p = 0.48). The MSAVR patients had a higher incidence of delayed pericardial effusions requiring pericardiocentesis (n = 4; p = 0.031), but this did not affect survival. The 30-day mortality was similar in both groups (MSAVR group, n = 1 (1.6%); SAVR group, n = 3 (3.7%); p = 0.64). At five years after surgery, freedom from cardiac-related death was 96 +/- 2.6% in MSAVR patients, and 89 +/- 4.9% in SAVR patients (p = 0.32). | Mini-sternotomy AVR is technically challenging with longer CPB and aortic cross-clamp times. However, with increasing surgical experience, it offers results comparable to those achieved with conventional AVR, and with acceptable cosmetic results. | closed_qa |
Is posttraumatic cerebrospinal fluid fistula a predictor of posttraumatic meningitis? | Various factors have been reported in literature to be associated with the development of posttraumatic meningitis. There is a paucity of data regarding skull fractures and facial fractures leading to CSF leaks and their association with the development of meningitis. The primary objective of this study was to analyze the US Nationwide Inpatient Sample (NIS) database to elucidate the factors associated with the development of posttraumatic meningitis. A secondary goal was to analyze the overall hospitalization cost related to posttraumatic meningitis and factors associated with that cost. The NIS database was analyzed to identify patients admitted to hospitals with a diagnosis of head injury from 2005 through 2009. This data set was analyzed to assess the relationship of various clinical parameters that may affect the development of posttraumatic meningitis using binary logistic regression models. Additionally, the overall hospitalization cost for the head injury patients who did not undergo any neurosurgical intervention was further categorized into quartile groups, and a regression model was created to analyze various factors responsible for escalating the overall cost of the hospital stay. A total of 382,267 inpatient admissions for head injury were analyzed for the 2005-2009 period. Meningitis was reported in 0.2% of these cases (708 cases). Closed skull base fractures, open skull base fractures, cranial vault fractures, and maxillofacial fractures were reported in 20,524 (5.4%), 1089 (0.3%), 5064 (1.3%), and 88,649 (23.2%) patients, respectively. Among these patients with fractures, meningitis was noted in 0.17%, 0.18%, 0.05%, and 0.10% admissions, respectively. Cerebrospinal fluid rhinorrhea was reported in 453 head injury patients (0.1%) and CSF otorrhea in 582 (0.2%). Of the patients reported to have CSF rhinorrhea, 35 (7.7%) developed meningitis, whereas in the cohort with CSF otorrhea, 15 patients (2.6%) developed meningitis. Cerebrospinal fluid rhinorrhea (p<0.001, OR 22.8, 95% CI 15.6-33.3), CSF otorrhea (p<0.001, OR 9.2, 95% CI 5.2-16.09), and major neurosurgical procedures (p<0.001, OR 5.6, 95% CI 4.8-6.5) were independent predictors of meningitis. Further, CSF rhinorrhea (p<0.001, OR 2.0, 95% CI 1.6-2.7), CSF otorrhea (p<0.001, OR 2.3, 95% CI 1.9-2.7), and posttraumatic meningitis (p<0.001, OR 3.1, 95% CI 2.5-3.8) were independent factors responsible for escalating the cost of head injury in cases not requiring any major neurosurgical intervention. | Cerebrospinal fluid rhinorrhea and CSF otorrhea are independent predictors of posttraumatic meningitis. Furthermore, meningitis and CSF fistulas may independently lead to significantly increased cost of hospitalization in head injury patients not undergoing any major neurosurgical intervention. | closed_qa |
Myoinositol: does it improve sperm mitochondrial function and sperm motility? | To evaluate whether an improvement in mitochondrial membrane potential was associated with sperm motility amelioration and greater sperm recovery after the swim-up procedure. A second purpose was to evaluate the effects of myoinositol (MYO) on sperm apoptosis, quality of chromatin compaction, and DNA integrity. Spermatozoa from 20 normozoospermic men and 20 patients with oligo-astheno-teratozoospermia were incubated in vitro with 2 mg/mL of MYO or phosphate-buffered saline as a control for 2 hours. After this incubation period, sperm motility was evaluated. Flow cytometry was used to analyze the mitochondrial membrane potential, phosphatidylserine externalization, chromatin compactness, and DNA fragmentation. We also evaluated the total number of motile spermatozoa recovered after swim-up after incubation with MYO or phosphate-buffered saline. MYO significantly increased the percentage of spermatozoa with progressive motility in both normozoospermic men and patients with oligo-astheno-teratozoospermia. Motility improvement in the latter group was associated with a significant increase in the percentage of spermatozoa with high mitochondrial membrane potential. MYO had no effects on mitochondrial function in spermatozoa from normozoospermic men. Sperm phosphatidylserine externalization, chromatin compactness, and DNA fragmentation were unaffected by MYO in both groups. After incubation with MYO, the total number of spermatozoa recovered after swim-up had improved significantly in both groups. | These data show that MYO increases sperm motility and the number of spermatozoa retrieved after swim-up in both normozoospermic men and patients with abnormal sperm parameters. In patients with oligo-astheno-teratozoospermia, the improvement in these parameters was associated with improved sperm mitochondrial function. These findings support the use of MYO in both in vivo- and in vitro-assisted reproductive techniques. | closed_qa |
Can conventional magnetic resonance imaging, prostate needle biopsy, or their combination predict the laterality of clinically localized prostate cancer? | To evaluate conventional magnetic resonance imaging (MRI), prostate needle biopsy (PBx), and the combination of both tests in predicting the laterality of final specimen pathology after radical prostatectomy. A total of 574 radical prostatectomy cases that had PBx with at least 12 cores and preoperative prostate MRI with pelvic coil were included. We analyzed the clinicopathologic data with laterality based on PBx and MRI. Unilateral disease in combination was defined as unilateral cancer in PBx and at the same time MRI findings of undetectable or ipsilateral disease. Cohen's kappa (κ) was used to measure agreement between the laterality data. There were a total of 316 (55.1%) unilateral cancers detected by PBx, whereas there were 139 (24.2%) cases in the final specimen pathology. MRI resulted in 119 (20.7%) undetectable and 205 (35.7%) unilateral cancers. Cancer laterality based on final specimen pathology had only fair agreements with PBx (κ = 0.286), MRI (κ = 0.200), and their combination (k = .291). The positive predictive values to predict pathologic concurrent unilaterality were only 30.4% (96/316), 25.9% (53/205), and 34.8% (72/207), respectively. These trends were similar in low-risk cases. | Preoperative PBx, MRI, and the combination of both methods had only a fair correlation with the laterality of prostate cancer (PC), even in low-risk cases. Approximately two thirds of cases diagnosed as unilateral disease by contemporary PBx, MRI, or their combination were not concurrent unilateral disease in final pathology. This should be recognized when planning nerve-sparing surgery and potentially for candidate selection for focal therapy to treat PC. | closed_qa |
Is co-morbid depression adequately treated in patients repeatedly referred to specialist medical services with symptoms of a medical condition? | Patients with a medical condition and co-morbid depression have more symptoms and use more medical services. We aimed to determine the prevalence of depression and the adequacy of its treatment in patients who had been repeatedly referred from primary to specialist medical care for the assessment of a medical condition. All patients who had at least three referrals to medical and surgical specialists for an assessment of symptoms attributed to a medical condition, over a five year period from five primary care practices in Edinburgh, UK were identified using a referral database and review of records. Participants were sent a questionnaire which included the PHQ-9 depression scale and additional questions about depression during the preceding 5years. Details of treatment for depression were obtained from primary care records. Questionnaires were sent to 230 patients and returned by 162 (70.4%). Forty-one (25.3%) had a PHQ-9 score of 10 or more and hence probable current depressive disorder. An additional 36 (22.2%) reported depression in the previous 5years. Only eight (19.5%) of those reporting current depression and 20 (26%) of the 77 patients reporting previous depression had received minimally adequate treatment for it. | Whilst we know that patients with medical conditions are often depressed and that such co-morbid depression is often undertreated, we have found that it is undertreated even in patients repeatedly referred to medical specialists. Better assessment and management of depression in such patients could both improve patients' quality of life and reduce the cost of care. | closed_qa |
Are therapeutics decisions homogeneous in multidisciplinary onco-urology staff meeting? | One of the priorities of the "Plan against the Cancer" in France is to ensure the discussion of all cancer cases in a multidisciplinary meeting staff (RCP). The multidisciplinary collaboration is proposed to guarantee a discussion between specialists in every cases, particularly in complex cases. The aim of this study was to compare the therapeutic decision taken in four RCP in Paris Île-de-France academic centres for three identical cases. Three cases of urological oncology (prostate cancer [PCa], renal cell carcinoma [RCC]and bladder tumour) were selected by a single urologist, not involved in further discussion. These cases were blindly presented in four academic urology department from Paris: Pitié-Salpêtrière Hospital, Mondor Hospital, the Georges-Pompidou European Hospital and Foch Hospital. The four centres met the criteria of quality of RCP in terms of multidisciplinarity, frequency and standardization. The therapeutic suggestions were similar in the RCC cases, there were differences in the surgical approaches and preoperative work-up in the PCa case and, lastly, the proposals were different for the bladder cancer case. | The decisions relies on clinical data and preoperative work-up but also on the experience and habits of the centre of excellence. For complex cases that does not fit with current guidelines, the panel discussion can lead to different therapeutic options from a centre to another and is largely influenced by the local organisation of the RCP. | closed_qa |
Does ED crowding decrease the number of procedures a physician in training performs? | The aim of the study was to determine whether the number of procedures performed by residents and medical students in the emergency department (ED) is affected by ED crowding. In this single-center, prospective, observational study, standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each ED shift from August 2009 to March 2010. Shifts with no trainees were excluded. All procedures that were offered to a trainee were recorded as well as the number of potential ED procedures that were, instead, referred to a consulting service. Emergency department crowding was measured in 2 ways: ED length of stay (LOS) and the EP's assessment of crowding during the shift. Poisson regression was used to assess the adjusted effect of ED crowding on the number of trainee procedures performed as well as on the number of procedures given away. There were 804 procedures performed by 113 trainees during 647 trainee shifts. Medical students comprised 51% of trainees. Median number of procedures performed per shift was 1.0 (Fine interquartile range, 0-2.0). Emergency department crowding was not associated with the adjusted number of procedures trainees performed using either the EP's assessment of crowding (P = .52) or ED LOS (P = .84). Emergency department crowding was associated with an adjusted 256% increase in the mean number of procedures given away (P = .02) when measured using physician assessment but was not associated with crowding when assessed using ED LOS (P = .06). | Crowding was not significantly associated with the number of procedures availed to ED trainees. In patients being considered for admission, however, when the managing EP felt that it was crowded, there was an association with giving procedures to consulting services. | closed_qa |
Mexican immigration to the US and alcohol and drug use opportunities: does it make a difference in alcohol and/or drug use? | Mexican immigrants in the US do not have increased risk for alcohol use or alcohol use disorders when compared to Mexicans living in Mexico, but they are at higher risk for drug use and drug use disorders. It has been suggested that both availability and social norms are associated with these findings. We aimed to study whether the opportunity for alcohol and drug use, an indirect measure of substance availability, determines differences in first substance use among people of Mexican origin in both the US and Mexico, accounting for gender and age of immigration. Data come from nationally representative surveys in the United States (2001-2003) and Mexico (2001-2002) (combined n=3432). We used discrete time proportional hazards event history models to account for time-varying and time-invariant characteristics. The reference group was Mexicans living in Mexico without migration experience. Female immigrants were at lower risk of having opportunities to use alcohol if they immigrated after the age of 13, but at higher risk if they immigrated prior to this age. Male immigrants showed no differences in opportunity to use alcohol or alcohol use after having the opportunity. Immigration was associated with having drugs opportunities for both sexes, with larger risk among females. Migration was also associated with greater risk of using drugs after having the opportunity, but only significantly for males. | The impacts of immigration on substance use opportunities are more important for drugs than alcohol. Public health messages and educational efforts should heed this distinction. | closed_qa |
Can we predict the severity of pulmonary hypertension in patients with scleroderma? | To describe the clinical-biological characteristics of patients with scleroderma (SSc) and pulmonary artery hypertension (PAH). To establish the relationship between pulmonary functional tests (PFT), Doppler echocardiography (ECHO) and the severity of the PAH. Retrospective study of patients with scleroderma treated at a tertiary center. All participants received a protocol study, which included a complete analysis and additional tests: Doppler Echocardiography and pulmonary functional tests (PFT) with carbon monoxide diffusing capacity (DLCO). Overall, 331 patients were treated, including 68 (20.5%) with PAH. The limited subtype of Scleroderma was the most prevalent. The Person's correlation coefficient was used for the following variables: FVC-sPAP, FVC/DLCO-sPAP, DLCO-sPAP and TRV-sPAP, showed a significant moderate linear association in the relationship DLCO-sPAP and TRV-sPAP. 29 deaths occurred, with 12 of them related to PAH. The median time between the PAH diagnosis and death was 1.8 years. | The decrease in DLCO and the increase in TRV are negative predictor factor of PAH which, at the same time, means a worsening prognosis for patients with Scleroderma. | closed_qa |
P-wave parameters and cardiac repolarization indices: does menopausal status matter? | Data regarding electrocardiographic characteristics of postmenopausal women are lacking. In this prospective, cross-sectional study, electrocardiographic P-wave parameters and cardiac repolarization indices of age-matched pre- and postmenopausal healthy women were compared. We hypothesized that menopausal status would have a significant effect on cardiac electrical activity and hence electrocardiography (ECG) recordings. Twelve-lead ECG recordings were obtained from 125 consecutively recruited postmenopausal healthy women aged between 44 and 54 years. The control group consisted of 125 age-matched premenopausal women. P-wave parameters and cardiac repolarization indices were measured and compared with respect to menopausal status. Demographic features of premenopausal and postmenopausal women were comparable. There were no significant differences between two groups regarding mean values of heart rate, maximum and minimum P-wave duration, P-wave dispersion, maximum and minimum QT interval, and QT dispersion. Mean values of QT interval obtained from lead V5 were also similar. Corrected values which were calculated according to Bazett and Fridericia formulas also did not differ between the groups. Mean values of Tpeak to Tend (TpTe) (p<0.001) and corrected TpTe (p=0.001) intervals obtained from lead V5 were significantly shorter in postmenopausal women when compared to those without menopause. | Tpeak to Tend interval decreased significantly while QT intervals and P-wave parameters did not change in postmenopausal women when compared to premenopausal women. Association of these findings with changes in levels of sex steroids and their prognostic implications need to be elucidated with further studies. | closed_qa |
Contrast enhanced ultrasound: Should it play a role in immediate evaluation of liver tumors following thermal ablation? | To compare the accuracy of immediate CEUS with results of 24-h CEUS and MDCT in early evaluation of liver tumors following thermal ablation, using the combined results of a 3 month follow-up MDCT and CEUS as a reference standard. From our database, we selected patients who underwent a thermal ablation immediately followed by CEUS (within 5-10min) between February 2009 and February 2011. There were 92 patients (median age 73 years), two of whom had repeat ablation during the study period for a total of 94 tumors. Sixty tumors were treated with radiofrequency and 34 with microwave ablation. All patients underwent CEUS and CT examinations at 24h. For patients with more than one treated tumor in the same session, the lesion imaged post-procedural and at 24-h with CEUS in all vascular phases was selected. All measurements of the necrotic zone, as an avascular zone, were performed during the portal-venous phase. Immediate post-procedural CEUS and 24h CEUS and MDCT were blindly reviewed by two radiologists. One radiologist blindly reviewed the follow-up imaging. The mean diameters of the necrotic zone at post-procedural CEUS, and CEUS and MDCT at 24h were compared and diagnostic accuracy to detect residual tumor calculated for each index tests compared to 3-months follow-up imaging. The mean diameter of the necrotic zone was: 29±9mm at post-procedural CEUS, 34±10mm at 24h CEUS and 35±11mm at 24h MDCT. Mean diameter of the necrotic zone was significantly smaller at post-procedural CEUS compared to either CEUS or MDCT at 24h (p<0.001 for all). With a 95% confidence interval, the sensitivity was 25% (11-47%) for immediate CEUS, 20% (8-42%) for CEUS at 24-h, and 40% (22-61%) for CT at 24-h. Specificity was 96% (89-99%) for immediate CEUS, 97% (91-99%) for CEUS at 24-h, and 97% (91-99%) for CT at 24-h. | Diagnostic accuracy of post-procedural CEUS in early evaluation of liver tumors following thermal ablation is comparable to both CEUS and MDCT performed at 24h. Therefore, post-procedural CEUS can be used to detect and retreat residual viable tissue in the same ablation session. | closed_qa |
The SEEK model of pediatric primary care: can child maltreatment be prevented in a low-risk population? | To examine the effectiveness of the Safe Environment for Every Kid (SEEK) model of enhanced pediatric primary care to help reduce child maltreatment in a relatively low-risk population. A total of 18 pediatric practices were assigned to intervention or control groups, and 1119 mothers of children ages 0 to 5 years were recruited to help evaluate SEEK by completing assessments initially and after 6 and 12 months. Children's medical records and Child Protective Services data were reviewed. The SEEK model included training health professionals to address targeted risk factors (eg, maternal depression), the Parent Screening Questionnaire, parent handouts, and a social worker. Maltreatment was assessed 3 ways: 1) maternal self-report, 2) children's medical records, and 3) Child Protective Services reports. In the initial and 12-month assessments, SEEK mothers reported less Psychological Aggression than controls (initial effect size = -0.16, 95% confidence interval [95% CI] -0.27, -0.05, P = .006; 12-month effect size = -0.12, 95% CI -0.24, -0.002, P = .047). Similarly, SEEK mothers reported fewer Minor Physical Assaults than controls (initial effect size = -0.16, 95% CI -0.29, -0.03, P = .019; 12-month effect size = -0.14, 95% CI -0.28, -0.005, P = .043). There were trends in the same positive direction at 6 months, albeit not statistically significant. There were few instances of maltreatment documented in the medical records and few Child Protective Services reports. | The SEEK model was associated with reduced maternal Psychological Aggression and Minor Physical Assaults. Although such experiences may not be reported to protective services, ample evidence indicates their potential harm. SEEK offers a promising and practical enhancement of pediatric primary care. | closed_qa |
Relationship of trauma patient volume to outcome experience: can a relationship be defined? | Five years experience recorded in a multi-institutional pediatric trauma registry was analyzed to define the relationship between case volume and outcome as measured by mortality. A total of 30,930 records with complete data were categorized by contributing hospital. Patients with fatal injury as indicated by an injury severity score of 75 or any abbreviated injury scale of 6 were excluded. Each center's experience was stratified by injury severity using injury severity score>or = 15 as indicative of severe injury. Centers were then classified as low volume (LV, 100-500 cases), mid volume (MV, 501-1,000 cases), or high volume (HV,>1,000 cases). Proportion of patients with severe injury (injury severity score>15) and mortality were compared among groups using the chi(2) test with significance accepted at p<0.05. Using the Pediatric Risk Indicator to adjust for mortality risk, the combined hospital experience of each volume group was further analyzed to assess performance with specific levels of increasing injury severity. Findings demonstrated a trend of increasing mortality with increasing volume, despite a consistent proportion of severe injury. Risk adjusted mortality for each volume class indicates best outcome in the mid level group. | Regardless of overall volume of patients encountered, there is a consistent proportion of severe injury. The increasing mortality with the most severe injuries seen in the high volume centers may reflect overdemand on resources. | closed_qa |
Higher prevalence of mental disorders in socioeconomically deprived urban areas in The Netherlands: community or personal disadvantage? | Major mental disorders occur more frequently in deprived urban areas. This study examines whether this occurs for all mental disorders, including less serious ones. It further assesses whether such a concentration can be explained by the socioeconomic status (SES) of the residents concerned or that a cumulation of problems in deprived areas reinforces their occurrence. Mental disorders were assessed by means of the General Health Questionnaire (GHQ) among 4892 residents. Additional data were obtained on area deprivation, and on individual SES. Multilevel logistic regression models were used to take the hierarchical structure of the data into account, residents being nested in boroughs. General population of the city of Amsterdam, the Netherlands. Prevalence of an increased (>or = 2) score on the GHQ, 12 item version. Mental disorders occur more frequently in deprived areas but this can be explained by the lower SES of the residents concerned. | The cumulation of mental disorders in deprived urban areas is mainly a result of a concentration of low SES people in these areas. Contextual factors of deprived urban areas give hardly any additional risk above that resulting from a low individual SES. | closed_qa |
Is forced dextrality an explanation for the fall in the prevalence of sinistrality with age? | The fall in the prevalence of left handedness with age has been attributed to either premature mortality or a cohort effect of forced dextrality. Evidence for forced dextrality was sought to differentiate between these competing theories. 6097 Edinburgh handedness inventories were used to calculate laterality quotients (LQ) with and without the questions relating to writing and drawing. These questions might be expected to be most influenced by forced dextrality. The study was performed in a small industrial town in Lancashire, UK. Using the British family practitioner service where over 95% of the population are registered with a general practitioner a response rate of 82.17% was obtained with respect to the Edinburgh Inventory. Questions about writing and drawing on the Edinburgh Inventory contributed to the positivity (right handedness) of the mean LQ, but equally across the ages. When a negative LQ was used to define left handedness the prevalence of left handedness fell from 11.2% at age 15 to 4.4% at age 70. Removal of the questions about writing and drawing caused the prevalence of left handedness to fall from 10.5% at age 15 to 4.95% at age 70. | Less than 20% of the fall in the prevalence of left handedness was accounted for by questions relating to writing and drawing. The fall in the prevalence of sinistrals in older age groups is not adequately explained by cohort effects of forced dextrality on the writing hand. | closed_qa |
Can GPs audit their ability to detect psychological distress? | General practitioners (GPs) should be able to detect psychological distress in their patients. However, there is much evidence of underperformance in this area. The principle of clinical audit is the identification of underperformance and amelioration of its causes, but there appear to be few evaluated models of audit in this area of clinical practice.AIM: To evaluate the feasibility of auditing GPs' performance as detectors of psychological distress. Specific objectives were to test a model of the audit cycle in the detection of psychological distress by GPs; to research GP perceptions of prior audit activity in this area and the validity of the instruments used to measure GP performance; and to research GP perceptions of the value of this specific approach to the audit of their performance and the particular value of different aspects of the model in terms of its impact on clinician behaviour. Prospective controlled study of an audit cycle of GP detection of psychological distress. Nineteen GP principals used a self-directed educational intervention involving measurement of their performance, followed by data feedback and review of selected videotaped consultations. Qualitative data on GP views of audit in this area of clinical activity were collected before and after the quantitative data collection. The study shows that the GP cohort had not previously considered auditing their performance as detectors of psychological distress. They found the instruments of measurement and the model of audit acceptable. However, they also suggested modifications that might be educationally more effective and make the audit more practical. These included smaller patient numbers and more peer contact. The implications of the study for a definitive model of audit in this area are discussed. | Effective audit of GP performance in detection of psychological distress is possible using validated instruments, and GP performance can be improved by educational intervention. GPs in this study appear more motivated by individual case studies and reflection through video analysis on undiagnosed patients than by quantitative data feedback on their performance. This study therefore supports other evidence that clinical audit has most impact when quantitative data is coupled with clinical examples derived from patient review. | closed_qa |
Do alterations in the sex ratio occur at fertilization? | The mechanisms by which the sex ratio might be altered at fertilization were reviewed, following a case of preimplantation gender analysis revealing a significantly skewed proportion of male-to-female embryos. The case of a known carrier of X-linked hydrocephalus with a history of three affected male pregnancies is presented. Her husband's family history consisted of a strong increase in the number of males relative to females. She had four cycles of stimulated in vitro fertilization, with sex chromosome analysis using fluorescent in situ hybridization (FISH) on suitable cleavage-stage embryos. The difference in the sex ratio of normal male-to-female embryos was compared using a significance probabilities test for sex ratio. The sex ratio of sperm from a semen sample from the male partner was determined by FISH. Fifty embryos were suitable for analysis. A significantly higher number of normal male (n = 20) than normal female (n = 8) embryos was obtained (P<0.05). The FISH assessment of the husband's semen analysis revealed no alteration in the normal X:Y ratio. | As the sperm analysis revealed a normal X:Y ratio, an alteration in the embryo sex ratio might be explained by the preferential binding of Y-bearing sperm to the oocyte, an oocyte-related "discouragement" of binding of X-bearing sperm, or a postfertilization event. | closed_qa |
Pediatric residents: are they ready to use computer-aided instruction? | To assess pediatric residents' readiness to use computer-aided instruction (CAI). Survey. Pediatric residency program based in a tertiary care children's hospital. Four pediatric residency classes. Self-administered questionnaire. Residents' access to computers and the Internet, experience with CD-ROM and World Wide Web computer tutorials, and attitudes toward CAI. Responses were stratified by age, training level, sex, and previous computer education. Fifty-one (69%) of the residents owned a computer. Men were more likely than women to own a computer (20 [87%] of 23 men vs 31 [61%]of 51 women; P=.02). Medical education software was used by 18 (28%) of 65, but only 2 (4%) of 74 had ever purchased CAI. Twenty-seven (36%) of 74 regularly accessed medical education World Wide Web sites. Nineteen (26%) of 74 had never accessed the Internet. Of those who had, 50 (91%) of 55 continued to do so at least weekly. Eighteen (95%) of the 19 residents who had never accessed the Internet were female (P=.005). Men were twice as likely to have Internet access at home (P=.01) and were more likely to regularly visit medical education World Wide Web sites (P=.02). Attitudes toward CAI were positive. Most respondents would be willing to use CAI developed at their institution. Most residents ranked CAI ahead of printed teaching materials but behind personal teaching by a pediatrician. Attitudes did not differ by sex. | Despite positive attitudes toward CAI, pediatric residents are not yet universally ready to use CAI. | closed_qa |
Neonatal thymectomy: does it affect immune function? | The purpose of this study was to determine whether thymectomy in the newborn has a negative effect on immune function. Twenty-five neonates (<30 days) who had thymectomy at congenital heart repair were prospectively studied to determine immune function. The percentage of T-cell subtypes including CD3 (all T cells), CD4 (helper T cells), and CD8 (suppressor T cells) was determined. In six patients, further testing of CD4 cells was done to determine whether they were newly formed, recent thymic emigrants (CD4, CD45, and RA+), or older educated lymphocytes (CD4, CD45, and RO+). Response to the mitogen phytohemagglutinin and to tetanus toxoid were determined, as were antibody titers to tetanus. Samples were drawn before the thymectomy, at approximately 3 months after immunization and at 1 year. Ten age-matched control patients were tested. At follow-up, parents were asked about infections. Prethymectomy T-cell subsets were all normal and comparable to controls. At 12 months, the percent of CD3 was significantly less than in the control group (48% +/- 3% versus 64% +/- 2% [mean +/- standard error of the mean]; p<0.01) as was CD4 (31% +/- 2% versus 46% +/- 2% [mean +/- standard error of the mean]; p =<0.01). CD8 did not drop. Surprisingly, the percent of CD4 that were recent thymic emigrants did not decrease significantly (50% +/- 8% versus 60% +/- 6% [mean +/- standard error of the mean]; p = not significant). Lymphocyte blastogenesis to phytohemagglutinin and tetanus toxoid and antibody to tetanus were all normal at 12 months. No patient required readmission for infection, and there were the expected number of minor infectious events (median 3; 95% confidence interval 1,4). | Thymectomy in neonates results in a modest but significant decrease in T-lymphocyte levels, but there is no compromise in immune function. | closed_qa |
Repair of nonsevere rheumatic aortic valve disease during other valvular procedures: is it safe? | To investigate the long-term performance of aortic valve repair, we analyzed the results obtained in a 22-year period in patients who underwent repair of nonsevere rheumatic aortic valve disease during other valvular procedures. Fifty-three patients (mean 40 +/- 11.6 years of age) with predominant rheumatic mitral valve disease had concomitant aortic valve disease in association with serious tricuspid valve disease in 25 of them. Preoperatively, aortic valve disease was considered moderate in 47.2% of the patients and mild in 52.8%. All patients underwent reparative techniques of the aortic valve (free edge unrolling, 44; subcommissural annuloplasty, 40; commissurotomy, 36) at the time of mitral or mitrotricuspid valve surgery. The completeness of follow-up during the closing interval was 100%, with a mean follow-up of 18.8 years (range 8 to 22.5 years). Hospital mortality rate was 7.5%. Of 49 surviving patients, 26 (53.1%) died during late follow-up. The actuarial survival curve including hospital mortality was 35.4% +/- 8.7% at 22 years. For patients who underwent mitral and aortic valve surgery, the actuarial survival curve at 22 years was 32.3% +/- 13%, whereas for patients who had a triple-valve operation the survival was 37.0% +/- 10.1% (p = 0.07). Twenty-five patients underwent an aortic prosthetic valve replacement. Actuarial free from aortic structural deterioration and valve-related complications at 22 years was 25.3% +/- 9.3% and 12.7% +/- 4.8%, respectively. | Long-term functional results of reparative procedures of nonsevere aortic valve disease in patients with predominant rheumatic mitral valve disease have been inadequate at 22 years of follow-up. According to these data, conservative operations for rheumatic aortic valve disease do not seem appropriate. | closed_qa |
Can retrograde perfusion mitigate cerebral injury after particulate embolization? | We assessed the impact on histologic and behavioral outcome of an interval of retrograde cerebral perfusion after arterial embolization, comparing retrograde cerebral perfusion with and without inferior vena caval occlusion with continued antegrade perfusion. Sixty Yorkshire pigs (27 to 30 kg) were randomly assigned to the following groups: antegrade cerebral perfusion control; antegrade cerebral perfusion after embolization; retrograde cerebral perfusion control; retrograde cerebral perfusion after embolization; retrograde cerebral perfusion with inferior vena cava occlusion, retrograde cerebral perfusion with inferior vena cava occlusion control, and retrograde cerebral perfusion with inferior vena cava occlusion after embolization. After cooling to 20 degrees C, a bolus of 200 mg of polystyrene microspheres 250 to 750 (microm diameter (or saline solution) was injected into the isolated aortic arch. After 5 minutes of antegrade cerebral perfusion, 25 minutes of antegrade cerebral perfusion, retrograde cerebral perfusion, or retrograde cerebral perfusion with inferior vena cava occlusion was instituted. After the operation, all animals underwent daily assessment of neurologic status until the time of death on day 7. Aortic arch return, cerebral vascular resistance, and oxygen extraction data during retrograde cerebral perfusion showed differences, suggesting that more effective flow occurs during retrograde cerebral perfusion with inferior vena cava occlusion, which also resulted in more pronounced fluid sequestration. Microsphere recovery from the brain revealed significantly fewer emboli after retrograde cerebral perfusion with inferior vena cava occlusion. Behavioral scores showed full recovery in all but one control animal (after retrograde cerebral perfusion with inferior vena cava occlusion) by day 7 but were considerably lower after embolization, with no significant differences between groups. The extent of histopathologic injury was not significantly different among embolized groups. Although no histopathologic lesions were present in either the antegrade cerebral perfusion control group or the retrograde cerebral perfusion control group, mild significant ischemic damage occurred after retrograde cerebral perfusion with inferior vena cava occlusion even in control animals. | Although effective washout of particulate emboli from the brain can be achieved with retrograde cerebral perfusion with inferior vena cava occlusion, no advantage of retrograde cerebral perfusion with inferior vena cava occlusion after embolization is seen from behavioral scores, electroencephalographic recovery, or histopathologic examination; retrograde cerebral perfusion with inferior vena cava occlusion results in greater fluid sequestration and mild histopathologic injury even in control animals. Retrograde cerebral perfusion with inferior vena cava occlusion shows clear promise in the management of embolization, but further refinements must be sought to address its still worrisome potential for harm. | closed_qa |
M. levator ani in the rat: does it really lift the anus? | There is a good deal of confusion about the denomination of the pelvic floor muscles of the rat in the literature. By carefully dissecting and observing tail and visceral movements and pressure measurements in the vagina, rectum, and urethra during electrical stimulation, we studied the anatomy and function of the different muscles and searched for similarities with the human anatomy. We found some degree of similarity between the M. pubococcygeus and M. iliococcygeus muscles in both species. The M. levator ani in the rat resembles in gross anatomy the M. puborectalis in man, but the insertion and function are different. More specifically, stimulation of the M. levator ani led to only a negligible pressure rise in the rectum and no lifting of the rectum or anus. | The M. pubococcygeus and the M. iliococcygeus share similarities with their homologues in the human. The M. levator ani, which is present only in the male rat, reveals some anatomical resemblance with the human M. puborectalis but has a different insertion and function. Because it does not lift the anus during contraction, its denomination as M. levator ani seems unjustified. Because of its principal sexual function, its fixation to the bulbus, and its sensitivity to testosterone, naming this muscle M. bulbocavernosus dorsalis would indeed seem more logical. | closed_qa |
Reconsidering menorrhagia in gynecological practice. Is a 30-year-old definition still valid? | To determine whether the 30-year-old definition of menorrhagia (menstrual blood loss of 80 ml or more) is still valid in gynecological practice today. Of 313 Dutch women, recruited from gynecological practice, the menstrual blood loss of one bleeding episode was objectively measured and related to the women's hemoglobin concentrations as well as their serum ferritin levels. Also, the 95th percentile of menstrual blood loss was calculated of women with normal hematological parameters, representing an upper normal limit. The percentage of women suffering from anemia exceeded the overall mean above 120 ml of menstrual blood loss. The 95th percentile of menstrual blood loss of women with normal hemoglobin concentrations (12 g/dl or above) and with normal serum ferritin levels (16 microg/l or above) was 115 ml. | The risk of developing anemia from heavy menstrual bleeding is substantially increased at a menstrual blood loss level of 120 ml, and not, like the current definition of menorrhagia suggests, at 80 ml. | closed_qa |
Evaluation of cervical dysplasia treatment by large loop excision of the transformation zone (LLETZ). Does completeness of excision determine outcome? | To evaluate the therapeutic and diagnostic potential of large loop excision of the transformation zone (LLETZ) in the management of cervical dysplasia (CD) when colposcopy is satisfactory; to determine if there is a relationship between completeness of excision and outcome. Ninety loop diathermies performed in the management of CD were studied prospectively. Eighty (88.89%) were indicated due to a high grade CD, 7 (7.78%) due to a low grade CD and 3 LLETZ (3.35%) due to a cytology-biopsy discordance. The margins were free of disease on 69 occasions (76.67%); on 15 (16.67%) the margins were affected by the disease and on 6 (6.67%) they were not evaluable. Using the Kaplan-Meier approach to survival analysis, the cumulative probability of continuing free of disease at the end of our study (36 months) was 0.89. In the margins free of disease group, patients stayed free of disease for an average of 32.98 months, and the cumulative probability of continuing free of disease at 36 months was 0.97. In the affected-margins group, patients stayed free of disease for an average of 20.91 months and the cumulative probability of continuing free of disease at 36 months dropped to 0.70. In the unevaluable-margins group, patients stayed free of disease for an average of 19.50 months and the cumulative probability of continuing free of disease at 36 months dropped still further to 0.67. Applying the Mantel-Cox Log-Rank Test we obtained differences among these three groups that are statistically significant (P<0.005). | LLETZ could be considered the treatment of choice for CD when colposcopy is satisfactory, as it is effective, simple, fast, inexpensive, unaggressive, and of low morbidity. It also permits adequate pathology reporting. When a pathology report states that the margins of the specimen are not free of disease or are not evaluable, special caution in follow-up may be warranted. | closed_qa |
A new paradigm for type 2 diabetes mellitus: could it be a disease of the foregut? | We previously reported, in a study of 608 patients, that the gastric bypass operation (GB) controls type 2 diabetes mellitus in the morbidly obese patient more effectively than any medical therapy. Further, we showed for the first time that it was possible to reduce the mortality from diabetes; GB reduced the chance of dying from 4.5% per year to 1% per year. This control of diabetes has been ascribed to the weight loss induced by the operation. These studies, in weight-stable women, were designed to determine whether weight loss was really the important factor. Fasting plasma insulin, fasting plasma glucose, minimal model-derived insulin sensitivity and leptin levels were measured in carefully matched cohorts: six women who had undergone GB and had been stable at their lowered weight 24 to 30 months after surgery versus a control group of six women who did not undergo surgery and were similarly weight-stable. The two groups were matched in age, percentage of fat, body mass index, waist circumference, and aerobic capacity. Even though the two groups of patients were closely matched in weight, age, percentage of fat, and even aerobic capacity, and with both groups maintaining stable weights, the surgical group demonstrated significantly lower levels of serum leptin, fasting plasma insulin, and fasting plasma glucose compared to the control group. Similarly, minimal model-derived insulin sensitivity was significantly higher in the surgical group. Finally, self-reported food intake was significantly lower in the surgical group. | Weight loss is not the reason why GB controls diabetes mellitus. Instead, bypassing the foregut and reducing food intake produce the profound long-term alterations in glucose metabolism and insulin action. These findings suggest that our current paradigms of type 2 diabetes mellitus deserve review. The critical lesion may lie in abnormal signals from the gut. | closed_qa |
Delayed primary repair of esophageal atresia with tracheoesophageal fistula: is it worth the wait? | To characterize a successful approach to the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF), significant prematurity with respiratory distress syndrome (RDS), or both, so as to preserve the native esophagus. A review of the medical records and office charts of a cohort of patients with EA and TEF. A tertiary care children's hospital affiliated with a major university. A total of 118 children with EA and TEF admitted from February 1986 through December 1996. All of the patients diagnosed as having EA and TEF during this period were included. Of the 118 infants, 88 received primary repair of EA and TEF within 48 hours of birth. An additional 23 children had the TEF divided and a gastrostomy placed secondary to (1) severe RDS and prematurity (n = 6), (2) long-gap EA (gap length>4 cm or the upper pouch above the thoracic inlet (n = 10), or (3) associated cardiac defects (n = 7). Delayed primary EA repair was done when the RDS resolved or the gap length was 2 cm or less. Successful anastomosis of native esophagus. Comparison of incidence of gastroesophageal reflux, anastomotic complications, or survival between groups undergoing primary or delayed repair. Primary EA was accomplished in 88 patients. Delayed EA was successfully accomplished in 18 of the 19 surviving patients within 5 months, thereby preserving the native esophagus in all surviving infants. There was no difference in anastomotic complications, gastroesophageal reflux, or survival when the delayed group was compared with those who had a primary repair. | Using delayed EA repair, all children with EA and TEF, regardless of gap length, can have their esophagus preserved. The primary cause of mortality was the association of a severe cardiac anomaly with EA and TEF. | closed_qa |
Development of vertebral fractures in patients with multiple myeloma: does MRI enable recognition of vertebrae that will collapse? | We assessed the relationship between the presence and size of focal marrow abnormalities detected with MRI in vertebral bodies and the subsequent occurrence of vertebral fractures at follow-up in patients with multiple myeloma (MM). We reviewed 179 follow-up MR examinations of the thoracic and lumbar spine prospectively obtained in 37 patients with Stage 3 MM. For each of 131 vertebral bodies that fractured during follow-up, the status of the vertebral bone marrow was assessed on the last MR study obtained at a mean time interval of 4 months prior to fracture occurrence. When focal lesions were observed before fracture in vertebral bodies that later collapsed, their size was compared with that of the contemporary lesions observed in vertebrae that did not collapse. Of 131 fractures, 82 (63%) appeared in vertebrae previously free of focal bone marrow abnormality at MRI and 49 (37%) appeared in vertebrae in which focal lesions were present on the previous MR study. The size of the lesions that preceded fractures (median 15 mm; range 6-50 mm) was not statistically different from the size of the contemporary lesions (median 15 mm; range 5-60 mm) that did not lead to fracture (p>0.30). | This study in patients with MM suggests a lack of correlation between the preexistence of focal vertebral marrow lesions detected with MRI and the subsequent development of vertebral fractures. | closed_qa |
Can different types of retinal emboli be reliably differentiated from one another? | To determine whether ophthalmologists can agree on the qualitative assessment of visible retinal emboli. Inter- and intraobserver agreement study. The retina and vitreous subspecialty session at the 1996 Canadian Ophthalmological Society meeting. A total of 42 observers, of whom 30 were retinal specialists. The observers viewed 17 fundus photographs of 11 patients with embolic acute retinal artery occlusion and classified the visible retinal emboli into one of three groups: cholesterol, calcific or other. Overall, there was slight agreement for the 17 observations (mean kappa = 0.063). The kappa statistic for all cases ranged from slight to fair agreement. Slight interobserver agreement for the six unique photographs was observed (mean kappa = 0.073). Slight intraobserver agreement was found for the three photographs that were shown in different orientations (mean kappa = 0.041) and for the two photographs shown with differing magnification (mean kappa = 0.102). | Overall both intraobserver and interobserver agreement on the qualitative assessment of retinal emboli was poor. With only slight agreement on the classification of emboli, systemic evaluation of acute retinal artery occlusion should not be based on qualitative assessment of retinal emboli. | closed_qa |
Is there an increased risk of second primaries following prostate irradiation? | To assess the risk of developing a second primary cancer following prostate irradiation compared to the underlying risk in patients with prostate cancer. The baseline rate of secondary cancers following prostate cancer was obtained from a study of 18,135 patients from the Connecticut Tumor Registry, of whom only 12.5% received radiotherapy. These patients, with a mean age of 72 and a mean follow-up of 3.9 years, were compared to a cohort of 543 patients (median age 70) with similar follow-up (median 3.9 years), all of whom were treated with definitive radiotherapy at Fox Chase Cancer Center. The possible association between various covariates (age, dose, palpation stage, field size, Gleason score, pretreatment PSA) and the development of a secondary cancer was assessed. 1,053 of 18,135 patients (5.8%) in the Connecticut Tumor Registry developed a second primary cancer compared with 31 of 543 (5.7%) patients treated with prostate radiation (p = 0.99). Although this risk increases gradually over time, it is not significantly different, at any time period, between the two groups of patients. Of the 31 secondary primaries in the irradiated group, 82% had a history of tobacco and/or alcohol use. Only melanomas were significantly increased compared to the expected rate in an age-matched population (p<0.001). Five of the 31 secondary cancers occurred within the radiation field (four bladder, one colon), four within 3 years and only one occurred 9 years after radiotherapy. No association was found between age (<70 vs.>or =70 and as a continuous variable), dose (<74 vs.>or =74 Gy), palpation stage (<T2C vs.>or =T2C), field size (prostate vs. pelvic), radiation technique (conventional vs. conformal), Gleason score (2-6 vs. 7-10), or pretreatment PSA (<15 vs.>or =15 and as a continuous variable) and the risk of developing a second primary. Although a lower radiation dose (as a continuous variable) correlated with an increased risk of developing a secondary cancer (p = 0.04), this phenomenon is likely due to differences in follow-up time. | Up to at least 10 years, there is no increased risk of developing a second primary cancer following prostate irradiation compared to the baseline rate from prostate cancer itself. This risk is not higher in younger patients with localized disease (<T2C), who often must choose between surgery and radiation. The vast majority of secondary cancers occurred outside of the radiation field (84%) and/or within 3 years of radiotherapy (97%), suggesting they were not caused by radiation. Most of these patients had lifestyles with predisposing risk factors. Patients with prostate cancer manifested a significantly increased risk of developing melanomas, suggesting that they may benefit from patient education and skin screening examinations. | closed_qa |
Necrotizing enterocolitis after gastroschisis repair: a preventable complication? | Necrotizing enterocolitis (NEC) has been documented in up to 20% of infants after repair of gastroschisis and is responsible for significant morbidity. NEC is reported to occur up to 10 times more in preterm infants receiving standard formula compared with those who have been fed exclusively with breast milk. Does breast milk confer a similar protection against NEC in infants who have undergone surgery for gastroschisis? All newborns with gastroschisis delivered between 1990 and 1996 and treated in a single neonatal unit were analyzed retrospectively. Clinical data, details of feeding regimens, and episodes of definite NEC were recorded. Of 60 infants with gastroschisis, 6 (10%) died but none had evidence of NEC. Of the remaining 54 infants, clinical and radiological signs of NEC developed in 8 (15%). All recovered with medical treatment including the three patients with recurrent episodes. NEC developed in none of the 12 babies exclusively fed with expressed breast milk (EBM) in contrast to 1 (5%) of the 19 who received both EBM and formula, and 7 (30%) of the 23 who were fed solely on formula. There was no significant difference in gestation, incidence of primary versus silo closure, or incidence of intestinal atresia/stenosis in those with NEC (n=8) compared with those without (n=46), but birth weight in the NEC group was lower. NEC was less likely to develop in infants who received EBM than those who were exclusively formula fed (P<.02). | After gastroschisis repair, feeding with maternal expressed breast milk may help to protect the infant from developing NEC. | closed_qa |
MR imaging of mammographically detected clustered microcalcifications: is there any value? | To assess the value of dynamic magnetic resonance (MR) imaging in patients with mammographically detected suspicious microcalcifications. Sixty-three patients (age range, 31-84 years; mean age, 56 years) with mammographically suspicious clustered microcalcifications underwent dynamic MR imaging of the breast before surgical biopsy. MR imaging was performed with a 1.5-T unit and a two-dimensional fast low-angle shot sequence with a flip angle of 80 degrees. Thirty-two axial sections, 4 mm thick and without interval gaps, were acquired before and five times after administration of gadopentetate dimeglumine (dose, 0.1 mmol per kilogram of bodyweight). Histologic findings were used as the standard of reference. Any effect of MR imaging on surgical management was noted. Biopsy findings verified five patients with T1 invasive carcinomas, 33 with ductal carcinomas in situ, 13 with proliferative fibrocystic disease, eight with nonproliferative fibrocystic disease, and four with sclerosing adenosis. Contrast material-enhanced dynamic MR imaging had a sensitivity of 45%, a specificity of 72%, and an overall accuracy of 56% in differentiating benign from malignant microcalcifications. All invasive tumors were detected with MR imaging. In no case was surgical management altered by MR imaging findings. | MR imaging of the breast is not reliable in differentiation of benign from malignant breast disease in mammographically suspicious clustered microcalcifications and has no effect on treatment. | closed_qa |
Retroperitoneal tumors: do the satellite tumors mean something? | Primary retroperitoneal tumors constitute a rather uncommon disease with an incidence of 2 in 100,000. Local recurrence after surgical resection is reported between 60% and 90% at 10 yr. The aim of this study was to present the problem of satellite tumors around the main tumor mass and their possible relation to local recurrence. Twenty-nine patients with retroperitoneal tumors underwent surgical resection in our department during an 8-yr period. We reviewed their records including their preoperative computed tomography (CT) scans. Twenty patients had "complete" resections requiring seven nephrectomies, four colectomies, two splenectomies, and one appendectomy. In nine cases the resection was incomplete because of tumor invasion to vital structures. Histopathology revealed that the resected tumors were: liposarcomas (12), leiomyosarcomas (4), paragangliomas (5), malignant fibrous histiocytomas (3), other sarcomas (3), schwannoma (1), myelolipoma (1), and the malignancy grade was I in 6, grade II in 11, and grade III in 12 cases. Two patients died within 30 d of the operation. The I year recurrence rate was 41.4% (12/29) and the total recurrence rate 55.2% (16/29). Survival at 5 yr was 31% (9/29), whereas the disease-free survival was 20.7% (6/29). Four patients required reoperations. In seven cases (24,1%) preoperative CT scans revealed small nodular lesions around the main tumor that were removed en bloc and were of the same histopathological type as the main tumor. We called these "satellite" tumors. All seven patients had local recurrence within 1 yr. | There seems to be a close relationship between the finding of satellite tumors and the recurrence of the disease. The existence of satellite tumors on the preoperative CT scan may be used as a guide for the extent of the resection, and further investigations are necessary before they are used as a prognostic sign. | closed_qa |
Is the capillary microscopic determination of the visible capillary length a diagnostic criterion in thromboangiitis obliterans? | The diagnosis of thromboangiitis obliterans may be difficult to establish in the everyday clinical setting. In 16 patients with thromboangiitis obliterans vital capillary microscopy was carried out on the nailfold on all ten digits. The longest visible capillary length was noted. As controls we employed 86 healthy subjects. The measurement of the respective longest visible capillary on the nailfold revealed a visible capillary length of more than 0.6 mm in 38% of all patients with thromboangiitis obliterans (n = 16), such capillary lengths were not to be found among healthy subjects (n = 86). | Vital capillary microscopic determination of the visible capillary length is a simple-to-perform, non-invasive examination, which can help to establish the diagnosis. | closed_qa |
Is prostate-specific antigen a reliable marker of bone metastasis in patients with newly diagnosed cancer of the prostate? | Staging in patients with newly diagnosed cancer of the prostate has significant ramifications in the management of the disease. At present, measurement of serum prostate-specific antigen (PSA) concentration and radionuclide bone scintigraphy are two important procedures in the metastatic work-up of these patients. We evaluated the efficacy of PSA as a staging marker to discriminate prostate cancer patients with and without bone metastases. In a retrospective study, 359 prostate cancer patients with (n = 40) and without (n = 319) bone metastases were analyzed. In all patients the initial PSA measurement as well as the radionuclide bone scan were evaluated. Patients without bone metastases demonstrated a median serum PSA concentration of 12 ng/ml, whereas those with bone metastases revealed a median serum PSA concentration of 59 ng/ml, with 7 patients demonstrating a serum PSA concentration of<10 ng/ml. This resulted in a negative predictive value of 96%. In addition, only 40% of these patients with bone metastases demonstrated a serum PSA concentration of>100 ng/ml, which resulted in a positive predictive value of 50%. | The serum PSA concentration seems only to provide limited information with regard to the presence of bone metastasis in patients with newly diagnosed cancer of the prostate. We therefore question whether a staging radionuclide bone scan may be omitted in patients with a serum PSA value of<10 ng/ml. | closed_qa |
The degree and type of relationship between psychosocial variables and smoking status for students in grade 8: is there a dose-response relationship? | While most research focuses on simply analyzing the differences between smokers and non-smokers, dose-response analyses may be used to find evidence of the nature of the association between psychosocial variables and involvement with smoking in adolescence. For the study, 1,614 grade 8 students from Scarborough, Ontario, Canada, completed a self-administered questionnaire that included items on sociodemographic characteristics, experience with smoking, lifestyle, health and weight, work status, and social involvement as well as parental education, occupation, and family and peer smoking. A series of scales measuring self-esteem, stress, coping, social support, mastery, social conformity, and rebelliousness was incorporated. Dose-response relationships were evidenced for all categories of variables and were demonstrated for the total group and, in most cases, for males and females when analyzed separately. | Relationships between variables are not "all or none," but may vary depending on amount or level of other factors. These relationships provide insight into the mechanisms underlying initiation to, maintenance of, and cessation of smoking and should be taken into account in programs to reduce or prevent adolescent tobacco use. | closed_qa |
Do GPs prescribe antidepressants differently for South Asian patients? | In spite of evidence from controlled trials and published guidelines, general practitioners prescribe antidepressants in lower doses and for shorter courses than are recommended [2]. However, these studies have not examined the effect of ethnicity on antidepressant prescribing by general practitioners. To compare the antidepressant treatment of South Asian patients with White patients. Patients, between 16 and 65 years prescribed an antidepressant between November 1993-1995, were selected from an east London training practice by searching the practice computer system EMIS. From a total of 438 patients identified, 40 cases were selected on the basis of their surname [3] as South Asian, and 50 cases formed the White comparison group. Data was collected retrospectively from the computer and paper records and analysed using Stata. The main outcome measures were presenting symptoms, maximum dose of antidepressant prescribed, duration of treatment and continuity of care. Women formed 2/3 of each group, the mean age in both groups being similar. Psychological symptoms were noted in the majority of both groups, but South Asians presented more physical complaints than the White group (67.5% compared to 22%, Chi squared=18.86, P=0.00001). The South Asian group were significantly more likely to be prescribed amitriptyline at doses of 75 mg or less than the White group (Fisher exact 2 tailed test, P=0.008), had significantly shorter median durations of antidepressant treatment (60 days, compared with 160 days for the White group, Mann Whitney test P=0.005). No differences were found between the groups in their continuity of care. | The results suggest that successful drug treatment of depressed South Asian patients may be less likely than in White patients. | closed_qa |
Do general practices adhere to organizational guidelines for effective cervical cancer screening? | Well-organized cervical screening has been shown to be effective in the reduction of both morbidity and mortality from cancer of the uterine cervix. In The Netherlands, the GP plays an important role in the cervical screening. The question is whether the general practices are able to organize an effective cervical cancer screening. We explored the extent to which Dutch general practices adhere to organizational guidelines for effective population-based prevention of cervical cancer and which practice characteristics are important for this adherence. A postal survey was conducted in a random sample of one-third of all 4758 Dutch general practices. Two sets of information were collected: practice characteristics and adherence to four organizational guidelines for effective cervical screening concerning inviting the women, monitoring attendance and sending reminders, organizing the taking of the smear and follow-up monitoring. A total of 1251 (79%) general practices returned a questionnaire; 90 questionnaires were excluded from analyses owing to missing data. The 1161 practices were representative of the Netherlands. A minority of the practices adhered to the four guidelines (in total, ten recommendations). The presence of the practice characteristics 'a general practice-based inviting system', 'a high delegation index' (delegating many tasks to the assistants) and a 'computerized patient information recording system' were positively associated with the adherence to most of the guidelines. | This study showed that most of the Dutch general practices are not yet ready to organize an effective cervical cancer screening system. A general practice-based inviting system, a high delegation index and a computerized patient information recording system proved to be important for the adherence to the guidelines. In order to organize a cervical screening programme to achieve optimal effectiveness, emphasis should be placed on the adherence to the four guidelines described in this study and on stimulating a general practice-based inviting system, delegation to the practice assistant and computerization. | closed_qa |
Improving influenza vaccination coverage among high-risk patients: a role for computer-supported prevention strategy? | Worldwide, population-based influenza vaccination strategies are being developed to trace, immunize and monitor high-risk persons efficiently. Computerized prevention modules may facilitate such a strategy in general practice. We established the applicability of a computerized influenza prevention module and specifically addressed improvement of immunization coverage in high-risk patients during two consecutive influenza vaccination rounds after introduction of the module. In this descriptive study, four computerized practices of the Utrecht General Practices Network, covering about 36000 patients, participated. In 1995, all patients with high-risk diseases were traced by relevant tags, ICPC- and ATC-codes, using the module. According to changed Dutch immunization guidelines in 1996, healthy elderly people over 65 years were also traced. Demographical and medical data included age, high-risk disease and vaccine uptake. In October 1995, 3871 high-risk patients were identified (11% of population); overall vaccination coverage was 68%. Over one-third of these patients had not been indicated before. In between the two vaccination rounds, 1104 previously unknown patients with high-risk disease<65 years were found by means of the module's on-line status. In October 1996, 6889 persons, including 2308 healthy elderly, were indicated (19%), and vaccination coverage was 62%. Of 3477 patients whose high-risk diseases were documented in both vaccination rounds, an overall improvement of vaccination coverage from 71 % in 1995 to 76% in 1996 was observed (P<0.05). Main improvements were found in elderly patients. Immunization rates were highest in those with more than one risk factor, lung or cardiac disease, and lowest in healthy elderly and patients under 65 years with lung, renal or other diseases. | Computerized prevention modules and CMRs may facilitate population-based prevention of influenza and the use should be further encouraged. | closed_qa |
Complex health problems in general practice: do we need an instrument for consultation improvement and patient involvement? | Many patients in general practice present with complex health problems. It is argued that the GP who is in a prime position to counsel patients with such problems, will, however, often perceive a lack of tools to manage them. The aim of the present study was to develop a novel instrument in terms of a patient-administered questionnaire, the Patient Perspective Survey (PPS), designed to enhance the quality of clinical communication in the consultation. It is based on a biopsychosocial patient perspective, patient centredness, patient resources, involvement and coping, and quality of life orientation. Development of the PPS has included comprehensive literature research, discussions and advice, during several phases, from groups of GPs, patients, broad panels of experts and testing in pilot studies. After many revisions, a 102-item version, consisting of a main somatic, mental and social domain axis, was evaluated by GPs and patients in 213 consultations. The basic idea, theoretical elements and purpose of the PPS appeared in general to be well accepted. Seventy-five to eighty-five per cent of the patients found the questions relevant and easy to understand and there were high positive scorings regarding influence on the doctor-patient relationship, communication, resource and coping aspects, occurrence of new information and general satisfaction with the consultation. Similar scorings were obtained from the GPs' evaluation. Both parties agreed that there is a need for a shorter and more specific PPS version, and that the resource and coping dimension should be even more extended. | We consider it well documented that there is a need for this new instrument to deal with complex health problems in general practice, and that it has promising potentials for consultation improvement. | closed_qa |
Are long working hours and shiftwork risk factors for subfecundity? | To estimate the effect of long working hours and shift work on time to pregnancy. Cross sectional samples with retrospective data collection from two 700 bed hospitals at secondary to tertiary care level in Hatyai district, Songkhla Province, Thailand. The study was conducted from March 1995 to November 1995 among 1496 pregnant women attending the antenatal clinics. Subfecundity was defined as time to pregnancy longer than 7.8, 9.5, or 12 months (time to pregnancy was calculated from the date at which the couples started having sexual relations without any contraception until last menstrual date). The descriptive analyses were restricted to 1201 planned pregnancies and the analytical part to 907 working women. Separate analyses on primigravid women were also done. Logistic regressions adjusted for age, education, body mass index, menstrual regularity, obstetric and medical history, coital frequency, and potential exposure to reproductive toxic agents, showed an odds ratio (OR) associated with female exposure to long working hours of 2.3 (95% confidence interval (95% CI) 1.0 to 5.1) in primigravid and 1.6 (1.0 to 2.7) in all pregnant women. Male exposure to long working hours and shiftwork showed no association with subfecundity. The OR of subfecundity was highest when both partners worked>70 hours a week irrespective of the cut off point used (OR 4.1 (95% CI 1.3 to 13.4) in primigravid women; OR 2.0 (95% CI 1.1 to 3.8) in all pregnant women). | Long working hours is a risk factor for subfecundity especially for women. Shiftwork was not associated with subfecundity in this study. | closed_qa |
Tongue cancer treated with brachytherapy: is thickness of tongue cancer a prognostic factor for regional control? | We aimed to investigate the predisposing factor for lymph node metastasis and examine the influence of thickness for lymph node recurrence in oral tongue cancer. We analysed 254 patients with early oral tongue cancer (T1-2N0) who were treated with brachytherapy from 1967 through 1985. T category (p = 0.005), and thickness (p = 0.04) were identified as a significant predisposing factors for neck failure. 50%, 40% and 30% were the incidences of lymph node metastasis for patients with thickness of tumor more than 11 mm, 6-10 mm and 5 mm or less. Furthermore, T category (largest diameter of lesion) correlates strongly to thickness of tumor. | Although it is not an independent factor, thickness is a significant predisposing factor for lymph node metastasis. | closed_qa |
Can sevoflurane save time in routine clincal use? | The volatile agent sevoflurane enables a rapid emergence from anaesthesia. The aim of this study was to investigate the possibility of increasing turnover in pediatric anaesthetic cases by use of sevoflurane in comparison with halothane. Often short cases or day cases need rapid turnover. The pediatric patients aged 4-14 years (ASA I) presenting for elective ophthalmic surgery were randomised to either the halothane or the sevoflurane group. Standard monitoring was applied to all patients, in addition the pEEG was used to determine comparable anaesthetic depth. Sevoflurane or halothane were titrated to a SEF 90 of 8-12 Hz. Management of the airway was done with the RLMA (reinforced laryngeal mask). All patients were under controlled ventilation. At the end of surgery and anaesthesia 3 time intervals were measured: phase I) end of anaesthetic application--start of spontaneous respiration; phase II) start of spontaneous respiration--removal of RLMA. The SEF 90 interval was also assessed. 18 cases were included (halo n = 8/sevo n = 10, no significant differences concerning weight, age, anaesthesia time). There is a significant advantage for the Sevoflurane group in phase II of 6.8 minutes. No differences were seen in phase I and SEF 90 interval. | Sevoflurane offers the potential for shortening turnover in pediatric anaesthesia. | closed_qa |
Is pancreatoscopy of any benefit in clarifying the diagnosis of pancreatic duct lesions? | Modern fine-caliber endoscopes enable clinicians to directly visualize the pancreatic duct. They allow intraductal manipulation under optical control. We tried to evaluate the additional diagnostic potential of pancreatoscopy in assessing inconclusive intraductal pancreatic changes. We prospectively performed 20 pancreatoscopies in 18 patients with inconclusive ductal abnormalities that had been previously investigated by computed tomography (CT) scan, abdominal ultrasound and endoscopic retrograde cholangiopancreatography (ERCP). The CHF-BP 30 (Olympus Optical Co., Japan) endoscope with an outer diameter of 3.1 mm and an instrumentation channel of 1.2 mm was used. Biopsies, cytological brushing and fluid collection were carried out, and the site of ductal abnormality was visualized. Endoscopic sphincterotomy (EST) was carried out in every patient prior to insertion of the pancreatoscope. Seven intraductal tumors were histologically confirmed, i.e. five intraductal papillary mucinous tumors and two adenocarcinomas. Benign appearance of the intraductal lesion plus negative histopathological examinations were confirmed by a follow-up of two years in eight patients. Five had chronic pancreatitis, and a further three had pancreatitis with strictures, blood clot obstruction, and idiopathic benign stricture, respectively. There were no complications with the exception of one bleeding episode after EST; no pancreatitis occurred. | Pancreatoscopy is of diagnostic value in addition to CT, transabdominal ultrasound and ERCP in the differential diagnosis of poorly defined pancreatic lesions, particularly when assessing alterations of the ductal caliber without parenchymatous lesions. | closed_qa |
Adrenal gland incidentaloma in the oncologic patient: is its histologic study obligatory? | To analyze the need for histological study in suprarenal incidentalomas in the specific status of the oncological patient. 21 patients with tumoral suprarenal masses, 12 diagnosed in the initial study and 9 during the follow-up 16 masses were benign in nature and 5 were metastatic. Neither the location nor the staging of the initial tumour, the time of diagnosis, or the hormonal study were of any use to separate the primitive tumour from the metastasis. All metastasis were equal to or greater than 5 cm in size. Radiological study only confirmed the nature of the tumour in a few cases. Percutaneous biopsy was resolutive in 4/8 cases (50%). Suprarenalectomy was performed in 15 occasions, associated in 10 to surgical treatment of the primary therapy with not added morbidity. | When incidentaloma is detected in tumoral patients at the time of diagnosis, it requires an histological study which in 1 out of 3 cases will modify the therapeutic attitude in the presence of metastasis. If the incidentaloma is detected during follow-up, it may be monitored in terms of evolution as we would only be delaying a palliative treatment. | closed_qa |
Are tobacco industry campaign contributions influencing state legislative behavior? | This study tested the hypothesis that tobacco industry campaign contributions influence state legislators' behavior. Multivariate simultaneous equations regression was used to analyze data on tobacco industry campaign contributions to state legislators and legislators' tobacco control policy scores in 6 states. Campaign contributions were obtained from disclosure statements available in the specific state agency that gathers such information in each state. Tobacco policy scores were derived from a survey of key informants working on tobacco issues in each state. As tobacco industry contributions increase, a legislator's tobacco policy score tends to decrease (i.e., become more pro-tobacco industry). A more pro-tobacco position was associated with larger contributions from the industry. These results were significant even after controls for partisanship, majority party status, and leadership effects. In California, campaign contributions were still significantly related to tobacco policy scores after controls for constituent attitudes and legislators' personal characteristics. | Tobacco industry campaign contributions influence state legislators in terms of tobacco control policy-making. | closed_qa |
Adolescents engaging in unhealthy weight control behaviors: are they at risk for other health-compromising behaviors? | This study sought to determine whether adolescents engaging in weight control behaviors are at increased risk for tobacco, alcohol, and marijuana use; suicide ideation and attempts; and unprotected sexual activity. Data were collected on a nationally representative sample of 16,296 adolescents taking part in the 1993 Youth Risk Behavior Survey. Adolescents using extreme weight control behaviors were at increased risk for health-compromising behaviors, while associations with other weight control behaviors were weak and inconsistent. | The findings have relevance to clinical work with youth, provide a better understanding of disordered eating, and open up a number of opportunities for future research. | closed_qa |
Axillary node removal in clinical node-negative breast carcinoma. Can its indication be individualized by "sentinel node" detection? | The status of the axillary lymph node(s) is an important prognostic factor in breast cancer and thus decisive in the indication for adjuvant treatment. This study investigated the extent to which examination of the sentinel node (SN) can individualize the need for axillary resection and the diagnosis of lymph nodes be optimized. 96 consecutive patients with breast cancer were studied (94 women, 2 men; mean age 59 [36-84] years) in whom no lymph node enlargement had been diagnosed clinically. After preoperative lymph-drainage scintigraphy with 99mTc Nanocoll combined with intraoperative scintillation probe detection the SN node was identified in 77 of the 96 patients and was removed. Subsequently the axillary lymph nodes in level I and II were removed by a standard technique and all removed lymph nodes and material then compared histologically. In nine of 77 patients with identifiable SN it was the only lymph node with metastasis. In 18 patients both the SN and other axillary lymph nodes were infiltrated. The SN and other axillary lymph nodes were free of metastases in 44 patients. In six patients the SN was not representative, since it was free of tumour, but other axillary nodes were not. Identification of a SN and prognostication of lymphogenic axillary metastases depended on tumour size. Among T3 and T4 tumours, ten of 16 had a verifiable SN, but in six of them it was not representative for axillary metastasization. But in 62 of 73 patients with tumours up to 5 cm in diameter without involvement of skin or chest wall (T1 and T2, respectively) a SN could be identified that was not representative for axillary metastases in only two cases. | SN resection in breast cancer makes it possible to individualize axillary node resection as part of primary treatment. Specific histological examination of serial sections and immunohistological testing may possibly increase the accuracy of histological diagnosis. | closed_qa |
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