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Intravenous cyclosporin as rescue therapy in severe ulcerative colitis: time for a reappraisal? | Intravenous cyclosporin is the only new therapy in recent years to have made a significant impact on the management of acute severe ulcerative colitis (UC). It is increasingly recommended for use in patients who prove refractory to the standard regimen of intravenous (i.v.) and rectal hydrocortisone but do not warrant immediate surgery. This practice is based on uncontrolled and controlled studies which suggest a short-term efficacy of 80% and long-term efficacy of 60% in avoiding colectomy.AIM: The aim of this study was to assess the short- and long-term efficacy of i.v. cyclosporin in patients admitted to our hospital with acute severe ulcerative colitis refractory to i.v. steroids, over a 6-year period. A retrospective survey of patients admitted to the John Radcliffe Hospital, Oxford, with acute severe UC over a 6-year period (1991-97) was performed. Truelove and Witts criteria for acute severe UC were satisfied by 216 patients. The standard regimen achieved remission in 132 patients (61%). Of the 84 patients who failed to respond, 34 (40%) proceeded directly to colectomy whilst 50 received cyclosporin (4 mg/kg by continuous slow infusion). Remission was achieved by i.v. cyclosporin in 28/50 (56%) patients who were subsequently transferred to oral cyclosporin (5 mg/kg). However, 8/28 (29%) who initially responded later relapsed after discharge from hospital and underwent colectomy. The short-term efficacy of 56% therefore falls to 40% in the longer term (mean follow-up of 19 months). | This is the largest survey to date of patients with refractory severe UC treated with i.v. cyclosporin. The findings confirm the potential value of i.v. cyclosporin in severe UC but its effectiveness in clinical practice is less dramatic than previously reported. | closed_qa |
Lower extremity arterial evaluation: are segmental arterial blood pressures worthwhile? | Physiologic observations with blood flow waveform analysis and pressure measurements can document the severity of lower extremity arterial disease. Segmental blood pressures (SEGPs) taken at the thigh, calf, and ankle are commonly used, but their utility has seldom been studied. We quantified improvements in accuracy compared with arteriography when ankle pressures alone (ABI) or SEGP data were added to velocity waveforms obtained by Doppler ultrasound. Continuous-wave Doppler velocity waveforms were recorded at common femoral (CFA), popliteal (POP), and dorsal pedal and posterior tibial (TIB) arterial levels. Systolic SEGP data were obtained with appropriately sized upper thigh, upper calf, and ankle cuffs. Waveforms, waveforms plus ABI, and waveforms plus SEGP data from 81 patients were randomly interpreted by 14 technologists or physicians from four institutions blinded to clinical and arteriographic data. Arteriograms were assigned negative or significant, severe (>75% diameter stenosis) values for four segments: iliofemoral (CFA), superficial femoral (SFA), popliteal (POP), and infrapopliteal (TIB) arteries. A total of 9072 segmental interpretations were analyzed. Compared with arteriography, the accuracy of waveform analysis was 83% for severe disease at and proximal to the CFA, 79% for SFA disease, 64% for POP disease, and 73% for TIB disease. Adding ABI improved the accuracy significantly (p<0.01) to 88% (CFA), 86% (SFA), 70% (POP), and 85% (TIB). Accuracy was inferior when SEGP data replaced ABI: 86% (CFA), 85% (SFA), 70% (POP), and 80% (TIB). | ABIs significantly improved Doppler waveform accuracy at all levels. Compared with ABI, the addition of segmental pressure to waveform data failed to improve accuracy. Pressure measurements above the ankle may lack cost effectiveness and clinical utility. | closed_qa |
Is the Barthel Scale appropriate in non-industrialized countries? | To determine if the Barthel Index, a conventional scale for assessing disability, is appropriate for stroke patients in rural Pakistan, rather than an observational study by visiting stroke patients in their homes. Stroke patients attending hospital out patient clinics in Islamabad, together with others identified in local villages, were assessed to test the validity of the Barthel Activities of Daily Living Scale. For each item on the disability scale, differences in local customs, lifestyle and architecture meant that the Barthel Scale was not appropriate in rural Pakistan. | There is unlikely to be a disability scale which can be applicable universally. Care must be taken when standard scales are used for international comparisons of stroke disability. | closed_qa |
Low overall mortality of Turkish residents in Germany persists and extends into a second generation: merely a healthy migrant effect? | To test the hypothesis that as a minority with lower socio-economic status, Turkish residents in Germany might experience a higher mortality than Germans. All-cause mortality rates by age group and sex of Turkish and German adults for the time period 1980-94 were calculated from death registry data and mid-year population estimates. The age-adjusted mortality rate (per 100000) of Turkish males aged 25-65 years resident in Germany was 299 in 1980 and 247 in 1990, consistently half that of German males. The mortality of Turkish females in Germany was 140 in 1990, half that of German females. Mortality of Turkish males/females in Ankara was 835 and 426 in 1990. | In view of the socio-economic status of Turkish residents in Germany the large mortality difference compared to Germans is unexpected. It cannot be fully explained by a selection at the time of hiring (healthy migrant effect) because it lasts over decades and extends into the second generation. A healthy worker effect is unlikely because Turkish residents have a lower employment rate than Germans. There is little evidence for movement of gravely ill persons back to Turkey. An 'unhealthy re-migration effect' in which socially successful migrants with a lower mortality risk stay in the host country while less successful ones return home even before becoming manifestly ill would partly explain our findings. | closed_qa |
Does exogenous melatonin improve day sleep or night alertness in emergency physicians working night shifts? | To determine whether exogenous melatonin improves day sleep or night alertness in emergency physicians working night shifts. In a double-blind, placebo-controlled crossover trial, emergency physicians were given 10 mg sublingual melatonin or placebo each morning during one string of nights and the other substance during another string of nights of equal duration. During day-sleep periods, subjective sleep data were recorded. During night shifts, alertness was assessed with the use of the Stanford Sleepiness Scale. Key outcome comparisons were visual analog scale scores for gestalt night alertness and for gestalt day sleep for the entire string of nights. We analyzed data from 18 subjects. Melatonin improved gestalt day sleep (P = .3) and gestalt night alertness (P = .03) but in neither case was the improvement statistically significant. Of 13 secondary comparisons, 9 showed a benefit of melatonin over placebo; none showed a benefit of placebo over melatonin. | Exogenous melatonin may be of modest benefit to emergency physicians working night shifts. | closed_qa |
Is international travel useful for general practitioners? | The Royal College of General Practitioners has offered international travel scholarships for the past decade. Each year a number of general practitioners travel from the UK to work or study assisted by the scheme, while others come to this country for similar purposes.AIM: To investigate the value of international scholarships for recipients and others. All those receiving awards in 1988-94 were surveyed by postal questionnaire. Fifty-one out of 58 award winners (88%) replied. Almost all cited some of a wide variety of personal benefits from international travel, and some established continuing links with colleagues overseas. Many gave examples of useful results for others, both patients and colleagues. Scholarships appear to have made a significant contribution to careers, especially for those based outside Britain. | Relatively modest travel scholarships were viewed both favourably in hindsight and produced a wide range of benefits to recipients, colleagues, and patients. International travel should probably be considered more widely in career planning. | closed_qa |
Intensive cardiovascular risk factor intervention in a rural practice: a glimmer of hope? | Large trials of primary care-based health promotion to modify coronary heart disease risks have shown only modest benefits. Could more intensive intervention, with doctors sharing with practice nurses in health promotion, produce better health outcomes in the context of the small family practice? How cost-effective might these interventions be?AIM: To assess the cost-effectiveness of an intensive programme of coronary heart disease (CHD) risk factor modification in a rural general practice in which doctors had a major input. A longitudinal study of changes in risk factors in a group of adult patients identified as having one or more major CHD risk factor and monitored for one to seven years. Patients were recruited from and followed up in health promotion clinics, routine practice nurse appointments, or routine doctors' surgeries. All received the practice's routine interventions to modify risk, and changes in risk factors were recorded. Time spent by members of the primary health care team on CHD health promotion was recorded over a two-year period. From a practice list of 2040, 760 patients with one or more CHD risk factors were identified and followed up over a mean of 3.61 years (range six months to seven years). Significant improvements in each of the risk factors occurred, except in body mass index (BMI). Mean Dundee risk scores fell from 7.4 to 5.7 (by 23.3%). The annual cost to the practice (including doctor/nurse/secretarial time plus sundry practice expenses and laboratory costs, but excluding drug costs) was 6000 pounds. Cost per coronary death prevented was calculated as approximately 10,000 pounds. | The results show an effect on risk factors broadly similar but slightly greater in magnitude than that achieved in the OXCHECK and British Family Heart Studies of nurse-delivered risk factor intervention in primary care. The results suggest that more intensive effort in lifestyle modification and health promotion, with more active involvement of doctors, could produce significant additional benefit. The cost-effectiveness of this approach compares favourably with many other accepted measures in coronary heart disease prevention. | closed_qa |
Posttransplant lymphoproliferative disorders not associated with Epstein-Barr virus: a distinct entity? | Organ recipients are at a high risk of posttransplant lymphoproliferative disorders (PTLD) as a result of immunosuppressive therapy. Most B-cell lymphomas are associated with Epstein-Barr virus (EBV) infection. We describe a morphologically and clinically distinct group of PTLD in 11 patients that occurred late after organ transplantation and were not associated with EBV. There were seven kidney, three heart, and one liver transplant recipients (group I). The clinical manifestations, pathologic findings, treatment, and outcome were compared with those in 21 patients with EBV-associated PTLD treated in our institution (group II). EBV was detected with at least two techniques: Epstein-Barr-encoded RNA (EBER) in situ hybridization with EBER 1 + 2 probes, Southern blotting, and detection of latent membrane protein 1 (LMP1) expression by immunohistochemistry. The time between transplantation and the diagnosis of lymphoma ranged from 180 to 10,220 days in group I (mean, 2,234; median, 1,800) and from 60 to 2,100 days in group II (mean, 546; median, 180), and was significantly shorter in group II (P = .02). Among 19 tumors diagnosed within 2 years after the graft, 16 were associated with EBV; among 13 tumors diagnosed after more than 2 years, only five were associated with EBV. All of the B-cell PTLDs in group I were classified as monomorphic, meeting the criteria of B diffuse large-cell lymphoma (B-DLCL) with a component of immunoblasts, and genotyping confirmed their monoclonality. Three tumors were T-cell pleomorphic lymphomas. Tumor sites were mainly bone marrow and lymph nodes. Overall median survival was 1 month in group I and 37 months in group II, with two patients still alive in group I and nine in group II. The survival time was significantly longer in group II (P<.01). | EBV-negative PTLD may be a late serious complication of organ transplantation. Half the tumors observed after kidney transplantation in our center were not associated with EBV and emerged after more than 5 years, which suggests the number of EBV-negative PTLDs in organ recipients might increase with time. | closed_qa |
Influenza and tetanus immunization. Are adults up-to-date in rural Alberta? | To discover what proportion of adults residing within the boundaries of a rural health district were up-to-date with influenza and tetanus vaccinations. A directory-seeded, random digit dial telephone survey of health knowledge, attitudes, and practices was conducted in summer 1993. Eligible subjects were aged 16 or older, lived within health district boundaries, and spoke English. Just over half (57.5%) of people aged 65 and older had received influenza vaccine in the previous 12 months, and 55.4% of people 16 years and older had received tetanus vaccine in the last 10 years (93% of people aged 16 to 24 were covered, but only 20.5% of people aged 65 or older). Most (89.8%) of those 65 and older knew that influenza vaccine was recommended for people their age. Only 59% of respondents knew that influenza vaccine was recommended for people with chronic health conditions, regardless of age. | Among adults, coverage with influenza and tetanus vaccines varies with age, but is generally unsatisfactory. Rates in this rural area of Alberta were similar to Canadian rates for tetanus vaccine coverage but higher for influenza vaccine coverage. | closed_qa |
Tuberculous pleurisy with or without radiographic evidence of pulmonary disease. Is there any difference? | A community teaching hospital in Alicante, Spain. To assess the characteristics of tuberculous pleurisy (TP) in our hospital, and to evaluate the differences between primary and reactivation forms. Between January 1984 and December 1993, all human immunodeficiency virus (HIV)-negative patients with TP were included in the study. From September 1987 onward, patients were prospectively studied. Charts, radiography, pleural fluid findings and diagnostic methods were evaluated. Two groups were distinguished according to chest radiographs: those patients with upper lobe lesions, calcified adenopathy and old pleural thickening were considered reactivation forms. Of the 129 patients (mean age, 31 +/- 18 years), 76% had primary TP and 24% reactivation TP. Differences were found in age (28 +/- 17 vs 40 +/- 18 years, P<0.01), smoking (43% vs 74%, P<0.01) and alcohol abuse (23% vs 47%, P<0.05), weight loss (29% vs 50%, P<0.05), positive sputum smears and cultures (2% vs 16%, 7% vs 28%, P<0.01), and number of large effusions (46% vs 26%, P<0.05), but not in tuberculin reactivity, pleural fluid findings, positive pleural cultures, or presence of pleural granuloma. | In our setting, TP predominantly affects young adults. Clinical, immunological, and pleural findings are similar to those of patients with classic symptoms of TP. Older age, smoking and alcohol abuse, smaller effusions and sputum yield are differential characteristics of reactivation forms. | closed_qa |
Twin studies of adult psychiatric and substance dependence disorders: are they biased by differences in the environmental experiences of monozygotic and dizygotic twins in childhood and adolescence? | Twin studies have long been used to disentangle the role of genetic and environmental factors in the aetiology of psychiatric disorders. However, the validity of the twin method depends on the equal environment assumption--that monozygotic (MZ) and dizygotic (DZ) twins are equally correlated in their exposure to environmental factors of aetiological importance for the disorder under study. Both members of 822 female-female twin pairs from a population-based registry previously assessed for a range of psychiatric and substance use disorders were asked 12 questions assessing the similarity of their environmental experiences in childhood and adolescence. We examined whether the similarity of environmental experiences predicted concordance for psychiatric and substance abuse disorders by both a 'pair-wise' and 'individual' method utilizing logistic regression. We also examined smoking initiation, where prior evidence suggested a role for adolescent social environment. Three factors were derived from these items: 'Childhood treatment', 'Co-socialization' and 'Similitude'. Members of twin pairs agreed substantially in their recollections of these experiences. Compared with DZ twins, MZ twins reported comparable resemblance in their childhood treatment, but socialized together more frequently and reported that parents, teachers and friends more commonly emphasized their similarities. None of these three factors significantly predicted twin resemblance for major depression, generalized anxiety disorder, panic disorder, phobias, nicotine dependence or alcohol dependence. However, co-socialization significantly predicted twin resemblance for smoking initiation and perhaps for bulimia. | Differential environmental experiences of MZ and DZ twins in childhood and adolescence are unlikely to represent a substantial bias in twin studies of most major psychiatric and substance dependence disorders but may influence twin similarity for the initiation of substance use. | closed_qa |
Is occupational organic solvent exposure a risk factor for scleroderma? | The primary objective was to determine whether occupational exposure to organic solvents is related to an increased risk of systemic sclerosis (SSc; scleroderma). Occupational histories were obtained from 178 SSc patients and 200 controls. Exposure scores were computed for each individual using job exposure matrices, which were validated by an industrial expert. Among men, those with SSc were more likely than controls to have a high cumulative intensity score (odds ratio [OR] 2.9, 95% confidence interval [95% CI]1.1-7.6) and a high maximum intensity score (OR 2.9, 95% CI 1.2-7.1) for any solvent exposure. They were also more likely than controls to have a high maximum intensity score for trichloroethylene exposure (OR 3.3, 95% CI 1.0-10.3). Among men and women, significant solvent-disease associations were observed among SSc patients who tested positive for the anti-Scl-70 autoantibody; these trends were not observed among the men and women who tested negative for anti-Scl-70. | These results provide evidence that occupational solvent exposure may be associated with an increased risk of SSc. | closed_qa |
Should a cancer patient be resuscitated following an in-hospital cardiac arrest? | Previous reports from general hospitals and cancer centers have identified the presence of malignancy as a poor prognostic indicator for successful cardiopulmonary resuscitation (CPR) for an in-hospital cardiac arrest. The purpose of this study was to evaluate the initial success of CPR as determined by return of spontaneous circulation (ROSC), patient survival to hospital discharge, and 1-year survival of this group as compared to previous studies in non-oncological centers. In addition, the charges incurred in caring for these patients were analyzed. All cardiac arrests occurring between 1 January 1993 and 31 December 1994 were identified from a centralized morbidity and mortality database and reviewed retrospectively. Cardiac arrest was defined as the absence of a palpable pulse and initiation of CPR. Patients suffering pure respiratory arrest or shock without loss of pulse were excluded. Age, gender, primary site of malignancy, initial and ultimate outcome, including Zubrod's functional status (ZFS), and total hospital charges following cardiac arrest were recorded. Computerized billing records were used to tabulate total charges. 83 cardiac arrests occurred during the study period (42 women, 41 men). Mean age was 56.2 years. Forty-two percent of the patients had hematologic malignancies, 19% lung, 15% gastrointestinal, 5% head and neck cancers and 19% other malignancies. Sixty-six percent of the patients had ROSC. Only eight (9.6%) patients survived to hospital discharge: three died within 6 weeks under hospice care, two died within 6 months of discharge and only three (3.6%) patients survived to 1 year. Functional status follow-up of these three patients revealed two with ZFS 1 and one with ZFS 2. Total hospital charges for these 83 patients were US$ 2,959,740. | Although ROSC after cardiac arrest in our patients was better than that reported for most series in general hospitals, their ultimate survival and hospital discharge was extremely poor. | closed_qa |
Iodine-131-MIBG scintigraphy in adults: interpretation revisited? | Iodine-131-metaiodobenzylguanidine (MIBG) scintigraphy is a reliable method used to diagnose pheochromocytoma. Although the adrenal medulla usually is not visualized, faint uptake can be observed in 16% of the patients 48-72 hr after injection of 18.5-37 MBq 131I-MIBG. We recently observed an increase in the frequency of visualization of the adrenal medulla in patients injected with 74 MBq 131I-MIBG. Therefore, we retrospectively evaluated the pattern of uptake and potential changes between 1984 and 1994. Scintigraphic data from 103 patients referred for suspected pheochromocytoma were reviewed randomly. Data from 19 patients with medullary thyroid carcinoma were analyzed separately. Patients were injected with 74 MBq 131I-MIBG and imaged at 24 hr postinjection, 48 hr postinjection, or both. Adrenal uptake was scored visually as 0 (no visible uptake) and 1 (uptake just visible) to 4 (most intense activity in the picture). Semiquantitative indicies were evaluated for discriminating between normal adrenal medullae and pheochromocytomas. Twenty-seven pheochromocytomas were surgically proven in 25 patients. A visual score>or =3 was noted in 81% and 90% of the pheochromocytomas at 24 hr and 48 hr postinjection, respectively. From 1984 to 1988, 16% and 31% of adrenal medullae were seen at 24 and 48 hr postinjection, respectively, whereas from 1989 to 1994, 56% and 73% were visualized at 24 and 48 hr postinjection, respectively. Before 1989, the best cutoff criterion to identify a pheochromocytoma, determined from receiver operating characteristic curve analysis, was a score>or =1 at 24 hr and>or =3 at 48 hr postinjection, with a sensitivity and specificity of 92% and 84% at 24 hr and 92% and 99% at 48 hr postinjection. From 1989, the best cutoff was a score>or =3 at both imaging sessions, with a sensitivity and specificity of 82% and 100% at 24 hr and 100% and 97% at 48 hr postinjection. Among the semiquantitative indicies, the adrenal-to-liver and adrenal-to-heart ratios were the best discriminators between normal and pathological adrenals. They were, however, of little use because of the overlap between normal adrenal medullae and pheochromocytomas. | The high rate of visualization of the normal adrenal medulla in this study was related to the larger-than-usual injected dose (74 MBq). Over recent years, however, this rate has been increasing, possibly because of the increased specific activity of 31I-MIBG. Adequate interpretation should take into account that a faint or definite uptake may be visible in more than 50% of normal adrenal medullae. | closed_qa |
Is P50 suppression a measure of sensory gating in schizophrenia? | Abnormal P50 response has been hypothesized to reflect the sensory gating deficit in schizophrenia. Despite the extensive literature concerning the sensory filtering or gating deficit in schizophrenia, no evidence has been provided to test the relationship of the P50 phenomenon with patients' experiences of perceptual anomalies. Sixteen drug-free DSM-IV diagnosed schizophrenic patients who reported moderate to severe perceptual anomalies in the auditory or visual modality were examined as compared to 16 schizophrenic patients who did not report perceptual anomalies, and 16 normal subjects. Both control groups were age- and gender-matched with the study group. Patients reporting perceptual anomalies exhibited P50 patterns that did not differ from normal subjects. In contrast, patients who did not report perceptual anomalies showed the abnormal P50 ratios previously found to be associated with schizophrenia. | These paradoxical findings do not support the hypothetical relationship between the P50 and behavioral measures of sensory gating, suggesting that additional studies are needed to further explore the clinical correlates of the P50. | closed_qa |
Should coronary artery bypass grafting be performed at the same time as repair of a post-infarct ventricular septal defect? | The value of coronary artery bypass grafting (CABG) at the time of repair of a post-infarct ventricular septal defect (VSD) remains controversial. The aim of this study was to analyse the effect of CABG on early mortality and survival following repair of an acquired VSD. Over 23 years, 179 patients, 118 male, 61 female, mean age 66 years (range 43-80), have undergone repair of a post-related VSD in our unit. A total of 29 patients, who predominantly form the earlier part of the series, were operated on greater than 1 month after the infarct and are, therefore, excluded. Coronary angiography was performed in 98 (65.3%) of the remaining 150 patients. Of these, 41 had coronary artery disease (CAD) limited to the infarct-related vessel and 57 had additional significant CAD. Those with CAD limited to the infarct-related vessel were not grafted (Group A). Of those, 40 with significant CAD underwent CABG at the time of VSD repair (Group B) and 17 did not (Group C). In 52 patients the coronary anatomy was not documented (Group D). Risk factors for early mortality were evaluated using logistic regression. Actuarial survival was compared using log rank and Wilcoxon tests. Cox's proportional hazards method was used to determine factors affecting survival. Overall, 30 day mortality was 32%. CABG did not significantly decrease operative mortality (logistic regression). There was no statistically significant difference in early mortality or actuarial survival between the four groups. CABG was not associated with an increased survival (Cox's method). | Concomitant CABG at the time of VSD repair does not affect early mortality nor confer survival benefits. There seems to be no demonstrable benefit in revascularisation at the time of repair and, therefore, it may be unnecessary to perform CABG or coronary angiography in these patients. | closed_qa |
Should endomyocardial biopsy be performed for detection of myocarditis? | Performance of endomyocardial biopsy (EMB) to diagnose myocarditis in patients with dilated cardiomyopathy is controversial because of a lack of evidence favoring immunosuppressive therapy. In spite of advances in heart failure treatment, dilated cardiomyopathy carries a poor prognosis, and myocardial inflammation and viral infection are potential therapeutic targets. We used decision analysis to determine the efficacy (5-year risk reduction in mortality or transplantation) that a treatment for myocarditis would require to favor a biopsy-guided approach over conventional therapy. Literature-based estimates included prevalence of myocarditis among patients with dilated cardiomyopathy with or without borderline myocarditis (16% and 11%, respectively); probability of 5-year transplantation-free survival (55%); sensitivity (50% and 63%, respectively), specificity (95.4%), and mortality rate (0.4%) of EMB; side effects resulting in withdrawal of immunosuppressive treatment (4%); and a 6-month mortality rate for immunosuppressive treatment (0.1%). All estimates were varied to determine impact on model results (sensitivity analysis). A therapy that decreased the rate of death or transplantation by 12.7% and 7.1% for patients without or with borderline myocarditis, respectively, favored EMB. Sensitivity analysis indicated that therapeutic efficacy was influenced by myocarditis prevalence and biopsy-related death, but not by accuracy of biopsy or probability of immunosuppressive therapy side effects. Randomized trials powered to detect 7% and 25% reductions in death and transplantation would require 5790 and 380 end points, respectively. | Decreasing the rate of death or transplantation by 7.1% offsets therapy side effects, EMB-related death, and inaccuracies in histologic diagnosis. Prospective randomized trials of treatments for myocarditis may be more feasible during periods of high prevalence or with more sensitive diagnostic techniques. | closed_qa |
Does lung transplantation prolong life? | Because of the assumed beneficial effect of lung transplantation on survival, controlled trials to assess the therapeutic benefit of lung transplantation are considered to be unethical. Therefore other methods must be used to provide control data. In this study the effect of lung transplantation on survival for patients with end-stage pulmonary disease was analyzed, with waiting list survival rates used as control data. The analysis was based on 157 consecutive patients who were put on the waiting list of the Dutch lung transplantation program during the period November 1990 to January 31, 1996, of whom 76 underwent transplantation. Following the principles of control group estimation as set out in the context of heart transplantation, a stepwise approach was used to arrive at a multivariate time-dependent Cox regression model. The following prognostic variables were included in the analyses: age, forced expiratory volume in 1 second, partial pressure of carbon dioxide, partial pressure of oxygen, and diagnosis. The 1- and 2-year waiting list survival rates were 78% and 58%, respectively. The 1- and 2-year transplantation survival rates (i.e., survival from placement on the waiting list, including posttransplantation survival) were 79% and 64%, respectively. The multivariate time-dependent Cox analysis showed that lung transplantation reduced the risk of dying by 55% (95% confidence interval, 3% to 79%). For patients with emphysema the risk of dying was estimated to be 77% lower than for patients with other diagnoses (96% confidence interval, 50% to 89%). | With Cox regression, adjusting for age, forced expiratory volume in 1 second, partial pressure of carbon dioxide, partial pressure of oxygen, and diagnosis, lung transplantation showed a statistically significant effect on survival in selected patients with end-stage pulmonary disease. | closed_qa |
Postoperative chronic pain and bladder dysfunction: windup and neuronal plasticity--do we need a more neurological approach in pelvic surgery? | Cases of combined symptoms of dysfunctional voiding and associated pelvic discomfort are difficult diagnostic and therapeutic challenges. Surgical solutions not uncommonly fail to relieve those symptoms. We determine why these symptoms persist postoperatively. Four cases of ureteral injury during gynecological laparoscopic procedures for pelvic/menstrual pain are presented. The cases are reviewed for their severity and similarity in presenting symptoms, complications and long-term consequences. In all cases light pain symptoms and/or dysfunctional voiding problems that existed before the initial surgery escalated severely after corrective pelvic surgery. | There are established neurophysiological mechanisms that would explain the observed increase in pain after surgical manipulation of the pelvis. Windup and changes in neuronal plasticity are direct consequences of wounding and/or neural injury to the central nervous system. These principles are important for surgeons to appreciate due to the impact they can have on the outcomes of surgery. Blocking the sensory input into the spinal cord, inherent to every surgical procedure, through use of local anesthetics, that is preemptive anesthesia, before creation of a wound provides the greatest protection against escalation of symptoms. Thorough evaluation of all patients before pelvic surgery is recommended to identify high risk groups (preexisting pain, voiding syndromes). | closed_qa |
Are pediatric patients more susceptible to major renal injury from blunt trauma? | We determine whether pediatric patients are more susceptible to major renal injury than adults. We retrospectively reviewed the medical records of 34 consecutive children 2 to 17 years old (mean age 10) and 35 consecutive adults 19 to 59 years old (mean age 32) with blunt renal trauma who presented to our 2 level I trauma centers between 1990 and 1996. Patients with incomplete charts were excluded from study. According to the organ injury scaling committee of the American Association for the Surgery of Trauma renal injuries were graded based on computerized tomography results or laparotomy findings (4 adults) with major injuries classified as grade IV or V. Vascular injuries were excluded from study. Injury severity scores were calculated using the abbreviated injury scale. Injury severity scores ranged from 4 to 75 (mean 16) in the pediatric and 5 to 50 (mean 22) in the adult populations (p<0.01). Overall 16 of the 34 children (47%) and 8 of the 35 adults (23%) sustained major renal injuries (p<0.04). In 4 children who required surgical exploration for hemodynamic instability injury severity score ranged from 17 to 42 (mean 26) and all had major renal injuries. In 7 of the 35 adults (20%) who underwent surgical exploration because of hemodynamic instability and/or positive diagnostic peritoneal lavage injury severity score ranged from 22 to 50 (mean 34). Three of these 7 adults (42%) had major renal injuries and all had other visceral injuries at exploration. | Children are more likely than adults to sustain renal injury from blunt abdominal trauma. | closed_qa |
Delayed and selective motor neuron death after transient spinal cord ischemia: a role of apoptosis? | The mechanism of spinal cord injury has been thought to be related to tissue ischemia, and spinal motor neuron cells are suggested to be vulnerable to ischemia. We hypothesized that delayed and selective motor neuron death is apoptosis. Thirty-seven Japanese domesticated white rabbits weighing 2 to 3 kg were used in this study and were divided into two subgroups: a 15-minute ischemia group and a sham control group. Animals were allowed to recover at ambient temperature and were killed at 8 hours, and 1, 2, 4, and 7 days after reperfusion (n = 3 at each time point). By means of this model, cell damage was histologically analyzed. Detection of ladders of oligonucleosomal DNA fragment was investigated with gel electrophoresis up to 7 days of the reperfusion. Immunocytochemistry, in situ terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling staining was also performed. After 15 minutes of ischemia, most of the motor neurons showed selective cell death at 7 days of reperfusion. Typical ladders of oligonucleosomal DNA fragments were detected at 2 days of reperfusion. Immunocytochemistry showed in situ terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end staining was detected at 2 days of reperfusion selectively in the nuclei of motor neurons. | These results suggest that delayed and selective death of the motor neuron cells after transient ischemia may not be necrotic but rather predominantly apoptotic. | closed_qa |
Can non-prosecutory enforcement of public health legislation reduce smoking among high school students? | Smoking by adolescents has been identified as a major public health issue. Raising the legal age of cigarette purchase from 16 to 18 years has attempted to address the issue by restricting adolescents' access. METHODS/ A prospective study evaluating the impact of non-prosecutory enforcement of public health legislation involving 'beat police' was conducted in the Northern Sydney Health region. Secondary students, aged 12 to 17 years, from both intervention and control regions were surveyed about cigarette smoking habits by means of a self-completed questionnaire administered pre- and post-intervention. 12,502 anonymous questionnaires were completed. At baseline, 19.3% of male students and 21.2% of female students indicated they were current smokers. Age and sex stratified chi-squared analysis revealed significantly lower post-intervention smoking prevalence for year 8 and 10 females and year 7 males among the intervention group. Higher post-intervention smoking prevalences were demonstrated for year 7 and 9 females and year 8 males among the intervention group and in year 10 males and year 11 females among the control group. The analysis of combined baseline and follow-up data from coeducational schools with logistic regression techniques demonstrated that the intervention had a significant effect in reducing smoking prevalence among year 7 students only (OR = 0.54). | Our study demonstrates the difficulties in restricting high school students' access to cigarettes. Isolated non-prosecutory strategies are likely to only have a limited impact on reducing smoking prevalence among high school students. | closed_qa |
Do treatment restrictions imposed by utilization management increase the likelihood of readmission for psychiatric patients? | The use of utilization management as a cost-containment strategy has led to debate and controversy within the field of mental health. Little is currently known about how this cost-containment approach affects patient care or quality. The aim of this investigation was to determine whether treatment restrictions imposed on privately insured psychiatric patients by a utilization management program affected the likelihood of readmission. The utilization management program included three review activities: preadmission certification, concurrent review, and case management. During a 5-year period (1989-1993), 3,073 inpatient reviews were performed on 2,443 privately insured psychiatric patients. Using logistic regression, restrictions imposed by utilization management on length-of-stay in relation to 60-day readmission rates were investigated. The most common diagnoses among the psychiatric patients whose care was reviewed were alcohol dependence (22.9%), recurrent depression (22.5%), and single-event depression (20.8%). On average, 22.4 days of inpatient psychiatric treatment was requested through the review procedures, and 15.5 days of care were approved by the utilization management program. Of the 2,443 patients reviewed, 7.9% had a readmission within 60 days of their initial admission. Patients whose length-of-stay was restricted by utilization management were more likely to be readmitted. For each day that the requested length-of-stay was reduced, the adjusted odds of readmission within 60 days increased by 3.1% (P = 0.004). | The utilization management program restricted access to inpatient psychiatric care by limiting length of stay. Although this approach may promote cost containment, it also appears to increase the risk of early readmission. Continuing attention should be paid to investigating the effects on quality of utilization management programs aimed at containing mental health costs. | closed_qa |
Does practice make perfect? | Most tests of the practice-makes-perfect hypothesis have used cross-sectional data, which reveal that patients receiving surgery in high-volume hospitals tend to experience better postsurgery outcomes. This study uses longitudinal data to explicitly examine whether any given hospital's patient outcomes change as its surgery volume varies with time. Longitudinal data from all hospitals conducting hip fracture surgery in Quebec between 1990 and 1993 were used to examine the relationship between surgery volume and outcomes. The longitudinal data allowed volume to be measured using the actual number of surgeries performed by the admitting hospital in the 12 months before a patient's surgery. Determinants of postsurgery length of stay were assessed using ordinary least squares regression, and the explanators of inpatient mortality were identified using logistic regression. The regressions included fixed effects (hospital-specific dummy variables) to control for systematic differences in outcomes across hospitals that persist with time. Therefore, the coefficient on hip fracture surgery volume in the regression models captured differences in outcomes that were attributable to changes in surgery volume within hospitals with time. The fixed effects were significant explanators of both postsurgery length of stay and inpatient mortality, indicating that there were significant differences in outcomes across hospitals that persisted with time. In regressions that excluded the fixed effects, the coefficient on surgery volume was significant. In contrast, the coefficient on surgery volume was insignificant when the fixed effects were included. | Longitudinal data revealed that after controlling for differences in hospital outcomes that were fixed with time, hospitals performing more surgeries in one period than in another experienced no significant improvement in outcomes. These results do not support the "practice makes perfect" hypothesis. The volume-outcome relationship for hip fracture patients thus appears to reflect fixed differences in quality between high-volume and low-volume hospitals. | closed_qa |
Semen quality in spinal cord injured men: does it progressively decline postinjury? | To determine if semen quality of men with spinal cord injury (SCI) undergoes a progressive decline as a function of years postinjury. A retrospective analysis of cross-sectional data. University-based research center. Semen quality was examined in 638 specimens from 125 men with SCI. Penile vibratory stimulation, electroejaculation, and masturbation were used as semen retrieval methods. Routine semen analysis was performed to evaluate semen quality. Sperm concentration, total sperm count, and percent sperm motility were examined at 2-year intervals from men whose injuries had occurred 6 weeks to 26 years earlier. No difference in any semen parameter was found as a function of time postinjury. | Semen quality in men with SCI does not progressively decline after the SCI. Men with SCI who are considering biologic fatherhood should be advised that the number of years after injury need not be a determinant in deciding when to start a family. | closed_qa |
Non-mydriatic fundus photography: a viable alternative to fundoscopy for identification of diabetic retinopathy in an Aboriginal population in rural Western Australia? | To evaluate the Canon CR5-45NM non-mydriatic fundus camera (Canon, Kanagawa, Japan) for identifying retinopathy and the need for laser treatment in a population of Aboriginal patients with diabetes mellitus in rural Western Australia. Diabetic Aboriginal patients were photographed through undilated pupils using a Canon CR5-45NM non-mydriatic fundus camera, after which ophthalmoscopy was performed using indirect ophthalmoscopy through dilated pupils. The examining ophthalmologist recorded the presence of retinopathy and the need for laser treatment. A proportion of patients were rephotographed through dilated pupils. Photographs were reviewed by a second ophthalmologist who evaluated the quality of the image, the presence of retinopathy and the need for laser treatment. Results of fundus photographs and ophthalmoscopy were compared. Three hundred and twenty-eight eyes in 164 Aboriginal patients were examined. The mean patient age was 48.2 years (range 16-81 years) and the mean duration of diabetes was 7.5 years (range 1-35 years). Seventy-four eyes (22.6%) were diagnosed with retinopathy using combined examination techniques, 44 (59.5%) of which were identified by ophthalmoscopy and 55 (74.3%) by photography. Thirty-five eyes were deemed to need treatment, 18 (51.4%) of which were identified by ophthalmoscopy and 30 (85.7%) by photography. Kappa coefficient measurement for agreement for presence of retinopathy and need for referral was 0.41 and 0.53, respectively. Photograph quality was significantly improved following pupil dilation. | The Canon CR5-45NM non-mydriatic fundus camera was relatively good at identifying diabetic retinopathy and could usefully be applied within a screening programme for treatable disease within this population. | closed_qa |
Can the effects of exercise on bone quality be detected using the CUBA clinical ultrasound system? | To determine whether the CUBA clinical quantitative ultrasound bone analyser was able to distinguish variations in bone quality between groups categorised according to activity level. Eighty one white women aged 32 to 89 completed a confidential questionnaire on general health, diet, and exercise participation and underwent ultrasound testing at the right calcaneus utilising a CUBA clinical ultrasound system. The results confirmed the inverse relationship between age and the ultrasound indicators of bone quality: broadband ultrasound attenuation (BUA) (r = -0.52) and velocity of sound (VOS) (r = -0.68). Subject height weakly but significantly correlated with BUA (r = 0.39) and VOS (r = 0.35), and subject weight only correlated significantly with BUA (r = 0.37). Activity level was significantly associated (p<0.05) with the changes in ultrasound attenuation (BUA). The use of hormone replacement therapy or the contraceptive pill, a family history of osteoporosis, and gross indicators of calcium consumption did not yield significant results. | Data obtained from the CUBA clinical system were sensitive enough to allow women to be classified into groups according to activity level. These data were within the range of "normal" ultrasound data and hence it is suggested that the machine has research as well as clinical value. | closed_qa |
Eclampsia: is there a seasonal variation in incidence? | To clarify whether seasonal variation of temperature and humidity has any effect on the incidence of eclampsia. Eclampsia is the second major cause of maternal mortality in Pakistan. Data was collected monthwise for the year 1996 from 4 large Govt. teaching hospitals of 4 provincial metropolis of Pakistan. Each province has diverse climate with considerable variation of air temperature and humidity. There were 395 cases of eclampsia amongst 18,483 deliveries in 1996, giving an incidence of 2.14%. In Karachi (Sindh Province) with mild hot and humid climate and mild winter months, there was increase in eclampsia cases from April-July and in September. Otherwise the incidence remained stable. In Rawalpindi (Punjab Province) with moderately hot summer and cold winter, it was highest in hot season from May to September but was stable in winter. In Peshawar (N.W.F.P) and Quetta (Baluchistan Province) with more severe cold and dry winter the incidence peaked in winter and summer months both. | The pattern of eclampsia cases showed variations in extremes of temperature but it was stable in mild weather. However, the statistical analysis revealed non-significant relationship of incidence of eclampsia with temperature when analysed by linear regression analysis. | closed_qa |
Atrial fibrillation after bypass surgery: does the arrhythmia or the characteristics of the patients prolong hospital stay? | The goal of this study was to determine whether prolonged hospital stay associated with atrial fibrillation or flutter (AF) after coronary artery bypass graft (CABG) surgery is attributable to the characteristics of patients who develop this arrhythmia or to the rhythm disturbance itself. An investigation was conducted through a prospective case series. Patients were from a single urban teaching hospital. Consecutive patients undergoing isolated CABG surgery between December 1994 and May 1996 were included in the study. No interventions were involved. Of 436 patients undergoing isolated CABG surgery, 101 (23%) developed AF. AF patients were older and more likely to have obstructive lung disease than patients without AF, but both patients with and without AF had similar left ventricular function and extent of coronary disease. ICU and hospital stays were longer in patients with AF. Multivariate analysis, adjusted for age, gender, and race, demonstrated that postoperative hospital stay was 9.2+/-5.3 days in patients with AF and 6.4+/-5.3 days in patients without AF (p<0.001). | Although AF is strongly associated with advanced age, most of the prolonged hospital stay appears to be attributable to the rhythm itself and not to patient characteristics. | closed_qa |
Does N-acetyl-L-cysteine influence cytokine response during early human septic shock? | To assess the effects of adjunctive treatment with N-acetyl-L-cysteine (NAC) on hemodynamics, oxygen transport variables, and plasma levels of cytokines in patients with septic shock. Prospective, randomized, double-blind, placebo-controlled study. A 24-bed medicosurgical ICU in a university hospital. Twenty-two patients included within 4 h of diagnosis of septic shock. Patients were randomly allocated to receive either NAC (150 mg/kg bolus, followed by a continuous infusion of 50 mg/kg over 4 h; n= 12) or placebo (n=10) in addition to standard therapy. Plasma concentrations of tumor necrosis factor-alpha (TNF), interleukin (IL)-6, IL-8, IL-10, and soluble tumor necrosis factor-alpha receptor-p55 (sTNFR-p55) were measured by sensitive immunoassays at 0, 2, 4, 6 and 24 h. Pulmonary artery catheter-derived hemodynamics, blood gases, hemoglobin, and arterial lactate were measured at baseline, after infusion (4 h), and at 24 h. NAC improved oxygenation (PaO2/FIO2 ratio, 214+/-97 vs 123+/-86; p<0.05) and static lung compliance (44+/-11 vs 31+/-6 L/cm H2O; p<0.05) at 24 h. NAC had no significant effects on plasma TNF, IL-6, or IL-10 levels, but acutely decreased IL-8 and sTNFR-p55 levels. The administration of NAC had no significant effect on systemic and pulmonary hemodynamics, oxygen delivery, and oxygen consumption. Mortality was similar in both groups (control, 40%; NAC, 42%) but survivors who received NAC had shorter ventilator requirement (7+/-2 days vs 20+/-7 days; p<0.05) and were discharged earlier from the ICU (13+/-2 days vs 32+/-9 days; p<0.05). | In this small cohort of patients with early septic shock, short-term IV infusion of NAC was well-tolerated, improved respiratory function, and shortened ICU stay in survivors. The attenuated production of IL-8, a potential mediator of septic lung injury, may have contributed to the lung-protective effects of NAC. | closed_qa |
Methyldibromoglutaronitrile (Euxyl K400): a new and important sensitizer in the United States? | Methyldibromoglutaronitrile (MDGN) is a component of Euxyl K400, a preservative used in many skin care products in Europe. MDGN has been used in skin care products in the United States for the last 5 years. Contact allergy from MDGN has been reported from Europe. The purpose of this study was to determine the frequency of MDGN as a sensitizer in patients undergoing routine patch testing. We reviewed the results in 163 patients who underwent patch testing during a 4-month period to determine the number who had any reaction to MDGN at two different concentrations (0.2% and 0.5%). Tests were graded with the use of the North American Contact Dermatitis Group criteria (0 to 3+), and readings were performed at 48 and 96 hours (all positive reactions were evaluated at a follow-up visit or by telephone interview). In the 4-month period, 45 of the 163 patients showed some reaction (+/- to 3+) at one or more readings. Of these, the results for 23 patients were considered to be irritant false-positive reactions; for 3 patients, the results were classified as uncertain; and for 19 patients, the results were classified as allergic. Of these, the results for eight patients were of definite relevance; the results for five patients were of probable relevance, and the results for six patients were of doubtful relevance to the problem condition. Other positive patch tests to a variety of allergens were frequently seen in persons positive to MDGN. | MDGN is a sensitizer in skin products and, with the increase of its use, should be considered in the patch test evaluation of patients with persistent dermatitis. Optimum patch test concentrations are yet to be determined. | closed_qa |
Focalized external radiotherapy for resected solitary brain metastasis: does the dogma stand? | To investigate whether whole brain irradiation might be replaced by focalized irradiation after resection of a single brain metastasis in patients where extracranial tumor control is deemed to be obtained. Twelve patients were introduced in a phase I/II prospective study of conformal postoperative external irradiation after resection of a solitary brain metastasis. The radiation treatment consisted of 50.4 Gy (1.8 Gy per fraction, five fractions per week). The planning target volume consisted of the tumor bed and a 2 cm safety margin. All treatments were optimized with head immobilization, dedicated tomodensitometry and computer assisted three-dimensional treatment planning. The median survival was 7.2 months (range 2.4-50.4 months). Eleven of the 12 patients died. Eight of the 12 patients presented intracranial recurrence and seven died as a consequence of intracranial tumor progression. | Focalized external irradiation cannot serve as a reasonable alternative to whole brain radiotherapy (WBRT) even for patients with apparently one single resected brain metastasis. The dogma of 'one metastasis = multiple metastases' seems to be confirmed. | closed_qa |
Does obesity influence ciprofibrate activity? | The association of obesity and dyslipidemia, namely high triglycerides and low HDL-cholesterol levels, is well known, but, as far as we are aware, the possible influence of obesity on the efficacy of current hypolipidemic drugs has never been studied. Therefore, we investigated the relationship between obesity and ciprofibrate efficacy. This was a post-hoc analysis of an open-label study with 6-month therapy of ciprofibrate carried out in the Atherosclerosis Out-Patient Clinic of Coimbra University Hospital. Eligible patients were 30 to 70 years old with cholesterol>6.2 mmol L-1 and/or triglycerides>2.23 mmol L-1. A sequential sample of 20 patients was selected but only 18 completed the study. After at least one month of diet or washout period all participants were given 100 mg day-1 of ciprofibrate. Triglycerides, total (TC) and HDL-cholesterol (HDL-C), apoproteins A-1, B100 and (a), and fibrinogen were measured at the beginning and at the end of the study. LDL-cholesterol (LDL-C) was calculated by the Friedewald formula. Baseline and the percentage of modification with ciprofibrate (delta%) of triglycerides correlated positively with body mass index (BMI) and waist/hip ratio (WHR). Baseline HDL-C correlated negatively with BMI and WHR, but delta% correlated positively with BMI. Fibrinogen behaved differently from triglycerides. The negative correlations between BMI and WHR and the delta% of LDL-C lost power and significance in stepwise regression after the introduction of types of dyslipidemias as an independent variable. | Ciprofibrate may be particularly effective in obese patients with high triglycerides and low HDL-C, a subject deserving further research. | closed_qa |
Report of 8 cases of dermatomyositis: does association of this entity and neoplasms exist? | To review eight cases of dermatomyositis (DM) and investigate the association of DM with cancer and mortality rate in this group of patients. Retrospective study of DM cases at Fundación Jiménez Díaz from January 1991 and March 1996. Only two out of the eight patients with DM had concomitant carcinomas (undifferentiated medium cell lung carcinoma and infiltrating ductal carcinoma of the breast). The mean age was 62 years (the two patients with carcinoma exceeded this age). As for gender incidence, one of the two male patients in this study had cancer, compared with one out of the six female patients. The cause of death in the three patients who died was an infection and so far none of the two patients with associated cancer has died. | Despite our small series, the incidence of cancer in patients with DM (25%) is similar to that observed in larger series (15%-30%). All patients presented with cutaneous lesions. Only one of them had also hemoptysis and was diagnosed of lung cancer. The diagnosis of breast cancer was obtained with a control mammography. The mortality rate in these two patients was not higher. The incidence of cancer is higher in older DM patients. | closed_qa |
Can breast cancer molecular subtype help to select patients for preoperative MR imaging? | To assess whether breast cancer molecular subtype classified by surrogate markers can be used to predict the extent of clinically relevant disease with preoperative breast magnetic resonance (MR) imaging. In this HIPAA-compliant, institutional review board-approved study, informed consent was waived. Preoperative breast MR imaging reports from 441 patients were reviewed for multicentric and/or multifocal disease, lymph node involvement, skin and/or nipple invasion, chest wall and/or pectoralis muscle invasion, or contralateral disease. Pathologic reports were reviewed to confirm the MR imaging findings and for hormone receptors (estrogen and progesterone subtypes), human epidermal growth factor receptor type 2 (HER2 subtype), tumor size, and tumor grade. Surrogates were used to categorize tumors by molecular subtype: hormone receptor positive and HER2 negative (luminal A subtype); hormone receptor positive and HER2 positive (luminal B subtype); hormone receptor negative and HER2 positive (HER2 subtype); hormone receptor negative and HER2 negative (basal subtype). All patients included in the study had a histologic correlation with MR imaging findings or they were excluded. χ(2) analysis was used to compare differences between subtypes, with multivariate logistic regression analysis used to assess for variable independence. Identified were 289 (65.5%) luminal A, 45 (10.2%) luminal B, 26 (5.9%) HER2, and 81 (18.4%) basal subtypes. Among subtypes, significant differences were found in the frequency of multicentric and/or multifocal disease (luminal A, 27.3% [79 of 289]; luminal B, 53.3% [24 of 45]; HER2, 65.4% [17 of 26]; basal, 27.2% [22 of 81]; P<.001) and lymph node involvement (luminal A, 17.3% [50 of 289]; luminal B, 35.6% [26 of 45]; HER2, 34.6% [nine of 26]; basal 24.7% [20 of 81]; P = .014). Multivariate analysis showed that molecular subtype was independently predictive of multifocal and/or multicentric disease. | Preoperative breast MR imaging is significantly more likely to help detect multifocal and/or multicentric disease and lymph node involvement in luminal B and HER2 molecular subtype breast cancers. Molecular subtype may help to select patients for preoperative breast MR imaging. | closed_qa |
Does patient ethnicity affect site of craniosynostosis? | There are no published papers examining the role of ethnicity on suture involvement in nonsyndromic craniosynostosis. The authors sought to examine whether there is a significant difference in the epidemiological pattern of suture(s) affected between different ethnic groups attending a regional craniofacial clinic with a diagnosis of nonsyndromic craniosynostosis. A 5-year retrospective case-notes analysis of all cases involving patients attending a regional craniofacial clinic was undertaken. Cases were coded for the patients' declared ethnicity, suture(s) affected by synostosis, and the decision whether to have surgical correction of synostosis. The chi-square test was used to determine whether there were any differences in site of suture affected between ethnic groups. A total of 312 cases were identified. Of these 312 cases, ethnicity data were available for 296 cases (95%). The patient population was dominated by 2 ethnic groups: white patients (222 cases) and Asian patients (56 cases). There were both more cases of complex synostosis and fewer cases of sagittal synostosis than expected in the Asian patient cohort (χ(2) = 9.217, p = 0.027). | There is a statistically significant difference in the prevalence of the various sutures affected within the nonsyndromic craniosynostosis patient cohort when Asian patients are compared with white patients. The data from this study also suggest that nonsyndromic craniosynostosis is more prevalent in the Asian community than in the white community, although there may be inaccuracies in the estimates of the background population data. A larger-scale, multinational analysis is needed to further evaluate the relationship between ethnicity and nonsyndromic craniosynostosis. | closed_qa |
Does neck-to-waist ratio predict obstructive sleep apnea in children? | Central adiposity and large neck circumference are associated with obstructive sleep apnea (OSA) in adults but have not been evaluated in children as predictors of OSA. Study objectives were to determine whether (1) anthropometric measures including neck-to-waist ratio are associated with OSA in older children; (2) body fat distribution, measured by neck-to-waist ratio, is predictive of OSA in overweight/obese children. Cross-sectional study involving children 7-18 years scheduled to undergo polysomnography at a tertiary care children's hospital. OSA was defined as total apnea-hypopnea index>5 events/h and/or obstructive apnea index>1 event/h. Recursive partitioning was used to select candidate predictors of OSA from: age, sex, height and weight percentile, body mass index (BMI) z-score, neck-to-waist ratio, tonsil size, and Mallampati score. These were then evaluated using log binomial models and receiver operator characteristic analysis. Two hundred twenty-two participants were included; 133 (60%) were overweight/obese, 121 (55%) male,47 (21%) had OSA. Neck-to-waist ratio (relative risk [RR] 1.97 per 0.1 units, 95% CI 1.48 to 2.84) and BMI z-score (RR 1.63 per unit, 95% CI 1.30 to 2.05) were identified as independent predictors of OSA. Considering only overweight/obese children, neck-to-waist ratio (RR 2.16 per 0.1 units, 95% CI 1.79 to 2.59) and BMI z-score (RR 2.02 per unit, 95% CI 1.25 to 3.26) also independently predicted OSA. However, in children not overweight/obese, these variables were not predictive of OSA. | Neck-to-waist ratio, an index of body fat distribution, predicts OSA in older children and youth, especially in those who were overweight/obese. | closed_qa |
Does aneurysmal wall enhancement on vessel wall MRI help to distinguish stable from unstable intracranial aneurysms? | Arterial wall enhancement on vessel wall MRI was described in intracranial inflammatory arterial disease. We hypothesized that circumferential aneurysmal wall enhancement (CAWE) could be an indirect marker of aneurysmal wall inflammation and, therefore, would be more frequent in unstable (ruptured, symptomatic, or undergoing morphological modification) than in stable (incidental and nonevolving) intracranial aneurysms. We prospectively performed vessel wall MRI in patients with stable or unstable intracranial aneurysms. Two readers independently had to determine whether a CAWE was present. We included 87 patients harboring 108 aneurysms. Interreader and intrareader agreement for CAWE was excellent (κ=0.85; 95% confidence interval, 0.75-0.95 and κ=0.90; 95% confidence interval, 0.83-0.98, respectively). A CAWE was significantly more frequently seen in unstable than in stable aneurysms (27/31, 87% versus 22/77, 28.5%, respectively; P<0.0001). Multivariate logistic regression, including CAWE, size, location, multiplicity of aneurysms, and daily aspirin intake, revealed that CAWE was the only independent factor associated with unstable status (odds ratio, 9.20; 95% confidence interval, 2.92-29.0; P=0.0002). | CAWE was more frequently observed in unstable intracranial aneurysms and may be used as a surrogate of inflammatory activity in the aneurysmal wall. | closed_qa |
Does prostate acinar adenocarcinoma with Gleason Score 3+3=6 have the potential to metastasize? | There is a worldwide debate involving clinicians, uropathologists as well as patients and their families on whether Gleason score 6 adenocarcinoma should be labelled as cancer. We report a case of man diagnosed with biopsy Gleason score 6 acinar adenocarcinoma and classified as low risk (based on a PSA of 5 ng/mL and stage cT2a) whose radical prostatectomy specimen initially showed organ confined Gleason score 3+3=6, WHO nuclear grade 3, acinar adenocarcinoma with lymphovascular invasion and secondary deposit in a periprostatic lymph node. When deeper sections were cut to the point that almost all the slice present in the paraffin block was sectioned, a small tumor area (<5% of the whole tumor) of Gleason pattern 4 (poorly formed glands) was found in an extraprostatic position. | The epilogue was that the additional finding changed the final Gleason score to 3+3=6 with tertiary pattern 4 and the stage to pT3a. | closed_qa |
Temocillin: a new candidate antibiotic for local antimicrobial delivery in orthopaedic surgery? | To assess the performance of the Gram-negative-specific antibiotic temocillin in polymethylmethacrylate bone cement pre-loaded with gentamicin, as a strategy for local antibiotic delivery. Temocillin was added at varying concentrations to commercial gentamicin-loaded bone cement. The elution of the antibiotic from cement samples over a 2 week period was quantified by LC-MS. The eluted temocillin was purified by fast protein liquid chromatography and the MICs for a number of antibiotic-resistant Escherichia coli were determined. The impact strength of antibiotic-loaded samples was determined using a Charpy-type impact testing apparatus. LC-MS data showed temocillin eluted to clinically significant concentrations within 1 h in this laboratory system and the eluted temocillin retained antimicrobial activity against all organisms tested. Impact strength analysis showed no significant difference between cement samples with or without temocillin. | Temocillin can be added to bone cement and retains its antimicrobial activity after elution. The addition of up to 10% temocillin did not affect the impact strength of the cement. The results show that temocillin is a promising candidate for use in antibiotic-loaded bone cement. | closed_qa |
Does pneumoperitoneum adversely affect growth, development and liver function in biliary atresia patients after laparoscopic portoenterostomy? | We assessed the effect of high partial pressure of arterial carbon dioxide (PaCO2) due to pneumoperitoneum (PP) on growth (height/weight) and development (gross/fine motor function, receptive/expressive communication, and social interaction), by comparing outcome after portoenterostomy (PE) for biliary atresia (BA) using laparoscopic PE (LPE: n = 13) and open PE (OPE: n = 13) cases performed between 2005 and 2014. Our PE is based on Kasai's original PE. All data were collated prospectively. Differences in duration of follow-up (LPE: 38.8 months; OPE: 38.1 months), jaundice clearance (LPE: 12/13 = 92.3 %; OPE: 9/13 = 69.2 %), survival with the native liver (LPE: 10/13 = 76.9 %; OPE: 9/13 = 69.2 %), incidence of cholangitis, hypersplenism, and incidence of esophageal varices were not significant. Mean intraoperative PaCO2 was significantly higher in LPE (LPE: 50.1 mmHg; OPE: 40.7 mmHg, p<0.05). Liver function impairment was not statistically different, although LPE results were slightly worse. There was no overall delay in growth observed, although height/weight gain was more consistent in LPE. The pattern of developmental delay observed was similar for LPE and OPE suggesting that developmental delay is not PE-related; in other words, PP is not implicated in developmental delay. | PP during LPE would appear to have no adverse effects on overall growth/development and liver function in BA patients. | closed_qa |
Duplex investigations in children: Are clinical signs in children with venous disorders relevant? | Ultra sound colored duplex sonography is the preferred method in diagnosing chronic venous disease. Data in children on incidence, indications, and results are lacking. From the total of 9180 duplex investigations performed in our hospital from 2009 to 2012, data on indication and results of the investigation as well as patient characteristics were evaluated retrospectively for the proportion of pediatric patients. Duplex investigations were performed 49 times in 38 children (6-18 years), with an average of 1.3 times (1-6 times) per child. Forty percent showed abnormalities: 17 times deep venous thrombosis was suspected; deep venous thrombosis was objectified in 18%. In the 21 investigations performed for varicosis-related complaints, varicose veins or venous malformations were objectified in 57%. Edema was never a symptom of chronic venous disease. | Duplex investigation is not often performed in children. In children with established deep venous thrombosis, a family history with deep venous thrombosis is common. In general, edema was not seen in children with varicose veins and, therefore, does not seem a reliable clinical sign at young age. | closed_qa |
Influence of body mass index on the outcome of brachial plexus surgery: are there any differences between elbow and shoulder results? | Body mass index (BMI) has recently been identified as a predictor of outcomes following reconstructive surgery of shoulder palsies. In this study, we sought to determine if the same holds true for the reconstruction of elbow flexion. Forty patients who had undergone partial ulnar-to-biceps nerve transfer (Oberlin's procedure) for shoulder palsy were assessed and compared against 18 previously reported patients who had undergone reconstruction for elbow palsies. The British Medical Research Council (BMRC) scale and an index dividing shoulder abduction strength in the affected arm by healthy arm were recorded. All patients had undergone surgery within 12 months of injury and had ≥ 12 months of follow-up. M4 or M3 biceps strength was obtained in 90 % of patients. Final strength on the affected side averaged 5.8 kg, versus 20.2 kg on the normal side, for a mean recovery index score of 0.30. In this sample of 40 patients, BMI did not predict percentage strength or BMRC grade recovery. Neither did age, number of roots involved, the affected side, nor time to surgery. Comparing patients with elbow versus shoulder reconstruction, there were no differences, except that patients undergoing Oberlin's procedure had a statistically longer duration of time between injury and surgical repair (7.4 vs 5.1 months, p<0.006). | Our data suggest that proximal muscle re-innervation is functionally more dependent upon BMI than distal re-innervation, likely because proximal muscles must support the weight of the entire extremity, while more distal muscles do not. BMI should be taken into consideration when planning surgery. | closed_qa |
Does IVF cleavage stage embryo quality affect pregnancy complications and neonatal outcomes in singleton gestations after double embryo transfers? | Embryo quality is associated with successful implantation and live births. Our retrospective study was carried out to determine whether or not cleavage stage embryo quality affects the miscarriage rate, pregnancy complications and neonatal outcomes of singletons conceived with assisted reproduction technology. The current study included 11,721 In Vitro Fertilization-Embryo Transfer cycles (IVF-ET) between January 2009 (the date at which electronic medical records were implemented at our center) and March 2013. Only women < 40 years of age undergoing their first fresh embryo transfer cycle using non-donor oocytes were included. Our study indicated that the transfer of poor-quality embryos resulted in higher miscarriage (19.77% vs. 13.28%, p = 0.02) and lower ongoing pregnancy rates (15.33% vs. 48.06%, p < 0.001). Logistic regression analysis performed on data derived from 744 cycles culminating in miscarriages versus 4,333 cycles culminating in live births, suggested that embryo quality (p = 0.04) is significantly associated with miscarriage rate after adjusting for other confounding factors. Moreover, there were no differences in the mean birth weight, low birth weight (<2,500 g), very low birth weight (<1,500 g), gestational age, preterm delivery (<37 weeks), very preterm delivery (<32 weeks), congenital malformations, small-for-gestational-age singletons (SGA), and large-for-gestational-age singleton (LGA) rate (p > 0.05). Similarly, pregnancy complications resulting from poor-quality embryos were not different from good-quality embryos (4.04% vs. 2.57 %, p = 0.33). Finally, logistic regression suggested that embryo quality was not significantly associated with pregnancy complications after adjusting for other confounding factors (p = 0.40). | Our study suggests that transfer of poor-quality embryos did not increase the risk of adverse outcomes; however, the quality of cleavage stage embryos significantly affected the miscarriage rate and ongoing pregnancies. | closed_qa |
Do moderate-intensity and vigorous-intensity physical activities reduce mortality rates to the same extent? | Limited data exist directly comparing the relative benefits of moderate- and vigorous-intensity activities with all-cause and cardiovascular (CV) disease mortality rates when controlling for physical activity volume. We followed 7979 men (Harvard Alumni Health Study, 1988-2008) and 38 671 women (Women's Health Study, 1992-2012), assessing their physical activity and health habits through repeated questionnaires. Over a mean follow-up of 17.3 years in men and 16.4 years in women, there were 3551 deaths (1077 from CV disease) among men and 3170 deaths (620 from CV disease) among women. Those who met or exceeded an equivalent of the federal guidelines recommendation of at least 150 minutes of moderate-intensity activity, 75 minutes of vigorous-intensity activity, or a combination of the 2 that expended similar energy experienced significantly lower all-cause and CV disease-related mortality rates (men, 28% to 36% and 31% to 34%, respectively; women: 38% to 55% and 22% to 44%, respectively). When comparing different combinations of moderate- and vigorous-intensity activity and all-cause mortality rates, we observed sex-related differences. Holding constant the volume of moderate- to vigorous-intensity physical activity, men experienced a modest additional benefit when expending a greater proportion of moderate- to vigorous-intensity physical activity in vigorous-intensity activities (Ptrend=0.04), but women did not (Ptrend<0.001). Moderate- to vigorous-intensity physical activity composition was not associated with further cardiovascular mortality rate reductions in either men or women. | The present data support guidelines recommending 150 minutes of moderate-intensity activity per week, 75 minutes of vigorous-intensity activity per week, or an equivalent combination for mortality benefits. Among men, but not women, additional modest reductions in all-cause mortality rates are associated with a greater proportion of moderate- to vigorous-intensity physical activity performed at a vigorous intensity. | closed_qa |
Does knee revision after an articulated spacer implant provide normal gait restoration? | The aim of this study was to quantitatively evaluate gait parameters in patients who underwent a revision procedure after an interval articulated spacer for septic knee prosthesis. Ten adult subjects underwent three-dimensional computerized gait analysis 12 months after second-stage knee revision procedure. Kinematic and kinetic parameters were acquired and compared with a normal reference population. Data were also compared with those collected in a previous study, in which the same cohort of patients underwent gait analysis 8-14 weeks after spacer implantation. Kinematic and kinetic parameters did not show any significant difference between the affected and unaffected limb. Compared to normal reference population, patients treated with revision knee prosthesis showed a reduced mean gait velocity, step frequency, stride and step length, average knee range of motion, knee power and ground reaction forces. When comparing average data with those observed after spacer implant, no difference was observed in kinematic variables, while kinetic analysis demonstrated a significant improvement in knee power. | This study shows that 1 year after second-stage knee revision surgery, kinematic and kinetic values remain lower than those observed in a normal reference population. Only slight improvements in walking ability are shown, when analysing data in comparison with those collected after a preformed articulated knee spacer. This finding points out the long time to full functional recovery after knee revision surgery and the limited improvement of gait when compared to the one achieved at the time of spacer implant. | closed_qa |
Does fibrin clot really enhance graft healing after double-bundle ACL reconstruction in a caprine model? | Graft healing following anterior cruciate ligament (ACL) reconstruction is a complex process characterized by phases of healing that lead to ACL remodelling. Our hypothesis is that fibrin clot addition to ACL reconstruction will result in advanced graft remodelling and healing when compared to a control group at 12 weeks as observed by histology, immunohistochemistry and magnetic resonance imaging (MRI). Eleven Spanish Boar goats underwent double-bundle ACL reconstruction: 8 were analysed and 3 were excluded. Group 1 was treated with DB ACL reconstruction utilizing autologous fibrin clots (n = 4), and group 2 was treated with standard DB ACL-R (n = 4). Histological and radiographic analysis was performed at 12 weeks. Each animal underwent 3-T MRI immediately after euthanization for evaluation of graft signal intensity utilizing the signal noise quotient (SNQ). Specimens were then sectioned and stored for standard histological and immunohistochemistry testing. The mean ligament tissue maturity index score was significantly higher for group 1 (15 ± 2.3) compared with group 2 (7.7 ± 5.2) (p<0.05). The mean vascularity (cell/mm(2)) for group 1 was 7.1 ± 1.3 and 9.3 ± 3.1 for group 2 (n.s.). The mean collagen type 1 (% 50× field) for group 1 was 35.8 ± 22.1 and 19.9 ± 20.5 for group 2 (n.s.). The mean SNQ for the AM bundle was 1.1 ± 0.7 for group 1 and 3.1 ± 1.8 for group 2 (n.s.). The mean SNQ for the total PL bundle was significantly lower for group 1 (1.1 ± 0.7) compared with group 2 (3.7 ± 1.3) (p<0.05). There was a significant correlation between the vascularity and the ligament tissue maturity index score as well as between collagen type 1 and SNQ, both AM and PL bundles (p<0.05). | The use of fibrin clot in ACL reconstruction in a caprine model demonstrated improved healing with respect to histological analysis of the intra-articular ACL reconstruction segment and decreased signal intensity on MRI. It may lead to improved graft healing and maturation. By accelerating the intra-articular healing and ligamentization, the outcome of patients after ACL-R can be improved with faster return to sports and daily activity. | closed_qa |
Is posterior tibial slope associated with noncontact anterior cruciate ligament injury? | This study aimed to: (1) examine whether the association between posterior tibial slope and noncontact ACL injury exists in Chinese population; (2) compare the reliability and consistency of the three methods (longitudinal axis, posterior and anterior tibial cortex axis) in lateral radiograph. Case-control study contained 146 patients in total (73 noncontact ACL injuries and 73 meniscus injuries, matched for age and gender), which were verified by arthroscopy, MRI and physical examination. For the total population and the male subgroup, the mean posterior tibial slope of the ACL-injured group was significantly higher than that of the control group (P < 0.001). In addition, the longitudinal axis method exhibited the highest inter-rater (0.898) and intrarater reliability (0.928), whereas the anterior tibial cortex was the most variable (inter-rater reliability, 0.805; intrarater reliability, 0.824). The anterior tibial cortex method produced largest posterior tibial slope measurements (13.8 ± 3.3 for injury group; 11.6 ± 2.7 for control group), while the posterior tibial cortex method was the smallest (9.1 ± 3.1 for injury group; 7.2 ± 2.6 for control group). All three methods were not affected by age, sex, height, weight and BMI (n.s.). | The results of this study suggested that an increased posterior tibial slope was associated with the risk of noncontact ACL injury in Chinese population. Meanwhile, the longitudinal axis method is recommended for measuring posterior tibial slope in lateral radiograph in future studies. Posterior tibial slope measured by longitudinal axis method may be used as predictor of ACL injury. | closed_qa |
Clinical outcome and evidence of high rate post-surgical anterior hypopituitarism in a cohort of TSH-secreting adenoma patients: Might somatostatin analogs have a role as first-line therapy? | Thyrotropin-secreting pituitary adenomas (TSHomas) represent a rare subtype of pituitary tumors. Neurosurgery (NCH) is still considered the first-line therapy. In this study we aimed to investigate the outcome of different treatment modalities, including first line somatostatin analogs (SSA) treatment, with a specific focus on neurosurgery-related complications. We retrospectively evaluated thirteen patients diagnosed for TSHomas (9 M; age range 27-61). Ten patients had a magnetic resonance evidence of macroadenoma, three with slight visual field impairment. In the majority of patients, thyroid ultrasonography showed the presence of goiter and/or increased gland vascularization. Median TSH value at diagnosis was 3.29 mU/L (normal ranges 0.2-4.2 mIU/L), with median fT4 2.52 ng/dL (0.9-1.7 ng/dL). Three patients (two microadenoma) were primarily treated with NCH and achieved disease remission, whereas ten patients (nine macroadenomas) were initially treated with SSA. Despite the optimal biochemical response observed during medical treatment in most patients (mean TSH decrease -72%), only two stayed on medical therapy alone, achieving stable biochemical control at the end of the follow-up. The remaining patients (n = 7) underwent NCH later on during their clinical history, followed by radiotherapy or adjuvant SSA treatment in two cases. Noteworthy, five of them developed hypopituitarism. All patients reached a biochemical control, after a multimodal therapeutic approach. | Neurosurgery ultimately led to complete disease remission or to biochemical control in majority of patients, whereas resulting in a considerable percentage of post-operative complications (mainly hypopituitarism, 50%). In the light of the optimal results unanimously reported for medical treatment with SSA, our experience suggests that a careful evaluation of risk/benefit ratio should be taken into consideration when directing the treatment approach in patients with TSHoma. | closed_qa |
Involuntary medication as the intervention of choice: can this be regarded as 'substitution' or as a preventive measure? | Since the Dutch Mental Health Act of 1984 came into effect, seclusion has often been used as the measure of choice for dealing with aggressive or dangerous patients. In 2012 the Ministry of Health formulated a policy whereby seclusion was to be phased out, but not replaced by involuntary medication. In 2007, within the framework of the Mental Health Act, the Argus system of registering coercive measures was introduced in order to monitor the reduction in the use of seclusion and involuntary medication. This article describes, in a longitudinal cohort study, the effect of the policy to reduce aggression by replacing seclusion through the use of involuntary medication or other measures.AIM: To investigate whether, in the long run, a reduction in the use of seclusion will lead to a proportional increase in the use of involuntary medication, and to assess whether this policy can really be termed 'substitution. We performed this study by analysing Argus data for the period 2007-2011, relating to 1843 patients being treated by Mediant. ESULTS The changing proportions of seclusion and involuntary medication over time demonstrated that the use of involuntary medication did result in patients being secluded for a shorter period of time. | In the case of dangerous psychiatric patients, medication, administered forcibly when necessary, is preferable to seclusion as far as subsidiarity, proportionality and expediency are concerned. A strategy whereby medication provides appropriate treatment and seclusion is kept within reasonable limits cannot be termed 'substitution'. | closed_qa |
Does treatment with an insulin pump improve glycaemic control in children and adolescents with type 1 diabetes? | To investigate long-term effects on glycaemic control, ketoacidosis, serious hypoglycaemic events, insulin requirements, and body mass index standard deviation scores (BMI-SDS) in children and adolescents with type 1 diabetes starting on continuous subcutaneous insulin infusion (CSII) compared with children and adolescents treated with multiple daily injections (MDI). This retrospective case-control study compares 216 patients starting CSII with a control group on MDI (n = 215), matched for glycated hemoglobin (HbA1c), sex, and age during a 2-yr period. Variables collected were gender, age, HbA1c, insulin requirement, BMI, BMI-SDS, ketoacidosis, and serious hypoglycaemic events. In the CSII group there was an improvement in HbA1c after 6 and 12 months compared with the MDI group. For boys and girls separately the same effect was detected after 6 months, but only for boys after 12 months. The incidence of ketoacidosis was higher in the CSII group compared with the MDI group (2.8 vs. 0.5/100 person-yr). The incidences of severe hypoglycaemic episodes per 100 person-yr were three in the CSII group and six in the MDI group (p<0.05). After 6, 12, and 24 months, the insulin requirement was higher in the MDI group. | This study shows that treatment with CSII resulted in an improvement in HbA1c levels up to 1 yr and decreased the number of severe hypoglycaemic events, but the frequency of ketoacidosis increased. The major challenge is to identify methods to maintain the HbA1c improvement, especially among older children and teenagers, and reduce the frequency of ketoacidosis. | closed_qa |
Does fluoride in the water close the dental caries gap between Indigenous and non-Indigenous children? | Indigenous children experience significantly more dental caries than non-Indigenous children. This study assessed if access to fluoride in the water closed the gap in dental caries between Indigenous and non-Indigenous children. Data from four states and two territories were sourced from the Child Dental Health Survey (CDHS) conducted in 2010. The outcomes were dental caries in the deciduous and permanent dentitions, and the explanatory variables were Indigenous status and access to fluoridated water (≥0.5 mg/L) prior to 2008. Dental caries prevalence and severity for Indigenous and non-Indigenous children, in both dentitions, was lower in fluoridated areas compared to non-fluoridated areas. Among non-Indigenous children, there was a 50.9% difference in mean dmft scores in fluoridated (1.70) compared to non-fluoridated (2.86) areas. The difference between Indigenous children in fluoridated (3.29) compared to non-fluoridated (4.16) areas was 23.4%. Among non-Indigenous children there was a 79.7% difference in the mean DMFT scores in fluoridated (0.68) compared to non-fluoridated (1.58) areas. The difference between Indigenous children in fluoridated (1.59) and non-fluoridated (2.23) areas was 33.5%. | Water fluoridation is effective in reducing dental caries, but does not appear to close the gap between non-Indigenous children and Indigenous children. | closed_qa |
Irreversible electroporation: just another form of thermal therapy? | Irreversible electroporation (IRE) is (virtually) always called non-thermal despite many reports showing that significant Joule heating occurs. Our first aim is to validate with mathematical simulations that IRE as currently practiced has a non-negligible thermal response. Our second aim is to present a method that allows simple temperature estimation to aid IRE treatment planning. We derived an approximate analytical solution of the bio-heat equation for multiple 2-needle IRE pulses in an electrically conducting medium, with and without a blood vessel, and incorporated published observations that an electric pulse increases the medium's electric conductance. IRE simulation in prostate-resembling tissue shows thermal lesions with 67-92°C temperatures, which match the positions of the coagulative necrotic lesions seen in an experimental study. Simulation of IRE around a blood vessel when blood flow removes the heated blood between pulses confirms clinical observations that the perivascular tissue is thermally injured without affecting vascular patency. | The demonstration that significant Joule heating surrounds current multiple-pulsed IRE practice may contribute to future in-depth discussions on this thermal issue. This is an important subject because it has long been under-exposed in literature. Its awareness pleads for preventing IRE from calling "non-thermal" in future publications, in order to provide IRE-users with the most accurate information possible. The prospect of thermal treatment planning as outlined in this paper likely aids to the important further successful dissemination of IRE in interventional medicine. Prostate 75:332-335, 2015. © 2014 The Authors. The Prostate Published by Wiley Periodicals, Inc. | closed_qa |
Can Porphyromonas gingivalis be a novel aetiology for recurrent miscarriage? | To study the association between Porphyromonas gingivalis (P. gingivalis) infection and recurrent miscarriage. This case control study included women with early pregnancy failure admitted for surgical evacuation of retained products of conception. Cases (group 1) included 50 women with unexplained recurrent early miscarriage whereas the control group (group 2) consisted of 50 women with no such history. The evacuated products of conception, subgingival plaques, cervicovaginal secretions and saliva of all participants were examined to detect P. gingivalis deoxyribonucleic acid (DNA) using a polymerase chain reaction. The prevalence of P. gingivalis DNA in the chorionic villous tissue samples of group 1 was significantly higher than in group 2 (8 [16%] vs. 1 [2%], respectively; p = 0.036, odds ratio [OR]: 9.3, 95% confidence interval [CI]: 1.1-76.9). The prevalence of P. gingivalis DNA was significantly higher in cervicovaginal secretions of group 1 than in group 2 (9 [18%] vs. 1 [2%], respectively; p = 0.02, OR: 10.8, 95% CI: 1.3-88.5). On the contrary, P. gingivalis DNA could not be detected in subgingival plaques and saliva samples of either group. | The current study found an association between P. gingivalis infection of the female genital tract and the occurrence of recurrent miscarriage. | closed_qa |
Juice and water intake in infancy and later beverage intake and adiposity: could juice be a gateway drink? | To examine the tracking and significance of beverage consumption in infancy and childhood. Among 1163 children in Project Viva, we examined associations of fruit juice and water intake at 1 year (0 oz, 1-7 oz [small], 8-15 oz [medium], and ≥16 oz [large]) with juice and sugar-sweetened beverage (SSB) intake and BMI z-score during early (median 3.1 years) and mid-childhood (median 7.7 years). In covariate adjusted models, juice intake at 1 year was associated with greater juice and SSB intake during early and mid-childhood and also greater adiposity. Children who drank medium and large amounts of juice at 1 year had higher BMI z-scores during both early (medium: β = 0.16 [95% CI = 0.01-0.32]; large: β = 0.28 [95% CI = 0.01-0.56]) and mid-childhood (medium: β = 0.23 [95% CI = 0.07-0.39]; large: β = 0.36 [95% CI = 0.08-0.64]). After covariate adjustment, associations between water intake at 1 year and beverage intake and adiposity later in childhood were null. | Higher juice intake at 1 year was associated with higher juice intake, SSB intake, and BMI z-score during early and mid-childhood. Assessing juice intake during infancy could provide clinicians with important data regarding future unhealthy beverage habits and excess adiposity during childhood. | closed_qa |
Do clinicians know which of their patients have central venous catheters? | Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown. To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients. Multicenter, cross-sectional study. 3 academic medical centers in the United States. Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings. To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests. 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003). Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded. | Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted. | closed_qa |
Epidemiology of Injuries in High School Football: Does School Size Matter? | More than 1 million US high school students play football. Our objective was to compare the high school football injury profiles by school enrollment size during the 2013-2014 season. Injury data were prospectively gathered on 1806 student athletes while participating in football practice or games by certified athletic trainers as standard of care for 20 high schools in the Atlanta Metropolitan area divided into small (<1600 students enrolled) or large (≥1600 students enrolled) over the 2013-2014 football season. Smaller schools had a higher overall injury rate (79.9 injuries per 10,000 athletic exposures vs. 46.4 injuries per 10,000 athletic exposures; P<.001). In addition, smaller schools have a higher frequency of shoulder and elbow injuries (14.3% vs. 10.3%; P = .009 and 3.5% vs. 1.5%; P = .006, respectively) while larger schools have more hip/upper leg injuries (13.3% vs. 9.9%; P = .021). Lastly, smaller schools had a higher concussion distribution for offensive lineman (30.6% vs. 13.4%; P = .006) and a lower rate for defensive backs/safeties (9.2% vs. 25.4%; P = .008). | This study is the first to compare and show unique injury profiles for different high school sizes. An understanding of school specific injury patterns can help drive targeted preventative measures. | closed_qa |
Another "string to the bow" of PJ34, a potent poly(ADP-Ribose)polymerase inhibitor: an antiplatelet effect through P2Y12 antagonism? | Neuro- and vasoprotective effects of poly(ADP-ribose)polymerase (PARP) inhibition have been largely documented in models of cerebral ischemia, particularly with the potent PARP inhibitor PJ34. Furthermore, after ischemic stroke, physicians are faced with incomplete tissue reperfusion and reocclusion, in which platelet activation/aggregation plays a key role. Data suggest that certain PARP inhibitors could act as antiplatelet agents. In that context, the present in vitro study investigated on human blood the potential antiplatelet effect of PJ34 and two structurally different PARP inhibitors, DPQ and INO-1001. ADP concentrations were chosen to induce a biphasic aggregation curve resulting from the successive activation of both its receptors P2Y(1) and P2Y(12). In these experimental conditions, PJ34 inhibited the second phase of aggregation; this effect was reduced by incremental ADP concentrations. In addition, in line with a P2Y(12) pathway inhibitory effect, PJ34 inhibited the dephosphorylation of the vasodilator stimulated phosphoprotein (VASP) in a concentration-dependent manner. Besides, PJ34 had no effect on platelet aggregation induced by collagen or PAR1 activating peptide, used at concentrations inducing a strong activation independent on secreted ADP. By contrast, DPQ and INO-1001 were devoid of any effect whatever the platelet agonist used. | We showed that, in addition to its already demonstrated beneficial effects in in vivo models of cerebral ischemia, the potent PARP inhibitor PJ34 exerts in vitro an antiplatelet effect. Moreover, this is the first study to report that PJ34 could act via a competitive P2Y(12) antagonism. Thus, this antiplatelet effect could improve post-stroke reperfusion and/or prevent reocclusion, which reinforces the interest of this drug for stroke treatment. | closed_qa |
Does small-dose fentanyl improve perioperative outcomes in the ambulatory setting? | Despite its widespread use, the beneficial effect of low-dose fentanyl administered at induction of anesthesia on perioperative outcomes has not been studied in the ambulatory setting. Therefore, this study was designed to test the hypothesis that administration of small-dose fentanyl vs. saline during induction reduces coughing and movements without adversely affecting recovery after day-surgery. One hundred consenting outpatients scheduled to undergo superficial surgical procedures under general anesthesia with a laryngeal mask airway (LMA) device for airway management were randomly assigned to one of two treatment groups: control (n = 50) or fentanyl (n = 50). After administration of 2 ml of the unlabelled study medication containing either fentanyl (100 μg) or saline, anesthesia was induced with lidocaine 30-50 mg and propofol 2 mg/kg IV followed by the insertion of an LMA device. General anesthesia was maintained using a propofol infusion, 75 μg/kg/min, and desflurane (2-5% end-tidal) in 100% oxygen. Coughing was observed in six (12%) and ten (20%) in the fentanyl and control group, respectively (P = 0.41). The incidence of movements during surgery was lower in the fentanyl group (18% vs. 31%, P<0001). There were no significant differences in early and late recovery times or pain scores between the two groups. | Administration of a small-dose of fentanyl at induction of anesthesia significantly reduced purposeful movements during day-surgery under propofol-desflurane anesthesia. No significant difference was found in coughing or recovery times. | closed_qa |
Does the time of osseointegration in the maxilla and mandible differ? | The objectives of the present study were to measure the implant stability quotient (ISQ) values at 3 different time points after the surgical insertion and to determine whether the time of osseointegration differs in the maxilla and mandible. To measure implant stability, resonance frequency analysis (RFA) was performed in 44 patients (40 women, 4 men) with a total of 100 Implacil De Bortoli implants; the patients were divided into 2 groups: group 1, implants in the maxilla (22 in the anterior maxilla and 37 in the posterior maxilla); and group 2, implants in the mandible (41 posterior mandibles). Using RFA, implant stability was measured immediately after implant placement to assess the immediate stability (time 1) and at 90 (time 2) and 150 (time 3) days. Overall, the mean (SD) ISQ was 63.3 (6.63) (95% confidence interval [CI], 39-79) for time 1, 70.5 (6.32) (95% CI, 46-88) for time 2, and 73.5 (6.03) (95% CI, 58-88) for time 3. In group 1, the mean (SD) ISQ was 61.8 (6.56) (95% CI, 39-79) for time 1, 68.8 (5.19) (95% CI, 57-83) for time 2, and 72.3 (5.91) (95% CI, 58-85) for time 3. In group 2, the mean (SD) ISQ was 65.5 (6.13) (95% CI, 44-75) for time 1, 72.9 (7.02) (95% CI, 46-88) for time 2, and 75.3 (5.80) (95% CI, 60-88) for time 3. | The stability of the implants placed in the maxilla and mandible showed a similar evolution in the ISQ values and, consequently, on osseointegration; however, the implants in the mandible presented superior values at all time points. | closed_qa |
Do all children with suicidal ideation receive a significant psychiatric intervention? | In most physicians' minds, suicidal ideation carries with it an ominous prognosis requiring intensive evaluation and treatment. The aim of this study was therefore to determine the proportion of children identified with suicide ideation who received a significant psychiatric intervention. Medical records were reviewed for psychiatric interventions of all children presenting to the emergency department (ED) with behavioral disorders between 2004 and 2007, for whom a psychiatry consultation was obtained. Suicidal children were those who had expressed suicidal ideation. Significant psychiatric intervention was defined as one of the following: hospitalization in a psychiatric facility, period of observation in the ED (≥ 12 h), use of restraints, and prescription of psychiatric medication. Suicidal labeling was considered appropriate if one or more of the aforementioned interventions were recommended by a psychiatrist. The presence of psychiatric intervention was compared with that in children who presented with a behavioral disorder, not labeled as suicidal. Chi-squared or Fisher's exact test, whenever appropriate, was used to evaluate the association between suicide status and intervention. A total of 160 children (27.1%) were labeled as suicidal, and 431 (72.9%) with a behavioral disorder were classified as non-suicidal. A total of 244/431 (56.6%) in the non-suicidal group had a significant psychiatric intervention compared to 79/160 (49.4%) in the suicidal ideation group (P = 0.116). This 49.4% is significantly different from an a priori assumption that 100% of children with suicidal ideation would have a significant psychiatric intervention. | More than half (50.6%) of the children presenting with a label of suicidal ideation did not receive significant psychiatric intervention. This study calls into question the accuracy of suicide labeling in children referred to the ED. | closed_qa |
Is chronic inhibition of phosphodiesterase type 5 cardioprotective and safe? | The myocardial effects of phosphodiesterase type 5 inhibitors (PDE5i) have recently received consideration in several preclinical studies. The risk/benefit ratio in humans remains unclear. We performed a meta-analysis of randomized, placebo-controlled trials (RCTs) to evaluate the efficacy and safety of PDE5i on cardiac morphology and function. From March 2012 to December 2013 (update: May 2014), we searched English-language studies from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and SCOPUS-selecting RCTs of continuous PDE5i administration that reported cardiovascular outcomes: cardiac geometry and performance, afterload, endothelial function and safety. The pooled estimate of a weighted mean difference between treatment and placebo was obtained for all outcomes using a random effects model. A test for heterogeneity was performed and the I2 statistic calculated. Overall, 1,622 subjects were treated, with 954 randomized to PDE5i and 772 to placebo in 24 RCTs. According to our analysis, sustained PDE5 inhibition produced: (1) an anti-remodeling effect by reducing cardiac mass (-12.21 g/m2, 95% confidence interval (CI): -18.85; -5.57) in subjects with left ventricular hypertrophy (LVH) and by increasing end-diastolic volume (5.00 mL/m2; 95% CI: 3.29; 6.71) in non-LVH patients; (2) an improvement in cardiac performance by increasing cardiac index (0.30 L/min/m2, 95% CI: 0.202; 0.406) and ejection fraction (3.56%, 95% CI: 1.79; 5.33). These effects are parallel to a decline of N-terminal-pro brain natriuretic peptide (NT-proBNP) in subjects with severe LVH (-486.7 pg/ml, 95% CI: -712; -261). PDE5i administration also produced: (3) no changes in afterload parameters and (4) an improvement in flow-mediated vasodilation (3.31%, 95% CI: 0.53; 6.08). Flushing, headache, epistaxis and gastric symptoms were the commonest side effects. | This meta-analysis suggests for the first time that PDE5i have anti-remodeling properties and improve cardiac inotropism, independently of afterload changes, with a good safety profile. Given the reproducibility of the findings and tolerability across different populations, PDE5i could be reasonably offered to men with cardiac hypertrophy and early stage heart failure. Given the limited gender data, a larger trial on the sex-specific response to long-term PDE5i treatment is required. | closed_qa |
Does obesity modify the relationship between exposure to occupational factors and musculoskeletal pain in men? | To analyze relationships between physical occupational exposures, post-retirement shoulder/knee pain, and obesity. 9 415 male participants (aged 63-73 in 2012) from the French GAZEL cohort answered self-administered questionnaires in 2006 and 2012. Occupational exposures retrospectively assessed in 2006 included arm elevation and squatting (never,<10 years, ≥10 years). "Severe" shoulder and knee pain were defined as ≥5 on an 8-point scale. BMI was self-reported. Mean BMI was 26.59 kg/m2 +/-3.5 in 2012. Long-term occupational exposure to arm elevation and squatting predicted severe shoulder and knee pain after retirement. Obesity (BMI≥30 kg/m2) was a risk factor for severe shoulder pain (adjusted OR 1.28; 95% CI 1.03, 1.90). Overweight (adjusted OR 1.71; 1.28,2.29) and obesity (adjusted OR 3.21; 1.90,5.41) were risk factors for severe knee pain. In stratified models, associations between long-term squatting and severe knee pain varied by BMI. | Obesity plays a role in relationships between occupational exposures and musculoskeletal pain. Further prospective studies should use BMI in analyses of musculoskeletal pain and occupational factors, and continue to clarify this relationship. | closed_qa |
Is primary spontaneous pneumomediastinum a truly benign entity? | This study aimed to investigate the benignancy of primary spontaneous pneumomediastinum (PSP), and to establish an appropriate management strategy. Patients diagnosed with PSP between January 2003 and December 2013 were analysed retrospectively. From January 2013 onwards, a simplified protocol, with consensus for the management of PSP, was applied in our hospital. In total, 37 patients were identified as having PSP during the study period. Among them, 27 were enrolled prior to applying the new protocol. Among these patients, extra diagnostic tests, in addition to chest radiography (CXR) and chest computed tomography (CT), were performed in 15 patients (55.5%). In the pre-protocol decade, a total of 15 patients (55.5%) were initially fasted and 16 (59.3%) were administered antibiotics. Mean hospital stay was 2.9 days (range, 0-5 days). No patient developed complications during the hospital stay and outpatient follow up. Since the revised protocol was in practical use, 10 consecutive patients with PSP were enrolled and reviewed. No additional diagnostic imaging studies or procedures (except for CXR and chest CT) were performed in these patients; furthermore, diet was not restricted and prophylactic antibiotics were not prescribed. Mean hospital stay was 14.5 h (range, 1-34 h). No complications were observed in any of the patients. | Our management protocol (i.e. routine check of chest CT without any additional diagnostic tests, no special treatment, and early discharge with short-term follow up) may be safe and feasible for the treatment of PSP. | closed_qa |
Does kidney transplantation to iliac artery deteriorate ischemia in the ipsilateral lower extremity with peripheral arterial disease? | This study was conducted to investigate the progression of lower extremity ischemia following kidney transplantation to iliac artery in patients with peripheral arterial disease. A retrospective chart review of all renal transplant patients completed at a university teaching medical center from January 2006 to December of 2011 was performed. A total of 219 patients underwent successful kidney transplantation to the common, external, or internal iliac artery. Pre- and post-transplantation ischemic changes in the ipsilateral lower extremity were reviewed and analyzed. Thirty-eight of the 219 patients had ipsilateral peripheral arterial disease and seven of them were symptomatic. Six of the seven symptomatic patients remained stable and one patient's rest pain improved, postoperatively. Eight patients developed new symptoms of ischemia 12 months later, including four with claudication, two with ischemic ulcers, and two with gangrene toes. The ulcers were healed following superficial femoral artery stenting and wound care. Toe amputation was performed in two patients with gangrene. No major amputation was required up to 48 months of follow-up. | Transplanted kidney to iliac artery does not significantly deteriorate ischemia in adults with ipsilateral lower extremity peripheral arterial disease. Late developed ischemic complications may be due to the progression of underlying arterial disease. | closed_qa |
Are there preoperative factors related to a "soft pancreas" and are they predictive of pancreatic fistulas after pancreatic resection? | Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistula. We conducted this study to clarify if there are preoperative factors related to a soft pancreatic remnant and to establish if they are useful for predicting pancreatic fistula. This was a retrospective study of patients who underwent pancreatic resections at the Department of Surgical Sciences of the S. Orsola-Malpighi Hospital, Bologna, Italy. The factors considered were sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, characteristics of the pancreatic remnant, and preoperative diagnosis. Data from 208 patients were recorded. The risk factors predictive of a soft pancreatic remnant were BMI>24 kg/m(2) (P = 0.011), a Wirsung duct size ≤3 mm (P<0.001), and coexisting periampullary diseases (P<0.001). Using these factors, we developed a risk score model that was validated by considering the pancreatic fistula rate. The overall and clinically relevant pancreatic fistula rate increased with increasing score values (P = 0.002 and P = 0.028, respectively). Using a score cut-off value of six points, patients with a score ≥6 were considered to be at high risk. | Body mass index>24 kg/m(2), a Wirsung duct size<3 mm, and preoperative diagnosis represented the preoperative factors related to a soft pancreas. These factors proved useful in the building of a risk score model to predict the incidence of pancreatic fistula. | closed_qa |
Failure of deactivation in the default mode network: a trait marker for schizophrenia? | Functional imaging studies in relatives of schizophrenic patients have had inconsistent findings, particularly with respect to altered dorsolateral prefrontal cortex activation. Some recent studies have also suggested that failure of deactivation may be seen. A total of 28 patients with schizophrenia, 28 of their siblings and 56 healthy controls underwent functional magnetic resonance imaging during performance of the n-back working memory task. An analysis of variance was fitted to individual whole-brain maps from each set of patient-relative-matched pair of controls. Clusters of significant difference among the groups were then used as regions of interest to compare mean activations and deactivations among the groups. In all, five clusters of significant differences were found. The schizophrenic patients, but not the relatives, showed reduced activation compared with the controls in the lateral frontal cortex bilaterally, the left basal ganglia and the cerebellum. In contrast, both the patients and the relatives showed significant failure of deactivation compared with the healthy controls in the medial frontal cortex, with the relatives also showing less failure than the patients. Failure of deactivation was not associated with schizotypy scores or presence of psychotic-like experiences in the relatives. | Both schizophrenic patients and their relatives show altered task-related deactivation in the medial frontal cortex. This in turn suggests that default mode network dysfunction may function as a trait marker for schizophrenia. | closed_qa |
Are trajectories of self-regulation abilities from ages 2-3 to 6-7 associated with academic achievement in the early school years? | The aim of this study was to estimate the association between two key aspects of self-regulation, 'task attentiveness' and 'emotional regulation' assessed from ages 2-3 to 6-7 years, and academic achievement when children were aged 6-7 years. Participants (n = 3410) were children in the Longitudinal Study of Australian Children. Parents rated children's task attentiveness and emotional regulation abilities when children were aged 2-3, 4-5 and 6-7. Academic achievement was assessed using the Academic Rating Scale completed by teachers. Linear regression models were used to estimate the association between developmental trajectories (i.e. rate of change per year) of task attentiveness and emotional regulation, and academic achievement at 6-7 years. Improvements in task attentiveness between 2-3 and 6-7 years, adjusted for baseline levels of task attentiveness, child and family confounders, and children's receptive vocabulary and non-verbal reasoning skills at age 6-7 were associated with greater teacher-rated literacy [B = 0.05, 95% confidence interval (CI) = 0.04-0.06] and maths achievement (B = 0.04, 95% CI = 0.03-0.06) at 6-7 years. Improvements in emotional regulation, adjusting for baseline levels and covariates, were also associated with better teacher-rated literacy (B = 0.02, 95% CI = 0.01-0.04) but not with maths achievement (B = 0.01, 95% CI = -0.01-0.02) at 6-7 years. For literacy, improvements in task attentiveness had a stronger association with achievement at 6-7 years than improvements in emotional regulation. | Our study shows that improved trajectories of task attentiveness from ages 2-3 to 6-7 years are associated with improved literacy and maths achievement during the early school years. Trajectories of improving emotional regulation showed smaller effects on academic outcomes. Results suggest that interventions that improve task attentiveness when children are aged 2-3 to 6-7 years have the potential to improve literacy and maths achievement during the early school years. | closed_qa |
Wall Enhancement of the Intracranial Aneurysms Revealed by Magnetic Resonance Vessel Wall Imaging Using Three-Dimensional Turbo Spin-Echo Sequence with Motion-Sensitized Driven-Equilibrium: A Sign of Ruptured Aneurysm? | Wall enhancement of saccular cerebral aneurysms has not been researched sufficiently. Our purpose of this study was to investigate the incidence of aneurysmal wall enhancement by the three-dimensional turbo spin-echo sequence with motion-sensitized driven equilibrium (MSDE-3D-TSE) imaging after gadolinium injection. We retrospectively reviewed the pre- and postcontrast MSDE-3D-TSE images of 117 consecutive patients with intracranial aneurysms from September 2011 to July 2013. A total of 61 ruptured and 83 unruptured aneurysms of 61 patients with subarachnoid hemorrhage (SAH) and 56 non-SAH patients were enrolled in this study. We evaluated the wall enhancement of each aneurysm on postcontrast MSDE-3D-TSE images compared with precontrast images. We classified the aneurysmal wall enhancement into three groups as "Strong enhancement," "Faint enhancement," and "No enhancement." "Strong/Faint enhancement" of the aneurysm was detected in 73.8/24.6 % of the ruptured aneurysms and 4.8/13.3 % of the unruptured aneurysms. "No enhancement" was found in 1.6 % of the ruptured aneurysms and 81.9 % of the unruptured aneurysms. | By magnetic resonance vessel wall imaging using the MSDE-3D-TSE sequence, wall enhancement was frequently observed on ruptured aneurysms. Therefore, aneurysmal wall enhancement may be an indicator of the ruptured condition, which is useful information for managing patients with SAH. | closed_qa |
Feeding practices and child weight: is the association bidirectional in preschool children? | Parental feeding practices are associated with children's body mass index (BMI). It has been generally assumed that parental feeding determines children's eating behaviors and weight gain, but feeding practices could equally be a parent's response to child weight. In longitudinal analyses, we assessed the directionality in the relation between selected controlling feeding practices and BMI in early childhood. Participants were 4166 children from the population-based Generation R Study. BMI was measured at ages 2 and 6 y. With the use of the Child Feeding Questionnaire, parents reported on restriction, monitoring, and pressure to eat (child age: 4 y). BMI and feeding-behavior scales were transformed to SD scores. With the use of linear regression analyses, there was an indication that a higher BMI at age 2 y predicted higher levels of parental restriction (adjusted β = 0.07; 95% CI: 0.04, 0.10) and lower levels of pressure to eat (adjusted β = -0.20; 95% CI: -0.23, -0.17) 2 y later. Restriction at age 4 y positively predicted child BMI at 6 y of age, although this association attenuated to statistical nonsignificance after accounting for BMI at age 4 y (β = 0.01; 95% CI: -0.01, 0.03). Pressure to eat predicted lower BMI independently of BMI at age 4 y (β = -0.02; 95% CI: -0.04, -0.01). For both restriction and pressure to eat, the relation from BMI to parenting was stronger than the reverse (Wald's test for comparison: P = 0.03 and<0.001, respectively). Monitoring predicted a lower child BMI, but this relation was explained by confounding factors. | Although the feeding-BMI relation is bidirectional, the main direction of observed effects suggests that parents tend to adapt their controlling feeding practices in response to their child's BMI rather than the reverse. Therefore, some components of current programs aimed at preventing or treating unhealthy child weight may need to be carefully scrutinized, especially those targeting parental food-related restriction and pressure to eat. | closed_qa |
Late-life depression in Rural China: do village infrastructure and availability of community resources matter? | This study aimed to examine whether physical infrastructure and availability of three types of community resources (old-age income support, healthcare facilities, and elder activity centers) in rural villages are associated with depressive symptoms among older adults in rural China. Data were from the 2011 baseline survey of the Chinese Health and Retirement Longitudinal Study (CHARLS). The sample included 3824 older adults aged 60 years or older residing in 301 rural villages across China. A score of 12 on the 10-item Center for Epidemiologic Studies Depression Scale was used as the cutoff for depressed versus not depressed. Village infrastructure was indicated by an index summing deficiency in six areas: drinking water, fuel, road, sewage, waste management, and toilet facilities. Three dichotomous variables indicated whether income support, healthcare facility, and elder activity center were available in the village. Respondents' demographic characteristics (age, gender, marital status, and living arrangements), health status (chronic conditions and physical disability), and socioeconomic status (education, support from children, health insurance, household luxury items, and housing quality) were covariates. Multilevel logistic regression was conducted. Controlling for individuals' socioeconomic status, health status, and demographic characteristics, village infrastructure deficiency was positively associated with the odds of being depressed among rural older Chinese, whereas the provision of income support and healthcare facilities in rural villages was associated with lower odds. | Village infrastructure and availability of community resources matter for depressive symptoms in rural older adults. Improving infrastructure, providing old-age income support, and establishing healthcare facilities in villages could be effective strategies to prevent late-life depression in rural China. | closed_qa |
Nitrate Supplementation, Exercise, and Kidney Function: Are There Detrimental Effects? | Recently, dietary supplementation with inorganic nitrate (NO3) has been proposed to endurance athletes to increase their performance. However, it has been suggested that an excess of NO3 might be harmful. The present study analyzed the effect of NO3 supplementation on kidney function. Thirteen young male subjects performed a 20-min cycling exercise at 85% of the maximal oxygen capacity. Seven days before exercise, the subjects ingested either a placebo (Pl) or 450 mg of potassium nitrate (PN) per day. Venous blood samples and urine collections were collected before and immediately after exercise and after 60 min of recovery. Glomerular filtration rates (GFR) and clearances (Cl) were calculated from serum content and urine output for creatinine (Crn), albumin (Alb), and urea. Under resting conditions, GFR and all clearance measures did not differ between Pl and PN. Immediately after exercise, GFR remained stable in both Pl and PN, whereas Cl-urea decreased significantly (P<0.05) in Pl (-44%) and PN (-49%). Alb urine outputs were enhanced by 18- to 20-fold in Pl and PN, respectively (P<0.05). After the recovery period, GFR remained enhanced under Pl conditions, whereas Cl-urea returned to initial values in placebo and nitrate supplementation. Alb output and Cl-Alb remained enhanced under PN conditions. | These results mainly indicate that dietary nitrate supplementation over a week does not induce any specific kidney function modifications either at rest or during sustained submaximal exercise as compared with Pl. | closed_qa |
Biceps Femoris Aponeurosis Size: A Potential Risk Factor for Strain Injury? | A disproportionately small biceps femoris long head (BFlh) proximal aponeurosis has been suggested as a risk factor for hamstring strain injury by concentrating mechanical strain on the surrounding muscle tissue. However, the size of the BFlh aponeurosis relative to BFlh muscle size, or overall knee flexor strength, has not been investigated. This study aimed to examine the relationship of BFlh proximal aponeurosis area with muscle size (maximal anatomical cross-sectional area (ACSAmax)) and knee flexor strength (isometric and eccentric). Magnetic resonance images of the dominant thigh of 30 healthy young males were analyzed to measure BFlh proximal aponeurosis area and muscle ACSAmax. Participants performed maximum voluntary contractions to assess knee flexion maximal isometric and eccentric torque (at 50° s and 350° s). BFlh proximal aponeurosis area varied considerably between participants (more than fourfold, range = 7.5-33.5 cm, mean = 20.4 ± 5.4 cm, coefficient of variation = 26.6%) and was not related to BFlh ACSAmax (r = 0.04, P = 0.83). Consequently, the aponeurosis/muscle area ratio (defined as BFlh proximal aponeurosis area divided by BFlh ACSAmax) exhibited sixfold variability, being 83% smaller in one individual than another (0.53 to 3.09, coefficient of variation = 32.5%). Moreover, aponeurosis size was not related to isometric (r = 0.28, P = 0.13) or eccentric knee flexion strength (r = 0.24, P ≥ 0.20). | BFlh proximal aponeurosis size exhibits high variability between healthy young men, and it was not related to BFlh muscle size or knee flexor strength. Individuals with a relatively small aponeurosis may be at increased risk of hamstring strain injury. | closed_qa |
A stiff price to pay: does joint stiffness predict disability in an older population? | To describe the prevalence of joint stiffness and associated comorbidities in community-living older adults and to determine whether joint stiffness, independent of pain, contributes to new and worsening disability. Population-based cohort. Urban and suburban communities in the Boston, Massachusetts, area. Adults aged 70 and older (N = 765) underwent a baseline home interview and clinic examination, 680 participants completed the 18-month follow-up. Morning joint stiffness on most days in the past month was assessed in the arms, back, hips, and knees. Mobility limitations were measured using self-reported difficulty and the Short Physical Performance Battery (SPPB). The home interview and clinic examination included extensive health measures. Four hundred one participants reported morning joint stiffness, half of these with one site of stiffness and the other half with multisite stiffness. Twenty percent of participants with multisite stiffness and 50% with single site stiffness did not have a major stiffness-associated condition. After adjustment for pain severity and other covariates, multisite stiffness was associated with a 64% greater risk of developing new or worsening mobility difficulty (relative risk = 1.64, 95% confidence interval = 1.05-2.79). Those with multisite stiffness had declined more quickly in physical performance over the 18-month follow up. | Older adults with multisite stiffness are more likely to be at risk of disability than those without joint stiffness after accounting for pain severity and the presence of stiffness-associated conditions. Better assessment, along with strategies to prevent and treat multisite joint stiffness is needed to prevent or slow the progression of disability in elderly adults. | closed_qa |
Radiographic Follow-up of DDH in Infants: Are X-rays Necessary After a Normalized Ultrasound? | Concerns about radiation exposure have created a controversy over long-term radiographic follow-up of developmental dysplasia of the hip (DDH) in infants who achieve normal clinical and ultrasonographic examinations. The purpose of this study was to assess the importance of continued radiographic monitoring by contrasting the incidence of residual radiographic dysplasia to the risks of radiation exposure. We reviewed a consecutive series of infants with idiopathic DDH presenting to our institution over 4 years. Infants with "normalized DDH" had achieved a stable clinical examination with an ultrasound revealing no signs of either hip instability or acetabular dysplasia. We excluded infants with persistently abnormal ultrasonographic indices, clinical examinations, or both by 6 months of age, including those requiring surgical reduction. Anteroposterior pelvic radiographs at approximately 6 and 12 months of age were then evaluated for evidence of residual radiographic acetabular dysplasia. Radiation effective dose was calculated using PCXMC software. We identified 115 infants with DDH who had achieved both normal ultrasonographic and clinical examinations at 3.1±1.1 months of age. At the age of 6.6±0.8 months, 17% of all infants demonstrated radiographic signs of acetabular dysplasia. Of infants left untreated (n=106), 33% had dysplasia on subsequent radiographs at 12.5±1.2 months of age. No significant differences were evident in either the 6- or 12-month rates of dysplasia between infants successfully treated with a Pavlik harness and infants normalizing without treatment but with a history of risk factors (P>0.05). The radiation effective dose was<0.01 mSv for the combined 6- and 12-month single-view anteroposterior radiographs of the pelvis. | The notable incidences of radiographic dysplasia after previous DDH normalization in our study cohort appear to outweigh the risks of radiation exposure. Our findings may warrant radiographic follow-up in this population of infants through at least walking age to allow timely diagnosis and early intervention of residual acetabular dysplasia. | closed_qa |
Does video gaming affect orthopaedic skills acquisition? | Previous studies have suggested that there is a positive correlation between the extent of video gaming and efficiency of surgical skill acquisition on laparoscopic and endovascular surgical simulators amongst trainees. However, the link between video gaming and orthopaedic trauma simulation remains unexamined, in particular dynamic hip screw (DHS) stimulation. To assess effect of prior video gaming experience on virtual-reality (VR) haptic-enabled DHS simulator performance. 38 medical students, naïve to VR surgical simulation, were recruited and stratified relative to their video gaming exposure. Group 1 (n = 19, video-gamers) were defined as those who play more than one hour per day in the last calendar year. Group 2 (n = 19, non-gamers) were defined as those who play video games less than one hour per calendar year. Both cohorts performed five attempts on completing a VR DHS procedure and repeated the task after a week. Metrics assessed included time taken for task, simulated flouroscopy time and screw position. Median and Bonett-Price 95% confidence intervals were calculated for seven real-time objective performance metrics. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Analysis was performed using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. A result was deemed significant when a two-tailed p-value was less than 0.05. All 38 subjects completed the study. The groups were not significantly different at baseline. After ten attempts, there was no difference between Group 1 and Group 2 in any of the metrics tested. These included time taken for task, simulated fluoroscopy time, number of retries, tip-apex distance, percentage cut-out and global score. | Contrary to previous literature findings, there was no correlation between video gaming experience and gaining competency on a VR DHS simulator. | closed_qa |
Do we need a femoral artery route for transvenous PDA closure in children with ADO-I? | The standard procedure in percutaneous closure of patent ductus arteriosus (PDA) with Amplatzer duct occluder-I (ADO-I) is transvenous closure guided by aortic access through femoral artery. The current study aims to compare the procedures for PDA closure with ADO-I: only transvenous access with the standard procedure. This study was designed retrospectively and 101 pediatric patients were included. PDA closure was done by only femoral venous access in 19 of them (group 1), arterial and venous access used in 92 patients (group 2) between 2004 to 2012 years. The position of the device and residual shunt in group1 was evaluated by the guidance of the aortogram obtained during the return phase of the pulmonary artery injection and guidance of transthoracic echocardiography. Shapiro-Wilk's test, Mann-Whitney U, chi-squared tests were used for statistical comparison. The procedure was successful in 18 (95%) patients in group 1 and 90 (98%) patients in group 2. Complications including the pulmonary artery embolization (n=1), protrusion to pulmonary artery (n=1), inguinal hematoma (n=3), bleeding (n=2) were only detected in group 2. In other words, while complications were observed in 7 (7.2%) patients in group 2, no minor/major complication was observed in group 1. Complete closure in group 1 was: in catheterization room 14 (77.8%), at 24th hour in 2 (11.1%), at first month in 2 (11.1%). Complete closure in group 2 was: 66 (73.4%) patients in the catheterization room, 21 (23.3%) at 24th hour, 3 (3.3%) at first month, complete closure occurred at the end of first month. | In percutaneouse PDA closure via ADO-I, this technique can be a choice for patients whose femoral artery could not be accessed, or access is impossible/contraindicated. But for the reliability and validity of this method, randomized multicenter clinical studies are necessary. | closed_qa |
The SPORT value compass: do the extra costs of undergoing spine surgery produce better health benefits? | The Spine Patient Outcomes Research Trial aimed to determine the comparative effectiveness of surgical care versus nonoperative care by measuring longitudinal values: outcomes, satisfaction, and costs. This paper aims to summarize available evidence from the Spine Patient Outcomes Research Trial by addressing 2 important questions about outcomes and costs for 3 types of spine problem: (1) how do outcomes and costs of spine patients differ depending on whether they are treated surgically compared with nonoperative care? (2) What is the incremental cost per quality adjusted life year for surgical care over nonoperative care? After 4 years of follow-up, patients with 3 spine conditions that may be treated surgically or nonoperatively have systematic differences in value endpoints. The average surgical patient enjoys better health outcomes and higher treatment satisfaction but incurs higher costs. | Spine care is preference sensitive and because outcomes, satisfaction, and costs vary over time and between patients, data on value can help patients make better-informed decisions and help payers know what their dollars are buying. | closed_qa |
Is preoperative pain duration important in spinal cord stimulation? | Conflicting data have been published as to whether the success rate of spinal cord stimulation (SCS) is inversely proportional to the time interval from the initial onset of symptoms to implantation. Recently, a new stimulation design called burst stimulation has been developed that seems to exert its effect by modulating both the medial and lateral pain pathways and has a better effect than tonic stimulation on global pain, back pain, and limb pain. We analyzed the effect of preoperative pain duration on the degree of pain suppression by both tonic and burst stimulation in a group of patients (n = 49) who underwent both tonic and burst SCS. Using Pearson correlation analysis and controlling for age and duration of SCS, no correlation could be found between the preoperative pain duration and the success of SCS, either for tonic or for burst SCS, as defined by a numeric rating scale for pain. Using a different analysis method, dividing patients into groups according to preoperative pain duration, the same absence of influence was found. Pain was better suppressed by burst stimulation than tonic stimulation, irrespective of the preoperative pain duration. | These results suggest that the duration of pain is not an exclusion criterion for SCS and that similar success rates can be obtained for longstanding pain and pain of more recent onset. | closed_qa |
The most critical question when reading a meta-analysis report: Is it comparing apples with apples or apples with oranges? | While the number of meta-analyses published has increased recently, most of them have problems in the design, analysis, and/or presentation. An example of meta-analyses with a study selection bias is a meta-analysis of over 160,000 patients in 20 clinical trials, published in Eur Heart J in 2012 by van Vark, which concluded that the significant effect of renin-angiotensin-aldosterone system (RAAS) inhibition on all-cause mortality was limited to the class of angiotensin-converting enzyme inhibitors (ACEIs), whereas no mortality reduction could be demonstrated with angiotensin receptor blockers (ARBs). Here, we aimed to discuss how to select studies for a meta-analysis and to present our results of a re-analysis of the van Vark data. The data were re-analyzed in three steps: firstly, only ACEI/ARB-based studies (4 ACEI and 12 ARB studies) were included; secondly, placebo-controlled studies were excluded, and 10 studies left were analyzed; and thirdly, 2 studies that were retracted after the manuscript of van Vark had been published were excluded. The final analysis included 8 studies with ~65,000 patients (3 ACEI and 5 ARB studies). The hazard ratios for all-cause mortality and cardiovascular mortality were 0.992 (95% CI 0.899-1.095; p=0.875) and 1.017 (0.932-1.110; p=0.703) for the ACEI versus control group and 1.007 (0.958-1.059; p=0.778) and 0.967 (0.911-1.025; p=0.258) for the ARB versus control group in the first step. The results were similar in the second and third steps. | The studies to be included in meta-analyses, particularly comparing ACEIs and ARBs, should be chosen carefully. | closed_qa |
Is duration of postoperative fasting associated with infection and prolonged length of stay in surgical patients? | Verify whether the postoperative fasting period increases the risk for infection and prolonged length of stay. Prospective cohort study. Elective surgery patients were included. Excluded: those with no conditions for nutritional assessment, admitted in minimal care units, as well as with<72h in-hospital stay. Postoperative fasting was recorded from the days of no nutrition therapy. The length of stay was considered prolonged when above the average according to the specialty and type of surgery. Logistic regression was used to assess associations and adjust for confounding factors. 521 patients were analyzed, 44.1% were fasted for a period ≥1 day, 91% for ≥3 days and 5.6% for more than 5 days. Patients with more than 5 days fasting were more eutrophic, more admitted to intensive care units, and had more postoperative surgical complications. After adjustment for confounding variables, it was noted that ≥1 day of postoperative fasting increased the infection risk by 2.04 (CI95%: 1.20 to 3.50), ≥3 days 2.81 (CI95%: 1.4-5.8), and in fasting for more than 5 days the infection risk was 2.88 times higher (CI95%: 1.17 to 7.16). The risk for prolonged hospitalization was 2.4 (CI95%: 1.48 to 3.77) among patients who had ≥1 day fasting, 4.44 (CI95%: 2.0 to 9.8)and 4.43 times higher (CI95%: 1.73 to 11.3) among patients with ≥3 days fasting and more than 5 days, respectively. | The longer duration of postoperative fasting was an independent risk factor both for infection and for prolonged hospital stay. | closed_qa |
Can highly purified collagen coating modulate polypropylene mesh immune-inflammatory and fibroblastic reactions? | Collagen has been proposed to be a useful biomaterial, but previous attempts to combine meshes with a collagen membrane have failed. The objective was to verify the effect of high-purified collagen gel coating in the immune-inflammatory response, host collagen metabolism, and angiogenesis around polypropylene mesh. In 20 female Wistar rats were implanted, at one side of the abdominal wall, a monofilament polypropylene mesh (PP), and, on the other side, a mesh coated with a new highly purified collagen gel (PPC). The animals were divided into sub-groups and euthanized at 7, 14, 21, and 90 days after implantation. Immunohistochemical analysis was performed using interleukin 1 (IL-1), matrix metalloproteinases (MMP-2, MMP-3), surface antigen CD-31, and tumor necrosis factor (TNF-α). Objective analysis (percent reactive area, average density, and vessels concentration) was performed using AxioVision Software. Comparative analysis showed: higher vessel density in the PPC group after 14 days (p = 0.002); a decrease in the average density of MMP-2 in the PPC group after 21 and 90 days (p = 0.046); more stability in the behavior of MMP-3 in the PPC group throughout the periods with the percentage reactive area for MMP-3 showing a significant decrease just in the PP group after 14 and 90 days (p = 0.017), and also for MMP-3 average density, in which reduction was significant after 21 days in the PP group, but not until after 90 days in PPC group (p < 0.001). | Highly purified collagen coating causes significant changes in angiogenesis and in the immune reaction of metalloproteinase around mesh implants in rats. These findings can be useful for improving mesh biocompatibility for pelvic floor surgery if such effects could be properly controlled. | closed_qa |
Do variable rates of alcohol drinking alter the ability to use transdermal alcohol monitors to estimate peak breath alcohol and total number of drinks? | Transdermal alcohol monitoring is a noninvasive method that continuously gathers transdermal alcohol concentrations (TAC) in real time; thus, its use is becoming increasingly more common in alcohol research. In previous studies, we developed models that use TAC data to estimate peak breath alcohol concentration (BrAC) and standard units consumed when the rate of consumption was tightly controlled. Twenty-two healthy participants aged 21 to 52 who reported consuming alcohol on 1 to 4 days per week were recruited from the community. The final study sample included 11 men and 8 women. Both TAC and BrAC were monitored while each participant drank 1, 2, 3, 4, and 5 beers in the laboratory on 5 separate days. In contrast to previous studies, a self-paced alcohol administration procedure was used. While there was considerable variation in the times it took to consume each beer, key TAC parameters were not affected by pace of drinking. TAC data were then used in combination with the previously derived equations and estimated peak BrAC and standard units of alcohol consumed. | Transdermal alcohol monitoring can be used to reliably estimate peak BrAC and standard number of units consumed regardless of the rate of consumption, further demonstrating its usefulness in clinical research. | closed_qa |
Cross-border policy effects on alcohol outcomes: drinking without thinking on the u.s.-Mexico border? | Rates of alcohol-related outcomes are sensitive to policy differences in politically distinct, adjacent territories. Factors that shape these cross-border effects, particularly when the policy differences are longstanding, remain poorly understood. We compared the ability of 2 classes of variables with theoretical relevance to the U.S.-Mexico border context-bar attendance and alcohol-related social-cognitive variables-to explain elevated drinking on the U.S. side of the border relative to other areas of the United States. Data were collected from multistage cluster samples of adult Mexican Americans on and off the U.S.-Mexico border (current drinker N = 1,351). Structural equation models were used to test drinking context (frequency of bar attendance) and 6 different social-cognitive variables (including alcohol-related attitudes, norms, motives, and beliefs) as mediators of border effects on a composite drinking index. The border effect on drinking varied by age (with younger adults showing a stronger effect), consistent with previous findings and known risk factors in the region. Contrary to theoretical expectations, 6 different social-cognitive variables-despite relating strongly with drinking-were comparable in border and nonborder areas (within and across age) and played no role in elevated drinking on the border. Conversely, elevated drinking among border youth was mediated by bar attendance. This mediated moderation effect held after adjusting for potential sociodemographic and neighborhood-level confounders. | Increased drinking among U.S.-Mexico border youth is explained by patterns of bar attendance, but not by more permissive alcohol-related social-cognitive variables in border areas: Border youth attend bars and drink more than their nonborder counterparts, despite having comparable alcohol-related beliefs, attitudes, norms, and motives for use. Alcohol's heightened availability and visibility on both sides of the border may create opportunities for border youth to drink that otherwise would not be considered. | closed_qa |
Are sulfonylurea and insulin therapies associated with a larger risk of cancer than metformin therapy? | Several meta-analyses of observational studies suggested that metformin use reduces cancer risk in type 2 diabetes. However, this result was not confirmed by the few available randomized controlled trials (RCTs), and many observational studies on metformin and cancer were potentially afflicted with time-related bias. We aimed to avoid this bias when comparing cancer incidence in users of sulfonylurea, insulin, and other diabetes medications, respectively, with cancer incidence in metformin users. In a retrospective observational study, we used the German Disease Analyzer database with patient data from general practices throughout Germany. The study sample included 22,556 patients diagnosed with type 2 diabetes. During the median follow-up time of 4.8 years, 1,446 (6.4%) patients developed any cancer. In Cox regression analyses with either monotherapies or first diabetes medications as drug exposure, users of sulfonylurea (or insulin or other antidiabetes medications) were compared with metformin users. In multivariable adjusted models, hazard ratios were 1.09 (95% CI 0.87-1.36) for sulfonylurea monotherapy, 1.14 (95% CI 0.85-1.55) for insulin monotherapy, and 0.94 (95% CI 0.67-1.33) for other diabetes medications compared with metformin monotherapy. Results were similar for comparison of first diabetes medications. | In a retrospective database analysis, taking into account potential time-related biases, no reduced cancer risk was found in metformin users. To clarify the association between diabetes medication and cancer risk, further well-designed observational studies and RCTs are needed. | closed_qa |
Reassessing the impact of smoking on preeclampsia/eclampsia: are there age and racial differences? | To investigate the association between cigarette use during pregnancy and pregnancy-induced hypertension/preeclampsia/eclampsia (PIH) by maternal race/ethnicity and age. This retrospective cohort study was based on the U.S. 2010 natality data. Our study sample included U.S. women who delivered singleton pregnancies between 20 and 44 weeks of gestation without major fetal anomalies in 2010 (n = 3,113,164). Multivariate logistic regression models were fit to estimate crude and adjusted odds ratios and the corresponding 95% confidence intervals. We observed that the association between maternal smoking and PIH varied by maternal race/ethnicity and age. Compared with non-smokers, reduced odds of PIH among pregnant smokers was only evident for non-Hispanic white and non-Hispanic American Indian women aged less than 35 years. Non-Hispanic Asian/Pacific Islander women who smoked during pregnancy had increased odds of PIH regardless of maternal age. Non-Hispanic white and non-Hispanic black women 35 years or older who smoked during pregnancy also had increased odds of PIH. | Our study findings suggest important differences by maternal race/ethnicity and age in the association between cigarette use during pregnancy and PIH. More research is needed to establish the biologic and social mechanisms that might explain the variations with maternal age and race/ethnicity that were observed in our study. | closed_qa |
Can we use incubators with atmospheric oxygen tension in the first phase of in vitro fertilization? | Aim of the present study was to compare two culture strategies used in our routine in vitro fertilization program. This is a retrospective analysis. Two culture systems were used in parallel and analysed retrospectively: 1) Use of atmospheric oxygen tension (~20 %) until insemination followed by use of low (~5 %) oxygen concentration; 2) Exclusive use of low oxygen concentration. Main outcome was the utilization rate defined as the number of transferred + vitrified embryos per inseminated oocytes. Secondary outcomes were clinical pregnancy and live birth rates. A total of 402 in vitro fertilization cycles were analyzed. Demographic and clinical data of patients belonging to the two culture systems were not significantly different. Utilization rate, cumulative clinical pregnancy rate and cumulative live birth rate per cycle was similar using two different oxygen concentration compared to exclusive use of low oxygen tension (37 % versus 39 %; 30 % versus 30 %; 23 % versus 28 %, respectively). | The use of a culture system with atmospheric oxygen tension from recovery of oocytes until insemination followed by culture in low oxygen gives results similar to exclusive use of low oxygen concentration. | closed_qa |
Do sex and BMI predict or does stem design prevent muscle damage in anterior supine minimally invasive THA? | Cadaveric and clinical studies have suggested that, despite being touted as muscle-sparing, the direct anterior approach is still associated with muscle damage, particularly to the tensor fascia lata (TFL). Patient body mass index (BMI) and/or sex may also influence this parameter.QUESTIONS/ The purposes of the study were to determine if using a shorter femoral component reduces TFL damage or if patient sex or increasing BMI increases intraoperative TFL damage in direct anterior THA. Over a 1-year period, 599 direct anterior THAs were performed by three experienced anterior hip surgeons; of those, 421 direct anterior hips had complete data (70%) and were included in the study. The amount of visible damage to the TFL was recorded before closure. Two stem types were used, a standard-length flat-wedge taper (standard) or a 3-cm shortened version of the same stem (short). Stem selection was based on timeframe of the surgery, surgeon preference, or matching a previous implant type. During the study period, the three surgeons performed an additional 225 primary THAs with other approaches such that the direct anterior approach represented 73% of the THAs performed. A member of the operating team, either a fellow or physician assistant, graded the extent of damage based on a 0 to 3 scale. On this scale, 0 represented no muscle fiber damage, 1 superficial tearing, 2 deep tearing or maceration, and 3 complete tear or severe damage. Patient sex and BMI were recorded and compared with stem type and muscle damage scores. An ordinal logistic regression model was used for statistical analysis. After controlling for relevant confounding variables using logistic regression, we found that mean muscle damage was associated with male sex (0.93, SD 0.76 versus 0.70, SD 0.68; p<0.001) and increasing BMI levels (p<0.001). As BMI increased, more muscle damage also was found in men compared with women (p=0.05; odds ratio [OR], 1.029; 95% confidence interval [CI], 1.000-1.060). There was no overall difference in mean muscle damage between short and standard-length stems (0.78, SD 0.77 versus 0.85, SD 0.69, p=0.32); however, as BMI increased, less damage was seen with a short stem (p=0.04; OR, 0.968; 95% CI, 0.931-0.997). | Visible muscle damage occurred in most hips during anterior supine intermuscular hip arthroplasty. The clinical importance of this muscle damage requires further study, because some evidence suggests earlier restoration of gait and cessation of walking aids with direct anterior THA despite this damage; however, this was not studied here. Surgeons performing this approach can expect more difficulty and as a result possibly more damage to the TFL in patients with male sex and increased BMI. The use of a short stem can be considered for patients with increased BMI to limit damage to the TFL. | closed_qa |
Can femoral rotation be localized and quantified using standard CT measures? | The terms "femoral anteversion" and "femoral torsion" have often been used interchangeably in the orthopaedic literature, yet they represent distinct anatomical entities. Anteversion refers to anterior tilt of the femoral neck, whereas torsion describes rotation of the femoral shaft. Together, these and other transverse plane differences describe what may be considered rotational deformities of the femur. Assessment of femoral rotation is now routinely measured by multiple axial CT methods. The most widely used radiographic technique (in which only two CT-derived axes are made, one through the femoral neck and one at the distal femoral condyles) may not accurately quantify proximal femoral anatomy nor allow identification of the anatomic locus of rotation.QUESTIONS/ (1) What CT methodology (a two-axis CT-derived technique, a three-axis technique adding an intertrochanteric axis--the "Kim method," or a volumetric three-dimensional reconstruction of the proximal femur) most accurately quantifies transverse plane femoral morphology; (2) localizes those deformities; and (3) is most reproducible across different observers? We constructed a high-definition femoral sawbones model in which osteotomies were performed at either the intertrochanteric region or femoral shaft. Transverse plane deformity was randomly introduced and CT-derived rotational profiles were constructed using three different CT methods. Accuracy and consistency of measurements of femoral rotation were calculated using p values and Fisher's exact test and intraclass correlation coefficients (ICCs). All three CT methodologies accurately quantified overall transverse plane rotation (mean differences 0.69° ± 3.88°, 0.69° ± 3.88°, and -1.09° ± 4.44° for the two-plane, Kim, and volumetric methods, respectively). However, use of a single neck and single distal femoral axis does not reliably identify the anatomic locus of rotation, whereas the Kim and volumetric methods do (p<0.0001). All three methods were highly reproducible between observers (ICCs of 0.9569, 0.9569, and 0.9359 for the traditional two-plane, Kim, and volumetric methods, respectively). | Only the Kim and volumetric methods can identify the anatomic location of transverse plane rotation and we recommend using one of the two techniques. Accurate anatomic localization of transverse plane rotation enables using precise anatomic terminology ("femoral torsion" versus "femoral [ante]version"). | closed_qa |
Do patient race and sex change surgeon recommendations for TKA? | Prior investigations have suggested that physician-related factors may contribute to differential use of TKA among women and ethnic minorities. We sought to evaluate the effect of surgeon bias on recommendations for TKA.QUESTIONS/ Using an experimental approach with standardized patient scenarios, we sought to evaluate surgeon recommendations regarding TKA, specifically to determine whether recommendations for TKA are influenced by (1) patient race, and (2) patient sex. We developed four computerized scenarios for all combinations of race (white or black) and sex (male or female) for otherwise similar patients with end-stage knee osteoarthritis. Patients gave an orthopaedic history of 2 years worsening pain with decreased functional status and failure of oral antiinflammatory medications and corticosteroid intraarticular injections. Orthopaedic surgeons attending the 2012 annual meetings of the New York State Society of Orthopaedic Surgeons and American Association of Hip and Knee Surgeons were recruited for the study. Surgeons passing an open recruitment table at each meeting were asked to participate. Of the 1111 surgeons in attendance at either meeting, 113 (10.2%) participated in the study. All participants viewed the "control" patient's story (white male) and were randomized to view one of the three "experimental" scenarios (white female, black male, black female). After viewing each scenario, the participants were anonymously asked whether they would recommend TKA. An a priori power analysis showed that 112 participants were needed to detect a 15% difference in the likelihood of recommending surgery for white versus nonwhite patients in the test scenarios evaluated with 90% power at a level of significance of 0.05. Of the 39 surgeons who viewed the white male plus black female scenario, there were 33 (85%) concordant responses (TKA offered to both patients) and six discordant responses (TKA offered to only one of the patients), with no effect of patient race and sex (p = 0.99). Of the 37 surgeons who viewed the white male plus black male scenario, there were 33 (89%) concordant responses and four discordant responses, with no effect of patient race (p = 0.32). Of the 37 surgeons who viewed the white male plus white female scenario, there were 30 (77%) concordant responses and seven discordant responses, with no effect of patient sex (p = 0.71). | After orthopaedic surgeons viewed video scenarios of patients with end-stage knee osteoarthritis, patient race and sex were not associated with a different likelihood of a surgical recommendation. Our findings support the notion that patient race and sex may be less influential on decision making when there are strong clinical data to support a decision. Physician bias may have a greater effect on decision making in situations where the indications for surgery are less clear. | closed_qa |
Does neuroanatomy account for superior temporal dysfunction in early psychosis? | Neuroimaging studies of ultra-high risk (UHR) and first-episode psychosis (FEP) have revealed widespread alterations in brain structure and function. Recent evidence suggests there is an intrinsic relationship between these 2 types of alterations; however, there is very little research linking these 2 modalities in the early stages of psychosis. To test the hypothesis that functional alteration in UHR and FEP articipants would be associated with corresponding structural alteration, we examined brain function and structure in these participants as well as in a group of healthy controls using multimodal MRI. The data were analyzed using statistical parametric mapping. We included 24 participants in the FEP group, 18 in the UHR group and 21 in the control group. Patients in the FEP group showed a reduction in functional activation in the left superior temporal gyrus relative to controls, and the UHR group showed intermediate values. The same region showed a corresponding reduction in grey matter volume in the FEP group relative to controls. However, while the difference in grey matter volume remained significant after including functional activation as a covariate of no interest, the reduction in functional activation was no longer evident after including grey matter volume as a covariate of no interest. Our sample size was relatively small. All participants in the FEP group and 2 in the UHR group had received antipsychotic medication, which may have impacted neurofunction and/or neuroanatomy. | Our results suggest that superior temporal dysfunction in early psychosis is accounted for by a corresponding alteration in grey matter volume. This finding has important implications for the interpretation of functional alteration in early psychosis. | closed_qa |
Physical restraint in the ICU: does it prevent device removal? | Physical restraint is frequently used in the intensive care setting but little is known regarding its clinical scenario and effectiveness in preventing adverse events (AEs), defined as device removal. We carried out a prospective observational study in three Intensive Care Units on 120 adult high-risk patients. The effectiveness of physical restraint was evaluated using the propensity score methodology in order to obtain comparable groups. Physical restraint was applied in 1371 of 3256 (43%) nurse shifts accounting for 120 patients. Substantial agitation, the nurse's judgement of insufficient sedation and sedative drug reduction were positively associated with physical restraint, whereas the presence of analgesics at admission, increased disease gravity and the treating hospital as the most substantial variable showed a negative association. Eighty-six AEs were observed in 44 patients. Quiet (SAS=1-4), unrestrained patients accounted for 40 cases, and agitated (SAS≥5) but physically restrained patients for 17 cases. The presence of any type of physical restraint had a protective effect against any type of AE (OR=0.28; CI 0.16-0.51). The observed AEs showed a limited impact on the patients' course of illness. No physical harm related to physical restraint was reported. | Physical restraint efficiently averts AEs. Its application is mainly driven by local habits. Typically, the almost recovered, apparently calm and hence unrestrained patient is at greatest risk for undesirable device removal. The control/interpretation of the patient's analgo-sedation might be inappropriate. | closed_qa |
Diuretics, first-line antihypertensive agents: are they always safe in the elderly? | Diuretics are frequently recommended as antihypertensive agents. Some of the main side effects of diuretic therapy are hypokalaemia and hyponatremia. The objective of the study was to describe the frequency of hyponatremia in a group of elderly hypertensive patients treated with diuretics. The study included 202 elderly hypertensive patients (over 65 years old), treated with diuretics at least 4 weeks before hospitalization, consecutivly admitted in the Internal Medicine Clinic of the Clinical Emergency Hospital of Bucharest during a period of 4 months. The distribution by sex: 103 (52.28%) men and 94 (47.71%) women. The mean age of the patients was 72 ± 8 years. Incidence of hyponatremia was 24.87% (49 patients) in the whole group. From the 49 hyponatremic patients, 31 (63.26%) were women and 18 (36.73%) men. The distribution by age of hypertensive hyponatremic female patients was: between 65-70 years old--4 patients (12.90%), between 70-75 years old--7 patients (22.58%), over 75 years old--20 patients (64.51%). The distribution by age of hypertensive hyponatremic male patients was: between 65-70 years old--3 patients (16.66%), between 70-75 years old--2 patients(11.11%), over 75 years old--13 patients (72.22%). Most of the patients affected (73.46%) used a thiazide-type diuretic, the other 26.54% being on loop diuretics. | Elderly hypertensive patients were more likely to develop hyponatremia after age 75. Female patients had a higher frequency of hyponatremia than male patients. The main cause of hyponatremia in patients treated with diuretics was thiazide. | closed_qa |
Does type of feeding in infancy influence lipid profile in later life? | To compare the lipid profile of exclusively breastfed and mixed-fed, term, appropriate for gestation age infants from 6 mo to 1 y of age. This prospective comparative study included one hundred ninety nine consecutive term healthy infants; 105 on exclusive breastfeeding (EBF) and 94 receiving mixed feeding (MF). These children were recruited at 6 mo of age and followed till 1 y of age. Serum lipid levels of babies were determined at recruitment (6 mo), 9 mo and 1 y of age. Statistical analysis was carried out using SPSS software. The mean total cholesterol (TC) at 6 mo in exclusively breastfed group (156.38 ± 50.42 mg/dl) was significantly higher than mixed fed group (139.5 ± 37.59 mg/dl). At 9 mo, high density lipoprotein cholesterol (HDL-C) and triglycerides (TG) levels were significantly different in EBF group than MF group. The lipid profile of both group of babies was comparable at 1 y of age. The HDL-C: LDL-C ratio was significantly different between the two groups (higher in breastfed group) at 1 y. | The present study highlights differential lipid profile of exclusively breastfed infants and mixed fed infants. | closed_qa |
Does integrating research into the prosthetics and orthotics undergraduate curriculum enhance students' clinical practice? | Problem-based learning (where rather than feeding students the knowledge, they look for it themselves) has long been thought of as an ideal approach in teaching because it would encourage students to acquire knowledge from an undetermined medium of wrong and right answers. However, the effect of such approach in the learning experience of prosthetics and orthotics students has never been investigated. This study explores the implications of integrating problem-based learning into teaching on the students' learning experience via implementing a research-informed clinical practice module into the curriculum of last year prosthetics and orthotics undergraduate students at the University of Jordan (Amman, Jordan). Qualitative research pilot study. Grounded theory approach was used based on the data collected from interviewing a focus group of four students. Students have identified a number of arguments from their experience in the research-informed clinical practice where, generally speaking, students described research-informed clinical practice as a very good method of education. | Integrating problem-based learning into teaching has many positive implications. In particular, students pointed out that their learning experience and clinical practice have much improved after the research-informed clinical practice. | closed_qa |
Nonresident parental influence on adolescent weight and weight-related behaviors: similar or different from resident parental influence? | Many parents do not live with, or have shared custody of, their adolescent children (i.e., nonresident parents). The degree of their influence on their children, as compared to parents who do live with their children the majority of the time (i.e. resident parents) has not been well-studied. The current study aimed to examine whether and how resident and nonresident parents' weight and weight-related behaviors are correlated with adolescents' weight and weight-related behaviors. Results will inform who may be important to include in adolescent obesity prevention interventions. Data from two linked population-based studies, EAT 2010 and F-EAT, were used for cross-sectional analyses. Resident parents (n = 200; 80% females; mean age =41.8), nonresident parents (n =200; 70% male; mean age =43.1), and adolescents (n =200; 60% girls; mean age =14.2 years) were socioeconomically and racially/ethnically diverse. Multiple regression models were fit to investigate the association between resident and nonresident parents' weight and weight-related behaviors and adolescents' weight and weight-related behaviors. Both resident and nonresident parents' BMI were significantly associated with adolescents' BMI percentile. Additionally, resident parents' sugar-sweetened beverage consumption and fruit and vegetable intake were significantly associated with adolescents' sugar-sweetened beverage intake and fruit and vegetable intake (p < 0.05), respectively. Furthermore, the association between nonresident parent physical activity and adolescent physical activity was marginally significant (p = 0.067). Neither resident nor nonresident parents' fast food consumption, breakfast frequency, or sedentary behaviors were significantly associated with adolescents' same behaviors. | These preliminary findings suggest that resident and nonresident parents may have slightly different influences on their adolescent children's weight-related behaviors. Longitudinal follow-up is needed to determine temporality of associations. | closed_qa |
Is thermochemotherapy with the Synergo system a viable treatment option in patients with recurrent non-muscle-invasive bladder cancer? | To prospectively evaluate the outcome of combined microwave-induced bladder wall hyperthermia and intravesical mitomycin C instillation (thermochemotherapy) in patients with recurrent non-muscle-invasive bladder cancer. Between 2003 and 2009, 21 patients (median age 70 years, range 35-95 years) with recurrent non-muscle-invasive bladder cancer (pTaG1-2 n = 9; pTaG3 n = 3; pT1 n = 9; concurrent pTis n = 8) were prospectively enrolled. Of 21 patients, 15 (71%) had received previous intravesical instillations with bacillus Calmette-Guérin, mitomycin C and/or farmorubicin. Thermochemotherapy using the Synergo system was carried out in 11 of 21 patients (52%) with curative intent, and in 10 of 21 patients (48%) as prophylaxis against recurrence. The median number of thermochemotherapy cycles per patient was six (range 1-12). Adverse effects were frequent and severe: urinary urgency/frequency in 11 of 21 patients (52%), pain in eight of 21 patients (38%) and gross hematuria in five of 21 patients (24%). In eight of 21 patients (38%), thermochemotherapy had to be abandoned because of the severity of the adverse effects (pain in 3/8, severe bladder spasms in 2/8, allergic reaction in 2/8, urethral perforation in 1/8). Overall, six of 21 patients (29%) remained free of tumor after a median follow up of 50 months (range 1-120), six of 21 patients (29%) had to undergo cystectomy because of multifocal recurrences or cancer progression and seven of 21 patients (33%) died (2/7 of metastatic disease, 5/7 of non-cancer related causes). | Given the high rate of severe side-effects leading to treatment discontinuation, as well as the limited tumor response, thermochemotherapy should be offered only in highly selected cases of recurrent non-muscle-invasive bladder cancer. | closed_qa |
Is endorectal ultrasound still useful for staging rectal cancer? | Staging in rectal carcinoma is important for planning treatment. Preoperative staging and treatment strategies have changed along with improvements in imaging techniques. The aim of this work is to evaluate the accuracy of endorectal ultrasound (ERUS) in rectal cancers, especially in low rectal cancers and stenotic cases. From January 2011 to December 2011, patients diagnosed with rectal cancer who were admitted to our endosonography unit for staging and who were operated on in our hospital were evaluated retrospectively. Patients who received neoadjuvant chemotherapy were excluded. Endosonographic staging was compared to postoperative pathological staging. In total, 38 patients (28 males, 10 females) were included. Their mean age was 57.6±11.3 years (27-75 years). Thirteen (34.2%) had stenotic lesions. The accuracy of ERUS for staging of lesions was evaluated according to pathology and was 73.7% overall (kappa coefficient = 0.317; p = 0.002). When patients were split into stenotic and non stenotic groups, the accuracy was 68% (kappa coefficient = 0.170; p = 0.125) for stenotic lesions and 84.6% (kappa coefficient = 0.606; p = 0.001) for non-stenotic lesions. Internal and external sphincter involvement were significantly correlated with the postoperative pathological evaluation in both groups. | Technological improvements in imaging methods have made the diagnosis and management of malignancies more precise. Low rectal tumours, have difficult characteristics for evaluation because of their unique location. Although ERUS has some disadvantages, it is still useful for T staging, evaluating sphincter involvement, and defining tumour size and distance from the anal verge. ERUS was less accurate for T staging of stenotic tumours, but the accuracy may still be within acceptable limits. | closed_qa |
Capsule endoscopy capture rate: has 4 frames-per-second any impact over 2 frames-per-second? | One hundred patients with an indication for capsule endoscopy were included in the study. All procedures were performed with the new device (SB24). After an exhaustive evaluation of the SB24 videos, they were then converted to "SB2-like" videos for their evaluation. Findings, frames per finding, and clinical and therapeutic impact derived from video visualization were analyzed. Kappa index for interobserver agreement and χ (2) and Student's t tests for qualitative/quantitative variables, respectively, were used. Values of P under 0.05 were considered statistically significant. Eighty-nine out of 100 cases included in the study were ultimately included in the analysis. The SB24 videos detected the anatomical landmarks (Z-line and duodenal papilla) and lesions in more patients than the "SB2-like" videos. On the other hand, the SB24 videos detected more frames per landmark/lesion than the "SB2-like" videos. However, these differences were not statistically significant (P>0.05). Both clinical and therapeutic impacts were similar between SB24 and "SB2-like" videos (K = 0.954). The time spent by readers was significantly higher for SB24 videos visualization (P<0.05) than for "SB2-like" videos when all images captured by the capsule were considered. However, these differences become non-significant if we only take into account small bowel images (P>0.05). | More frames-per-second detect more landmarks, lesions, and frames per landmark/lesion, but is time consuming and has a very low impact on clinical and therapeutic management. | closed_qa |
Quality of life research in endometrial cancer: what is needed to advance progress in this disease site? | Quality of life (QoL) in endometrial cancer (EC) is understudied. Incorporation of QoL questionnaires and patient-reported outcomes in clinical trials has been inconsistent, and the tools and interpretation of these measures are unfamiliar to most practitioners. In 2012, the Gynecologic Cancer InterGroup Symptom Benefit Working Group convened for a brainstorming collaborative session to address deficiencies and work toward improving the quality and quantity of QoL research in women with EC. Through literature review and international expert contributions, we compiled a comprehensive appraisal of current generic and disease site-specific QoL assessment tools, strengths and weaknesses of these measures, assessment of sexual health, statistical considerations, and an exploration of the unique array of histopathologic and clinical factors that may influence QoL outcomes in women with EC. This collaborative composition is the first publication specific to EC that addresses methodology in QoL research and the components necessary to achieve high quality QoL data in clinical trials. Future recommendations regarding (1) the incorporation of patient-reported outcomes in all clinical trials in EC, (2) definition of an a priori hypothesis, (3) utilization of validated tools and consideration of new tools corresponding to new therapies or specific symptoms, (4) publication within the same time frame as clinical outcome data, and (5) attempt to correct for disease site-specific potential confounders are presented. | Improved understanding of methodology in QoL research and an increased undertaking of EC-specific QoL research in clinical trials are imperative if we are to improve outcomes in women with EC. | closed_qa |
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