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Does OCT morphology provide indications for prognosis of visual acuity after venous occlusion? | Even though macular edema (ME) in patients with retinal vein occlusion (RVO) is resolved after intravitreal treatment with anti-vascular endothelial growth factor (VEGF), impairment of visual acuity (VA) often persists. A qualitative and quantitative evaluation of spectral domain optical coherence tomography (SD-OCT) images was carried out in patients with RVO and resolved ME to investigate a correlation between retinal morphology and functional results. Foveal SD-OCT scans of 13 patients with RVO and resolved ME after treatment were retrospectively evaluated. The thickness of inner retinal layers up to the external limiting membrane (ELM) and up to the photoreceptors in the retinal pigment epithelium (RPE) was measured by automatic segmentation software. Foveal continuity of the four outer hyperreflective bands, the ellipsoid zone of the inner segments (ISe), the ELM, the interdigitation zone (IZ), the RPE and the location of the initial ME were evaluated. Patients with good (≤ 0.3 logMAR, n = 10) and poor VA (≥ 1.0 logMAR, n = 3) were compared. Inner retinal layers up to ELM were thinner in the the poor VA group. In the good VA group the initial ME was significantly more often above the ISe and after resolution of ME the ISe tended to be intact more frequently. | In patients with poor VA despite resolved ME the inner retinal layers up to the ELM were significantly thinner, which could be a sign of atrophy. Qualitative differences were seen at the photoreceptor level, which could be explained by ischemia or an involvement of the outer retina during initial ME that leads to permanent destruction of the ISe. | closed_qa |
Do artisanal fishers perceive declining migratory shorebird populations? | This paper discusses the results of ethno-ornithological research conducted on the local ecological knowledge (LEK) of artisanal fishers in northeast Brazil between August 2013 and October 2014. The present study analyzed the LEK of 240 artisanal fishermen in relation to Nearctic shorebirds and the factors that may be affecting their populations. We examined whether differences occurred according to the gender and age of the local population. The research instruments included semi-structured and check-list interviews. We found that greater knowledge of migratory birds and the areas where they occur was retained by the local men compared with the local women. Half of the male respondents stated that the birds are always in the same locations, and most of the respondents believed that changes in certain populations were caused by factors related to habitat disturbance, particularly to increases in housing construction and visitors to the island. The main practices affecting the presence of migratory birds mentioned by the locals were boat traffic and noise from bars and vessels. According to the artisanal fishermen, the population of migratory birds that use the area for foraging and resting has been reduced over time. | Changes in the local landscape related to urbanization and tourism are most likely the primary causes underlying the reduced migratory shorebird populations as reported by local inhabitants. Thus, managing and monitoring urbanization and tourism are fundamental to increasing the success of the migration process and improving the conservation of migratory shorebird species. | closed_qa |
The orientation of transcription factor binding site motifs in gene promoter regions: does it matter? | Gene expression is to large degree regulated by the specific binding of protein transcription factors to cis-regulatory transcription factor binding sites in gene promoter regions. Despite the identification of hundreds of binding site sequence motifs, the question as to whether motif orientation matters with regard to the gene expression regulation of the respective downstream genes appears surprisingly underinvestigated. We pursued a statistical approach by probing 293 reported non-palindromic transcription factor binding site and ten core promoter motifs in Arabidopsis thaliana for evidence of any relevance of motif orientation based on mapping statistics and effects on the co-regulation of gene expression of the respective downstream genes. Although positional intervals closer to the transcription start site (TSS) were found with increased frequencies of motifs exhibiting orientation preference, a corresponding effect with regard to gene expression regulation as evidenced by increased co-expression of genes harboring the favored orientation in their upstream sequence could not be established. Furthermore, we identified an intrinsic orientational asymmetry of sequence regions close to the TSS as the likely source of the identified motif orientation preferences. By contrast, motif presence irrespective of orientation was found associated with pronounced effects on gene expression co-regulation validating the pursued approach. Inspecting motif pairs revealed statistically preferred orientational arrangements, but no consistent effect with regard to arrangement-dependent gene expression regulation was evident. | Our results suggest that for the motifs considered here, either no specific orientation rendering them functional across all their instances exists with orientational requirements instead depending on gene-locus specific additional factors, or that the binding orientation of transcription factors may generally not be relevant, but rather the event of binding itself. | closed_qa |
Cardiomyopathy in children: Can we rely on echocardiographic tricuspid regurgitation gradient estimates of right ventricular and pulmonary arterial pressure? | Introduction Agreement between echocardiography and right heart catheterisation-derived right ventricular systolic pressure is modest in the adult heart failure population, but is unknown in the paediatric cardiomyopathy population. All patients at a single centre from 2001 to 2012 with a diagnosis of cardiomyopathy who underwent echocardiography and catheterisation within 30 days were included in this study. The correlation between tricuspid regurgitation gradient and catheterisation-derived right ventricular systolic pressure and mean pulmonary artery pressure was determined. Agreement between echocardiography and catheterisation-derived right ventricular systolic pressure was assessed using Bland-Altman plots. Analysis was repeated for patients who underwent both procedures within 7 days. Haemodynamic data from those with poor agreement and good agreement between echocardiography and catheterisation were compared. A total of 37 patients who underwent 48 catheterisation procedures were included in our study. The median age was 11.8 (0.1-20.6 years) with 22 males (58% total). There was a modest correlation (r=0.65) between echocardiography and catheterisation-derived right ventricular systolic pressure, but agreement was poor. Agreement between tricuspid regurgitation gradient and right ventricular systolic pressure showed wide 95% limits of agreement. There was a modest correlation between the tricuspid regurgitation gradient and mean pulmonary artery pressure (r=0.6). Shorter time interval between the two studies did not improve agreement. Those with poor agreement between echocardiography and catheterisation had higher right heart pressures, but this difference became insignificant after accounting for right atrial pressure. | Transthoracic echocardiography estimation of right ventricular systolic pressure shows modest correlation with right heart pressures, but has limited agreement and may underestimate the degree of pulmonary hypertension in paediatric cardiomyopathy patients. | closed_qa |
Implementation of tuberculosis infection control measures in designated hospitals in Zhejiang Province, China: are we doing enough to prevent nosocomial tuberculosis infections? | Tuberculosis (TB) infection control measures are very important to prevent nosocomial transmission and protect healthcare workers (HCWs) in hospitals. The TB infection control situation in TB treatment institutions in southeastern China has not been studied previously. Therefore, the aim of this study was to investigate the implementation of TB infection control measures in TB-designated hospitals in Zhejiang Province, China. Cross-sectional survey using observation and interviews. All TB-designated hospitals (n=88) in Zhejiang Province, China in 2014. Managerial, administrative, environmental and personal infection control measures were assessed using descriptive analyses and univariate logistic regression analysis. The TB-designated hospitals treated a median of 3030 outpatients (IQR 764-7094) and 279 patients with confirmed TB (IQR 154-459) annually, and 160 patients with TB (IQR 79-426) were hospitalised in the TB wards. Most infection control measures were performed by the TB-designated hospitals. Measures including regular monitoring of TB infection control in high-risk areas (49%), shortening the wait times (42%), and providing a separate waiting area for patients with suspected TB (46%) were sometimes neglected. N95 respirators were available in 85 (97%) hospitals, although only 44 (50%) hospitals checked that they fit. Hospitals with more TB staff and higher admission rates of patients with TB were more likely to set a dedicated sputum collection area and to conduct annual respirator fit testing. | TB infection control measures were generally implemented by the TB-designated hospitals. Measures including separation of suspected patients, regular monitoring of infection control practices, and regular fit testing of respirators should be strengthened. Infection measures for sputum collection and respirator fit testing should be improved in hospitals with lower admission rates of patients with TB. | closed_qa |
Does the duration of symptoms influence outcome in patients with sciatica undergoing micro-discectomy and decompressions? | Early surgical treatment for back and leg pain secondary to disc herniation has been associated with very good outcomes. However, there are conflicting data on the role of surgical treatment in case of prolonged radicular symptomatology. We aimed to evaluate whether the duration of symptoms at presentation affects the subjective outcome.STUDY DESIGN/ This is a retrospective review of prospectively collected data from a single surgeon including micro-discectomies and lateral recess decompressions in patients younger than 60 years old using patient medical notes, radiology imaging, operation notes, and Patient Reported Outcome Measures (PROMS) including Oswestry Disability Index (ODI), visual analogue scale for back pain and leg pain (VAS-BP and VAS-LP). The final follow-up was carried out through postal questionnaire or telephone consultation. Demographic information, duration of symptoms, type and incidence of complications, length of hospital stay, and follow-up were analyzed. Data were categorized into four subgroups: symptoms 0≥6 months, 6 months≥1 year, 1 year≥2 years, and>2 years. A clinically significant result was an average improvement of 2 or more points in the VAS and of 20% and over in the ODI. The level of statistical significance was<0.05%. A total number of 107 patients who underwent 109 operations were included. The level of surgery was L5/S1 (50), L4/L5 (43), L3/L4 (3), L2/L3 (2), and two levels (11). The mean improvement was from 0 to ≤6 months (VAS-LP 5.21±2.81, VAS-BP 3.04±3.15, ODI 35.26±19.25), 6 months to ≤1 year (VAS-LP 4.73±2.61, VAS-BP 3.30±3.05, ODI 26.92±19.49), 1 year to ≤2 years (VAS-LP 3.78±3.68, VAS-BP 3.00±2.78, ODI 19.03±20.24), and>2 years (VAS-LP 4.77±3.61, VAS-BP 3.54±3.43, ODI 28.36±20.93). The length of hospital stay and complication rate was comparable between groups. Average follow-up was 15.69 months. | Our study showed significant improvement in patients with symptoms beyond 1 as well as 2 years since onset, and surgery is a viable option in selected patients. | closed_qa |
Is There a Consensus when Physicians Evaluate the Relevance of Retrieved Systematic Reviews? | A significant challenge associated with practicing evidence-based medicine is to provide physicians with relevant clinical information when it is needed. At the same time it appears that the notion of relevance is subjective and its perception is affected by a number of contextual factors. To assess to what extent physicians agree on the relevance of evidence in the form of systematic reviews for a common set of patient cases, and to identify possible contextual factors that influence their perception of relevance. A web-based survey was used where pediatric emergency physicians from multiple academic centers across Canada were asked to evaluate the relevance of systematic reviews retrieved automatically for 14 written case vignettes (paper patients). The vignettes were derived from prospective data describing pediatric patients with asthma exacerbations presenting at the emergency department. To limit the cognitive burden on respondents, the number of reviews associated with each vignette was limited to three. Twenty-two academic emergency physicians with varying years of clinical practice completed the survey. There was no consensus in their evaluation of relevance of the retrieved reviews and physicians' assessments ranged from very relevant to irrelevant evidence, with the majority of evaluations being somewhere in the middle. This indicates that the study participants did not share a notion of relevance uniformly. Further analysis of commentaries provided by the physicians allowed identifying three possible contextual factors: expected specificity of evidence (acute vs chronic condition), the terminology used in the systematic reviews, and the micro environment of clinical setting. | There is no consensus among physicians with regards to what constitutes relevant clinical evidence for a given patient case. Subsequently, this finding suggests that evidence retrieval systems should allow for deep customization with regards to physician's preferences and contextual factors, including differences in the micro environment of each clinical setting. | closed_qa |
Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? | Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34% of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women. From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres. Overall, only 514 (30%) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21% to 37%, p = 0.0172), month of diagnosis (37% in February 2015 and 23% in March 2015 p = 0.0004) and age group (26% in 25-64 years and 49% in 18-25 years, p<0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36% from 30%. | Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women. | closed_qa |
Can the follow-up of patients with papillary thyroid carcinoma of low and intermediate risk and excellent response to initial therapy be simplified using second-generation thyroglobulin assays? | In view of the low probability of recurrence, the cost-effective follow-up of patients with papillary thyroid carcinoma (PTC) of low or intermediate risk and excellent response to initial therapy represents a challenge. This study evaluated the cases of structural recurrence among these patients. The sample comprised 578 patients with PTC of low or intermediate risk, who were submitted to total thyroidectomy with or without (131) I therapy and exhibited an excellent response to initial therapy defined based on nonstimulated thyroglobulin (Tg) ≤0·2 ng/ml and negative neck ultrasonography (US). Twelve patients (2%) showed structural recurrence. At the time when recurrence was 'confirmed', Tg elevation had not occurred in only two patients, one with lymph node metastases<1 cm detected by US and the other with pulmonary metastases. Antithyroglobulin antibodies (TgAb) were undetectable in both patients. The first alteration observed in patients with recurrence was Tg elevation in six patients, Tg elevation associated with suspicious US in three, and suspicious US in two. An increase in TgAb was not the first alteration in any of the patients. Among the 560 patients who continued to have Tg ≤ 0·2 ng/ml, US permitted the detection of only one neck recurrence. Measurement of TgAb did not detect any recurrence. | Our results confirm that in patients with PTC of low or intermediate risk an excellent response to initial therapy can be defined based on nonstimulated Tg ≤ 0·2 ng/ml. Follow-up consisting only of clinical examination and periodic measurement of Tg with a second-generation assay may be sufficient. | closed_qa |
Abdominal compartment syndrome in traumatic hemorrhagic shock: is there a fluid resuscitation inflection point associated with increased risk? | The volume of fluid administered during trauma resuscitation correlates with the risk of abdominal compartment syndrome (ACS). The exact volume at which this risk rises is uncertain. We established the inflection point for ACS risk during shock resuscitation. Using the Glue Grant database, patients aged ≥16 years with ACS were compared with those without ACS (no-ACS). Stepwise analysis of the sum or difference of the mean total fluid volume (TV)/kg, TV and/or body weight, (μ) and standard deviations (σ) vs % ACS at each point was used to determine the fluid inflection point. A total of 1,976 patients were included, of which 122 (6.2%) had ACS. Compared with no-ACS, ACS patients had a higher emergency room lactate (5.8 ± 3.0 vs 4.5 ± 2.8, P<.001), international normalized ratio (1.8 ± 1.5 vs 1.4 ± .8, P<.001), and mortality (37.7% vs 14.6%, P<.001). ACS group received a higher TV/kg (498 ± 268 mL/kg vs 293 ± 171 mL/kg, P<.001) than no-ACS. The % ACS increased exponentially with the sum of μ and incremental σ, with the sharpest increase occurring at TV and/or body weight = μ + 3σ or 1,302 mL/kg. | There is a dramatic rise in ACS risk after 1,302 mL/kg of fluid is administered. This plot could serve as a guide in limiting the ACS risk during resuscitation. | closed_qa |
Could transesophageal echocardiography be useful in selected cases during liver surgery resection? | Although only limited scientific evidence exists promoting the use of transesophageal echocardiography (TEE) in non cardiac surgery, several recent studies have documented its usefulness during liver surgery. In the present case study, through the use of color Doppler TEE, compression of the inferior vena cava and the right hepatic vein was clearly evident, as was their restoration after surgery. | TEE should be encouraged in patients undergoing liver resection, not only for hemodynamic monitoring, but also for its ability to provide information about the anatomy of the liver, its vessels, and inferior vena cava patency. | closed_qa |
Is 3-hour cyclosporine blood level superior to trough level in early post-renal transplantation period? | Cyclosporine dose is traditionally based on trough blood levels. Cyclosporine trough blood level correlates poorly with acute rejection and cyclosporine nephrotoxicity after renal transplantation. We determined whether cyclosporine blood level at any other time point is superior to cyclosporine trough blood level as a predictor of acute rejection and cyclosporine nephrotoxicity. Cyclosporine blood level was measured before (trough), and 1, 2, 3 and 4 hours after the dose in 156 initial renal transplant cases 2 to 4 days after the initiation of cyclosporine micro-emulsion formula administration. The cylosporine micro-emulsion dose was based on cyclosporine trough blood level targeting 250 to 400 microg./l. Regression analysis revealed that only delayed graft function (p = 0.007) and cyclosporine blood level after 3 hours (p = 0.008) predicted acute rejection. Mean cyclosporine trough blood level plus or minus standard error was not significantly different in patients with and without acute rejection (293+/-21 versus 294+/-11 microg./l.). Mean cyclosporine blood level after 3 hours was significantly lower in patients with acute rejection (1,156+/-90 versus 1,421+/-50, p = 0.008). Cases were divided into tertiles at levels after 3 hours (1,100 and 1,500 microg./l.). The group in which the level after 3 hours was less than 1,100 microg./l. had the highest acute rejection rate (22 of 50 patients, 44%) and a cyclosporine nephrotoxicity rate of 13% (7 of 52 patients). The group in which the level after 3 hours was 1,100 to 1,500 microg./l. had the lowest acute rejection rate (5 of 46 patients, 11%) without increased cyclosporine nephrotoxicity (7 of 52 patients, 13%). A level after 3 hours of greater than 1,500 microg./l. was associated with a rejection rate of 15% (7 of 47 patients) but significantly higher cyclosporine nephrotoxicity (16 of 52 patients, 30%). | Cyclosporine blood level after 3 hours in the early post-transplantation period is associated with acute rejection and cyclosporine nephrotoxicity. A cyclosporine blood level range after 3 hours of 1,100 to 1,500 microg./l. is associated with an optimal outcome. Our data suggest that cyclosporine blood level after 3 hours may represent a better method of monitoring cyclosporine micro-emulsion dose than cyclosporine trough blood level. This hypothesis must be further studied in randomized trials. | closed_qa |
Lack of diagnostic tools to prove erectile dysfunction: consequences for reimbursement? | Oral medications for treatment of erectile dysfunction may drastically increase health care expenses. Therefore, reimbursement for treatment will be limited in many countries. Proof of erectile dysfunction on an individual basis may be required. We determine whether erectile dysfunction can be proved by pharmacostimulation tests. We prospectively evaluated 77 consecutive patients with a median age of 54 years (range 25 to 75) who presented with previously untreated erectile dysfunction. Assessment included patient reported semiquantitative data on sexual erections (rigidity, ability for vaginal intromission, duration), standard clinical and laboratory tests, and intracavernous injection test and color duplex sonography with 10 microg. intracavernous prostaglandin E1. Data were compared on the basis of the most important complaint, namely whether vaginal intromission was impossible, feasible only with manual assistance or possible but not long enough for satisfactory sexual performance. Of the 77 patients 36 (47%) were unable to perform vaginal intromission, 28 (37%) needed manual help and 13 (17%) had erections sufficient for penetration but were not satisfied with sexual performance. Patient reports were reliable as shown by the significant correlation of items (r = 0.77) and significant discriminating power among categories for penetration (analysis of variance p<0.001). In contrast, clinical response to intracavernous pharmacostimulation and flow parameters assessed by color duplex sonography could not discriminate among the groups. | Erectile dysfunction could not be defined by pharmacostimulated erections but relevant erectile dysfunction was honestly reported. New and reliable tests for clinical assessment are required to support the application for reimbursement of treatment expenses for erectile dysfunction. | closed_qa |
Should vasectomy reversal be performed in men with older female partners? | An assumption exists that men with older female partners who seek treatment of post-vasectomy infertility should undergo in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) rather than vasectomy reversal. Although several studies have reviewed ICSI success rates with advancing maternal age, to our knowledge none has compared them to outcomes for vasectomy reversal in men with older partners. The records of all patients with ovulating partners older than 37 years who underwent vasectomy reversal from 1994 through 1998 were reviewed. Patients were contacted to establish pregnancy and birth rates. Costs of vasectomy reversal, testicular sperm extraction, IVF and ICSI were obtained from the financial office of our institution. A total of 29 patients underwent vasectomy reversal with a followup of 3 to 59 months (median 25). Median male age was 46 years (range 37 to 67) and median female age was 40 years (range 38 to 48). A total of 5 pregnancies and 4 live births were achieved. In the 23 patients followed for more than 1 year the pregnancy rate was 22% and live birth rate was 17%. Using this 17% birth rate at our $4,850 cost for vasectomy reversal the cost per newborn was $28,530. In comparison, using the 8% birth rate per cycle of ICSI for women older than 36 years at a cost of $8,315 for testicular sperm extraction and 1 cycle of IVF with ICSI, the cost per newborn was estimated at $103,940. | Vasectomy reversal appears to be cost-effective to achieve fertility in men with ovulating partners older than 37 years. | closed_qa |
Should the age specific prostate specific antigen cutoff for prostate biopsy be higher for black than for white men older than 50 years? | Investigators who have examined age specific reference ranges recommend a higher prostate specific antigen (PSA) cutoff for biopsy for black than for white men older than 50 years. We controlled for PSA to determine whether age specific reference range cutoffs for diagnosis defined by the Walter Reed Army Medical Center group (Walter Reed group) would improve the disproportionate prostate cancer prognosis between black and white men. We studied 651 consecutive patients who underwent radical prostatectomy at Wayne State University between 1991 and 1995 with a mean followup of 34 months (range 1.5 to 75). Log rank tests were used to determine the homogeneity of survival functions between black and white men with similar PSA ranges, and between groups defined by age specific PSA reference ranges for each race. Disease stage and grade were similar or worse in black men for any PSA range, and biochemical disease-free survival was similar or worse within each range. Black men had a higher percentage of high grade prostate cancer than white men 60 to 69 years old who would not have undergone biopsy using the Walter Reed group proposed PSA cutoff. | Black men have similar or worse prostate cancer severity and outcome than white men with similar PSA ranges. Using age specific reference ranges for the PSA test defined by the Walter Reed group, black men have worse outcome than white men after radical prostatectomy. Therefore, we recommend that the PSA cutoff for biopsy should not be higher for black men at any age range. | closed_qa |
Is surgery for large hepatocellular carcinoma justified? | Most hepatocellular carcinomas are still discovered at an advanced stage and are left untreated as large hepatocellular carcinomas are contraindications to liver transplantation and percutaneous ethanol injection and are usually considered as poor indications for liver resection. The aim of this study was to reassess the results of surgery in these patients. Between 1984 and 1996, 256 patients underwent resection of biopsy-proven, non-fibrolamellar hepatocellular carcinoma. Of these, 121 had a tumour diameter of less than 5 cm (small hepatocellular carcinomas) and 94 a tumour diameter of more than 8 cm (large hepatocellular carcinomas). The short- and long-term outcome of patients with small and large hepatocellular carcinomas were compared. The in-hospital mortality rate following resection of small and large hepatocellular carcinomas was comparable (11.5 vs. 10.6%), even after stratifying for the presence and severity of an underlying liver disease. In patients with a chronic liver disease, large hepatocellular carcinomas were associated with a greater risk of death and recurrence during the first 2 operative years. In the long term, however (3-5 years), survival and disease-free survival following resection of small and large hepatocellular carcinomas were comparable (34 vs. 31% and 25 vs. 21% at 5 years). Similarly, treatment of and survival after the onset of recurrence were not influenced by the size of the initial tumour. | Patients with large hepatocellular carcinomas should not be abandoned and should be considered for liver resection as this treatment may be associated with an in-hospital mortality rate and a long-term survival comparable to that observed after resection of small hepatocellular carcinomas. | closed_qa |
DSM-IV substance abuse and dependence: are there really two dimensions of substance use disorders in adolescents? | Data were collected using the 1995 Minnesota Student Survey. Survey items were designed to correspond to DSM-IV diagnostic criteria for substance abuse and dependence. Public schools, alternative schools and area learning centers. Of the 78,800 students between the ages of 14 and 18 years who completed the survey, 18,803 reported substance use and at least one substance use disorder diagnostic criterion during the previous 12 months and were used for the analyses. The sample was divided randomly into two groups in order to conduct data analyses on one group (n = 9490) and confirm the findings in the other group (n = 9313). Confirmatory factor analyses were conducted to test three competing factor structure models consisting of a single factor model, a two-factor model of distinct dimensions and a two-factor model with interrelated dimensions. The single factor and correlated two-factor models had similar parameter estimates and fit the data better than the competing two-factor model with distinct dimensions. Findings were confirmed in a second sample. | The study findings indicate that DSM-IV substance abuse and dependence criteria may be more optimally structured as a unidimensional construct rather than as bidimensional constructs for adolescents. | closed_qa |
Complications in the first year of laparoscopic gastric banding: is it acceptable? | From December 1997 to December 1998, 25 laparoscopic adjustable silicone gastric banding (LASGB) procedures were done without previous experience in bariatric surgery. Body mass index (BMI) ranged from 37 to 57 kg/m2 (average 45.5 kg/m2). Retrospective analysis of the 1-year experience was done. Operating time was measured, and BMI and complications were reviewed. Five complications were observed. There was a complication rate of 20%. On two occasions, it was gastric wall slippage, and both were corrected laparoscopically. In one patient, the intususception of the gastric wall through the band resulted after profuse vomiting. Removal of the band was necessary, with conversion to an open procedure. On two occasions, the infection of the port-site was observed, in one of these patients, port removal was necessary. No antibiotic prophylaxis was used. | Despite lack of experience in bariatric surgery in these laparoscopic surgeons, the complications with LASGB appear to be acceptable. Although prior bariatric surgical experience is preferable. | closed_qa |
Fingerstick Helicobacter pylori antibody test: better than laboratory serological testing? | Antibody testing is the recommended method to screen for Helicobacter pylori (H. pylori) infection. Whole-blood fingerstick antibody tests are simple, in-office tests providing rapid results, but the accuracy of first-generation tests was lower than other diagnostic tests. We assessed a new whole-blood antibody test, using endoscopic biopsy tests as a "gold standard," and compared it with a laboratory quantitative serological test. Two hundred-one patients not previously treated for H. pylori who were undergoing endoscopy had gastric biopsies for rapid urease test and histological examination; whole-blood antibody tests and quantitative serological tests were also performed. Two separate gold standards for H. pylori infection were employed: either rapid urease test or histological exam positive; and both rapid urease test and histological exam positive. Sensitivities for whole-blood test versus quantitative serology with gold standard 1 (either biopsy test positive) were 86% versus 92% (95% confidence interval [CI] of difference, -2-14%; p = 0.19) and specificities were 88% versus 77% (95% CI of difference, 0.4-22%; p = 0.052). Sensitivities with gold standard 2 (both biopsy tests positive) were 90% versus 94% (95% CI of difference, -4-12%; p = 0.41) and specificities were 79% versus 67% (95% CI of difference, 1-24%; p = 0.048). | New generation in-office, whole-blood antibody tests that can achieve a sensitivity and specificity similar to or better than those of widely used quantitative laboratory serological tests may be used as the initial screening tests of choice for H. pylori. | closed_qa |
Mortality in rheumatoid arthritis: have we made an impact in 4 decades? | To evaluate trends in survival among patients with rheumatoid arthritis (RA) over the past 4 decades. Three population based prevalence cohorts of all Rochester, Minnesota, residents age>or =35 years with RA (1987 American College of Rheumatology criteria) on January 1, 1965, January 1, 1975, and January 1, 1985; and an incidence cohort of all new cases of RA occurring in the same population between January 1, 1955 and January 1, 1985, were followed longitudinally through their entire medical records (including all inpatient and outpatient care by any provider) until death or migration from the county. Mortality was described using the Kaplan-Meier method and the influence of age, sex, rheumatoid factor (RF) positivity, and comorbidity (using the Charlson Comorbidity Index) on mortality was analyzed using Cox proportional hazards models. Mortality was statistically significantly worse than expected for each of the cohorts (overall p<0.0001). A trend toward increased mortality in the 1975 and 1985 prevalence cohorts compared to the 1965 prevalence cohort was present, even after adjusting for significant predictors of mortality (age, RF positivity, and comorbidity). Survival for the general population of Rochester residents of similar age and sex improved in 1975 compared to 1965, and in 1985 compared to 1975. | The excess mortality associated with RA has not changed in 4 decades. Moreover, people with RA have not enjoyed the same improvements in survival experienced by their non-RA peers. More attention should be paid to mortality as an outcome measure in RA. | closed_qa |
Does social integration confound the relation between alcohol consumption and mortality in the Multiple Risk Factor Intervention Trial (MRFIT)? | It has been proposed that social integration would act as a confounder in the relationship between alcohol consumption and all-cause mortality. This study tested the assumption that the J-shaped relationship between drinking and all-cause mortality may partly reflect a protective effect of social integration, to the extent that moderate drinkers are more socially integrated than either abstainers or heavy drinkers, and to the extent that social integration offers direct protection from mortality. This hypothesis was tested using data from 10,832 of the 12,866 men in the Multiple Risk Factor Intervention Trial (MRFIT). Indicators of social integration were derived from an exploratory factor analysis of 25 relevant items in the MRFIT data and from a scale of six items selected by the investigators. We failed to confirm a direct protective effect of social integration. Nondrinkers had the highest rates of all-cause mortality. Compared with heavy drinking, relative risks of all-cause mortality for abstinence, light and moderate drinking were unaffected by inclusion of social integration variables in the proportional hazards models. | The MRFIT data fail to confirm a confounding effect of social integration. | closed_qa |
Prostaglandin E1: a new agent for the prevention of renal dysfunction in high risk patients caused by radiocontrast media? | Acute renal failure following the administration of radiocontrast media (RCM) is a complication found especially in patients with impaired renal function. Within the limits of a pilot study, the objective was to (a) show the effectiveness and compatibility of prostaglandin E(1) (PGE(1)=Alprostadil) in preventing acute renal failure in patients with elevated levels of serum creatinine and (b) to identify the most appropriate PGE(1)-dose. 130 patients with renal impairment (serum creatinine>/=1.5 mg/dl) were included in the study prior to intravascular RCM injection. The patients received one of three different doses of PGE(1) (10, 20, or 40 ng/kg bodyweight/min) or placebo (physiologic sodium chloride solution) intravenously over a time period of 6 h (beginning 1 h prior to RCM application). Serum creatinine was measured 12, 24, and 48 h post RCM-application and creatinine clearance was determined with two 12 h collection periods, as well as one 24 h collection within 48 h post RCM administration. Adverse events during PGE(1) administration were recorded. In the placebo group, the mean elevation of serum creatinine was markedly higher (0.72 mg/dl) 48 h after RCM administration compared with the three PGE(1) groups (0.3 mg/dl in the 10 ng/kg/min group, 0. 12 mg in the 20 ng/kg/min group, and 0.29 mg/dl in the 40 ng/kg/min group). No clinically relevant changes were seen regarding the creatinine clearance in the four groups examined. | Results from this pilot-study suggest that intravenous PGE(1) may be used efficaciously and safely to prevent RCM-induced renal dysfunction in patients with pre-existing impaired renal function. | closed_qa |
Can nurses screen all outpatients? | This paper outlines and evaluates a nurse based model for screening outpatients that is utilized in our free standing Surgical Day Care Centre (SDCC). For 668 outpatients presenting at our SDCC, the attending anesthesiologist completed a study survey that was designed to identify: completeness of history; important concerns as judged by the pre-admission nurse; whether the patient was seen in the anesthesia preadmission clinic (PAC) for a consultation; if there was a delay in SDCC, the duration and reasons for the delay; whether in the opinion of the attending anesthesiologist the patient should have had an anesthetic consultation; whether the patient was canceled and the reason for cancellation. A nurse based model for screening all outpatients in a university affiliated tertiary hospital day care unit had an accuracy of 81%, specificity of 86%, sensitivity of 46% and a negative predictive value of 92%. The cancellation rate with this model was 1.4%(8/551) and the case delay rate was 3.4%(19/551). The referral rate to anesthesiology staff was 17.5%(117/668) and the referral rate to the PAC for anesthetic consultation was 5.1%(34/668). | The use of the nurse based model allowed for the efficient use of anesthesia and surgical day care centre resources. The model was better at 'ruling out' patients who do not need to be seen by anesthesiology ahead of the day of surgery rather than 'ruling in' patients who need to be seen by anesthesiology. | closed_qa |
Surgical management of renal trauma: is vascular control necessary? | To assess in a randomized prospective manner nephrectomy rate, transfusion rate, blood loss, and time of operation in penetrating renal trauma patients randomized to vascular control or no vascular control before opening Gerota's fascia. During a 53-month period from January of 1994 to May of 1998, 56 patients with penetrating renal injuries were entered into a randomized prospective study at an urban Level I trauma center. The patients were randomized to a preliminary vascular control group or no vascular control group. Randomization was performed intraoperatively before opening Gerota's fascia. All renal injuries were identified and diagnosed intraoperatively. Intravenous pyelography was not performed preoperatively. If the patient was randomized to the no control group and significant bleeding ensued after opening of Gerota's fascia, the renal hilum was cross-clamped. All injuries were included regardless of patient age, associated injuries, blood loss, severity of renal injury, or other abdominal organs injured. All injuries that required renorrhaphy or partial nephrectomy underwent drainage with closed Jackson-Pratt drainage. Twenty-nine patients were randomized to the preliminary vascular control group, and 27 patients were randomized to the no vascular control group. The average age in the vascular control group was 25.3 years (SD, 10.9) and 23.4 years (SD, 8.2) in the no control group. The average penetrating abdominal trauma index in the vascular control group was 22.9 (SD, 10.9) and in the no control group 23.7 (SD, 13.7). Nine nephrectomies (31%) were performed in the vascular control group, and eight nephrectomies (30%) were performed in the no vascular control group (p>0.05). The average operative time for the vascular control group was 127 minutes and for the no control group was 113 minutes (p>0.05). Eleven patients (38%) required intraoperative blood transfusion in the vascular control group (average, 5.5 U/patient transfused) versus eight patients (30%) in the no vascular control group (average, 5.2 U/patient transfused) (p>0.05). The average blood loss in the vascular control group was 1.06 liters versus 0.91 liters in the no control (p>0.05). There was one mortality in the study population. | Vascular control of the renal hilum before opening Gerota's fascia has no impact on nephrectomy rate, transfusion requirements, or blood loss. Operative time may be increased with the vascular control technique. | closed_qa |
A preliminary investigation into the use of virtual environments in memory retraining after vascular brain injury: indications for future strategy? | In a preliminary investigation of the use of Virtual Environments (VEs) in neurorehabilitation, this study compares the effects of active and passive experience of a VE on two types of memory in vascular brain injury patients and controls. Forty-eight patients with vascular brain injury and 48 non-impaired control participants were randomly assigned to active and passive VE conditions. The active participants explored a virtual bungalow seeking a particular object; the passive participants observed, but did not control movement through the VE, also seeking the object. Afterwards, both active and passive participants completed spatial recognition and object recognition tests. Expectedly, the patients were impaired relative to the controls but were able to perform the virtual tasks. Active participation in the VE enhanced memory for its spatial layout in both patients and controls. On object recognition, active and passive patients performed similarly, but passive controls performed better than active controls. | The findings are discussed in relation to their implications for memory rehabilitation strategies. | closed_qa |
Should the patient with an interatrial defect recognized in adulthood always be operated on? | Atrial septal defect (ASD) can be recognized in adult age, mostly in asymptomatic or scarcely symptomatic patients. These patients differ from patients in "historical" clinical series, in whom diagnosis was done on the basis of clinical evidence, and their natural history is probably different. Our aim was to verify retrospectively results of surgery versus medical follow-up in an adult population with ASD with age at first diagnosis>or = 30 years. Seventy-two patients with ASD, 52 females (72%), observed at our Institution since 1978, were considered. Mean age at diagnosis was 48 +/- 12 years (range 30-79); 36 patients (50%, group A) are still on medical therapy, 36 patients (group B) were operated. As groups A and B did not differ significantly in any demographic, clinical or echocardiographic parameter, they were compared for the incidence of complications. During follow-up (100 +/- 70 months, range 12-240), the incidence of major clinical events showed no significant differences in the two groups, as cardiac death or cardiovascular complications (cerebral ischemic events, severe mitral insufficiency, reoperation) occurred in 4 patients in group A (11%) and in 4 patients in group B (11%). Worsening of NYHA class was observed in 3 patients from group A (8%) and 2 patients from group B (5.5%; p = ns). New onset of supraventricular arrhythmias occurred more frequently in group B (14 patients, 39%) than in group A (5 patients, 14%) (p = 0.01; OR = 3.9; CI 95%: 1.2-12.6). | In an adult population affected with asymptomatic or mildly symptomatic ASD and age at first diagnosis>or = 30 years, surgical closure of the defect did not modify morbidity and mortality at a mid-term follow-up. We suggest that, mostly in older asymptomatic patients, surgery should not be a routine choice and clinical decision-making should be individualized in each case. | closed_qa |
Parathyroid adenomas: is bilateral neck exploration necessary? | The traditional surgical treatment for primary hyperparathyroidism is bilateral neck exploration with identification of all parathyroid glands. Multiple investigators who recommend initial unilateral neck exploration based on more advanced localization studies have recently challenged this approach. We reviewed our experience with primary hyperparathyroidism to determine if localization study-aided unilateral neck exploration is sufficient for a cure. Retrospective chart review of patients with primary hyperparathyroidism. Sixty-eight patients underwent surgery for primary hyperparathyroidism. Forty-four patients were treated with localization study-aided unilateral neck exploration, and 24 patients were treated with bilateral neck exploration without preoperative localization studies. The most successful preoperative localization study was the technetium 99m sestamibi (T99mS) scan which correctly identified the location of adenomas in all cases in which it was used (n = 15). All patients were treated with unilateral neck exploration and were cured. This success was matched only by surgical exploration (n = 24). | Unilateral neck exploration based on the results of a T99mS scan can be used as an initial approach for primary hyperparathyroidism if the scan identifies a solitary lesion. The second gland on the same side of the lesion should be biopsied, and if it is normal, the opposite side of the neck may be left undisturbed. If the second gland is not normal, or if the T99mS scan shows multiple lesions, bilateral neck exploration should be performed. | closed_qa |
Does axillary dissection affect prognosis in T1 breast tumors? | The treatment of patients with breast cancer has undergone many revisions over recent decades. The current trend is toward limited resections and breast conservation. Some authors advocate the abandonment of axillary lymph node dissection (ALND) for small tumors. While it is accepted that ALND has no therapeutic effect in breast cancer patients, its prognostic significance for small tumors is debated. Eligibility criteria for surgical treatment without axillary dissection are evolving. Considering that problem, we retrospectively reviewed the charts of 100 patients with T1 invasive carcinoma of the breast treated at Hippokration Hospital of Athens between 1986 and 1987. Patients were divided into two groups: those that underwent ALND (n=76) and those that did not (n=24). The following data were recorded: age, tumor size, grade, hormone receptor status and postoperative treatment. The ten-year overall and disease-free survival were analysed. A multivariate analysis was used to identify prognostic variables. There was no statistically significant difference in the ten-year overall and disease-free survival between the two groups. The univariate analysis showed that tumor size predicts both recurrence and survival. In the multivariate analysis tumor size was found to be an independent prognostic factor for overall survival. | ALND did not influence the ten-year survival or the recurrence rate. Tumor size was the only statistically significant and independent prognostic factor for T1 breast cancer patients. | closed_qa |
Pure stress leakage symptomatology: is it safe to discount detrusor instability? | To determine whether the combination of a urological history and urinary diary, with rigorous selection criteria, can be used to define a group of women on whom urodynamic assessment is unnecessary prior to offering surgery for urinary stress incontinence. Retrospective review of the urodynamic records of women attending for assessment between January 1992 and December 1996. Urodynamic Department, Southmead Hospital, Bristol. 5193 women who attended the urodynamic clinic during the five year study period. Self-completion of a urinary diary in the preceding week before urodynamic assessment and a detailed urological history before undergoing cystometry by all women in the study period. Data were entered onto a computer database. Women reporting stress incontinence in the absence of bladder filling symptoms, with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once, had the results of their filling cystometry analysed. Of 5193 women, 555 had symptoms of pure stress incontinence and a normal urinary diary. Incontinence was confirmed objectively in 81%, with 9% having incontinence secondary to detrusor instability; 5% had detrusor instability as the sole cause of their incontinence with 4% having a mixed picture of detrusor instability incontinence and urethral sphincter weakness. | Genuine stress incontinence cannot be diagnosed reliably from a urological history, even when rigorous selection criteria are used in combination with a normal urinary diary. Without cystometry, incontinence secondary to detrusor instability will be missed. | closed_qa |
Is an ultrasound assessment of gestational age at the first antenatal visit of value? | To assess the efficacy of an ultrasound scan at the first antenatal visit. Randomised clinical trial. Women's and Children's tertiary level hospital, Adelaide, Australia. Six hundred and forty-eight women attending for their first antenatal visit at less than 17 weeks of gestation who had no previous ultrasound scan in the pregnancy, who were expected to give birth at the hospital, and for whom there was no indication for an ultrasound at their first visit. Eligible consenting women were enrolled by telephone randomisation into either the ultrasound at first visit group, who had an ultrasound at the time of their first antenatal visit, or the control group in whom no ultrasound assessment was done at their first antenatal visit. Both groups of women completed a questionnaire at the end of the first visit on their feelings towards the pregnancy and anxiety levels. Data were collected on details of any ultrasound assessments, including the 18 to 20 weeks morphology scan, and pregnancy outcome. All primary analyses were on an intention-to-treat basis. The number of women who needed adjustment in dates of 10 days or more on the basis of their 18 to 20 weeks ultrasound morphology scan, who were booked for their morphology scan at sub-optimal gestations, who had a repeat of their maternal serum screening test, or who felt worried about their pregnancy at the end of the first antenatal visit. Fewer women (9%) in the ultrasound at first visit group needed adjustment of their expected date of delivery as a result of the 18 to 20 week ultrasound, compared with 18% of women in the control group (RR 0.52, 95% CI 0.34-0.79; P = 0.002). The number of women who had the 18 to 20 week ultrasound assessment timed suboptimally was similar to that in the control group (16% vs. 21%), as was the number of women who had a repeat blood sample taken for maternal serum screening (6% vs. 6%). Fewer women in the ultrasound at first visit group reported feeling worried about their pregnancy (RR 0.80, 95% CI 0.65-0.99; P = 0.04) or not feeling relaxed about their pregnancy (RR 0.73, 95% CI 0.56-0.96; P = 0.02), compared with women in the control group. | A routine ultrasound assessment for dating offered to women at the first antenatal visit provides more precise estimates of gestational age and reduces the need to adjust the estimate of the date of delivery in mid-gestation. Women who had an ultrasound at the first visit reported more positive feelings about their pregnancy, compared with women in the control group at that time. | closed_qa |
Does an inflatable obstetric belt facilitate spontaneous vaginal delivery in nulliparae with epidural analgesia? | To assess whether an inflatable obstetric belt, synchronised to apply uniform fundal pressure during a uterine contraction, reduces operative delivery rates when used in the second stage of labour. Randomised controlled trial. Five hundred nulliparae with a singleton cephalic pregnancy at term and with an epidural in labour were recruited during the first stage and randomised at full dilatation. Standard care involved one hour passive second stage and one hour active pushing after which instrumental delivery was performed if delivery was not imminent. Those randomised to the belt group, in addition to standard care, had the inflatable obstetric belt for the whole second stage of labour. Mode of delivery. One hundred and eleven of the 260 women in the belt group (42.7%) compared with 94 of the 240 in the control group (39.2%) had a spontaneous vertex delivery (P = 0.423). The lift-out instrumental delivery rate was similar between the two groups: 108 belts (41.5%), compared with 101 controls (42.1%) (P = 0.902), whereas rotational instrumental deliveries in the belt group were 26 belts (10%) compared with 36 controls (15%) (P = 0.09). Fifteen women (5.8%) in the belt group and nine women (3.8%) in the control group had a caesarean section in the second stage (P = 0.292). An intact perineum was more likely in the belt group (16.5% compared with 9.6%, P = 0.022) as was a third degree tear (6.5% compared with 0.4%, P = 0.001). | The inflatable obstetric belt did not significantly reduce operative delivery rates when used in this clinical setting in the second stage of labour. | closed_qa |
Isolated fetal echogenic intracardiac foci or golf balls: is karyotyping for Down's syndrome indicated? | To determine the prevalence of isolated echogenic intracardiac foci and the subsequent risk for Down's syndrome at 18-23 weeks in an unselected obstetric population. Prospective study. A district general hospital serving a routine obstetric population. 16,917 pregnant women who underwent a routine ultrasound screening at 18-23 weeks of gestation between November 1994 and August 1998. All women were offered screening for Down's syndrome by nuchal translucency or maternal serum biochemistry. The prevalence of isolated echogenic intracardiac foci was determined and the relative risk for Down's syndrome was calculated for different ultrasound findings. The combined sensitivity of age, nuchal translucency and maternal serum biochemistry for Down's syndrome was 84% (27/32). The relative risk for Down's syndrome was 0.17 (95% CI 0.07-0.41) for the women with normal scan findings at 18-23 weeks. The prevalence of isolated echogenic intracardiac foci at 18-23 weeks was 0.9% (144/16,917). None of these pregnancies were affected by Down's syndrome. | The significance of the association between isolated echogenic intracardiac foci and Down's syndrome is a matter of ongoing debate. The data of this study suggest that in an unselected obstetric population with prior, effective, routine Down's syndrome screening, the association between isolated echogenic intracardiac foci and Down's syndrome is no longer significant. | closed_qa |
Preparation of the internal thoracic artery by vasodilator drugs: is it really necessary? | The internal thoracic artery has become the conduit of choice for coronary artery bypass grafting. To avoid spasm of the artery, and increases in its diameter and flow, various vasodilators have been used either intraluminally or by topical application by different surgeons. In order to define the best vasodilating agent for preparation of the internal thoracic artery, a randomized double-blind placebo-controlled clinical study was performed in a group of patients submitted for elective coronary artery bypass grafting. Eighty (80) consecutive patients submitted for elective first time coronary artery bypass grafting were randomly subdivided into five treatment groups. Free flow of the left internal thoracic artery was measured using an electromagnetic flow meter. The first measurement was performed shortly after the internal thoracic artery was dissected from the chest wall and the second just prior to performing distal anastomosis to the left anterior descending coronary artery. During the time interval between the two measurements the internal thoracic artery was immersed in a special applicator tube containing 20 ml solution of one of the following drugs: papaverin 2 mg/ml, nitroglycerin 1 mg/ml, verapamil 0.5 mg/ml, nitroprusside 0.5 mg/ml, normal saline 0.9%. No statistically significant differences were found between the groups in respect to age, body surface area, bypass time, cross clamping time, and time interval between the two flow measurements. Mean arterial pressure at the time of the first and second internal thoracic artery flow measurements did not show statistically significant differences either within or between the groups. In all five groups, the free flow of the internal thoracic artery increased significantly with time. However, no statistically significant differences were shown between the five groups with respect to second flow (P = 0.2). | Within the limits of our study design, we suggest that preparation of the LITA by topical vasodilator drugs using a special applicator tube does not result in a significantly superior free flow than placebo. | closed_qa |
The medical review article revisited: has the science improved? | The validity of a review depends on its methodologic quality. To determine the methodologic quality of recently published review articles. Critical appraisal. All reviews of clinical topics published in six general medical journals in 1996. Explicit criteria that have been published and validated were used. Of 158 review articles, only 2 satisfied all 10 methodologic criteria (median number of criteria satisfied, 1). Less than a quarter of the articles described how evidence was identified, evaluated, or integrated; 34% addressed a focused clinical question; and 39% identified gaps in existing knowledge. Of the 111 reviews that made treatment recommendations, 48% provided an estimate of the magnitude of potential benefits (and 34%, the potential adverse effects) of the treatment options, 45% cited randomized clinical trials to support their recommendations, and only 6% made any reference to costs. | The methodologic quality of clinical review articles is highly variable, and many of these articles do not specify systematic methods. | closed_qa |
Does a glass of red wine improve endothelial function? | To examine the acute effect of red wine and de-alcoholized red wine on endothelial function. High frequency ultrasound was used to measure blood flow and percentage brachial artery dilatation after reactive hyperaemia induced by forearm cuff occlusion in 12 healthy subjects, less than 40 years of age, without known cardiovascular risk factors. The subjects drank 250 ml of red wine with or without alcohol over 10 min according to a randomized procedure. Brachial artery dilatation was measured again 30 and 60 min after the subjects had finished drinking. The subjects were studied a second time within a week of the first study in a cross-over design. After the red wine with alcohol the resting brachial artery diameter, resting blood flow, heart rate and plasma-ethanol increased significantly. After the de-alcoholized red wine these parameters were unchanged. Flow-mediated dilatation of the brachial artery was significantly higher (P<0.05) after drinking de-alcoholized red wine (5.6+/-3.2%) than after drinking red wine with alcohol (3.6+/-2.2%) and before drinking (3.9+/-2.5%). | After ingestion of red wine with alcohol the brachial artery dilated and the blood flow increased. These changes were not observed following the de-alcoholized red wine and were thus attributable to ethanol. These haemodynamic changes may have concealed an effect on flow-mediated brachial artery dilatation which did not increase after drinking red wine with alcohol. Flow-mediated dilatation of the brachial artery increased significantly after de-alcoholized red wine and this finding may support the hypothesis that antioxidant qualities of red wine, rather than ethanol in itself, may protect against cardiovascular disease. | closed_qa |
Does a completely accomplished duplex-based surveillance prevent vein-graft failure? | to assess the benefits of duplex-based vein-graft surveillance over clinical surveillance with distal pressure measurements. prospective randomised comparative trial. three hundred and forty-four patients with 362 consecutive infrainguinal vein bypasses were prospectively randomised to a follow-up regime with or without duplex scanning (ABI group and DD group) at 1, 3, 6, 9, and 12 months postoperatively. one hundred and eighty-three grafts were enrolled to the ABI group and 179 to the DD group. The primary assisted patency, secondary patency and limb salvage rates were 67%, 74%, 85% for the ABI group and 67%, 73%, 81% for the DD group. Ninety grafts in the ABI group and 57 in the DD group had surveillance that completely adhered to the protocol. The outcome was also similar for these groups at one year (77%, 87%, 94% and 77%, 83%, 93% respectively), although grafts were revised more frequently in the DD group. | intensive surveillance with duplex scanning did not improve the results of any outcome criteria examined. To demonstrate any potential benefit of duplex scanning for vein-graft surveillance a multicentre study with a large number of patients to ensure sufficient power is needed. | closed_qa |
Do prostaglandins have a salutary role in skeletal muscle ischaemia-reperfusion injury? | the effects of prostaglandins (PG) E1, E2, and the prostacyclin analogue iloprost with and without the addition of free-radical scavengers catalase and superoxide dismutase on gastrocnemius blood flow and oedema were studied in a rodent model of hindlimb ischaemia-reperfusion. male Sprague-Dawley rats underwent 6-h hindlimb ischaemia with 4-h reperfusion. Prostaglandins were infused prior to reperfusion and their effects on limb blood flow and oedema examined. control animals exhibited a triphasic pattern of muscle blood flow during reperfusion compared to normal animals. PGE1 did not abolish low reflow at 10 min, relative reperfusion was preserved but reperfusion injury was abolished at 120 min. Muscle blood flow was increased at 240 min compared to controls. Increased limb swelling was also seen. Addition of free-radical scavengers caused the abolition of low reflow. Similar results were seen with iloprost. PGE2 abolished low reflow at 10 min and increased perfusion at 120 min but did not prevent reperfusion injury at 240 min. | PGE1 and iloprost enhance muscle blood flow at 4-h reperfusion, though neither abolishes low reflow; PGE2 improved flow at 10 and 120 min but not after 240 min. This study demonstrates a potentially beneficial role for prostaglandins in improving muscle blood flow in skeletal muscle ischaemia-reperfusion injury. | closed_qa |
Occurrence of hippocampal sclerosis: is one hemisphere or gender more vulnerable? | We analyzed a large group of patients investigated for suspected seizures to test whether gender or side are important factors in the origins of hippocampal sclerosis (HS). We studied 996 consecutive patients (48% men, 52% women) by using standard hippocampal T2-relaxometry methods. HS was associated with a highly abnormal T2 time (<or =113 ms). Categoric analysis showed that hippocampal T2 time was independent of gender and side. T2 time was bilaterally normal in 81% of men and in 79% of women; it was unilaterally abnormal in 15% of both men and women; and bilaterally abnormal in 4% of men and in 6% of women. Highly abnormal T2 relaxometry, suggesting HS, occurred with equal frequency in men and women and on the right and left sides. Quantitative analysis of hippocampal T2 times showed values not differing significantly between men and women or between the right and left hemispheres. There was no significant interaction between gender and side. | In patients with seizure disorders, hippocampal T2 relaxometry is not different in adult men and women and in the right and left hemispheres. | closed_qa |
Can interpectoral nodes be sentinel nodes? | This study was designed to determine if interpectoral nodes could be sentinel nodes for some breast cancers. Thirty-five consecutive breast cancer patients undergoing axillary node dissection had a dissection of the interpectoral nodes. These were sent to pathology as a separate specimen. Three patients were identified with isolated interpectoral nodal metastasis. | In upper quadrants or deep breast cancers the interpectoral nodes may be the earliest site of nodal metastasis. This may lead to false negative results in some sentinel node biopsies. | closed_qa |
Do subjects with asthma have greater perception of acute bronchoconstriction than smokers with airflow limitation? | Smokers who develop chronic airflow limitation (CAL) do not usually present for medical attention until their lung disease is well advanced. In contrast, asthmatic subjects experience acute symptoms and present for care early in the course of their disease. The aim of this study was to determine whether subjects with asthma differ from smokers with CAL in their ability to perceive acute methacholine-induced bronchoconstriction. Thirteen subjects with diagnosed asthma and 10 current smokers with CAL, defined as forced expiratory volume in 1 s (FEV1)<75% predicted and FEV1/forced vital capacity<80%, with no previous diagnosis of asthma, were challenged with methacholine. Symptom severity was recorded on a Borg scale. Lung volumes were measured before challenge and after the FEV1 had fallen by 20%. After methacholine falls in FEV1 were similar in the asthmatic subjects and smokers. The regression lines relating change in FEV1 to symptom score were significantly steeper in asthmatic subjects than smokers (0.13 +/- 0.04, 0.03 +/- 0.04, respectively, P<0.01). At 20% fall in FEV1 there were no significant differences between asthmatic subjects and smokers in the magnitude of change of lung volumes. | In asthmatic subjects, symptoms are closely related to change in FEV1. In smokers with CAL, symptoms change little during bronchial challenge despite large changes in FEV1. The differences in perception between the two subject groups are not due to differences in acute hyperinflation during challenge. We propose that heavy smokers may adapt to poor lung function, or may have damaged sensory nerves as a result of prolonged cigarette smoking. | closed_qa |
Is there a relationship between serum S-100beta protein and neuropsychologic dysfunction after cardiopulmonary bypass? | Over the past decade, the glial protein S-100beta has been used to detect cerebral injury in a number of clinical settings including cardiac surgery. Previous investigations suggest that S-100beta is capable of identifying patients with cerebral dysfunction after cardiopulmonary bypass. Whether detection of elevated levels S-100beta reflects long-term cognitive impairment remains to be shown. The present study evaluated whether perioperative release of S-100beta after coronary artery operations with cardiopulmonary bypass could predict early or late neuropsychologic impairment. A total of 100 patients undergoing elective coronary bypass without a previous history of neurologic events were prospectively studied. To exclude noncerebral sources of S-100beta, we did not use cardiotomy suction or retransfusion of shed mediastinal blood. Serial perioperative measurements of S-100beta were performed with the use of a new sensitive immunoluminometric assay up to 8 hours after the operation. Patients underwent cognitive testing on a battery of 11 tests before the operation, before discharge from the hospital, and 3 months later. No significant correlation was found between S-100beta release and neuropsychologic measures either 5 days or 3 months after the operation. | Despite using a sensitive immunoluminometric assay of S-100beta, we found no evidence to support the suggestion that early release of S-100beta may reflect long-term neurologic injury capable of producing cognitive impairment. | closed_qa |
Is herniography an effective and safe investigation? | The records of all patients undergoing herniography within one unit over a 1 year period were studied retrospectively. A follow-up postal questionnaire was sent out to all patients enquiring about outcome and any complications of herniography. From a total of 64 patients undergoing a herniogram, 36% were found to have a positive result and 64% a negative result. This study showed a sensitivity rate of 0.94 and a specificity rate of 0.95. There was a 5% major complication rate leading to hospital admission, and 42% of patients described minor complications occurring within 24 hours of herniography. | Herniography is a useful diagnostic tool for identification of clinically occult hernias, with good rates of sensitivity and specificity. In most cases it is a safe investigation but it is not without a significant complication rate. | closed_qa |
Does exchanging comments of Indian and non-Indian reviewers improve the quality of manuscript reviews? | The quality of peer reviewing in developing countries is thought to be poor. To examine whether this was so, we compared the performance of Indian and non-Indian reviewers who were sent original and review articles submitted to The National Medical Journal of India. We also tested whether informing reviewers that their comments would be exchanged improved the quality of their reviews. In a prospective, randomized, blinded study, we sent 100 manuscripts to pairs of peer reviewers (Indian and non-Indian) of which 78 pairs of completed replies were available for analysis. Thirty-eight pairs of reviews were exchanged and 40 were not. The quality of the reviews was assessed by two editors who were unaware of the reviewers' nationality and whether they had been told that their reviews would be exchanged. The quality of the reviews was scored out of 100 (based on a predesigned evaluation proforma). We also measured the time taken to return a manuscript. Overall, non-Indian reviewers scored higher than Indians (mean scores non-Indians first, 56.7 v. 48.6, p<0.001), especially those in the non-exchanged group (58.4 v. 47.3, p<0.001) but not the exchanged group (54.8 v. 50.0, p<0.06). Being informed that reviews would be exchanged did not affect the quality of reviews by non-Indians (54.8 exchanged v. 58.4 non-exchanged) or of reviews by Indians (50.0 exchanged v. 47.3 non-exchanged). The editors' assessment of the reviewers matched well (r = 0.59, p<0.001). Non-Indians took the same amount of time as Indians to return their reviews, although the postage time was at least eight days longer. | We found that non-Indian peer reviewers were better than Indians and informing them that their views would be exchanged did not seem to affect the quality of their reviews. We suggest that Indian editors should also use non-Indian reviewers and start training programmes to improve the quality of peer reviews in India. | closed_qa |
Radiation exposure during fluoroscopy: should we be protecting our thyroids? | Recent reports on thyroid cancer among Australian orthopaedic surgeons prompted the present study which sought to evaluate the effectiveness of lead shielding in reducing radiation exposure (RE) to the thyroid region during endo-urological procedures. Radiation exposure to the thyroid region of the surgeon and scrubbed nurse was monitored for 20 consecutive operations over a 6-week period by thermoluminescent dosimeters (TLD). A TLD was placed over and underneath a thyroid shield of 0.5 min lead equivalent thickness to monitor the effect of shielding. Eight percutaneous nephrolithotomies, seven retrograde pyelograms and ureteric stentings and five ureteroscopies for calculous disease were monitored. Total exposure time was 63.1 min. For the surgeon, the total cumulative RE over and under the lead shield was 0.46 and 0.02 mSv, respectively, equating to a 23-times reduction in RE if shielding was used. This effectively reduced RE to almost background levels, which was represented by the control TLD exposure (0.01 mSv). | Although RE without thyroid shields did not exceed current standards set by radiation safety authorities, no threshold level has been set below which thyroid carcinogenesis is unlikely to occur. Because lead shields are easy to wear and can effectively reduce RE to the thyroid region to near-background levels, they should be made easily available and used by all surgeons to avoid the harmful effects of radiation on the thyroid. | closed_qa |
Gender differences in musculoskeletal injury rates: a function of symptom reporting? | This study determined gender differences in voluntary reporting of lower extremity musculoskeletal injuries among U.S, Marine Corps (USMC) recruits, and it examined the association between these differences and the higher injury rates typically found among women trainees. Subjects were 176 male and 241 female enlisted USMC recruits who were followed prospectively through 11 wk (men) and 12 wk (women) of boot camp training. Reported injuries were measured by medical record reviews. Unreported injuries were determined by a questionnaire and a medical examination administered at the completion of training. Among female recruits the most commonly reported injuries were patellofemoral syndrome (10.0% of subjects), ankle sprain (9.1%), and iliotibial band syndrome (5.8%); the most common unreported injuries were patellofemoral syndrome (2.1%), metatarsalgia (1.7%), and unspecified knee pain (1.7%). Among male recruits iliotibial band syndrome (4.0% of subjects), ankle sprain (2.8%), and Achilles tendinitis/bursitis (2.8%) were the most frequently reported injuries; shin splints (4.6%), iliotibial band syndrome (4.0%), and ankle sprain (2.8%) were the most common unreported diagnoses. Female recruits were more likely to have a reported injury than male recruits (44.0% vs 25.6%, relative risk (RR) = 1.72, 95% confidence interval (CI) 1.29-2.30), but they were less likely to have an unreported injury (11.6% vs 23.9%, RR = 0.49, 95% CI 0.31-0.75). When both reported and unreported injuries were measured, total injury rates were high for both sexes (53.5% women, 45.5% men, RR = 1.18, 95% CI 0.96-1.44), but the difference between the rates was not statistically significant. | Our results indicate that the higher injury rates often found in female military trainees may be explained by gender differences in symptom reporting. | closed_qa |
Minimally invasive saphenous vein harvesting: is there an improvement of the results with the endoscopic approach? | In the postoperative course after conventional open removal of the greater saphenous vein, wound healing disturbances are common and often painful. Therefore the primary goal of this investigation was to prove the safety and practicability of this new less invasive technique for saphenous vein harvesting and the effect on complications and morbidity. The study comprised 103 coronary artery bypass grafting (CABG) patients with an endoscopic approach to harvest the saphenous vein (MIVH). We used the VasoView II system developed by Origin, and compared the intraoperative procedure time and the clinical results with 105 equivalent patients in which a conventional open technique was used. In 101 patients endoscopic vein harvesting was successful; a conversion into open technique was necessary in two patients. On average 2.6 vein segments could be harvested in the endogroup versus 2.9 segments in the opengroup. The mean procedure time was 13.2 min per segment in the endogroup compared to 12.2 min per segment in the opengroup. Relevant hematoma were found in 29 patients (27.6%) of the opengroup, whereas only nine patients (8.7%) of the endogroup revealed severe hematoma. Infection was apparent in nine patients (8.5%) after conventional vein harvesting. Two infections were found after endoscopic intervention. | Endoscopic saphenous vein harvesting as part of a less invasive concept in cardiac surgery is a safe and after the learning curve, fast alternative to harvest the saphenous graft. The cosmetic result is excellent and the complication rate seems to be lower. It must be noted however, that the cost effectiveness of the method has to be proved and that further histological and functional studies are needed in order to check the intimal structure of the vein. | closed_qa |
Endogenous mediators in emergency department patients with presumed sepsis: are levels associated with progression to severe sepsis and death? | We sought to determine whether levels of the endogenous mediators tumor necrosis factor (TNF)-alpha, interleukin (IL) 6, and nitric oxide (NO) measured in patients with presumed sepsis (systemic inflammatory response syndrome [SIRS] and infection) are different than levels in patients with presumed noninfectious SIRS, whether levels are associated with septic complications, and whether there are potential relationships between mediators. A prospective, observational tricenter study of a convenience sample of adults presenting to the emergency department meeting Bone's criteria for SIRS (any combination of fever or hypothermia, tachycardia, tachypnea, or WBC count aberration) was performed. Mediator levels were determined and associated with deterioration to severe sepsis (hypotension, hypoperfusion, or organ dysfunction) and death in subjects admitted to the hospital with presumed sepsis. One hundred eighty subjects with SIRS were enrolled and classified into 3 groups: group 1 (SIRS, presumed infection, admitted; n=108), group 2 (SIRS, presumed infection, discharged; n=27), and group 3 (SIRS, presumed noninfectious, admitted; n=45). Group 1 TNF-alpha and IL-6 levels were significantly higher than those found in the other groups. NO levels for groups 1 and 2 were significantly lower than those for group 3. TNF-alpha and IL-6 levels were higher in the group 1 subjects who had bacteremia or progressed to severe sepsis or death. NO levels were not associated with these outcomes. | ED patients admitted with presumed sepsis have elevated cytokine levels compared with patients with sepsis who are discharged and with those patients with presumed noninfectious SIRS. An association appears to exist between cytokines and subsequent septic complications in these patients. The importance of these measures as clinical predictors for the presence of infection and subsequent septic complications needs to be evaluated. | closed_qa |
Angel trumpet: a poisonous garden plant as a new addictive drug? | Angel's trumpet (Species Brugmansia) is widely used as a garden plant because it is easily kept and the luxuriance of its flowering. Belonging to the Family Solanacea it contains a large amount of alkaloids (parasympatholytics). Because of its hallucinogenic action, its leaves and flowers are increasingly used by young people as a substitute for the hallucinogen LSD (lysergic acid diethylamide). In the summer of 1997, one of a group of youths died after they had ingested its flowers which they had gathered from front gardens. An investigation was undertaken to identify the alkaloids and measure their concentration in the various parts of the plant. Four young and one eight-year old plant were kept outdoors from May until October, and its flowers and leaves were removed for analysis weekly. All samples were deep-frozen at -20 degrees C and later, at the same time, thawed out, weighed and extracted in methanol. The alkaloids were identified by high pressure liquid chromatography (HPLC), diode array detector, separated by means of a Hypersil HyPurity cartridge, and measured at a wave-length of 220 nm. All 66 flowers, 32 leaves and 2 speed capsules contained tropane alkaloids, mainly scopolamine. The highest concentrations were found in the seed capsules, lower ones in the flowers, while the leaves contained only small amounts. Total alkaloid content per flower of the younger plants averaged 0.94 mg, of the younger ones 1.81 mg. The flowers of the old plant contained up to 3 mg scopolamine. | The ingestion of even a few flowers of Angel's trumpet can cause symptoms of poisoning. Easy availability of the plant thus presents a danger. Because of the increasing incidence of deliberate ingestion by young people, poisoning by Angel's trumpet should be included in the differential diagnosis in patients with confusion and hallucinations of uncertain origin, especially during the summer months. | closed_qa |
Malacoplakia: a possible complication of poorly controlled diabetes mellitus? | A 47-year-old woman with poorly controlled diabetes mellitus (HbA1C 9.2%, fasting blood glucose>200 mg/dl) had complained of moderately severe stabbing pain in the left abdomen. On admission there were no abnormal findings on abdominal palpation. Abdominal ultrasound and computed tomography (CT) revealed a partly solid partly cystic well-circumscribed space-occupying lesion, about 15 cm in diameter, in the left abdomen, extending from the lower third of the kidney into the pelvis. Biopsy of the lesion showed chronic granulating inflammation with foamy histiocytes (Hansemann macrophages) as characteristic substrate of extensive malakoplakia. Despite the size of the lesion it was not excised but long-term treatment with ciprofloxacin undertaken. At the same time, the diabetes was carefully controlled with ordinary insulin. Ten months later there was no longer any evidence of the lesion by ultrasound and CT. | Even extensive malakoplakia can be successfully treated with ciprofloxacin. Poorly controlled diabetes together with a weak immune status (CD4/CD8<or = 1) may have favoured the occurrence of malakoplakia. | closed_qa |
Iodine deficiency in ambulatory participants at a Sydney teaching hospital: is Australia truly iodine replete? | To assess iodine status in four separate groups--pregnant women, postpartum women, patients with diabetes mellitus and volunteers. Prospective cross-sectional study at a tertiary referral hospital in Sydney. 81 pregnant women attending a "high risk" obstetric clinic; 26 of these same women who attended three months postpartum; 135 consecutive patients with diabetes mellitus attending the diabetes clinic for an annual complications screen; and 19 volunteers. There were no exclusion criteria. Spot urine samples were obtained, and urinary iodine was measured by inductively coupled plasma mass spectrometer. Iodine status based on urinary iodine concentration categorised as normal (>100 micrograms/L), mild deficiency (51-100 micrograms/L) and moderate to severe deficiency (<50 micrograms/L). Moderate to severe iodine deficiency was found in 16 pregnant women (19.8%), five postpartum women (19.2%), 46 patients with diabetes (34.1%) and five volunteers (26.3%). Mild iodine deficiency was found in an additional 24 pregnant women (29.6%), nine postpartum women (34.6%), 51 patients with diabetes (37.8%) and 9 normal volunteers (47.4%). Median urinary iodine concentration was 104 micrograms/L in pregnant women, 79 micrograms/L in postpartum women, 65 micrograms/L in patients with diabetes mellitus and 64 micrograms/L in volunteers. | The high frequency of iodine deficiency found in our participants suggests that dietary sources of iodine in this country may no longer be sufficient. Further population studies are required. | closed_qa |
Co-infection with malaria and HIV in injecting drug users in Brazil: a new challenge to public health? | To describe AIDS and malaria geography in Brazil, highlighting the role of injecting drug users (IDUs) in malaria outbreaks occurring in malaria-free regions, and the potential clinical and public health implications of malaria/HIV co-infection. Review of the available literature and original analyses using geoprocessing and spatial analysis techniques. Both HIV/AIDS and malaria distribution are currently undergoing profound changes in Brazil, with mutual expansion to intersecting geographical regions and social networks. Very recent reports describe the first clinical case of AIDS in a remote Amazonian ethnic group, as well as malaria cases in Rio de Janeiro state (hitherto a malaria-free area for 20 years); in addition, two outbreaks of both infections occurred at the beginning of the 1990s in the most industrialized Brazilian state (São Paulo), due to the sharing of needles and syringes by drug users. Spatial data point to: (a) the expansion of HIV/AIDS towards malarigenic areas located in the centre-west and north of Brazil, along the main cocaine trafficking routes, with IDU networks apparently playing a core role; and (b) the possibility of new outbreaks of secondary malaria in urban settings where HIV/AIDS is still expanding, through the sharing of needles and syringes. | New outbreaks of cases of HIV and malaria are likely to occur among Brazilian IDUs, and might conceivably contribute to the development of treatment-resistant strains of malaria in this population. Health professionals should be alert to this possibility, which could also eventually occur in IDU networks in developed countries. | closed_qa |
Does the subspecialty of the surgeon performing primary colonic resection influence the outcome of patients with hepatic metastases referred for resection? | To compare resection rates and outcome of patients subsequently referred with hepatic metastases whose initial colon cancers were resected by surgeons with different specialty interests. Variation in practice among noncolorectal specialist surgeons has led to recommendations that colorectal cancers should be treated by surgeons trained in colorectal surgery or surgical oncology. The resectability of metastases, the frequency and pattern of recurrence after resection, and the length of survival were compared in patients referred to a single center for resection of colorectal hepatic metastases. The patients were divided into those whose colorectal resection had been performed by general surgeons (GS) with other subspecialty interests (n = 108) or by colorectal specialists (CS; n = 122). RESULTS No differences were observed with respect to age, sex, tumor stage, site of primary tumor, or frequency of synchronous metastases. Comparing the GS group with the CS group, resectable disease was identified in 26% versus 66%, with tumor recurrence after a median follow-up of 19 months in 75% versus 44%, respectively. Recurrences involving bowel or lymph nodes accounted for 55% versus 24% of all recurrences, with respective median survivals of 14 months versus 26 months. | Fewer patients referred by general surgeons had resectable liver disease. After surgery, recurrent tumor was more likely to develop in the GS group; their overall outcome was worse than that of the CS group. This observation is partly explained by a lower local recurrence rate in the CS group. | closed_qa |
Linked production of antibodies to mammalian DNA and to human polyomavirus large T antigen: footprints of a common molecular and cellular process? | To test whether the presence of antibodies to human polyomavirus large T antigen, a viral DNA-binding protein essential for productive polyomavirus replication, correlates with the presence of antibodies to single-stranded DNA (ssDNA), double-stranded DNA (dsDNA), or the autologous TATA-binding protein (TBP). Sera from patients with various diagnosed or suspected autoimmune syndromes were analyzed for the presence of antibodies to T antigen, DNA, or TATA-binding protein, and correlations were determined. Rheumatoid factor (RF) was studied as a control antibody. A highly significant correlation between antibodies to T antigen and antibodies to ssDNA or TATA-binding protein, but not between anti-T antigen antibodies and RF, was found in all patient groups. Of all sera that were positive for antibodies to dsDNA, 62% were positive for antibodies to T antigen (P<0.03). | A non-self DNA-binding protein such as human polyomavirus large T antigen may render DNA immunogenic upon binding to nucleosomes when expressed in vivo. This is indicated by the strong correlation between antibodies to T antigen and antibodies to DNA or TBP and is consistent with a hapten-carrier model. This model implies cognate antigen-selective interaction of T antigen-specific T helper cells and DNA-specific B cells or B cells specific for other components of nucleosomes, consistent with the results of previous experiments. | closed_qa |
Radicular pain caused by synovial cyst: an underdiagnosed entity in the elderly? | Synovial cyst is a recognized but infrequent cause of nerve root or spinal canal compression. The authors undertook a review of 839 decompressive spinal procedures performed over a 5-year period. They found seven cases in which the symptoms were caused by synovial cysts. Six of these cases were in a subgroup of 80 patients who were older than 60 years of age, which represents 7.5% of the total for this age group. More than 200 cases of this abnormality have been reported in the world literature, but the incidence, prevalence, and natural history remain unknown. | The authors propose that the incidence of synovial cysts may be more common than recognized in the elderly and suggest that preoperative diagnosis may help limit the extent of the surgical approach. | closed_qa |
Risk factors for the acquisition of genital warts: are condoms protective? | To characterise risk factors for the acquisition of genital warts and specifically to determine whether condoms confer protection from infection. A retrospective case-control study comparing demographic, behavioural, and sexual factors in men and women with and without newly diagnosed genital warts, who attended Sydney Sexual Health Centre (SSHC), an inner city public sexual health centre, in 1996. Data were extracted from the SSHC database. Crude odds ratios (OR) were calculated to compare cases and controls and significant factors were then controlled for using multivariate logistic regression to obtain adjusted odds ratios (ORs). 977 patients with warts and 977 controls matched by sex and date of attendance were included. In both sexes, univariate analysis revealed that younger age, more lifetime sexual partners, failure to use condoms, greater cigarette smoking and alcohol consumption were associated with warts, and there was a negative association with previous infection with Chlamydia trachomatis, Neisseria gonorrhoeae, hepatitis B, and genital herpes. In males, on multivariate analysis, factors which remained significant were younger age, more lifetime sexual partners; failure to use condoms, greater cigarette smoking, and previous chlamydia. In women, factors which remained significant were younger age, more lifetime sexual partners, condom use, marital status, and previous infections with Chlamydia trachomatis and herpes. | Independent risk factors for genital warts include younger age, greater number of lifetime sexual partners, and smoking. Consistent condom use significantly reduces the risk of acquiring genital warts. | closed_qa |
Cervical cytology: are national guidelines adequate for women attending genitourinary medicine clinics? | To study whether all women attending a genitourinary medicine (GUM) clinic warrant a cervical smear as part of a routine screen for infection, or whether this "at risk" population is adequately covered by the national screening programme. A cervical smear and a screen for sexually transmitted infections (STI) were taken from 900 women attending a GUM clinic between May 1996 and April 1997. Of 812 smears available for analysis, 613 (75.5%) were normal, 176 (21.7%) were mildly abnormal, and 23 (2.8%) were moderately or severely abnormal. In the absence of an STI there was a 14% (37/273) risk of having an abnormal cervical smear. In the presence of cervicitis the risk was 26% (22/84) and with genital warts the risk was 34% (75/215). | The national screening programme guidelines for cervical cytology should be followed in the GUM clinic. There is no benefit in performing extra smears outside the programme nor in adopting a policy of universal screening. | closed_qa |
Can children with autistic spectrum disorders perceive affect in music? | Children with autistic spectrum disorders typically show impairments in processing affective information within social and interpersonal domains. It has yet to be established whether such difficulties persist in the area of music; a domain which is characteristically rich in emotional content. Fourteen children with autism and Asperger syndrome and their age and intelligence matched controls were tested for their ability to identify the affective connotations of melodies in the major or minor musical mode. They were required to match musical fragments with schematic representations of happy and sad faces. The groups did not differ in their ability to ascribe the musical examples to the two affective categories. | In contrast to their performance within social and interpersonal domains, children with autistic disorders showed no deficits in processing affect in musical stimuli. | closed_qa |
Is there a role for pneumonectomy in pulmonary metastases? | Although sublobar and lobar resections are accepted operations for pulmonary metastases, pneumonectomy is viewed as a major incursion on Stage IV patients. We considered it important to ascertain the current results of pneumonectomy for pulmonary metastases since little information is available. Of the 5,206 patients with pulmonary metastasectomy reported by the International Registry of Lung Metastases, 133 (3%) underwent primary, and 38 (1%) completion pneumonectomy between 1962 and 1994. Data were analyzed to determine the operative mortality rates, survival rates, and determinants of survival. Primary pneumonectomy was performed for metastatic disease mainly from epithelial (49%, 65 of 133) and sarcomatous (33%, 43 of 133) tumors. Indications were central lesion, eg, proximal endobronchial or hilar nodal metastases. Operative mortality was 4% (4 of 112) and a 5-year survival rate of 20% was achieved following complete resection (R0) in 112 patients. In contrast, the 21 incompletely resected patients had an operative mortality rate of 19% (4 of 21), and the majority did not survive beyond 2 years (p = 0.02). Survival was determined by the completeness of resection and not histology of the primary tumor, number of metastases, nodal status, and disease-free interval. In the 38 completion pneumonectomy patients, 35 were operated for recurrent disease and 3 for residual disease. Sarcomatous secondaries predominated in 28 patients. Complete resection was achieved in 31 patients (82%). The operative mortality rate was 3% (1 of 38 patients) and the 5-year survival rate was 30%. | Pneumonectomies for pulmonary metastases, albeit infrequently performed, were associated with acceptable operative mortality and long-term survival when performed in selected patients amenable to complete resection. | closed_qa |
Cardiac surgery in octogenarians: can elderly patients benefit? | Increasing numbers of the very old are presenting for cardiac surgical procedures. There is little information about quality of life after hospital discharge in this group. From March 1995 to February 1997, 127 patients older than 80 years at operation (mean age, 83+/-2.5 years; range, 80 to 92 years) were entered into the cardiac surgery database and analyzed retrospectively. The RAND SF-36 Health Survey and the Seattle Angina Questionnaire were used to assess quality of life by telephone interview (mean follow-up, 15.7+/-6.9 months). No patient was lost to follow-up. Operations included coronary artery bypass grafting (65.4%), coronary artery bypass grafting plus valve replacement (15.8%), and isolated valve replacement (14.2%). Preoperatively, 63.8% were in New York Heart Association class IV. Thirty-day mortality was 7.9%, and actuarial survival was 83% (70% confidence interval, 79% to 87%) at 1 year and 80% (70% confidence interval, 75% to 85%) at 2 years. Preoperative renal failure significantly increased the risk of early death (relative risk, 3.96) as did urgent or emergent operation (relative risk, 6.70). In addition, cerebrovascular disease (relative risk, 3.54) and prolonged ventilation (relative risk, 3.82) were risk factors for late death. Ninety-five patients (92.2%) were in New York Heart Association class I or II at follow-up. Seattle Angina Questionnaire scores for anginal frequency (92.3+/-18.9), stability (94.4+/-16.5), and exertional capacity (86.8+/-25.1) indicated good relief of symptoms. SF-36 scores were equal to or better than those for the general population of age greater than 65 years. Of the survivors, 83.7% were living in their own home, 74.8% rated their health as good or excellent, and 82.5% would undergo operation again in retrospect. | Octogenarians can undergo cardiac surgical procedures at a reasonable risk and show remarkable improvement in their symptoms. Elderly patients benefit from improved functional status and quality of life. | closed_qa |
Are older patients with mechanical heart valves at increased risk? | Controversy exists regarding the use of mechanical valves in older patients. Many authorities believe that the use of anticoagulants in the elderly is associated with an increased risk of warfarin-related complications. Therefore, we compared the results with mechanical valves in older patients to a cohort of younger patients. Aortic (AVR) or mitral valve replacement (MVR) with a mechanical valve was performed in 1,245 consecutive patients who were followed prospectively. They were grouped by age (group 1,<or = 65 years; group 2,>65 years). The study groups consisted of AVR (group 1, 459 patients; group 2, 323 patients) MVR (group 1, 313 patients; group 2, 150 patients). The average age for the groups was: AVR (group 1, 51 years; group 2, 70 years; p = 0.03) and MVR (group 1, 53 years; group 2, 70 years; p = 0.03). For AVR the incidence of thromboembolism was 0.050 (group 1) and 0.038 (group 2) (p = 0.37) and the actuarial freedom from thromboembolism was 83.0%+/-3.0% and 86.5%+/-1.0%, respectively (p = 0.13). The incidence of bleeding after AVR was 0.021 for group 1 and 0.028 for group 2 (p = 0.49). For MVR the incidence of thromboembolism was 0.059 for group 1 and 0.051 for group 2 (p = 0.75) and the actuarial freedom from thromboembolism was 78.8%+/-3.0% and 75.4%+/-8.7%, respectively (p = 0.71). The incidence of bleeding after MVR was 0.020 for group 1 and 0.027 for group 2 (p = 0.62). | Mechanical valves perform well in selected older patients with no increased risk of bleeding or thromboembolism. | closed_qa |
Myocardial recovery after mechanical support for acute myocarditis: is sustained recovery predictable? | At present, myocardial recovery with mechanical support for acute myocarditis is a more frequently observed issue. However, predictive parameters of a sustained myocardial recovery are still under investigation. Two recent cases of mechanical support for acute lymphocytic myocarditis with two different outcomes are reported. Literature about this disease and predictability of a sustainable myocardial recovery are reviewed. Acute lymphocytic myocarditis is an individual entity whose outcome is associated with the importance of healed cell damage. Unfortunately, there are no available means of quantifying the fibrotic scar and endomyocardial biopsy has a high percentage of false-negative results. Echocardiographic assessment of systolic and diastolic cardiac function is difficult while under mechanical support and its significance is not obvious. Forthcoming development of Doppler could better correlate myocardial contractility and histology to be predictive of a sustained recovery after acute myocarditis under mechanical support. | Long-lasting recovery after mechanical support for acute myocarditis remains unpredictable in our experience. More predictive factors are needed. | closed_qa |
Catastrophic hemorrhage on sternal reentry: still a dreaded complication? | To define the incidence of catastrophic hemorrhage (CH) during reoperations, the experience of the University of New Mexico was reviewed and compared with the practice of surgeons contacted by questionnaire. At the University of New Mexico, 610 reoperations were reviewed and 210 deemed high risk because of multiple reoperation, aneurysm, patent grafts, chamber's enlargement, conduit or previous mediastinitis. In the questionnaire, we asked about reentry technique, occurrence and outcome of CH, and precautions for high-risk patients. At the University of New Mexico there were 4 CH with 1 death, and in the questionnaire there were 2,046 CH with 392 deaths. Our rate per surgeon was lower than that of the questionnaire. Rate of CH according to the saw was 2.09 for reciprocating, 2.0 for sagittal, and 1.74 for stryker in the questionnaire. Our rate was lower (0.65) with a micro sagittal saw. High-risk category predicted CH during sternotomy (p = 0.01) but only conduit (p = 0.005) was significant by univariate analysis. | The risk of CH could be as high as 1%. The sagittal micro oscillating saw is the safest reported to date. Presence of a conduit increases the risk by 2.5 fold. | closed_qa |
Can technetium 99m pyrophosphate be used to quantify myocardial injury in donor hearts? | There are no prospective methods available to quantify the myocyte injury in hearts prior to transplantation. The potential of the isotope labeled infarct marker 99m Technetium pyrophosphate (TcPPT) being used in this role was investigated. Brain death was induced by creating an extradural space occupying lesion in young adult swine after which hemodynamic changes were monitored and myocyte injury was quantified by histochemistry. TcPPT was administered 5 hours after induction of intracranial hypertension, and after hearts were harvested myocardial uptake was measured. These latter measurements were related to the histochemical assessment of myocyte injury. Sham animals (n = 4) maintained cardiovascular stability and experienced minimal myocyte injury, grades 0 to 3. BD animals (n = 10) exhibited varying patterns of hemodynamic change and myocyte injury, the latter was significant in 6, graded 4 to 11, p less than 0.05. Uptake of TcPPT by BD hearts was greater than twice the 90th centile sham value in 6. The sensitivity and specificity of greater uptake indicating the presence of myocyte injury was 83.3% and 75% respectively. | TcPPT has the potential to quantify myocardial injury induced by brain death and its potential utility merits further investigation. | closed_qa |
Does sensitization to contact allergens begin in infancy? | Because previous studies have found allergic contact sensitization common in children by 5 years of age, our aim was to determine the prevalence of positive epicutaneous test results in children<5 years of age and to determine whether sensitization to contact allergens was as common in infancy. We recruited 95 asymptomatic children 6 months to 5 years of age from well-child visits at Denver area pediatric practices for epicutaneous patch testing using the T.R.U.E. Test system. Allergens were placed on the skin for 48 hours, and at a later follow-up visit, positive reactions were evaluated. A total of 85 patients completed the study. Of these, 20 (24.5%) had 1 or more positive reactions to the tested allergens. Positive reactors ranged from 6 to 65.5 months of age, with an average of 30.4 months of age. Of the children, 16 reacted to 1 allergen, and 4 reacted to 2. Eleven positive reactions were observed to nickel, followed by 8 to thimerosal. Other positive reactions were to neomycin, cobalt, and kathon CG. | Children as young as 6 months of age may be sensitized to contact allergens. Within this pediatric population, the prevalence of sensitization is 24.5%. Sensitization to contact allergens may occur in infants. | closed_qa |
Prostate-specific antigen: A surrogate endpoint for screening new agents against prostate cancer? | An endpoint for clinical trials of prostate cancer which simplifies traditional endpoints (response of measurable lesions, progression rates, and death) is urgently needed. This is especially true for hormone-unresponsive disease, for which many new drugs are presently in a development phase. This paper presents a rationale for the use of prostate-specific antigen (PSA) in clinical trials of progressive prostate cancer under endocrine treatment. The study is based on 84 patients who progressed after radical prostatectomy or node dissection, of whom 24 showed increasing PSA levels under subsequent endocrine treatment. An average linear relationship between (log-transformed) PSA and time and a subject-specific deviation from this average relationship were assessed. The predictive value of the subject-specific parameters of the linear fit with respect to time to prostate cancer-specific death was determined. The outcomes of the fitting procedure were used to calculate sample sizes for future studies (duration, 6 months) using PSA increase over time in hormone-unresponsive prostate cancer as a marker for treatment efficacy. The average PSA doubling time in this population was 4 months (corresponding time constant = 0.25). The assessed variance of the time constants equalled 0.04; the overall residual variance equalled 0.265. The subject-specific rate of change of the log-transformed PSA value in hormone-unresponsive prostate cancer was a highly significant predictor of prostate cancer-specific death. This suggests the potential usefulness of PSA as an endpoint in trials of hormone-unresponsive prostate cancer. Depending on conditions chosen (e.g, desired power and changes in log PSA slope), 18-70 participants per arm will be necessary in future phase III studies. A suggestion (algorithm) for the use of PSA in drug development is presented. | Relatively small PSA-based trials in patients with hormone-unresponsive prostate cancer are possible if a similar patient population is utilized. As long as surrogacy is not established, such studies cannot be considered conclusive with respect to effectiveness of treatment, but are likely to be useful as a screening tool for new drugs. Experimental confirmation in human prostate cancer model systems of synergism between PSA decrease and tumor control by a given test treatment is likely to enhance the level of certainty of PSA-based drug evaluation. | closed_qa |
Neuroendocrine cells during human prostate development: does neuroendocrine cell density remain constant during fetal as well as postnatal life? | Knowledge concerning differentiation of neuroendocrine (NE) cells during development of the human prostate is rather fragmentary. Using immunohistochemistry combined with a morphometric method, we investigated the distribution and density of NE cells in the developing human prostate, with special emphasis on the topographical relationship of NE cells with the developing gland. Consecutive sections from a total of 42 human prostates taken during autopsy of fetuses (12-38 weeks of gestation), prepubertal males, and young adults were immunostained for chromogranin A and serotonin. Computer-assisted image analysis was used to assess the total number of cells in the different parts of the branching glandular anlage, i.e., budding tips and acini/ducts. Next, the number of NE cells was counted manually. The NE cell density (NE cell index) was then determined. NE cells could first be detected in the prostate from 13 weeks of gestation. By 21 weeks of gestation, all prostates contained NE cells. NE cells were mainly confined to the acinous/ductal regions, while most of the budding tips lacked NE staining. NE cell indexes of individuals were highly variable, mostly in the youngest age group. | In the normal prostate, NE cell density probably remains constant in acini/ducts from fetuses to young adulthood. The presence of neuroendocrine cells in well-developed glandular structures at such an early fetal age and their absence in the less differentiated budding tips possibly indicates that differentiation of NE cells is associated with glandular maturation. NE cells occur preferentially in the acinous/ductal region, implying a paracrine function during secretory differentiation of exocrine epithelial cells. | closed_qa |
Dietary influences on bone mass and bone metabolism: further evidence of a positive link between fruit and vegetable consumption and bone health? | The role of nutritional influences on bone health remains largely undefined because most studies have focused attention on calcium intake. We reported previously that intakes of nutrients found in abundance in fruit and vegetables are positively associated with bone health. We examined this finding further by considering axial and peripheral bone mass and markers of bone metabolism. This was a cross-sectional study of 62 healthy women aged 45-55 y. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry at the lumbar spine and femoral neck and by peripheral quantitative computed tomography at the ultradistal radial total, trabecular, and cortical sites. Bone resorption was calculated by measuring urinary excretion of pyridinoline and deoxypyridinoline and bone formation by measuring serum osteocalcin. Nutrient intakes were assessed by using a validated food-frequency questionnaire; other lifestyle factors were assessed by additional questions. After present energy intake was controlled for, higher intakes of magnesium, potassium, and alcohol were associated with higher total bone mass by Pearson correlation (P<0.05 to P<0.005). Femoral neck BMD was higher in women who had consumed high amounts of fruit in their childhood than in women who had consumed medium or low amounts (P<0.01). In a regression analysis with age, weight, height, menstrual status, and dietary intake entered into the model, magnesium intake accounted for 12.3% of the variation in pyridinoline excretion and 12% of the variation in deoxypyridinoline excretion. Alcohol and potassium intakes accounted for 18.1% of the variation in total forearm bone mass. | The BMD results confirm our previous work (but at peripheral bone mass sites), and our findings associating bone resorption with dietary factors provide further evidence of a positive link between fruit and vegetable consumption and bone health. | closed_qa |
Is there an association between duration of untreated psychosis and 24-month clinical outcome in a first-admission series? | The authors examined the duration of untreated psychosis, defined as the interval from first psychotic symptom to first psychiatric hospitalization, in a county-wide sample of first-admission inpatients who had received no previous antipsychotic medication. Differences between diagnostic groups in 24-month illness course and clinical outcomes as well as relationships between outcomes and duration of untreated psychosis were evaluated. The data were derived from subjects in the Suffolk County Psychosis Project who were diagnosed at 24-month follow-up according to DSM-IV as having schizophrenia or schizoaffective disorder (N=155), bipolar disorder with psychotic features (N=119), or major depressive disorder with psychotic features (N=75). Duration of untreated psychosis was derived from the Structured Clinical Interview for DSM-III-R, medical records, and information from significant others. Measures at 24-month follow-up included consensus ratings of illness course, Global Assessment of Functioning Scale scores for the worst week in the month before interview, and current affective and psychotic symptoms. The median duration of untreated psychosis was 98 days for schizophrenia, 9 days for psychotic bipolar disorder, and 22 days for psychotic depression. Duration of untreated psychosis was not significantly associated with 24-month illness course or clinical outcomes in any of the diagnostic subgroups. | Although these findings require replication in other epidemiologically based first-admission samples, at face value they do not support the suggestion of a psychotoxic effect of prolonged exposure to untreated psychosis. | closed_qa |
Is preinfarction angina related to the presence or absence of coronary plaque rupture? | To analyse the prodrome of acute myocardial infarction in relation to the plaque morphology underlying the infarct. A retrospective investigation of the relation between rupture and erosion of coronary atheromatous plaques and the clinical characteristics of acute myocardial infarction. The coronary arteries of 100 patients who died from acute myocardial infarction were cut transversely at 3 mm intervals. Segments with a stenosis were examined microscopically at 5 micrometer intervals. The clinical features of the infarction were obtained from the medical records. A deep intimal rupture was encountered in 81 plaques, whereas 19 had superficial erosions only. There were no differences in the location of infarction, the incidence of hypertension, diabetes mellitus, or hyperlipidaemia, diameter stenosis of the infarcted related artery, Killip class, Forrester's haemodynamic subset, or peak creatine kinase between plaque rupture and plaque erosion groups. The presence of plaque rupture was associated with significantly greater incidences of leucocytosis, current smoking, and sudden or unstable onset of acute coronary syndrome. In patients with unstable preinfarction angina, new onset rest angina rather than worsening angina tended to develop more often in the plaque rupture group than in the plaque erosion group (p = 0.08). | Plaque rupture causes the sudden onset of acute myocardial infarction or unstable preinfarction angina, which may be aggravated by smoking and inflammation. | closed_qa |
Management of heart failure among very old persons living in long-term care: has the voice of trials spread? | Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail. Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model. The mean age of the population was 84.9 +/- 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities. | Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics. | closed_qa |
Does hysteroscopy facilitate tumor cell dissemination? | In several case reports, distension and irrigation of the uterine cavity during fluid hysteroscopy was suspected to cause tumor cell dissemination into the abdominal cavity in patients with endometrial carcinoma. It was the aim of this study to compare the incidence of positive peritoneal cytology in patients who underwent dilatation and curettage (D&C) with or without previous hysteroscopy. The authors conducted a multicentric, retrospective cohort analysis. One hundred thirteen consecutive patients with endometrial carcinoma treated between 1996 and 1997 were included. Endometrial carcinoma had to be limited to the inner half or less than the inner half of the myometrium (pathologic Stage IA,B). Positive peritoneal cytology was obtained during staging laparotomy. Patients underwent D&C either with or without prior diagnostic fluid hysteroscopy. No selection or randomization was applied to the two groups. Positive peritoneal cytology, defined as malignant or suspicious, was considered the primary statistical endpoint. Peritoneal cytology was suspicious or positive in 10 of 113 patients (9%). The presence of suspicious or positive peritoneal cytology was associated with a history of hysteroscopy (P = 0.04) but not with myometrial invasion (P = 0.57), histologic subtype (P = 1.00) or grade (r = 0.16, P = 0.10), or the time between D&C and staging laparotomy (r = 0.04, P = 0.66). | Based on the limited extent of endometrial carcinoma in the current analysis, our data strongly suggest dissemination of endometrial carcinoma cells after fluid hysteroscopy. Determining whether a positive peritoneal cytology affects the prognoses of patients without further evidence of extrauterine disease will require longer follow-up. | closed_qa |
Sympathetic skin response in diabetic children: do diabetic children have diabetic neuropathy? | Abnormal sympathetic skin response (SSR) has been reported in adult patients with diabetic neuropathy. In addition, other studies have revealed abnormal SSR in diabetic patients not having autonomic symptoms and autonomic dysfunctions. These findings have been only obtained from adult patients. There have been few reports on the autonomic functions in diabetic children. Accordingly, it is not clear whether the autonomic neuropathy occurs in diabetic children. The aim of the present study is to clear autonomic function in children with insulin-dependent diabetes mellitus by SSR. The SSR was measured in 28 normal healthy children and in eight patients with IDDM not having symptoms of dysautonomia. The SSR was elicited using 10 stimuli on programmed Nihonkoden Neuropack Sigma model machine. Following a single electrical stimulation, four SSR were recorded in both the palms and the soles simultaneously. The SSR were simultaneously obtained in 100% of the two groups. The amplitudes in the palms and soles were not significantly different between the two groups. The mean and shortest latency in the soles were significantly longer in the IDDM group than in the control group (P<0.01). None of the measurements of SSR revealed correlation with duration of diabetes and onset of illness. | Diabetic neuropathy may not have occurred in young patients having shorter duration of illness. Conversely, assuming that prolonged latency is abnormal, it may even have occurred in them. Follow up on these patients with prolonged latencies would be required. | closed_qa |
Are the newer antidepressant drugs as effective as established physical treatments? | The aim of this study was to determine, in a clinical panel sample, the extent to which patients with depression (and melancholic and non-melancholic subtypes) judged the effectiveness of previously received antidepressant treatments, particularly the comparative effectiveness of the older and newer antidepressant drugs. Twenty-seven Australasian psychiatrists assessed 341 non-psychotic depressed patients and rated the extent to which previous antidepressant treatments had been effective. Patients were assigned to 'melancholic' and residual 'non-melancholic' categories by two processes (DSM-IV decision rules, and a cluster analysis-derived allocation) and treatment effectiveness examined within each category. Electroconvulsive therapy (both bilateral and unilateral) was judged as highly effective by both melancholic and non-melancholic patients. Antipsychotic medication similarly rated highly (but was judged as more effective by the non-melancholic than melancholic patients). The tricyclics and irreversible monoamine oxidase inhibitors (MAOIs) were rated as more effective by the whole sample than several newer antidepressant classes (including the selective serotonin re-uptake inhibitors [SSRIs], venlafaxine, mianserin and moclobemide), whether effectiveness was examined dimensionally or categorically. Comparison of the overall tricyclic and SSRI classes indicated that any superior tricyclic effectiveness was specific to the melancholic subjects. | Despite methodological limitations intrinsic to such clinical panel data, the judged greater effectiveness of the older antidepressants (tricyclics and irreversible MAOIs) for melancholic depression is of importance. If valid, such data are of intrinsic clinical relevance but also have the potential to inform us about the neurobiological determinants of 'melancholia' and pharmacological actions which contribute to its effective treatment. | closed_qa |
Does syndrome X exist in hypertensive elderly persons with impaired glycemic control? | This report focuses on the glycemic state in relation to insulin and lipid levels of a cohort of elderly hypertensive persons to estimate the prevalence of syndrome X. A cross-sectional study was performed at the University of Tennessee, Memphis, and the General Clinical Research Center (GCRC) on 95 participants in the Trial of Nonpharmacologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study. A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels and a fasting lipid profile were obtained. In this sample of healthy elderly participants with hypertension who were taking an antihypertensive medication, 43 (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had impaired glucose tolerance (IGT), and 11 (11.6%) had undiagnosed non-insulin-dependent diabetes mellitus (NIDDM). Fasting hyperinsulinemia occurred in only one participant, who was in the IGT group. Hypertriglyceridemia and low high density lipoprotein (HDL) occurred in four persons, none of whom had hyperinsulinemia. Persons in the NIDDM and IGT groups had decreased beta cell function compared to persons in the NGT group, but did not have increased peripheral insulin resistance as estimated from the OGTT data. | Our data demonstrated that in this cohort of elderly hypertensive participants with a high prevalence of central obesity, impaired glycemic control was common, but was not associated with fasting hyperinsulinemia or peripheral insulin resistance. Furthermore, we conclude that syndrome X essentially did not occur in these participants and postulate that the primary etiology for their impaired glycemic control is beta cell dysfunction. Further research is needed to elucidate these relationships. | closed_qa |
Fish allergy: is cross-reactivity among fish species relevant? | Allergic reactions to fish are a common cause of food allergy in many areas of the world where fish is a major source of protein. Although different species of fish may be consumed, possible cross-reactivity has received limited investigation. The aim of this study was to assess potential cross-reactivity to different species of fish species using double-blind, placebo-controlled food challenges (DBPCFC) in fish-allergic adults and to compare skin test and RAST reactivity with the challenge response. Nine skin prick test and/or RAST-positive adult individuals with histories of an immediate-type reaction following fish ingestion were challenged with different fish species using double-blind, placebo-controlled food challenge. Of a total of 19 double-blind, placebo-controlled fish challenges performed, 14 challenges (74%) resulted in the induction of objective signs that were consistent with an IgE-mediated response. The most common sign observed was emesis (37%); the most prevalent subjective symptoms reported were compatible with the oral allergy syndrome (84%). Three subjects reacted to at least three fish species and one subject reacted to two fish species tested. In regard to the positive challenges, predictive accuracy of skin prick test and RAST was 84% and 78%, respectively. | Our results indicate that clinically relevant cross-reactivity among various species of fish may exist. Advising fish-allergic subjects to avoid all fish species should be emphasized until a species can be proven safe to eat by provocative challenge. | closed_qa |
Do eosinophil counts correlate differently with asthma severity by symptoms versus peak flow rate? | Discrepancy in asthmatic assessment by symptoms and peak flow rate (PFR) is a frequent dilemma. Currently, total peripheral eosinophil count (TPEC) is under study for asthma evaluation. To explore the correlation between TPEC and asthma severity assessed by symptoms alone versus symptoms and PFR. Adults asthmatics were selected from the Asthma Clinic. Severity assessment was based on two methods: symptoms alone or symptoms and PFR. Expiratory PFR was recorded by a Wright peak flow meter. Severity levels included mild intermittent, mild persistent, moderate persistent, and severe persistent. Total peripheral eosinophil count was performed on a Celldyn-3500 counter. Data was analyzed for statistical significance. Sixty asthmatics aged 15 to 70 years (mean = 34 years), of which 68.3% were female, were studied. Severity levels differed between the two assessment methods in 45% of the cases and showed a predominance of the moderate persistent type. Total peripheral eosinophil count ranged between 22 and 2470 cells/mm3 (mean = 520 +/- SD = 393) and eosinophilia was found in 50% of the cases. Total peripheral eosinophil count showed a high positive correlation with increased asthma severity level assessed by history alone (r = 0.460, P<.001); more than by history and PFR (r = 0.328, P<.05). | The discrepancy between symptoms and PFR is confirmed by these results. A reliable objective parameter in asthma assessment is a continuous challenge. This study advocates the possible supplementation of TPEC as another objective parameter that might help in selecting the appropriate severity level in asthmatics. | closed_qa |
Do immunoassays differentially detect different acidity glycoforms of FSH? | The possibility of the carbohydrate residues of glycoproteins affecting their recognition in immunoassays is an important and unresolved issue. This study looked for evidence of differential recognition of FSH glycoform preparations, of variable isoelectric point (pI) and known molarity, using three routine assays employing different antibody configurations. Seven glycoform preparations with differing pI bands (between 3.8 and 5.5) were produced by isoelectric focusing of recombinant human FSH and the molecular weights determined by mass spectroscopy. Three concentrations of each glycoform were assayed and the results expressed relative to unfractionated material. From the relative responses, recognition differences between the assay methods and between the glycoform preparations were investigated. Three routine assays were employed: the commercially available Amerlite(R) enzyme immunoassay and Delfia(R) immunofluorometric assay, together with an in-house competitive two-site radioimmunoassay (RIA). Overall, the three assays gave the same relative responses for equivalent glycoforms, with the only exceptions involving small differences between some assay pairs for the fractions at the extremes of the pI range investigated. Within each assay type, differences (P<0.05) of up to 33% existed between glycoforms of different pI, however, these differences showed no patterns or trends across the entire acidity range examined. | Between the assay methods investigated in this study, few differences exist in the recognition of individual pI bands of FSH when expressed relative to a common unfractionated standard. Differences were apparent in the recognition of the different acidity glycoforms within each assay method, however, these were small and unlikely to be of clinical significance. | closed_qa |
Is high peritoneal transport rate an independent risk factor for CAPD mortality? | Is high peritoneal transport rate an independent risk factor for CAPD mortality? Patients with high peritoneal transport display the lowest serum albumin (SAlb) and the highest peritoneal protein loss. An association between high peritoneal membrane permeability and diabetes mellitus (DM) has been suggested. As malnutrition, hypoalbuminemia, and DM cause high mortality, it is probable that a high peritoneal transport rate is associated with high mortality on continuous ambulatory peritoneal dialysis (CAPD). The aim of the study was to identify whether a high peritoneal transport rate is an independent risk factor for mortality on CAPD. We included 167 patients with a peritoneal equilibration test that was performed between January 1994 and July 1997. The endpoint was the patient's status (alive, dead, or lost) in December 1997. Survival analysis was done by the Kaplan-Meier method and multivariate Cox proportional-hazard model. DM was significantly more frequent in the high (H) peritoneal transport type (20 out of 33) and was less frequent in the low (L) transport group (3 out of 18). SAlb (g/dL) was significantly lower as the peritoneal transport type was higher [H 2.7 +/- 0.5, high average (HA) 2.9 +/- 0.7, low average (LA) 3.2 +/- 0.6, and L 3.6 +/- 0.5]. Serum creatinine (SCr) was significantly higher in the L transport type (12.0 +/- 4.3 mg/dL) than in the other transport groups (H 8.7 +/- 3.1, HA 8.6 +/- 3.7, and LA 9.6 +/- 4.5). No other differences were found between peritoneal transport types. In the univariate analysis, high peritoneal transport rate, DM, low SCr, low SAlb, and older age significantly predicted mortality. However, in the multivariate analysis (chi2 = 40.55, P<0.0001), only DM (b = 1.34, P = 0.0001), low SCr (b = -0.11, P = 0.02), and high peritoneal transport rate (b = 2.6, P = 0.06) were shown as mortality risk factors. | DM was the most important risk factor for mortality on CAPD. A high peritoneal transport rate also predicted mortality, yet its role seems to be related to the presence of DM. The role of higher SCr predicting a better survival might have been associated with a better nutritional status. Hypoalbuminemia, previously shown as risk factor for mortality, did not play an important role in this study, probably because of its collinearity with DM. | closed_qa |
Expression of CD44 in uterine cervical squamous neoplasia: a predictor of microinvasion? | CD44, an integral membrane glycoprotein, may have an important role in early tumorigenesis, specifically, facilitating early tumor progression. Reports of the expression of CD44 in early uterine cervical squamous carcinogenesis are conflicting. We examined the expression of CD44 in microinvasive carcinoma of the cervix (MIC), as yet unreported, and compared it to that in cervical intraepithelial neoplasia (CIN) 1 and CIN 3 to further elucidate its role in early squamous carcinogenesis. Seventeen cases of CIN 1, 24 cases of CIN 3, and 20 cases of MIC were stained with antibodies to CD44s, CD44v5, and CD44v6. Only membranous staining was considered positive. Positive membranous staining (>50% cells) was observed in 97% of cases of CIN 1 using all three antibodies. In CIN 3, positive staining was seen more often with CD44v6 (18/24) and CD44v5 (19/24) than with CD44s (6/24). Expression of CD44v6 was retained more often in MIC (16/20) compared with CD44s (3/20) and CD44v5 (9/20). Those cases of CIN 3 and MIC that failed to meet our criteria for positive staining showed either heterogeneous or absent staining. | There is a qualitative and quantitative reduction in expression of CD44 in MIC and CIN 3 compared with CIN 1. Down-regulation of CD44 variants may occur later in neoplastic progression than CD44s. This pattern may reflect their important biological function in early progression by cervical cancer cells. Patchy and heterogeneous staining in more advanced lesions limits the usefulness of CD44 and its variants in the assessment of microinvasion. | closed_qa |
Was the decreasing trend in hospital mortality from heart failure attributable to improved hospital care? | To assess the trend in risk-adjusted hospital mortality from heart failure. Oregon hospital discharge data from 1991 through 1995 were analyzed. A total of 29,530 hospitalizations because of heart failure in elderly patients (age>or = 65 years) were identified from International Classification of Diseases, 9th Revision, codes 428.0-428.9. The logistic regression and life table analyses were used to assess the risk-adjusted trend in hospital mortality from heart failure. From 1991 through 1995, 1757 (5.9%) patients with heart failure died in the hospital; 920 (52.4%) of them died within 3 days. The percentage of patients discharged to skilled nursing facilities increased from 6.1% in 1991 to 9.8% in 1995 (P value for trend<.001), whereas the percentage of patients discharged directly to home decreased from 69.2% in 1991 to 62.4% in 1995 (P value for trend<.001). The mean length of stay decreased from 5.15 days in 1991 to 3.97 days in 1995. The age- and sex-standardized mortality rate decreased by 33.8% from 7.4 in 1991 to 4.8 in 1995 (P value for trend<.01). Additional adjustment for comorbidity using multiple logistic regression revealed a greater reduction of 41.0% in the mortality rate (odds ratio = 0.59; 95% confidence interval = 0.50, 0.69) and a reduction of 46.0% in the 3-day mortality rate (odds ratio = 0.54; 95% confidence interval = 0.43, 0.67) across the 5-year period. Life table analysis showed consistently lower cumulative mortality rates during the first week after admission in 1995 compared with those in 1991 (P<.001). | There was a decreasing trend over time in the risk-adjusted hospital mortality rates from heart failure, which was not an artifact of decreasing length of stay. Our findings raised the possibility of improved hospital care for heart failure in Oregon. | closed_qa |
Is a third-trimester antibody screen in Rh+ women necessary? | To determine the need for routine third-trimester antibody screening in Rh+ women. An analytic case-control study. We identified Rh+ pregnant women who had received prenatal care and retrospectively analyzed their laboratory data. Patients were grouped into those with a positive third-trimester antibody screen (cases) and those with a negative third-trimester screen (controls). Because entry into a group was decided by the investigators, it could not be randomized. We reviewed the maternal medical records for antibody identification and final pregnancy outcome. We also reviewed the neonatal medical records for evidence of direct Coombs-positive cord blood, anemia, need for transfusion or phototherapy, other medical complications, and death. Using a computerized laboratory database from 2 teaching hospitals, we identified 10,581 obstetric patients who underwent routine first- and third-trimester antibody screening between 1988 and 1997. Of these, 1233 patients were Rh- and 9348 were Rh+. Among the Rh+ patients, 178 (1.9%) had 1 or more atypical antibodies at the first-trimester screen, and 53 (0.6%) had a positive third-trimester antibody screen despite a negative first-trimester screen. Although 6 of these 53 patients (0.06% of the study population) had clinically relevant antibodies for hemolytic disease of the new-born, no significant neonatal sequelae occurred among these 6 patients. | Based on the patient and hospital records studied, a repeat third-trimester antibody screen for Rh+ patients is clinically and economically unjustified. Eliminating this laboratory test from clinical practice will not adversely affect pregnancy outcomes and will decrease the costs of prenatal care. | closed_qa |
Do nursing home residents make greater demands on GPs? | The number of people residing in nursing homes has increased. General practitioners (GPs) receive an increased capitation fee for elderly patients in recognition of their higher consultation rate. However, there is no distinction between elderly patients residing in nursing homes and those in the community.AIM: To determine whether nursing home residents receive greater general practice input than people residing in the community. Prospective comparative study of all 345 residents of eight nursing homes in Glasgow and a 2:1 age, sex, and GP matched comparison group residing in the community. A comparison of contacts with primary care over three months in terms of frequency, nature, length, and outcome was carried out. Nursing home residents received more total contacts with primary care staff (P<0.0001) and more face-to-face consultations with GPs (P<0.0001). They were more likely to be seen as an emergency (P<0.01) but were no more likely to be referred to hospital, and were less likely to be followed-up by their GP (P<0.0001). Although individual consultations with nursing home residents were shorter than those with the community group (P<0.0001), the overall time spent consulting with them was longer (P<0.001). This equated to an additional 28 minutes of time per patient per annum. Some of this time would have been offset by less time spent travelling, since 61% of nursing home consultations were done during the same visit as other consultations, compared with only 3% of community consultations (P<0.0001). | Our study suggests that nursing home residents do require a greater input from general practice than people of the same age and sex who are residing in the community. While consideration may be given to greater financial reimbursement of GPs who provide medical care to nursing home residents, consideration should also be given to restructuring the medical cover for nursing home residents. This would result in a greater scope for proactive and preventive interventions and for consulting with several patients during one visit. | closed_qa |
Does teaching during a general practice consultation affect patient care? | General practice differs from hospital medicine in the personal nature of the doctor-patient relationship and in the need to address social and psychological issues as well as physical problems. Recent changes in undergraduate medical education have resulted in more teaching and learning taking place in general practitioner (GP) surgeries.AIM: To explore patients' experiences of attending a surgery with a medical student present. A questionnaire was designed, based on semi-structured interviews. Questionnaires were posted to patients who had attended teaching surgeries in London and Newcastle-upon-Tyne. Four hundred and eighty questionnaires were sent; of these, 335 suitable for analysis were returned. The response rate in Newcastle was 79%, and in London 60%. Ninety-five per cent of responders agreed that patients have an important role in teaching medical students. Patients reported learning more and having more time to talk, however, up to 10% of responders left the consultation without saying what they wanted to say and 30% found it more difficult to talk about personal matters. | The presence of a student has a complex effect on the general practice consultation. Future developments in medical education need to be evaluated in terms of how patient care is affected as well as meeting educational aims. | closed_qa |
Are postal questionnaire surveys of reported activity valid? | Postal questionnaire surveys are commonly used in general practice and often ask about self-reported activity. The validity of this approach is unknown.AIM: To explore the criterion validity of questions asking about self-reported activity in a self-completion questionnaire. A comparison was made between (a) the self-reported actions of all general practitioner (GP) principals in 51 general practices randomly selected within the nine family health services authorities of the former northern regional health authority, and (b) the contents of the medical records (case notes and computerized records) of patients classified as hypertensive from a 1 in 7 random sample of all patients registered in these practices and aged between 65 and 80. Data were gathered from the GPs by self-completion postal questionnaires. Six comparisons were made for two groups of items: first, target and achieved blood pressure; secondly, patient's weight, smoking status, alcohol consumption, exercise and salt intake. The frequency with which the data items were recorded in patient records was compared with the GPs' self-reported frequency of performing the actions. No relationship was found between achieved blood pressure and stated target levels. For each of the other actions, more than half of the responders reported that they usually or always performed the activity. For four of these (smoking, weight, alcohol and exercise), a significant association was noted, but the size of this varied considerably. | There is a variable relationship between what responders report that they do in self-completion questionnaires, and what they actually do as judged by the contents of their patients' medical records. In the absence of prior, knowledge of the validity of questions on reported activity, or of concurrent attempts to establish their validity, the questions should not be asked. | closed_qa |
Underestimation of the small residual damage when measuring DNA double-strand breaks (DSB): is the repair of radiation-induced DSB complete? | To overcome the underestimation of the small residual damage when measuring DNA double-strand breaks (DSB) as fraction of activity released (FAR) by pulsed-field gel electrophoresis. The techniques used to assess DNA damage (e.g. pulsed-field gel electrophoresis, neutral elution, comet assay) do not directly measure the number of DSB. The Blöcher model can be used to express data as DSB after irradiation at 4 degrees C by calculating the distribution of all radiation-induced DNA fragments as a function of their size. We have used this model to measure the residual DSB (irradiation at 4 degrees C followed by incubation at 37 degrees C) in untransformed human fibroblasts. The DSB induction rate after irradiation at 4 degrees C was 39.1+/-2.0 Gy(-1). The DSB repair rate obtained after doses of 10 to 80 Gy followed by repair times of 0 to 24 h was expressed as unrepaired DSB calculated from the Blöcher formula. All the damage appeared to be repaired at 24h when the data were expressed as FAR, whereas 15% of DSB remained unrepaired. The DSB repair rate and the chromosome break repair rate assessed by premature condensation chromosome (PCC) techniques were similar. | The expression of repair data in terms of FAR dramatically underestimates the amount of unrepaired DNA damage. The Blöcher model that takes into account the size distribution of radiation-induced DNA fragments should therefore be used to avoid this bias. Applied to a normal human fibroblast cell line, this model shows that DSB repair is never complete. | closed_qa |
Contracting for quality: does length matter? | To examine whether longer-term contracts for health services will shift attention away from concern for finance and activity levels and towards the achievement of better quality services. Analysis of 288 contracts from the British National Health Service (NHS) and 12 semi-structured interviews with staff from provider (NHS hospital trusts) and purchaser (health authorities) organisations. No relationship was found between the duration of a contract and the duration of service specifications or quality frameworks. The annual contracting cycle is concerned largely with ensuring that all parties stay within activity targets and financial constraints, and this is unlikely to be affected by a shift to longer-term contracts. The setting of standards and initiatives to improve quality is largely independent of the contracting process and the duration of contracts, and relies on relationships rather than contracts. | It is optimistic to expect longer-term contracts automatically to produce a greater focus on quality and the incentives needed to ensure that improvements in quality are delivered. However, this may not matter as issues of quality are being addressed more appropriately in the British NHS through a variety of other routes. | closed_qa |
Is radiation therapy a preferred alternative to surgery for squamous cell carcinoma of the base of tongue? | To evaluate irradiation alone for treatment of base-of-tongue cancer. Two hundred seventeen patients with squamous cell carcinoma of the base of tongue were treated with radiation alone and had follow-up for>/= 2 years. Local control rates at 5 years were as follows: T1, 96%; T2, 91%; T3, 81%; and T4, 38%. Multivariate analysis revealed that T stage (P =.0001) and overall treatment time (P =.0006) significantly influenced local control. The 5-year rates of local-regional control were as follows: I, 100%; II, 100%; III, 83%; IVA, 64%; and IVB, 65%. Multivariate analysis revealed that the following parameters significantly affect the probability of this end point: T stage (P =.0001), overall treatment time (P =.0001), overall stage (P =.0131), and addition of a neck dissection (P =.0021). The rates of absolute and cause-specific survival at 5 years were as follows: I, 50% and 100%; II, 81% and 100%; III, 65% and 76%; IVA, 42% and 56%; and IVB, 44% and 52%. Severe radiation complications developed in eight patients (4%). | The likelihood of cure after external-beam irradiation was related to stage, overall treatment time, and addition of a planned neck dissection. The local-regional control rates and survival rates after radiation therapy were comparable to those after surgery, and the morbidity associated with irradiation was less. | closed_qa |
Section of the sublingual frenulum. Are the indications correct? | To see the relationship of the lingual frenum with speech and other oral functions, evaluating the surgical indications and the results of frenectomy. In 1997 we operated 72 children with sublingual frenulum, a telephone questionnaire to the mothers of these patients was done, obtaining data about: age at surgery, professional reasons for referral, preoperative findings, pre-post operative speech therapy, place of surgery and type of anesthesia and mother's impression about the final result. Fifty valid questionnaires were obtained, the mean age at frenectomy was 3.03 years, 38% of children were sent due to speech problems, 60% due to some degree of tongue-tie and 2% due to dentofacial developmental anomalies. In 70% the patients were sent by a pediatrician and in 14% by a speech therapist. In 20% preoperative speech therapy was done and postoperatively in 30%. In 48% of cases, aged less than 2 years, speech was not possible to be evaluated. In the 11 cases with questionable results, a multidisciplinary reevaluation showed 7 cases with lingual dysfunction and poor tongue control, 4 cases with deglutitory anomalies and 3 cases with orofacial occlusal problems secondary to lingual dysfunction or altered oral habits. | The presence of a nondisturbing lingual frenulum does not justify its surgical section, the frenectomy is indicated only in presence of altered oro-lingual functions caused by the tongue-tie such as: speech problems, errors of bite and deglutition, lingual dysfunction and anomalous oral habits. | closed_qa |
Physician education and report cards: do they make the grade? | We sought to determine whether tailored educational interventions call improve the quality of care, as measured by the provision of preventive care services recommended by the US Preventive Services Task Force, as well as lead to better patient satisfaction. We performed a randomized controlled study among 41 primary care physicians who cared for 1,810 randomly selected patients aged 65 to 75 years old at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California. All physicians received ongoing education. Physicians randomly assigned to the comprehensive intervention group also received peer-comparison feedback and academic detailing. Baseline and postintervention (2 to 2.5 years later) surveys examining the provision of preventive care and patient satisfaction were performed and medical records were reviewed. Based on the results of patient surveys, there were significant improvements over time in the provision of preventive care in both the education and the comprehensive intervention groups for influenza immunization (79% versus 89%, P<0.01, and 80% versus 91%, P<0.01), pneumococcal immunization (42% versus 73%, P<0.01 and 34% versus 73%, P<0.01), and tetanus immunization (64% versus 72%, P<0.01, and 59% versus 79%, P<0.01). Mammography (90% versus 80%, P<0.01) and clinical breast examination (85% versus 79%, P<0.05) scores worsened in the education only group but not in the comprehensive intervention group. However, there were few differences in rates of preventive services between the groups at the end of the study, and the improvements in preventive care were not confirmed by medical record review. Patient satisfaction scores improved significantly in the comprehensive intervention group (by 0.06 points on a 1 to 5 scale, P = 0.02) but not in the education only group (by 0.02 points, P = 0.42); however, the improvement was not significantly greater in the comprehensive intervention group (P = 0.20). | A physician-targeted approach of education, peer-comparison feedback, and academic detailing has modest effects on patient satisfaction and possibly on the offering of selected preventive care services. The lack of agreement between patient reports and medical records review raises concerns about current methods of ascertaining compliance with guidelines for preventive care. | closed_qa |
In-house referral: a primary care alternative to immediate secondary care referral? | Methods are needed to ensure that those patients referred from primary to secondary care are those most likely to benefit. In-house referral is the referral of a patient by a general practitioner to another general practitioner within the same practice for a second opinion on the need for secondary care referral. To describe whether in-house referral is practical and acceptable to patients, and the health outcomes for patients. Practices were randomized into an intervention or a control group. In intervention practices, patients with certain conditions who were about to be referred to secondary care were referred in-house. If the second clinician agreed referral was appropriate the patient was referred on to secondary care. In control practices patients were referred in the usual fashion. Patient satisfaction and health status was measured at the time of referral, 6 months and one year. Eight intervention and seven control practices took part. For the 177 patients referred in-house, 109 (61%) were judged to need referral on to secondary care. For patient satisfaction, the only difference between the groups studied was that at 12 months patients who had been referred in-house reported themselves as being more satisfied than those referred directly to hospital. For health status, the only difference found was that at the time of referral, patients who had been referred in-house and judged to need hospital referral reported themselves as being less able on the 'Physical function' subscale of the SF-36 than patients who were referred in-house and judged to not need hospital referral. | In-house referral is acceptable to patients and provides a straightforward method of addressing uncertainty over the need for referral from primary to secondary care. | closed_qa |
Do better quality consultations result in better health? | In theory, a positive relationship is expected between the quality of a consultation and a patient's subsequent health status. However, such a relationship has not yet been firmly established in daily practice. We aimed to study the relationship between the quality of the first consultation in a new episode of non-acute abdominal complaints and subsequent health status of patients in general practice. Quality scores for 743 consultations were calculated on the basis of review criteria developed by expert panels. Functional health status was measured by the SIP (Sickness Impact Profile) at baseline, and at 1 and 6 months after the consultation. Multilevel regression analysis was used to examine the relationship between the quality of consultations and health status, and to identify factors of influence on this relationship. In the majority of these patients (97%) health status improved regardless of consultation quality. In patients with malignant disease, and chronic colitis, however, an association between consultation quality and subsequent health status was found: in those with a high consultation quality score (>66-percentile) the health status deteriorated in the first month but improved over the following 5 months; in those with a low consultation quality score (<33-percentile) it deteriorated continuously. | For the great majority of patients we found no relation between the quality of consultation and health status. However, for a very small subgroup of patients there is proof of benefit from better quality consultations. | closed_qa |
Development of a computer clinical instruction program. Is the game worth the candle? | Use of computers in medicine, as tools for information and education, is increasing. Many computer-assisted learning tools have been marketed. For clinician-teachers, computer-assisted learning offers interesting possibilities. Is this educational technology within the reach of family physicians? To describe development of a computer-based learning tool and to suggest indications for its use. A team of clinician-teachers and information technologists developed a tool called Didacticiel sur l'Aviseur to train family physicians and family medicine residents on a clinical decision-making tool called l'Aviseur pharmacothérapeutique, which consists of a database and nine search functions. The Didacticiel in turn consists of an interactive guided tour, a series of exercises with formative evaluation and feedback, a real-time test with a final evaluation, and an integrated, multidimensional project evaluation program. | Developing a computerized learning tool is a worthwhile investment if the content has longevity; the learning process is highly interactive; there is a market for the product; and the tool is developed by a team of experienced, committed information technologists. | closed_qa |
Can sonographic signs predict long-term results of laparoscopic cholecystectomy? | To determine whether sonographic signs of the gallbladder can predict the long-term outcome of laparoscopic cholecystectomy (LC). All 346 patients, who underwent LC at our institution between January 1, 1993 and March 1, 1996, were interviewed using a structured questionnaire on the persistence of pre-operative abdominal symptoms. Patients without a sonographic examination 6 months prior to surgery were excluded. Sonographic parameters, scored on the pre-operative examination, were evaluated by univariate analysis using the relief of abdominal symptoms as a dependent variable. The response rate of correctly returned questionnaires was 68%. The follow-up ranged from 14-53 months. Fourteen percent (18/133) of all patients reported persistence of abdominal complaints after cholecystectomy. Grit in the gallbladder on the pre-operative ultrasound examination was significantly associated with a higher relative risk (RR) for persistence of pre-operative abdominal symptoms (RR 4.5, 95% confidence intervals (CI) 2.0-10.1). The presence of echogenic bile (RR 1.9, 95% CI 0.8-4.9), gallbladder distention (RR 1.9, 95% CI 0.6-5.7), and gallbladder wall thickening (RR 1.5, 95% CI 0.5-4.1) were associated with the persistence of symptoms. A contracted gallbladder (RR 0.6, 95% CI 0.4-1.1) and stone impaction (RR 0.44, 95% CI 0.1-1.8) were associated with the relief of abdominal symptoms. None of these sonographic signs reached significance. There was no difference in the post-operative symptoms rate between patients with a laparoscopic cholecystectomy and those who were converted to an open cholecystectomy. | This retrospective study showed that the sonographic sign of grit in the gallbladder is associated with a high relative risk for persistent abdominal symptoms after cholecystectomy. These findings will be re-evaluated in a prospective study to estimate the definitive clinical importance. | closed_qa |
Jugular phlebectasia in children: is it rare or ignored? | Phlebectasia of the jugular veins is a venous anomaly that usually presents in children as a soft cystic swelling in the neck during straining. The purpose of this report is to discuss the differential diagnosis, the methods of imaging, the mode of treatment, and to demonstrate some factors that have made us believe that the condition may not be an actual rarity but rather has been ignored. Eight cases of unilateral internal jugular phlebectasia were treated surgically (ie, excision of the dilated portion of the vein) from 1987 to 1998. The age of the patients ranged from 3 to 14 years. There were 3 girls and 5 boys. The lesions were right sided in 6, and left sided in 2 children. The patients underwent surgery after comparative ultrasonographic confirmation of the diagnosis. Furthermore, the authors prepared a simple questionnaire for evaluating the level of knowledge about this lesion among the related specialists. One hundred ten physicians were asked to describe the jugular phlebectasia and its ideal treatment. All of the patients were discharged from the hospital 24 hours after surgery. Follow-up periods ranged from 6 months to 6 years and no complaints were noted at the time of most recent visits. Our questionnaire results showed that 96% of 73 pediatricians, 37% of 22 otorhinolaryngologists, and 40% of 15 pediatric surgeons did not know what the jugular phlebectasia was. | Color Doppler sonography alone is sufficient for the diagnosis of jugular phlebectasia. The authors recommend surgical excision in asymptomatic cases for cosmetic and psychological purposes. The rarity of the lesion may be caused by a lack of knowledge among the related physicians and the tendency of reporting only surgical results. | closed_qa |
Alcoholics' selective attention to alcohol stimuli: automated processing? | This study investigated alcoholics' selective attention to alcohol words in a version of the Stroop color-naming task. Alcoholic subjects (n = 23) and nonalcoholic control subjects (n = 23) identified the color of Stroop versions of alcohol, emotional, neutral and color words. Manual reaction times (RTs), skin conductance responses (SCRs) and heart rate (HR) were recorded. Alcoholics showed overall longer RTs than controls while both groups were slower in responding to the incongruent color words than to the other words. Alcoholics showed longer RTs to both alcohol (1522.7 milliseconds [ms]) and emotional words (1523.7 ms) than to neutral words (1450.8 ms) which suggests that the content of these words interfered with the ability to attend to the color of the words. There was also a negative correlation (r = -.41) between RT and response accuracy to alcohol words for the alcoholics, reflecting that the longer time the alcoholics used to respond to the color of the alcohol words, the more incorrect their responses were. The alcoholics also showed significantly greater SCRs to alcohol words (0.16 microSiemens) than to any of the other words (ranging from 0.04-0.08 microSiemens), probably reflecting the emotional significance of the alcohol words. Finally, the alcoholics evidenced smaller HR acceleration to alcohol (1.9 delta bpm) compared to neutral (2.8 delta bpm), which could be related to difficulties alcoholics experience in terminating their attention to the alcohol words. | These findings indicate that it is difficult for alcoholics to regulate their attention to alcohol stimuli, suggesting that alcoholics' processing of alcohol information is automated. | closed_qa |
Alcohol effects on movement-related potentials: a measure of impulsivity? | To assess the effects of acute alcohol intoxication on lateralized readiness potential (LRP), a central measure of movement-related brain activity, and the potential association of such effects with personality measures. Male volunteers (N = 12) alternated responding hands during a "go/no go" verbal recognition task across all four sessions of the balanced placebo design in which beverage content (either juice only or a vodka and juice mixture that raised the average blood alcohol concentration to 0.045%) was crossed with instructions as to beverage content. Whereas the instructions had no effect on behavioral (response accuracy and reaction time) and physiological (LRP) measures, alcohol decreased reaction times adjusted for psychometer speed. As expected, large LRPs were recorded on "go" trials and were not affected by the beverage. However, the "no go" words that did not require and did not evoke motor responses, also evoked significant LRPs under alcohol but not placebo. Since only trials with correct responses and correct abstentions from responses were included in the averages, the motor preparation was not completed and was terminated before the motor response on "no go" trials. Similarly, there was a decrease in spectral power of the movement-related mu-rhythm on "no go" trials under alcohol. | Alcohol may result in disinhibition such that the "response execution" process is activated based on very preliminary stimulus evaluation. This alcohol-induced brain activity signaling premature motor preparation exhibited correlation trends with personality traits related to impulsivity, hyperactivity and antisocial tendencies, thus concurring with other evidence that indicates commonalities between alcoholism and impulsivity, disinhibition and antisocial behaviors. The LRP on "no go" trials could potentially be used as a psychological index of the impulsiveness induced by alcohol intoxication. | closed_qa |
Lower frequency of focal lip sialadenitis (focus score) in smoking patients. Can tobacco diminish the salivary gland involvement as judged by histological examination and anti-SSA/Ro and anti-SSB/La antibodies in Sjögren's syndrome? | Prospectively collected computer database information was previously assessed on a cohort of 300 patients who fulfilled the Copenhagen classification criteria for primary Sjögren's syndrome. Analysis of the clinical data showed that patients who smoked had a decreased lower lip salivary gland focus score (p<0.05). The aim of this original report is to describe the tobacco habits in patients with primary Sjögren's syndrome or stomatitis sicca only and to determine if there is a correlation between smoking habits and focus score in lower lip biopsies as well as ciculating autoantibodies and IgG. All living patients with primary Sjögren's syndrome or stomatitis sicca only, who were still in contact with the Sjögren's Syndrome Research Centre were asked to fill in a detailed questionnaire concerning present and past smoking habits, which was compared with smoking habits in a sex and age matched control group (n=3700) from the general population. In addition, the patients previous lower lip biopsies were blindly re-evaluated and divided by the presence of focus score (focus score = number of lymphocyte foci per 4 mm(2) glandular tissue) into those being normal (focus score</= 1) or abnormal (focus score>1). Furthermore the cohort was divided into three groups; 10-45, 46-60 and>/= 61 years of age. Finally the focus score was related to the smoking habits. Seroimmunological (ANA; anti-SSA/Ro antibodies; anti-SSB/La antibodies; IgM-RF and IgG) samples were analysed routinely. The questionnaire was answered by 98% (n=355) of the cohort and the percentage of current smokers, former smokers and historical non-smokers at the time of lower lip biopsy was not statistically different from that of the control group. Cigarette smoking at the time of lower lip biopsy is associated with lower risk of abnormal focus score (p<0.001; odds ratio 0.29, 95%CI 0.16 to 0.50). The odds ratio for having focal sialadenitis (focus score>1) compared with having a non-focal sialadenitis or normal biopsy (focus score</= 1) was decreased in all three age groups (10-45: odds ratio 0.27, 95%CI 0.11 to 0.71; 46-60: odds ratio 0.22, 95%CI 0. 08 to 0.59; and>/= 61: odds ratio 0.36, 95%CI 0.10 to 1.43) although there was only statistical significance in the two younger age groups. Moreover, among current smokers at the time of the lower lip biopsy there was a decreasing odds ratio for an abnormal lip focus score with increasing number of cigarettes smoked per week (p trend 0.00). In the group of former smokers, which included patients that had stopped smoking up to 30 years ago, the results were in between those of the smokers and the historical non-smokers (odds ratio 0.57, 95%CI 0.34 to 0.97, compared with never smokers). Present or past smoking did not correlate with the function of the salivary glands as judged by unstimulated whole sialometry, stimulated whole sialometry or salivary gland scintigraphy. Among former smokers, the median time lapse between the first symptom of primary Sjögren's syndrome and the performance of the lower lip biopsy was approximately half as long as the median time lapse between smoking cessation and biopsy (8 versus 15 years). Hence, symptoms of Sjögren's syndrome are unlikely to have had a significant influence on smoking habits at the time of the biopsy. Among the seroimmunological results only anti-SSA/Ro and anti-SSB/La antibodies reached statistical significance in a manner similar to the way smoking influenced the focus score in lower lip biopsies. On the other hand the level of significance was consistently more pronounced for the influence of smoking on the focus score than for the influence on anti-SSA/Ro and anti-SSB/La autoantibodies. | This is believed to be the first report showing that cigarette smoking is negatively associated with focal sialadenitis-focus score>1-in lower lip biopsy in patients with primary Sjögren's syndrome. Furthermore, tobacco seems to decrea | closed_qa |
Is routine procaine spirit application necessary in the care of episiotomy wound? | A randomised controlled trial to investigate the usefulness of local application of procaine spirit versus cleansing with water for care of episiotomy wound after normal vaginal delivery was conducted in 100 women. Fifty women entered the study arm and 50 entered the control arm of the study. Women in the two arms were similar in their demographic and obstetric characteristics. The pain scores on a verbal analogue scale was highest (score = 2.5) on Day 1 of the delivery. This was the same in women in both arms. The number of paracetamol tablets consumed was also low and was similar in both groups of women. By the fourteenth day of delivery, all the women were pain-free and the wound had healed well. It was noted that all the women maintained a high standard of perineal hygiene with a mean of 5 washes a day. | It is concluded that in a woman with normal vaginal delivery, local application of procaine spirit is unnecessary in the care of a routine episiotomy wound. | closed_qa |
Is it necessary to biopsy the obvious? | The radiologist and oncologist are often confident that biopsy will confirm their suspicion of recurrent disease, but a biopsy is performed to confirm the histologic diagnosis before beginning or altering therapy. We have examined data to determine how often the biopsied lesion represents recurrent disease from the primary tumor or is an instance of new cancer, and whether recurrent disease can be predicted. We reviewed the medical and imaging records of 253 patients who underwent CT-guided biopsy of an abdominal or pelvic lesion between 1993 and 1996. Sixty-nine of the 253 patients had a previously diagnosed primary tumor and were being examined for possible tumor recurrence or metastasis. The images of these 69 patients were analyzed to determine if the pattern of disease was typical of recurrence or metastasis. In 55 of the 69 patients, the pattern was judged to be typical of metastatic or recurrent disease. Biopsy confirmed this suspicion in all 55 patients. In 14 of the 69 patients, the pattern of spread was judged not to be typical of recurrence or metastasis. These 14 patients were found to have a new primary tumor (n = 4), benign processes (n = 2), and recurrences (n = 8). | Of the patients for whom radiographic findings suggested recurrence, we found no patients in whom a new primary tumor would have been missed if biopsy had been avoided. Data should now be acquired prospectively to determine whether it may be prudent to make treatment decisions on the basis of imaging findings alone, without histologic confirmation. | closed_qa |
Improving the recognition and management of depression: is there a role for physician education? | Many patients who visit primary care physicians suffer from depression, but physicians may miss the diagnosis or undertreat these patients. Improving physicians' communication skills pertaining to diagnosing and managing depression may lead to better outcomes. We performed a randomized controlled trial involving 49 primary care physicians to determine the effect of the Depression Education Program on their knowledge of depression and their behavior toward depressed patients. After randomization, physicians in the intervention group completed the Depression Education Program, which consists of 2 4-hour interactive workshops that combine lectures, discussion, audiotape review, and role-playing. Between sessions, physicians audiotaped an interview with one of their patients. Two to 6 weeks following the intervention program, physicians completed a knowledge test and received office visits from 2 unannounced people acting as standardized patients with major depression. These "patients" completed a checklist and scales. Logistic and linear regression were used to control for sex, specialty, and suspicion that the patient was a standardized patient. For both standardized patients, more intervention physicians than control physicians asked about stresses at home, and they also scored higher on the Participatory Decision-Making scale. During the office visits of one of the standardized patients, more intervention physicians asked about at least 5 criteria for major depression (82% and 38%, P = .006), discussed the possibility of depression (96% and 65%, P = .049), scheduled a return visit within 2 weeks (67% and 33%, P = .004), and scored higher than control physicians on the Patient Satisfaction scale (40.3 and 35.5, P = .014). | The Depression Education Program changed physicians' behavior and may be an important component in the efforts to improve the care of depressed patients. | closed_qa |
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