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<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is naturopathy as effective as conventional therapy for treatment of menopausal symptoms? Answer the question given the following information: Context: Although the use of alternative medicine in the United States is increasing, no published studies have documented the effectiveness of naturopathy for treatment of menopausal symptoms compared to women receiving conventional therapy in the clinical setting. Context: To compare naturopathic therapy with conventional medical therapy for treatment of selected menopausal symptoms. Context: A retrospective cohort study, using abstracted data from medical charts. Context: One natural medicine and six conventional medical clinics at Community Health Centers of King County, Washington, from November 1, 1996, through July 31, 1998. Context: Women aged 40 years of age or more with a diagnosis of menopausal symptoms documented by a naturopathic or conventional physician. Context: Improvement in selected menopausal symptoms. Context: In univariate analyses, patients treated with naturopathy for menopausal symptoms reported higher monthly incomes ($1848.00 versus $853.60), were less likely to be smokers (11.4% versus 41.9%), exercised more frequently, and reported higher frequencies of decreased energy (41.8% versus 24.4%), insomnia (57.0% versus 33.1%), and hot flashes (69.6% versus 55.6%) at baseline than those who received conventional treatment. In multivariate analyses, patients treated with naturopathy were approximately seven times more likely than conventionally treated patients to report improvement for insomnia (odds ratio [OR], 6.77; 95% confidence interval [CI], 1.71, 26.63) and decreased energy (OR, 6.55; 95% CI, 0.96, 44.74). Naturopathy patients reported improvement for anxiety (OR, 1.27; 95% CI, 0.63, 2.56), hot flashes (OR, 1.40; 95% CI, 0.68, 2.88), menstrual changes (OR, 0.98; 95% CI, 0.43, 2.24), and vaginal dryness (OR, 0.91; 95% CI, 0.21, 3.96) about as frequently as patients who were treated conventionally. Think step by step to answer my question. [/INST] Naturopathy appears to be an effective alternative for relief of specific menopausal symptoms compared to conventional therapy.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can randomised trials rely on existing electronic data? Answer the question given the following information: Context: To estimate the feasibility, utility and resource implications of electronically captured routine data for health technology assessment by randomised controlled trials (RCTs), and to recommend how routinely collected data could be made more effective for this purpose. Context: Four health technology assessments that involved patients under care at five district general hospitals in the UK using four conditions from distinct classical specialties: inflammatory bowel disease, obstructive sleep apnoea, female urinary incontinence, and total knee replacement. Patient-identifiable, electronically stored routine data were sought from the administration and clinical database to provide the routine data. Context: Four RCTs were replicated using routine data in place of the data already collected for the specific purpose of the assessments. This was done by modelling the research process from conception to final writing up and substituting routine for designed data activities at appropriate points. This allowed a direct comparison to be made of the costs and outcomes of the two approaches to health technology assessment. The trial designs were a two-centre randomised trial of outpatient follow-up; a single-centre randomised trial of two investigation techniques; a three-centre randomised trial of two surgical operations; and a single-centre randomised trial of perioperative anaesthetic intervention. Context: Generally two-thirds of the research questions posed by health technology assessment through RCTs could be answered using routinely collected data. Where these questions required analysis of NHS resource use, data could usually be identified. Clinical effectiveness could also be judged, using proxy measures for quality of life, provided clinical symptoms and signs were collected in sufficient detail. Patient and professional preferences could not be identified from routine data but could be collected routinely by adapting existing instruments. Routine data were found potentially to be cheaper to extract and analyse than designed data, and they also facilitate recruitment as well as have the potential to identify patient outcomes captured in remote systems that may be missed in designed data collection. The study confirmed previous evidence that the validity of routinely collected data is suspect, particularly in systems that are not under clinical and professional control. Potential difficulties were also found in identifying, accessing and extracting data, as well as in the lack of uniformity in data structures, coding systems and definitions. Think step by step to answer my question. [/INST] Routine data have the potential to support health technology assessment by RCTs. The cost of data collection and analysis is likely to fall, although further work is required to improve the validity of routine data, particularly in central returns. Better knowledge of the capability of local systems and access to the data held on them is also essential. Routinely captured clinical data have real potential to measure patient outcomes, particularly if the detail and precision of the data could be improved.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is laparoscopic radical prostatectomy better than traditional retropubic radical prostatectomy? Answer the question given the following information: Context: To compare morbidity in two groups of patients who underwent retropubic or laparoscopic radical prostatectomy in the same period. Context: The clinical and pathological data obtained in 50 consecutive patients who underwent retropubic radical prostatectomy (RRP) from January 2001 to December 2001 were compared to those obtained in 71 consecutive patients who were treated in the same year by extraperitoneal laparoscopic radical prostatectomy (LRP). The two groups were comparable in terms of mean pre-operative PSA and biopsy Gleason score. The peri-operative data included operative time, intra-operative and post-operative transfusion rates, complication rates, hospitalization length, and duration of catheterization. The following pathological parameters were considered: Gleason score, pathological stage, and positive surgical margin rate. A comparative evaluation of continence recovery (no pads and any leakage) was made only in patients with follow-up longer than 12 months. Context: The two groups were comparable in terms of pathological stage and definitive Gleason score. Operating times were significantly shorter in RRP (p<0.0001). LRP patients showed higher autologous (p<0.001) and eterologous transfusion (p=0.03). No significant difference was observed in terms of complication rates (p=0.07). The rectal injury rate was 2.8% in the laparoscopic group. The mean post-operative hospital stay was 10.2+/-2 days in the surgery group and 7.2+/-3.4 days in the laparoscopy group (p<0.001). Catheterization time was 8.4+/-0.9 days in the surgery group and 8+/-2.8 days in the laparoscopy group (p=0.27). After 12 months, complete continence was achieved in 64% of RRP and 40% of LRP patients, respectively (p=0.29). Think step by step to answer my question. [/INST] The results of our non-randomized study show that up to now laparoscopic radical prostatectomy does not provide significant advantages in terms of peri-operative morbidity compared with the traditional retropubic approach.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does bacterial gastroenteritis predispose people to functional gastrointestinal disorders? Answer the question given the following information: Context: Irritable bowel syndrome (IBS) might develop after gastroenteritis. Most previous studies of this relationship have been uncontrolled, and little is known regarding other functional gastrointestinal disorders (FGIDs) after gastroenteritis. The primary aim of this study was to determine the frequency of IBS, functional dyspepsia, or functional diarrhea 6 months after bacterial gastroenteritis. Context: This was a prospective, community-based, case-control study. Cases had proven bacterial gastroenteritis, and controls were community-based. FGIDs were diagnosed with the use of self-completed Rome II modular questionnaires administered at baseline, 3, and 6 months. Subjects with prior FGIDs were excluded. The primary endpoint was the presence of one of the three specific FGIDs at 6 months. Context: A total of 500 cases and 705 controls were identified. Of the 500 cases, 265 (53%) consented, but only 128 cases and 219 community controls who consented were eligible. At 6 months, 108 cases and 206 controls returned the questionnaire. FGIDs were diagnosed in significantly more cases (n = 27, 25%) than controls (n = 6, 2.9%) (OR = 11.11, 95% CI = 4.42-27.92). IBS was diagnosed in 18 cases (16.7%) and four controls (1.9%) (OR = 10.1, 95% CI = 3.32-30.69); functional diarrhea in six cases (5.6%) and no controls. Functional dyspepsia was uncommon in both cases and controls. Similar findings were found at 3 months, with 29% of cases and 2.9% of controls having an FGID. Think step by step to answer my question. [/INST] Symptoms consistent with IBS and functional diarrhea occur more frequently in people after bacterial gastroenteritis compared with controls, even after careful exclusion of people with pre-existing FGIDs. The frequency is similar at 3 and 6 months. Our findings support the existence of postinfectious IBS and give an accurate estimate of its frequency.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is early colonoscopy after admission for acute diverticular bleeding needed? Answer the question given the following information: Context: Urgent colonoscopy has been proposed for the diagnosis and management of acute colonic diverticular bleeding. Identification of active bleeding and nonbleeding stigmata facilitates diagnosis and endoscopic therapy, but it is unclear whether urgent colonoscopy after presentation increases the diagnostic yield. This study evaluated the association between timing of colonoscopy and diagnostic yield in patients admitted with acute colonic diverticular bleeding. Context: Patients admitted for hematochezia and receiving a diagnosis of diverticular hemorrhage were identified using the Mayo Clinic GI Bleeding Team and Emergency Room Admissions Databases for the years 1998-2000. Timing of colonoscopy was determined from the time of admission. Logistic regression analysis was used to assess whether the timing of colonoscopy was associated with an endoscopic finding of active bleeding or nonbleeding stigmata (or both). Context: A diagnosis of definitive or presumptive diverticular bleeding was made in 78 patients (39 men and 39 women, mean age 78 yr, range 49-96 yr). Twelve patients (15%) had active bleeding or stigmata. Colonoscopies were performed a mean of 18 +/- 11 h after admission. The association between a definitive diagnosis of acute diverticular bleeding and the timing of colonoscopy was not significant (p>0.46). Think step by step to answer my question. [/INST] No significant association is apparent between the timing of colonoscopy after admission and encountering active bleeding or nonbleeding stigmata. Based on these observations, urgent colonoscopy for these patients does not seem advantageous.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does the use of a specialised paediatric retrieval service result in the loss of vital stabilisation skills among referring hospital staff? Answer the question given the following information: Context: To compare the proportion of airway and vascular access procedures performed by referring hospital staff on critically ill children in two discrete time periods, before and after widespread use of a specialised paediatric retrieval service. Context: Transport data were obtained from retrieval logs of all children for whom a paediatric retrieval team was launched in each of two time periods (October 1993 to September 1994; and October 2000 to September 2001). Context: The overall intubation rate was similar in the first and second time periods (83.9% v 79.1%). However, 31/51 (61%) retrieved children were intubated by referring hospital staff in 1993-94, compared to 227/269 (84%) in 2000-01. Referring hospital staff gained central venous access in 11% v 18% and arterial access in 22% v 19% of retrieved children in the first and second time periods respectively. This was in spite of a significant reduction in the proportion of children on whom these procedures were performed. Think step by step to answer my question. [/INST] Referring hospital staff are performing a greater proportion of initial airway and vascular access procedures undertaken in the stabilisation of sick children retrieved by a specialised paediatric retrieval team. The provision of this service has not resulted in the loss of vital skills at the local hospital.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Management of thoracic empyema in childhood: does the pleural thickening matter? Answer the question given the following information: Context: To determine the clinical course and long term outcome of empyema treated without decortication. Context: Fourteen consecutive admissions to one hospital were studied; radiological resolution and lung function were subsequently followed. The children were aged 2-14 years. All were treated with intravenous antibiotics and chest drain only. Context: All patients had extensive pleural thickening evident on chest x ray examination at the time of discharge, which resolved entirely over a period of 2-16 months. Lung function was measured in 13 children, and showed no evidence of restrictive or obstructive deficit: mean (SD) values as per cent predicted for height were: forced expiratory volume in one second (FEV1) 107.5 (9.6), forced vital capacity (FVC) 95.5 (8.8), total lung capacity (TLC) 98.6 (20.7). Individual children all had values in the normal range (80-120 per cent predicted). Think step by step to answer my question. [/INST] Results suggest that decortication is not necessary in children to prevent long term problems with pleural thickening, and should be undertaken on the basis of the clinical picture (failure of fever resolution), rather than radiological appearance.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does repeated hyperbaric exposure to 4 atmosphere absolute cause hearing impairment? Answer the question given the following information: Context: Direct pressure applied on the inner ear cannot induce hearing loss. Context: Three possible causes have been described in the literature for inner ear permanent lesions during scuba diving: pressure imbalance between the middle ear and the external ear, appearance of microbubbles in the internal ear, and direct effect of pressure on the inner ear. We seek to determine whether this last factor can be involved. Context: We submitted two groups of guinea pigs previously implanted with an electrode in the round window to a protocol of air diving in a hyperbaric chamber. Eardrums of animals in one of the two groups had been perforated beforehand. Twenty dives were practiced over 4 weeks. We chose dive parameters consistent with common sport diving: maximal pressure of 4 atmosphere absolute and duration of 30 minutes. Auditory threshold and cochlear spontaneous activity were recorded at regular intervals. Furthermore, we recorded spontaneous cochlear activity in Heliox 400-m and 600-m dives to determine whether our conclusions hold for "extreme" diving. Context: In the group with perforated eardrums, no variation of those parameters were recorded, even in extreme diving. Important variations were noticed in the other group. Think step by step to answer my question. [/INST] Pressure applied directly on the inner ear during diving does not disturb cochlear activity.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Lower urinary tract reconstruction for duplicated renal units with ureterocele. Is excision of the ureterocele with reconstruction of the bladder base necessary? Answer the question given the following information: Context: Current practice in reconstruction of the lower urinary tract for duplicated renal systems with an associated ureterocele is excision of the ureterocele with reconstruction of the bladder and a common sheath ureteroneocystostomy. For a nonfunctioning upper pole treatment is partial nephroureterectomy. We postulate that lower urinary tract reconstruction can be performed successfully through an extravesical approach without excision of the ureterocele or reconstruction of the bladder base. We present our experience with that approach. Context: Between 1996 and 2001, 60 patients presented with the diagnosis of ureterocele and obstruction of the upper pole ureter. Partial nephrectomy was performed in 12 cases of which 4 had reflux to the lower pole moiety. Upper pole only dismembered ureteroneocystostomy was performed in 7 of 15 cases reconstructed using the extravesical approach. Context: Average postoperative stay was 3.7 days. The Foley catheter was removed within 24 to 48 hours. Postoperative ultrasound showed decompression of the obstructed system and the ureterocele. Reflux was corrected in all patients. Flow rate with measurement of post-void residual 6 weeks postoperatively in toilet trained children showed complete bladder emptying. Think step by step to answer my question. [/INST] Lower urinary tract reconstruction for duplicated renal systems with obstruction of the upper pole can be accomplished safely with decreased morbidity through the extravesical approach without excision of the ureterocele or reconstruction of the bladder base. Moreover, in instances when there is no reflux to the lower pole moiety, upper pole only extravesical ureteroneocystostomy can be performed.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is common sheath extravesical reimplantation an effective technique to correct reflux in duplicated collecting systems? Answer the question given the following information: Context: We evaluate the outcome vesicoureteral reflux (VUR) in duplicated collecting systems compared to single collecting systems corrected using an extravesical detrusorrhaphy approach. Context: We reviewed the records of 266 patients (422 ureters) treated for VUR using an extravesical approach between 1991 and 2001. Inclusion criteria were primary reflux in single (201 patients, 125 bilateral) or duplicated collecting systems (65, 31 bilateral) in patients not undergoing other concomitant surgery with at least 1 year of postoperative followup. The indication for surgical intervention was unresolved reflux (greater than 4 years) in more than 70% of patients. Postoperative evaluation included a voiding cystourethrogram at 3 months and 12 months if reflux was unresolved at 3 months. Also ultrasound was performed at 6 weeks or earlier if clinically indicated and 12 months. Context: Group 1 (duplicated collecting systems) and group 2 (single collecting systems) were comparable for age, sex distribution and reflux grade distribution. Overall success rate at 3 and 12 months was 94.7% and 98.9% for group 1, and 95.1% and 98.5% for group 2, respectively. The difference in success rate at 3 and 12 months was not statistically significant (p>0.05). Of note in both groups postoperative VUR was contralateral in more than 40% of cases. Postoperative hydronephrosis (Society for Fetal Urology grade 1, 2 or 1 increment in grade from preoperative status) was observed in 5.3% and 7.3% of ureteral units at 6 weeks in groups 1 and 2, respectively (p>0.05). At 12 months less than 1% of ureteral units exhibited low grade residual hydronephrosis. No high grade postoperative hydronephrosis was observed in either group, and there were no intraoperative complications. Postoperative urinary retention occurred in 4.7% and 4% of patients in groups 1 and 2, respectively (p>0.05). Think step by step to answer my question. [/INST] Common sheath extravesical reimplantation is highly effective in treating VUR. The common sheath extravesical reimplantation for duplicated collecting systems is as effective in nonduplicated systems and is associated with minimal perioperative morbidity.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is an empty left hemiscrotum and hypertrophied right descended testis predictive of perinatal torsion? Answer the question given the following information: Context: We determine whether the finding of a nonpalpable left testis and hypertrophied(2 cc or greater) right testis is predictive of an atrophic (perinatal torsion) left testis. Context: Prospectively, all boys with a nonpalpable left testis and hypertrophied right testis seen between May 2000 and May 2002 were included in the study. Testicular measurement was performed preoperatively with an orchidometer. In 19 of 22 boys size was also confirmed intraoperatively. Surgical exploration was done initially through a scrotal incision. Diagnostic laparoscopy was performed in boys in whom intrascrotal tissue that was consistent with a "nubbin" was not found. All tissue removed was submitted for histological evaluation. Context: In 19 of 22 boys tissue was found in the left hemiscrotum that was clinically consistent with a scrotal nubbin, and histological confirmation was absolute in 18. In 1 patient a hollow oval mass attached to a cord extending to the external inguinal ring was found without the other classic histological features of torsion. In 3 cases scrotal exploration was negative and diagnostic laparoscopy was performed. Of this group the pathognomonic findings of a closed internal ring with hypoplastic vas and vessels were noted in 2 cases, and normal vas and vessels were seen to exit an open internal inguinal ring in 1. Inguinal exploration demonstrated an enlarged intracanalicular testis measuring 3 cc in volume, comparable in size to the descended right testicle. Think step by step to answer my question. [/INST] The combination of a nonpalpable left testis and an enlarged right testis is highly predictive of perinatal testicular torsion. When both criteria were met 20 of 22 (91%) consecutive patients had histological or laparoscopically confirmed perinatal torsion and 1 had only clinical features. This finding supports the concept of scrotal exploration as the initial procedure in the child who has an empty left hemiscrotum and hypertrophied descended right testis. Laparoscopy should be reserved for boys in whom a distinct remnant is not found on scrotal exploration.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does treatment with clean intermittent catheterization in boys with posterior urethral valves affect bladder and renal function? Answer the question given the following information: Context: In boys with resected posterior urethral valves (PUV) deterioration of renal function is seen during childhood and adolescence, which may partly be caused by bladder dysfunction. We present data on renal and bladder function initially and at followup of boys with PUV in whom the bladder dysfunction has been treated since infancy. Context: The study included 35 boys with PUV. Bladder regimen, including early toilet training from the age of 1.5 years and detrusor relaxant drugs for the treatment of incontinence from ages 4 to 6 years, was introduced to all patients. A total of 19 boys were started on clean intermittent catheterization (CIC) at a median age of 8 months due to pronounced bladder dysfunction with poor emptying, unsafe pressure levels, high grade reflux and renal impairment. Context: No serious complications of CIC have been seen during followup. Of the 19 boys 2 stopped performing CIC due to noncompliance of the parents at 1 and 3 years, respectively. Initial renal function, measured as median glomerular filtration rate (GFR) in percent of expected for age, was 60% in the CIC group and 90% in the nonCIC group. At followup at a median age of 8 years the CIC group (n = 14, 3 transplanted boys excluded) had an increase in median differential GFR (difference between followup and initial GFR) of 7% (p<0.01), which was similar increase to that of the nonCIC group. In the 2 boys who stopped performing CIC renal function deteriorated with a median differential GFR of -24%. In the CIC group detrusor instability decreased. Poor compliance was seen in 6 of the 19 boys initially and only one remained poorly compliant. In 1 of the boys who stopped performing catheterization a low compliant bladder developed. In all of the other cases bladder capacity increased more than expected for age. Think step by step to answer my question. [/INST] The results suggest that treatment of bladder dysfunction in boys with PUV can counteract the deterioration in renal function seen during childhood but the number of patients in our study is limited.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can bladder outflow obstruction be diagnosed from pressure flow analysis of voiding initiated by involuntary detrusor overactivity? Answer the question given the following information: Context: We investigated whether a diagnosis of bladder outflow obstruction could be established from pressure flow analysis of a void initiated by involuntary detrusor overactivity. Context: A total of 79 men with lower urinary tract symptoms were identified prospectively. In each subject 2 sequential pressure flow studies were performed during the same session. Pressure flow data were recorded during a voluntary void and voiding initiated by involuntary detrusor overactivity. Pressure flow parameters were compared using the paired t test and differences in classification according to the International Continence Society nomogram were analyzed using the chi-square test. Context: The maximum flow rate showed no significant difference between voluntary voiding and voiding initiated by involuntary detrusor overactivity. Detrusor pressure at maximum flow showed a slight, statistically significant but not clinically significant increase during voiding initiated by involuntary detrusor overactivity. However, the diagnostic classification remained unchanged in 64 of 79 men (80%). In no case was the diagnosis altered from bladder outflow obstruction to nonobstruction or vice versa when comparing the 2 pressure flow studies. There were significant increases in maximum detrusor pressure and detrusor pressure at the initiation of voiding during voiding initiated by involuntary detrusor overactivity. Think step by step to answer my question. [/INST] This study demonstrates that increased detrusor pressure observed during voiding subsequent to detrusor overactivity does not change the diagnostic classification in 80% of men. The results provide evidence that bladder outflow obstruction can be reliably diagnosed based on pressure flow parameters recorded during voiding initiated by involuntary detrusor overactivity.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Optimal lesion assessment following acute radio frequency ablation of porcine kidney: cellular viability or histopathology? Answer the question given the following information: Context: Radio frequency ablation (RFA) has been used as a minimally invasive alternative to nephrectomy for small renal tumors. Questions have arisen regarding the accuracy of cell viability determination on standard hematoxylin and eosin (H&E) staining. We investigated and compared the histological characteristics of RF ablated renal tissue using nicotinamide adenine dinucleotide (NADH) and H&E staining. Context: Ten porcine kidneys underwent laparoscopic RFA of the upper and lower poles using a 2 (8) or 3 cm (2) protocol with 2 cycles of 90 W, target temperature 105C and treatment time 5.5 minutes per cycle. Following tract ablation the kidneys were immediately harvested, gross lesion size was measured and tissue was processed for standard H&E and NADH staining. Context: H&E staining of ablated tissue revealed a number of alterations in renal tubular histology. However, all of these findings were focal with areas of parenchyma that appeared well preserved. Corresponding areas on NADH processed sections showed the complete absence of staining, indicating the lack of cellular viability. There were no skip areas noted on NADH processed sections and treated portions demonstrated a well demarcated border of ablation. Think step by step to answer my question. [/INST] While RFA produces discernible histological changes acutely on H&E, these alterations are variable and patchy, and they alternate with areas of well preserved tissue. Therefore, NADH staining should always be used to assess and verify cellular death in RFA lesions. In this study no skip areas of viable cells were noted within areas of ablated tissue on NADH staining.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Efficacy of secondary isoniazid preventive therapy among HIV-infected Southern Africans: time to change policy? Answer the question given the following information: Context: To determine the efficacy of secondary preventive therapy against tuberculosis (TB) among gold miners working in South Africa. Context: An observational study. Context: Health service providing comprehensive care for gold miners. Context: The incidence of recurrent TB was compared between two cohorts of HIV-infected miners: one cohort (n = 338) had received secondary preventive therapy with isoniazid (IPT) and the other had not (n = 221). Context: The overall incidence of recurrent TB was reduced by 55% among men who received IPT compared with those who did not (incidence rates 8.6 and 19.1 per 100 person-years, respectively; incidence rate ratio, 0.45; 95% confidence interval 0.26-0.78). The efficacy of isoniazid preventive therapy was unchanged after controlling for CD4 cell count and age. The number of person-years of IPT required to prevent one case of recurrent TB among individuals with a CD4 cell count<200 x 106 cells/l, and>or = 200 x 106 cells/l was 5 and 19, respectively. Think step by step to answer my question. [/INST] Secondary preventive therapy reduces TB recurrence: the absolute impact appears to be greatest among individuals with low CD4 cell counts. International TB preventive therapy guidelines for HIV-infected individuals need to be expanded to include recommendations for secondary preventive therapy in settings where TB prevalence is high.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is it necessary to obtain serum levels of thyroid stimulating hormone and prolactin in asymptomatic women with infertility? Answer the question given the following information: Context: Most obstetricians and gynecologists order serum levels of thyroid stimulating hormone (TSH) and prolactin (PRL) in every female patient undergoing an infertility evaluation (regardless of their menstrual rhythm). Context: Patients were recruited from the clinical practice of the named authors in a prospective manner. Serum TSH and PRL were ordered at the time of the couple's initial consult. Context: 2.48% of patients (21 out of 846 patients) had abnormal levels of TSH, and 1.77% (15 of 844 patients) had elevated levels of PRL. Think step by step to answer my question. [/INST] The practice of routinely ordering serum levels of TSH and PRL in infertility patients having normal periods is questioned.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Valuing the outcomes of treatment: do patients and their caregivers agree? Answer the question given the following information: Context: Treatment outcomes are an important determinant of patients' treatment preferences. Although studies have examined how well surrogates agree with patients' preferences for specific treatment interventions, agreement regarding the valuation of health states as treatment outcomes is unknown. Context: Cross-sectional cohort study consisting of in-home interviews with 193 persons 60 years or older and seriously ill with cancer, congestive heart failure, or chronic obstructive pulmonary disease and their caregivers. Patients were asked whether, facing an exacerbation of illness, they would find a series of health states acceptable as a result of treatment (a rating of "unacceptable" meant they would prefer to die than to receive treatment). Caregivers were asked whether they would find these states acceptable for the patient. Context: There was 80% or greater agreement for health states that were overall rated either acceptable (current health, mild memory impairment, mild pain, or other symptoms) or unacceptable (coma). There was 58% to 62% agreement (kappa = 0.10-0.25) about states with more severe physical or cognitive impairment. When disagreement occurred, caregivers were more likely to rate the state as acceptable. There was 61% to 65% agreement (kappa = 0.20-0.28) about states with severe pain or other symptoms. When disagreement occurred, caregivers and patients were equally likely to rate the state as acceptable. Think step by step to answer my question. [/INST] Patient-caregiver agreement about the acceptability of health states with functional or cognitive impairment, severe pain, or other symptoms was poor. Caregivers making surrogate decisions based on considerations of treatment outcomes may not effectively represent patients' preferences.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do different mattresses affect the quality of cardiopulmonary resuscitation? Answer the question given the following information: Context: To determine the effect of different mattresses on cardiopulmonary resuscitation performance and establish whether emergency deflation of an inflatable mattress improves the quality of resuscitation. Context: Randomised controlled cross-over trial performed in a general Context: Critical care staff from a general ICU. Context: Cardiopulmonary resuscitation on a manikin on the floor or on a bed with a standard foam mattress and inflated and deflated pressure redistributing mattresses. Maximal compression force was measured at different bed heights. Context: Compression depth, duty cycle and rate and percentage correct expired air ventilation were recorded on a manikin. Compression depth was significantly lower on the foam (35.2 mm), inflated (37.2 mm) and deflated mattress (39.1 mm) than the floor (44.2 mm). There were no clinically important differences in duty cycle or compression rate. The quality of ventilation was poor on all surfaces. Maximal compression force declined as bed height increased. Think step by step to answer my question. [/INST] Resuscitation performance is adversely affected when performed on a bed (irrespective of mattress type) compared to the floor. There were no differences between the inflated and deflated mattresses, although the deflation process did not adversely affect performance. This study does not support the routine deflation of an inflated mattress during resuscitation and questions the potential benefits from using a backboard. The finding that bed height affects maximal compression forces, challenges the recommendation that cardiopulmonary resuscitation be performed with the bed at middle-thigh level and requires further investigation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Could health care costs for depression be decreased if the disorder were correctly diagnosed and treated? Answer the question given the following information: Context: The aim of the present study was to assess the general population from two Sardinian areas to ascertain the direct health care costs involved in a diagnosis of major depression, and to verify the hypothesis of an increased expenditure for untreated depressed subjects. Context: A case-control study was carried out using the database of an epidemiological community survey. Cases were subjects with a diagnosis of Major Depressive Episode (ICD-10, WHO 1992) in the last year, and controls comprised two groups matched to cases for sex and age, made up of healthy subjects and subjects affected by chronic somatic disorders, respectively. Context: Depressed subjects use more health care resources than those affected by chronic somatic disorders or healthy subjects. An increase in health care costs is observed for drugs and hospitalisations in depressed subjects for whom no adequate antidepressive treatment has been prescribed. Think step by step to answer my question. [/INST] In spite of the limitations of the small sample size, the results seem to confirm an increase of direct health care costs in untreated depressed subjects. In view of the availability of efficient forms of treatment for depression, the findings obtained indicate that depression should be considered a priority question for public health and assigning of resources. Further confirmation should be sought in larger population-based studies representing the entire national context.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: MR imaging of anterior cruciate ligament tears: is there a gender gap? Answer the question given the following information: Context: Clinically, females receive anterior cruciate ligament (ACL) tears more commonly than males. We explored whether gender differences exist in MR imaging patterns of ACL tears. Context: At 1.5 T, two observers evaluated MR examinations of 84 consecutive age-matched patients (42 males, 42 females, aged 16-39) with ACL tears, for mechanism of injury, extent and type of tear, the presence of secondary signs and associated osseous, meniscal and ligamentous injuries. Context: The most common mechanism of injury for both females and males was the pivot shift mechanism (67 and 60%, respectively). Females were more commonly imaged in the acute stage of tear than males (98 and 67%, respectively, p=0.001) and more commonly possessed the typical posterolateral tibial bone contusion pattern (88 and 62%, respectively, p=0.0131). Males exhibited a deeper femoral notch sign (2.7 and 2.0 mm, p=0.007) and medial meniscal, lateral collateral ligament and posterior cruciate ligament injuries more commonly than females (48 and 24%, p=0.009, 30 and 7%, p=0.035, 17 and 0%, p=0.035). There was no significant difference between genders for the presence of other secondary signs and contusion patterns, associated lateral meniscal tears, presence of O'Donoghue's triad or associated medial collateral ligament injuries. Think step by step to answer my question. [/INST] Gender differences in MR imaging patterns of ACL tears exist: females are more commonly imaged in the acute stage and more commonly possess posterolateral tibial bone contusions; males have a more severe presentation than females, associated with more severe lateral femoral condyle and soft tissue injuries.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Distribution of spinal fractures in children: does age, mechanism of injury, or gender play a significant role? Answer the question given the following information: Context: The distribution of fractures in the spine reported in the literature is quite variable. Application of such data to the pediatric population needs to take into account differences between children and adults, including overall decreased fracture frequency in children, developmental and physiological differences, and mechanism of injury. Knowledge of specific regions of injury may alter search patterns and protocols. Context: To determine if the distribution of spinal injuries in pediatric patients is related to age, mechanism of injury, or gender. Context: All pediatric patients (<18 years old) referred to our trauma service over a 5-year period were retrospectively reviewed. All patients with vertebral fracture and/or neurological injury were included. The levels of the spinal fractures were tabulated. Correlation was then made with age, gender, and mechanism of injury (motor vehicle accident versus non-motor vehicle accident). Context: Of the 2614 pediatric patients, 84 sustained vertebral fracture and 50 had neurological injury without radiographic abnormality. A total of 164 fractures were identified. The thoracic region (T2-T10) was most commonly injured, accounting for 47 fractures (28.7%) followed by the lumbar region (L2-L5) with 38 fractures (23.2%), the mid-cervical region with 31 fractures (18.9%), the thoracolumbar junction with 24 fractures (14.6%), the cervicothoracic junction with 13 fractures (7.9%), and the cervicocranium with 11 fractures (6.7%). There was no relationship to gender or mechanism of injury. Think step by step to answer my question. [/INST] Regardless of gender or mechanism of injury, the thoracic spine (T2-T10) is the most common region of fracture in pediatric trauma patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do people recognise mental illness? Answer the question given the following information: Context: Mental health literacy has been defined as the public's knowledge and the beliefs about mental disorders enhancing the ability to recognise specific disorders. Context: Firstly, to determine whether the public recognises a person depicted in a vignette as mentally ill or as experiencing a crisis. Secondly, to reveal the factors influencing the correct recognition. Context: Multiple logistic regression analysis of an opinion survey conducted in a representative population sample in Switzerland (n=844). Context: The depression vignette was correctly recognised by 39.8% whereas 60.2% of the respondents considered the person depicted as having a 'crisis.' The schizophrenia vignette was correctly identified by 73.6% of the interviewees. A positive attitude to psychopharmacology positively influenced the recognition of the two vignettes whereas a positive attitude to community psychiatry had the inverse effect. Moreover, for the depression vignette previous contact to mentally ill people had a positive influence on the recognition. For the schizophrenia vignette instead, rigidity and interest in mass media had a negative influence, respectively. Think step by step to answer my question. [/INST] The low knowledge about mental disorders, particularly depression, confirms the importance and the need to increase mental health literacy. Furthermore, professionals must openly discuss illness models with their patients, especially emphasising the differences between illness and crisis.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Documentation of idiotypic cascade after Lym-1 radioimmunotherapy in a patient with non-Hodgkin's lymphoma: basis for extended survival? Answer the question given the following information: Context: The purpose of this study was to examine idiotypic cascade mechanisms in the plasma of a prolonged survivor patient with aggressive non-Hodgkin's lymphoma (NHL). It is a follow-up to previously published seminal studies by this laboratory showing survival benefit associated with radioimmunotherapy in NHL patients. Immunoglobulin from the patient's plasma was purified, characterized, and shown to possess the activities expected of idiotypic antibodies. Context: Plasma from a NHL patient treated with Lym-1 was precipitated with ammonium sulfate and octanoic acid, followed by immunoadsorbant chromatography with solid phase Lym-1 monoclonal antibody to purify Ab2. The last purification step involved the binding of Ab3 to glutaraldehyde-fixed Raji cells, followed by acid elution of Ab3. Proteins were quantified and characterized. Antibody-dependent cellular cytotoxicity activity was determined using a standard (51)Cr release assay. Context: Purified immunoglobulin populations exhibited the characteristics of Ab2beta and Ab3 antibodies. Both showed ability to compete with the binding of Lym-1 to its tumor cell target, and Ab3 showed ability to induce antibody-dependent cellular cytotoxicity. Think step by step to answer my question. [/INST] This study offers direct evidence for initiation of a multilevel idiotypic cascade in a patient undergoing passive monoclonal antibody therapy for NHL. The patient's prolonged disease-free survival may, thus, be understood in the context of the generation of endogenous, self-perpetuating tumor-specific antibodies.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Management of cancer of the ampulla of Vater: does local resection play a role? Answer the question given the following information: Context: The clinical outcome of patients with ampullary carcinoma is significantly more favorable than for patients with pancreatic head carcinoma. The Whipple procedure is the operation of choice for both diagnoses. Still local resection is recommended in selected cases. The aim of this study was to assess the outcome of local resection of cancer of the ampulla of Vater by comparison with pancreaticoduodenectomy. Context: 92 patients with cancer of the ampulla of Vater treated between 1975 and 1999 with local resection (n = 10), pancreatic resection (n = 49) or laparotomy and no resection (n = 33) were studied retrospectively. The main outcome measures were postoperative morbidity and mortality, surgical radicality and long-term survival. Context: The postoperative complication rate was significantly lower after local resection (p = 0.036) whereas mortality did not differ between the 2 resection groups. UICC stages were less advanced in the local resection group (p<0.04). Still, the frequency of positive resection margins and RO resections was the same in both groups, as was long-term survival. Local recurrence was diagnosed in 8/10 (80%) patients after local and in 11/49 (22%) patients after pancreatic resection (p = 0.001). Think step by step to answer my question. [/INST] Pancreaticoduodenectomy is the preferred operation for cancer of the ampulla of Vater in patients who are fit for the procedure. Local resection plays a limited role in carefully selected patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is hypothyroidism a risk factor for non-alcoholic steatohepatitis? Answer the question given the following information: Context: Thyroid hormones play an important role in the regulation of lipid and carbohydrate metabolism, both of which are affected in patients with non-alcoholic steatohepatitis (NASH). Anecdotally, we have observed that a number of patients with NASH carried a diagnosis of hypothyroidism. However, it is unknown if thyroid dysfunction plays any role in the pathogenesis of NASH. To further investigate this observation, we conducted a case-control study to determine the association between hypothyroidism and NASH. Context: Cases were defined as patients with well-documented NASH attending hepatology clinics at Indiana University Hospital from January 1, 1995 to December 31, 2000. Age, gender, race, and body-weight matched individuals seen during the same period in the general medical clinics served as controls. Patients with a previous diagnosis of hypothyroidism who are currently on synthetic T4 replacement were considered to be "hypothyroid". The strength of association was assessed by logistic regression analysis after controlling for the frequency of diabetes mellitus, hyperlipidemia, and hypertension. Context: One hundred seventy-four patients with NASH (cases) and 442 controls were included. The mean age of cohort was 49 +/- 13 years, 59% were female, and 98% were white. The prevalence of hypothyroidism in patients with NASH was 15% was significantly higher than in the controls (7.2%, P<0.001). By multivariate analysis, the prevalence of hypothyroidism in the NASH group was significantly higher than in control group (OR: 2.3, 95% CI: 1.2-4.2, P = 0.008). Think step by step to answer my question. [/INST] These data suggest that hypothyroidism is associated with human NASH. Further research is needed to confirm this finding and to understand its implications.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Spontaneous subarachnoid hemorrhage,: is emergency transcranial Doppler sonography useful? Answer the question given the following information: Context: To ascertain the value of transcranial Doppler ultrasonography (TCD) in the first 24 hours of hospital admission in patients suffering good-grade spontaneous subarachnoid hemorrhage (SAH) in order to detect a high-risk group for symptomatic vasospasm. Context: Forty-nine spontaneous good-grade SAH were included. The first TCD studies were carried out at the Emergency Department. At least one more TCD recording was performed between the 4th and 14th day. Patients were classified according to whether they came to the hospital during the first 72 hours after the haemorrhage (Group 1) or later (Group 2). Context: Thirty three patients were included in Group 1 and sixteen patients in Group 2. Thirteen patients (26.5%) had sonographic vasospasm. In eight of these patients (61 %), the vasospasm was symptomatic. The initial mean velocity (MV) for Group 1 was normal. The increase in MV/24h (MV/24h) within the first 72 hours after SAH was higher (p<0.007), in those whose developed sonographic vasospasm. In Group 2, the initial MV was greater (p<0.001)) in patients who suffered sonographic vasospasm, with or without symptoms. Think step by step to answer my question. [/INST] The ability of TCD recorded in the first 24 hours of hospital admission to detect high-risk vasospasm patients for SAH with low clinical severity helps decide the most efficient patient destination. During the first three days the MV/24h is of value but not the absolute figure of the MV. In contrast, between the 4th and 14th day after SAH, the absolute figure of MV was useful to predict vasospasm.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Chronic vulvar purpura: persistent pigmented purpuric dermatitis (lichen aureus) of the vulva or plasma cell (Zoon's) vulvitis? Answer the question given the following information: Context: Lichen aureus is localized variant of persistent pigmented purpuric dermatitis that typically affects the legs and can be associated with delayed hypersensitivity reactions or vascular abnormalities. Plasma cell vulvitis (Zoon's vulvitis) is a rare condition that frequently contains hemosiderin deposits and is suspected to be a mucosal reaction pattern due to variety of insults, most often local irritation or trauma. Context: A 50-year-old female with longstanding complaints of spotting, vulvar dryness, irritation, and dyspareunia presented with circumscribed, purpuric, erythematous vulvar patches. Past estrogen cream treatment evoked symptoms of discomfort. On biopsy, siderophages and extravasated red blood cells were found in conjunction with a lichenoid, lymphocyte and plasma cell infiltrate, and dilated dermal and intraepithelial vessels. Think step by step to answer my question. [/INST] Reported herein is an unusual vulvar dermatosis that is best classified as a localized variant of persistent pigmented dermatosis (lichen aureus) but overlaps clinically and histologically with Zoon's vulvitis. This constellation of findings may represent a site-specific mucosal reaction to an erosive process that could either be inflammatory (hypersensitivity reaction) and/or traumatic in nature.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is it possible to diagnose acute otitis media accurately in primary health care? Answer the question given the following information: Context: Acute otitis media causes human suffering and enormous costs to society. Symptoms of acute otitis media overlap those of the common cold, and diagnostic methods confirming the diagnosis are used only occasionally. Uncertainty in diagnostics may lead either to overdiagnosis and unnecessary treatment or to underdiagnosis and an increase in complications. Context: Our aim was to evaluate the inter-rater agreement in diagnosis of acute otitis media for children in primary health care. Context: The GP on duty and the otorhinolaryngology resident at a primary health care clinic examined the same 50 children with caregiver-suspected acute otitis media. The otorhinolaryngologist photographed the tympanic membranes. Afterwards, two experienced clinicians evaluated the photographs with and without tympanograms. Diagnostic rates and diagnostic methods between clinicians were compared. Context: The otorhinolaryngologist diagnosed acute otitis media in 44% and the GP in 64%. The GP based the diagnoses on symptoms and on the colour of the tympanic membrane, whereas the otorhinolaryngologist paid more attention to the movement and position of the tympanic membrane. Think step by step to answer my question. [/INST] The use of a pneumatic otoscope and tympanometry reduces the number of acute otitis media diagnoses by>30%, suggesting that acute otitis media may be misdiagnosed often. Between clinicians, there was a substantial discrepancy in diagnoses of acute otitis media.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Using the Internet to conduct surveys of health professionals: a valid alternative? Answer the question given the following information: Context: The purpose of this study was to examine whether Internet-based surveys of health professionals can provide a valid alternative to traditional survey methods. Context: (i) Systematic review of published Internet-based surveys of health professionals focusing on criteria of external validity, specifically sample representativeness and response bias. (ii) Internet-based survey of GPs, exploring attitudes about using an Internet-based decision support system for the management of familial cancer. Context: The systematic review identified 17 Internet-based surveys of health professionals. Whilst most studies sampled from professional e-directories, some studies drew on unknown denominator populations by placing survey questionnaires on open web sites or electronic discussion groups. Twelve studies reported response rates, which ranged from nine to 94%. Sending follow-up reminders resulted in a substantial increase in response rates. In our own survey of GPs, a total of 268 GPs participated (adjusted response rate = 52.4%) after five e-mail reminders. A further 72 GPs responded to a brief telephone survey of non-respondents. Respondents to the Internet survey were more likely to be male and had significantly greater intentions to use Internet-based decision support than non-respondents. Think step by step to answer my question. [/INST] Internet-based surveys provide an attractive alternative to postal and telephone surveys of health professionals, but they raise important technical and methodological issues which should be carefully considered before widespread implementation. The major obstacle is external validity, and specifically how to obtain a representative sample and adequate response rate. Controlled access to a national list of NHSnet e-mail addresses of health professionals could provide a solution.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Providing information on metered dose inhaler technique: is multimedia as effective as print? Answer the question given the following information: Context: Metered dose inhalers (MDIs) are not easy to use well. Every MDI user receives a manufacturer's patient information leaflet (PIL). However, not everyone is able or willing to read written information. Multimedia offers an alternative method for teaching or reinforcing correct inhaler technique. Context: The aim of this study was to compare the effects of brief exposure to the same key information, given by PIL and multimedia touchscreen computer (MTS). Context: A single-blind randomized trial was conducted in 105 fluent English speakers (53% female; 93% White) aged 12-87 years in London general practices. All patients had had at least one repeat prescription for a bronchodilator MDI in the last 6 months. Inhaler technique was videotaped before and after viewing information from a PIL (n = 48) or MTS (n = 57). Key steps were rated blind using a checklist and videotape timings. The main outcome measures were a change in (i) global technique; (ii) co-ordination of inspiration and inhaler actuation; (iii) breathing-in time; and (iv) information acceptability. Context: Initially, over a third of both groups had poor technique. After information, 44% (MTS) and 19% (PIL) were rated as improved. Co-ordination improved significantly after viewing information via MTS, but not after PIL. Breathing-in time increased significantly in both groups. Half the subjects said they had learned 'something new'. The MTS group were more likely to mention co-ordination and breathing. Think step by step to answer my question. [/INST] Short-term, multimedia is as least as effective as a good leaflet, and may have advantages for steps involving movement. MTS was acceptable to all age groups. The method could be used more widely in primary care.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Expression of PRPF31 mRNA in patients with autosomal dominant retinitis pigmentosa: a molecular clue for incomplete penetrance? Answer the question given the following information: Context: To investigate whether the incomplete penetrance phenotype characteristic of adRP families linked to chromosome 19q13.4 (RP11) with mutations in the PRPF31 gene is due to differentially expressed wild-type alleles in symptomatic and asymptomatic individuals. Context: Real-time quantitative RT-PCR was performed on RNA from lymphoblastoid cell lines derived from a large adRP family (RP856/AD5) that segregates an 11bp deletion in exon 11 of PRPF31. The mRNA levels from only the wild-type allele of PRPF31 were assayed using a probe designed across the deletion. The Mann-Whitney U test was used to compare the median mRNA copy numbers of the symptomatic with the asymptomatic carriers of the mutant PRPF31 allele. The PRPF31 protein levels from symptomatic and asymptomatic individuals were also assayed by Western blot analysis using an antibody specific to the wild-type PRPF31 protein. Context: The use of cell lines was validated by the observation that cell transformation did not alter PRPF31 expression in the cell lines compared with nucleated blood cells and donor retinas. A significant difference in wild-type PRPF31 mRNA levels was observed between symptomatic and asymptomatic individuals (P<0.001) and was supported by Western blot analysis of the PRPF31 protein. Think step by step to answer my question. [/INST] Partial penetrance in RP11 could be due to the coinheritance of a PRPF31 gene defect and a low-expressed wild-type allele. This study revealed a potential avenue for future therapy in that it appears the moderate overexpression of wild-type PRPF31 may prevent clinical manifestation of the disease.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Blunted cortisol responses to psychosocial stress in asthmatic children: a general feature of atopic disease? Answer the question given the following information: Context: Atopy is defined by the individual predisposition to develop a group of inflammatory disorders in response to certain food or environmental substances that are otherwise innocuous for the host. In previous studies we could demonstrate a reduced responsiveness of the hypothalamus-pituitary-adrenal (HPA) axis to psychosocial stress in young and adult patients with atopic dermatitis (AD), a chronic atopic skin disorder. With respect to the important immunoregulatory role of the HPA axis, especially under stress, this observation could be of clinical relevance and may at least partly explain stress-induced exacerbation of AD. The present study was designed to investigate whether attenuated responsiveness of the HPA axis to stress represents a characteristic feature of AD or whether it can also be found in other chronic manifestations of atopy. Context: Children (aged 7-12) with allergic asthma (AA; N = 17) and age- and sex-matched healthy controls (N = 18) were exposed to the "Trier Social Stress Test for Children"(TSST-C), which mainly consists of a free speech and mental arithmetic tasks in front of an audience. Salivary cortisol was measured in ten-minute intervals before and after the TSST-C, while heart rate was monitored continuously. In addition, early morning cortisol levels (after awakening, +10, +20, +30 minutes) were assessed on three consecutive days. Context: Data analysis yielded a significant increase of cortisol concentrations (F (9297)= 16.79; p<.001) and heart rates (F(32,992)= 9.16; p<.001) after the stressor with no between-group difference in heart rate responses. However, AA children showed a significantly blunted cortisol response to the TSST-C when compared with the control group (F(9297)= 2.95; p<.01). Awakening in the morning was accompanied by a significant rise of cortisol levels on all three experimental days in AA and control subjects (all p<.001) that was not different between the two groups. Think step by step to answer my question. [/INST] These findings suggest that a blunted adrenocortical response to stress may represent a common feature of chronic allergic inflammatory processes that may be relevant in different forms of chronic manifestation of atopy.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does depression influence symptom severity in irritable bowel syndrome? Answer the question given the following information: Context: Irritable bowel syndrome (IBS) is frequently associated with mood disorder. However, it is typically difficult to distinguish between disturbed mood as a causal agent and disturbed mood as a consequence of the experience of IBS. This report considers the association between mood and symptom severity in a patient with diarrhea-predominant IBS and stable, rapid cycling bipolar disorder with a predominantly depressive course. Such a case provides an important opportunity to determine the direction of the relationship between mood and IBS symptom severity because the fluctuations of mood in bipolar disorder are assumed to be driven largely by biological, rather than psychosocial, processes. Context: The study was carried out prospectively, with ratings of mood and IBS symptom severity made daily by the patient for a period of almost 12 months. Context: The patient experienced regular and substantial changes in mood as well as fluctuations in the level of IBS symptoms during the study period. Contrary to expectation, the correlation between mood and IBS symptom severity on the same day suggested that the patient experienced less severe IBS symptoms during periods of more severe depression. However, time series analysis revealed no significant association between these two processes when serial dependence within each series was controlled for. Think step by step to answer my question. [/INST] The unusual co-occurrence of IBS with bipolar disorder provides direct evidence to indicate that depression does not necessarily lead to an increase in the reported severity of IBS, at least in the context of bipolar disorder, and may under certain circumstances actually be associated with a reduction in the severity of IBS symptoms. Factors that might moderate the relationship between depression and symptom severity are discussed.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do peritoneal macrophages play an essential role in the progression of acute pancreatitis in rats? Answer the question given the following information: Context: Macrophages are considered to play an essential role in the events leading to systemic inflammatory response. Some are known to reside in the peritoneal cavity but there are no reports defining the participation of peritoneal macrophages (PMs) in the progression of acute pancreatitis.AIM: To clarify the role of PMs in the progression of acute pancreatitis. Context: Acute pancreatitis was induced in rats from which macrophages other than PMs were greatly depleted, and in rats greatly depleted of macrophages including PMs. Macrophages were depleted by the injection of liposome encapsulated dichloromethylene bisphosphonate. After the induction of acute pancreatitis, local pancreatic inflammation, intraperitoneal inflammation and lung injury were compared between the 2 groups. Context: Local pancreatic inflammation did not differ between the 2 groups. However, intraperitoneal inflammation was clearly improved by the depletion of PMs. Serum cytokine level and lung injury were also improved by the depletion of PMs. Think step by step to answer my question. [/INST] Peritoneal macrophages extend inflammation from the pancreas to the peritoneal cavity and subsequently induce lung injury in acute pancreatitis. Peritoneal macrophages play an essential role in the systemic inflammatory response and the progression of acute pancreatitis in the rat.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Long-term survival following Kasai portoenterostomy: is chronic liver disease inevitable? Answer the question given the following information: Context: Extrahepatic biliary atresia (EHBA) is the most common indication for liver transplantation in childhood. Most children who do not undergo transplant are reported to have chronic liver disease and its complications. The aim of this single-center study was to identify children with normal laboratory indices and no clinical evidence of chronic liver disease 10 or more years after Kasai portoenterostomy (KP). Context: A retrospective analysis of the medical notes of all children surgically treated at the authors' center between 1979 and 1991 was undertaken. Criteria for inclusion were absence of surgical complications, unremarkable clinical examination, and normal bilirubin, aspartate aminotransferase, albumin, international normalized prothrombin ratio, and platelet count. Context: Of 244 children surgically treated during the observation period, the authors identified 28 (11%) adolescents (14 male) who fulfilled the entry criteria. Their median age was 13.4 years (range, 10.2-22.2 years). Twenty-six with type 3 EHBA had conventional KP, whereas 2 underwent modified operations. The corrective surgery was performed at a median age of 58 days (range, 20-99 days). Median time of complete clearance of jaundice from the date of KP was 75 days (range, 21-339 days). Twelve (43%) patients had history of cholangitis at a median age of 3.4 years. The liver histologic findings were suggestive of mild to moderate fibrosis in 54.2% and cirrhosis in 40.7% of the patients who underwent biopsy. No child had gastrointestinal bleeding during follow-up. Thirteen (46%) patients had an elective esophagogastroduodenoscopy, which was normal in all. Twenty-six (93%) patients were in mainstream education, whereas the remaining two (7%) attended special school because of reasons unrelated to liver disease. Think step by step to answer my question. [/INST] A sizable proportion of children with EHBA avoid significant chronic liver disease and its complications 10 years or more after conventional surgical correction and have an excellent quality of life. Their good outcome is not hampered by isolated episodes of ascending cholangitis. Whether or not the residual histologic damage will become symptomatic during their lifetime remains to be established.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Shortage of donation despite an adequate number of donors: a professional attitude? Answer the question given the following information: Context: A major problem in the field of transplantation is the persistent shortage of donor organs and tissues for transplantation. This study was initiated to (1) chart the donor potential for organs and tissue in The Netherlands and (2) to identify factors influencing whether donation is discussed with next of kin. Context: A registration form was constructed to obtain information at time of death of patients about the demographic characteristics, diagnosis, and medical suitability for donation. A prospective study was conducted among 11 hospitals in The Netherlands that gathered 4,877 filled-in forms equaling 8% to 10% of the people dying in a hospital in The Netherlands per year. Context: In the year of the study, organs were retrieved from 22 donors and tissues from 264 donors in the 11 hospitals. The organ potential is estimated at a maximum of 38.7 per million population per year. A mere 5% of the physicians got a 100% score on criteria and contraindications for donation. Factors of influence on receiving consent for donation were the will of the donor, using a protocol, giving verbal information to the relatives, and presence of the partner of the deceased patient. For 26% of the potential tissue donors and 69% of the potential organ donors, donation was discussed with the relatives. Consent for tissue donation was obtained in 27%, and consent for organ donation was obtained in 60%. Think step by step to answer my question. [/INST] In The Netherlands, when taking into account current refusal percentages, 320 to 360 organ donations and 5,800 tissue donations could be effectuated if organ donation is posed to all possible donors. For this, knowledge of medical criteria and contraindications for donation by the physicians and their willingness to discuss donation with next of kin must be improved.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is posttransplant lymphoproliferative disorder (PTLD) caused by any specific immunosuppressive drug or by the transplantation per se? Answer the question given the following information: Context: An association between posttransplant lymphoproliferative disorder (PTLD) and cyclosporine A (CsA) and OKT3 has often been postulated on the basis of retrospective studies, although a randomized study with PTLD as the endpoint will probably never be performed. Because focus on PTLD coincided with the use of these drugs, a bias could be suspected. Context: In a retrospective, nonrandomized study, we reevaluated all lymphoma-like lesions arising in kidney-transplant patients grafted at our center during 1969 to 1998 and observed up to 2002. Case pathology was reviewed, and an association with Epstein-Barr virus (EBV) infection (and latency pattern) was assessed. Context: We did not find any significant difference in the incidence of PTLDs when comparing the prednisolone/azathioprine, and CsA eras (P=0.89), the periods before or after OKT3 (P=0.61), and those before or after antilymphocyte globulin (ALG) (P=0.22). Occurrence time was shorter in the CsA (P=0.059), OKT3 (P=0.007), and ALG (P=0.007) eras. In the OKT3 era, 182 patients received, and 224 did not receive, OKT3; after the same observation time, there had been eight and five PTLDs, respectively (P=0.34). The use of mycophenolate mofetil (MMF) was associated with a reduction in the number of PTLDs (P=0.01). EBV was detected in 16 of 21 (76%) cases. Think step by step to answer my question. [/INST] We found no evidence to implicate any one drug regime preferentially in the development of PTLDs. The risk of developing PTLD seems to be a result of the whole transplantation process, which includes the antigenicity of the foreign graft, the immunosuppression resulting in inadequate cytotoxic T-cell activity, and the result of EBV infection. An important minority of cases are EBV negative.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is there an inhibitory role of cortisol in the mechanism of male sexual arousal and penile erection? Answer the question given the following information: Context: It has been speculated for more than 2 decades whether there is a significance of adrenal corticosteroids, such as cortisol, in the process of normal male sexual function, especially in the control of sexual arousal and the penile erectile tissue. However, only few in vivo studies have been carried out up until now on the effects of cortisol on human male sexual performance and penile erection. In order to evaluate further the role of cortisol in male sexual activity, the present study was conducted to detect serum levels of cortisol in the systemic and cavernous blood taken during different penile conditions from healthy males. Context: The effects of cortisol derivative prednisolone, catecholamine norepinephrine (NE) and the peptide endothelin-1 (ET-1) on isolated human corpus cavernosum (HCC) were investigated using the organ bath technique. Fifty-four healthy adult male subjects were exposed to erotic stimuli in order to elicit penile tumescence and rigidity. Whole blood was simultaneously aspirated from the corpus cavernosum and the cubital vein during different penile conditions. Serum levels of cortisol (microg/dl) were determined by means of a radioimmunoassay (ELISA). Context: In the healthy volunteers, cortisol serum levels significantly decreased in the systemic circulation and the cavernous blood with increasing sexual arousal, when the flaccid penis became rigid. During detumescence, the mean cortisol level remained unaltered in the systemic circulation, whereas in the cavernous compartment, it was found to decrease further. Under all penile conditions, no significant differences were registered between cortisol levels in the systemic circulation and in the cavernous blood. Cumulative addition of NE and ET-1 (0.001-10 microM) induced contraction of isolated HCC strips, whereas the contractile response to prednisolone was negligible. Think step by step to answer my question. [/INST] Our results strongly suggest an inhibitory role for cortisol in the mechanism of male sexual response and behaviour. These properties are mediated rather via an effect on central structures than on the penile erectile tissue. Future studies to include patients suffering from erectile dysfunction may reveal whether or not there are differences in the cortisol serum profiles of healthy subjects and patients under different stages of sexual arousal.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Nasal and hand carriage of Staphylococcus aureus in staff at a Department for Thoracic and Cardiovascular Surgery: endogenous or exogenous source? Answer the question given the following information: Context: To investigate the rates of Staphylococcus aureus carriage on the hands and in the noses of healthcare workers (HCWs) and the relatedness of S. aureus isolates found in the two sites. Context: Point-prevalence study. Context: Department for Thoracic and Cardiovascular Surgery at the University Hospital of Uppsala, Uppsala, Sweden. Context: Samples were obtained from 133 individuals, 18 men and 115 women, using imprints of each hand on blood agar and a swab from the nose. S. aureus isolates were identified by standard methods and typed by pulsed-field gel electrophoresis. Context: S. aureus was found on the hands of 16.7% of the men and 9.6% of the women, and in the noses of 33.3% of the men and 17.4% of the women. The risk ratio for S. aureus carriage on the hands with nasal carriage was 7.4 (95% confidence interval, 2.7 to 20.2; P<.001). Among the 14 HCWs carrying S. aureus on their hands, strain likeness to the nasal isolate was documented for 7 (50%). Think step by step to answer my question. [/INST] Half of the HCWs acquired S. aureus on the hands from patients or the environment and half did so by apparent self-inoculation from the nose. Regardless of the source of contamination, good compliance with hand hygiene is needed from all HCWs to protect patients from nosocomial infections. The moderate rate of S. aureus carriage on hands in this setting could be the result of the routine use of alcoholic hand antisepsis.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does impaired left ventricular relaxation affect P wave dispersion in patients with hypertension? Answer the question given the following information: Context: P wave dispersion (PD) is considered to reflect the heterogeneous conduction in atria. We investigated whether there was a correlation between the left ventricular (LV) relaxation and PD. Context: Fifty-three hypertensive patients<or =60 years old were divided into two groups: Group A, 27 patients, aged 54+/-5 years with the impaired LV relaxation and Group B, 26 patients, aged 51+/-8 years with normal LV relaxation. The P wave durations were measured in all 12 leads of ECG and PD was defined as the difference between maximum and minimum P wave duration (Pmax-Pmin). Mitral inflow velocities (E and A), E deceleration time (DT), isovolumic relaxation time (IVRT), left atrial and ventricular diameters, and wall thickness of LV were obtained by echocardiography. Clinical characteristics of both groups were comparable. The wall thickness of LV, Pmax, and left atrial dimension were not different in both groups. A velocity was higher (P<0.001), but E velocity (P=0.03) and E/A ratio (P<0.001) were lower in group A than in group B. IVRT and DT were also significantly longer in group A. PD was significantly higher in group A compared to group B (51+/-9 vs 41+/-11 ms, P=0.01). This difference resulted from the Pmin (61+/-10 vs 67+/-9 ms, P=0.03, respectively). Multivariate analysis revealed a significant correlation between PD and A velocity (r=0.46, P=0.01), E/A ratio (r=-0.53, P=0.001), DT (r=0.65, P<0.001), and IVRT (r=0.73, P<0.001). Think step by step to answer my question. [/INST] This study suggests that impaired LV relaxation contributes to the heterogeneous atrial conduction in hypertensive patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does overnight normalization of plasma glucose by insulin infusion affect assessment of glucose metabolism in Type 2 diabetes? Answer the question given the following information: Context: In order to perform euglycaemic clamp studies in Type 2 diabetic patients, plasma glucose must be reduced to normal levels. This can be done either (i) acutely during the clamp study using high-dose insulin infusion, or (ii) slowly overnight preceding the clamp study using a low-dose insulin infusion. We assessed whether the choice of either of these methods to obtain euglycaemia biases subsequent assessment of glucose metabolism and insulin action. Context: We studied seven obese Type 2 diabetic patients twice: once with (+ ON) and once without (- ON) prior overnight insulin infusion. Glucose turnover rates were quantified by adjusted primed-constant 3-3H-glucose infusions, and insulin action was assessed in 4-h euglycaemic, hyperinsulinaemic (40 mU m-2 min-1) clamp studies using labelled glucose infusates (Hot-GINF). Context: Basal plasma glucose levels (mean +/- sd) were 5.5 +/- 0.5 and 10.7 +/- 2.9 mmol/l in the + ON and - ON studies, respectively, and were clamped at -5.5 mmol/l. Basal rates of glucose production (GP) were similar in the + ON and - ON studies, 83 +/- 13 vs. 85 +/- 14 mg m-2 min-1 (NS), whereas basal rates of glucose disappearance (Rd) were lower in the + ON than in the - ON study, 84 +/- 8 vs. 91 +/- 11 mg m-2 min-1 (P = 0.02). During insulin infusion in the clamp period, rates of GP, 23 +/- 11 vs. 25 +/- 10 mg m-2 min-1, as well as rates of Rd, 133 +/- 32 vs. 139 +/- 37 mg m-2 min-1, were similar in the + ON and - ON studies, respectively (NS). Think step by step to answer my question. [/INST] Apart from basal rates of Rd, assessment of glucose turnover rates in euglycaemic clamp studies of Type 2 diabetic patients is not dependent on the method by which plasma glucose levels are lowered.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the conservative management of chronic retention in men ever justified? Answer the question given the following information: Context: To assess the outcome of men presenting with lower urinary tract symptoms (LUTS) associated with large postvoid residual urine volumes (PVR). Context: The study included men presenting with LUTS and a PVR of>250 mL who, because of significant comorbidity, a low symptom score or patient request, were managed conservatively and prospectively, and were followed with symptom assessment, serum creatinine levels, flow rates and renal ultrasonography. Patients were actively managed if there was a history of previous outflow tract surgery, prostate cancer, urethral strictures, neuropathy, elevated creatinine or hydronephrosis. In all, 93 men (mean age 70 years, range 40-84) with a median (range) PVR of 363 mL (250-700) were included in the study and followed for 5 (3-10) years. At presentation, the median maximum flow rate was 10.2 (3-30) mL/s and the voided volume 316 (89-714) mL. Context: The measured PVR remained stable in 47 (51%), reduced in 27 (29%) and increased in 19 (20%) patients; 31 patients (33%) went on to transurethral resection of the prostate after a median of 30 (10-120) months, because of serum creatinine elevation (two), acute retention (seven), increasing PVR (eight) and worsening symptoms (14). Of 31 patients 25 were available for evaluation after surgery; their median PVR was 159 (0-1000) mL, flow rate 18.4 (4-37) mL/s and voided volume 321 (90-653) mL. Symptoms were improved in all but five men. There was no difference in initial flow rate, voided volume or PVR between those who developed complications or went on to surgery and those who did not. Urinary tract infections (UTIs) occurred in five patients and two developed bladder stones. Think step by step to answer my question. [/INST] Complications such as renal failure, acute retention and UTIs are uncommon in men with large, chronic PVRs. Conservative management for this group of patients is reasonable but outpatient review is prudent. There were no factors that could be used to predict those patients who eventually required surgery.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Open mini-access ureterolithotomy: the treatment of choice for the refractory ureteric stone? Answer the question given the following information: Context: To report the experience in one centre of the efficacy and safety of open mini-access ureterolithotomy (MAU) and to discuss relevant current indications. Context: MAU was undertaken in 112 patients (mean age 38 years, range 26-57) between 1991 and 2001; the details and outcomes are reviewed. The mean (range) stone size was 12 (8-22) mm, with 30 stones in the upper, 69 in the mid- and 13 in the lower ureter. In 15 cases the stones were impacted and there were signs of infection in the proximal ureter. Context: MAU was successful in 111 patients; the one failure was caused by proximal stone migration early in the series. The mean (range) operative duration was 28 (10-44) min and the hospital stay 42 (24-72) h; 33 patients were in hospital for 24 h, 72 for 48 h and seven for 72 h. The blood loss was minimal, at 50 (30-150) mL. The drain was removed after 5 (5-7) days. Patients reported using opioid or nonsteroidal anti-inflammatory analgesia for a mean of 4 (1-7) days after surgery. The mean time to resumption of work was 16 (8-35) days. Think step by step to answer my question. [/INST] MAU is a safe and reliable minimally invasive procedure; its role is mainly confined to salvage for failed first-line stone treatments but in selected cases, where a poor outcome can be predicted from other methods, it is an excellent first-line treatment.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: The minimum data set weight-loss quality indicator: does it reflect differences in care processes related to weight loss? Answer the question given the following information: Context: To determine whether nursing homes (NHs) that score differently on prevalence of weight loss, according to a Minimum Data Set (MDS) quality indicator, also provide different processes of care related to weight loss. Context: Cross-sectional. Context: Sixteen skilled nursing facilities: 11 NHs in the lower (25th percentile-low prevalence) quartile and five NHs in the upper (75th percentile-high prevalence) quartile on the MDS weight-loss quality indicator. Context: Four hundred long-term residents. Context: Sixteen care processes related to weight loss were defined and operationalized into clinical indicators. Trained research staff conducted measurement of NH staff implementation of each care process during assessments on three consecutive 12-hour days (7 a.m. to 7 p.m.), which included direct observations during meals, resident interviews, and medical record abstraction using standardized protocols. Context: The prevalence of weight loss was significantly higher in the participants in the upper quartile NHs than in participants in the lower quartile NHs based on MDS and monthly weight data documented in the medical record. NHs with a higher prevalence of weight loss had a significantly larger proportion of residents with risk factors for weight loss, namely low oral food and fluid intake. There were few significant differences on care process measures between low- and high-weight-loss NHs. Staff in low-weight-loss NHs consistently provided verbal prompting and social interaction during meals to a greater proportion of residents, including those most at risk for weight loss. Think step by step to answer my question. [/INST] The MDS weight-loss quality indicator reflects differences in the prevalence of weight loss between NHs. NHs with a lower prevalence of weight loss have fewer residents at risk for weight loss and staff who provide verbal prompting and social interaction to more residents during meals, but the adequacy and quality of feeding assistance care needs improvement in all NHs.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Prehospital DNR orders: what do physicians in Washington know? Answer the question given the following information: Context: To assess whether physicians know of Washington State's prehospital do-not-resuscitate (DNR) policy, 6 years after its implementation. Context: Cross-sectional survey. Context: Washington State, April 2001. Context: Four hundred seventy-one practicing physicians. Context: Multivariate logistic regression was used to determine relationships between physician and practice characteristics with knowledge of policies governing advance care planning. Context: Among respondents, 60% did not know that Washington State requires an emergency medical service (EMS)-specific DNR order authored by a physician. Seventy-nine percent did not know that patient-authored advance directives apply only in hospitals and medical offices. Think step by step to answer my question. [/INST] The findings in this study suggest that most physicians in Washington State lack knowledge about the documentation needed for EMS personnel to forgo pre-hospital attempts at cardiopulmonary resuscitation. Further study is needed to determine whether physician education or legislative change is necessary.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does lipoprotein(a) inhibit elastolysis in abdominal aortic aneurysms? Answer the question given the following information: Context: to test the hypothesis that there is a negative association between serum levels of lipoprotein(a) (Lp(a)) and elastin-derived peptides (EDP) as well as matrix metalloproteinase (MMP)-9 activation in the aneurysm wall in patients with asymptomatic abdominal aortic aneurysms (AAA). Context: from 30 patients operated for asymptomatic AAAs, preoperative serum samples and AAA biopsies were collected. Lp(a) (mg/L) and EDP (ng/ml) in serum were measured by enzyme linked immunosorbent assays. MMP-9 activity (arbitrary units) in the AAA wall was measured by gelatin zymography and the ratio: active MMP-9/total MMP-9 were calculated. Context: there was a significant negative correlation (Spearman's rho) between serum levels of Lp(a) and EDP (r= -0.707, p<0.001), as well as the share of activated MMP-9 (r= -0.461, p=0.01) in the AAA wall. Think step by step to answer my question. [/INST] this preliminary study indicate that Lp(a) inhibit elastolysis in asymptomatic AAA.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Thin-section CT of the lung: does electrocardiographic triggering influence diagnosis? Answer the question given the following information: Context: To determine the impact of prospective electrocardiographic (ECG) triggering on image quality and diagnostic outcome of thin-section computed tomography (CT) of the lung. Context: Forty-five consecutive patients referred for thin-section CT of the lung were examined with prospectively ECG-triggered and nontriggered thin-section CT of the lung with a multi-detector row helical CT scanner. Subjective image quality criteria (image noise, motion artifacts, and diagnostic accessibility) were rated by three radiologists in consensus for the upper lobe, middle lobe and/or lingula, and lower lobe. Pathologic changes were assessed for the various lobes, and a diagnosis was assigned. The diagnoses were compared by two radiologists in consensus to determine the effects of CT technique on diagnostic outcome. Quantitative measurements were performed, including determination of image noise and signal-to-noise ratios in different anatomic regions. The Wilcoxon signed rank test and paired sign test (both with Bonferroni correction) were used for statistical analysis. Context: Subjective assessment showed significant differences in motion artifact reduction in the middle lobe, lingula, and left lower lobe. The diagnostic assessibility of triggered CT was rated significantly higher only for the left lower lobe compared with nontriggered data acquisition. No differences in diagnostic outcome were determined between triggered and nontriggered techniques. Mean image noise in tracheal air was 68.2 +/- 17 (SD) for triggered CT versus 37.4 +/- 9 for nontriggered CT (P<.05). Mean signal-to-noise ratio in the upper versus lower lobes was 22.5 +/- 8 versus 25.4 +/- 10 for triggered and 35.6 +/- 9 versus 39.2 +/- 10 for nontriggered techniques (P<.05). Think step by step to answer my question. [/INST] Given the lack of improvement in diagnostic accuracy and the need for additional resources, ECG-triggered thin-section CT of the lung is not recommended for routine clinical practice.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Tanning facility use: are we exceeding Food and Drug Administration limits? Answer the question given the following information: Context: The US Food and Drug Administration (FDA) recommends exposure limits for tanning bed use. Tanning patrons may not be following these recommendations and may be overexposed to damaging ultraviolet radiation (UV). Context: This study was conducted to assess tanning patrons' adherence to FDA-recommended exposure limits and to measure the amount of UVA and UVB radiation emitted by tanning beds. Context: A community-based survey was administered during routine state inspections of North Carolina tanning facilities (n = 50). At each facility, patron records were randomly selected (n = 483) for a survey of exposure records, and UVA and UVB outputs were measured for each tanning bed. Context: The recommended limits were exceeded by 95% of patrons, and 33% of patrons began tanning at the maximum doses recommended for maintenance tanning. Average tanning bed output was 192.1 W/m(2) UVA and 0.35 W/m(2) erythemally weighted UVB. Think step by step to answer my question. [/INST] Interventions for tanning bed operators and patrons are needed to increase compliance with federally recommended exposure limits.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are there racial and sex differences in the use of oral isotretinoin for acne management in the United States? Answer the question given the following information: Context: Treatment of various diseases has been noted to vary by patient demographics. There is reason to suspect that there may be sex and racial differences in the treatment of severe acne. Context: We sought to determine if treatment of severe acne with oral isotretinoin varied with patient sex, race, or both. Context: We analyzed the demographics of patients with acne and patients using oral isotretinoin, minocycline, and tetracycline recorded in the 1990 to 1997 National Ambulatory Medical Care Survey. Context: There were 35 million visits to physicians for the treatment of acne between 1990 and 1997, and isotretinoin was prescribed at 5.8 million (17%) of these visits. Per capita visit rates for acne among whites was 2.3 times that of blacks, and whites were 1.8 times more likely to receive isotretinoin at acne visits. Per capita, women had 1.4 times as many visits for acne as men, but men were 1.7 times more likely than women to receive isotretinoin at an acne visit. Dermatologists managed 83% of all isotretinoin visits. Dermatologists accounted for 100% of isotretinoin visits for which pregnancy prevention education and counseling was reported. Think step by step to answer my question. [/INST] Patients who are black receive less oral isotretinoin than those who are white, and the expense of isotretinoin appears to be one factor in this difference. Women are less likely than men to receive isotretinoin at acne visits. Expense does not appear to be a factor in this difference. Dermatologists have more experience than nondermatologists managing acne, prescribing isotretinoin, and counseling women treated with isotretinoin concerning pregnancy prevention. Pregnancy prevention is an essential component of isotretinoin use in women that must not be ignored.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are breastfeeding and complementary feeding of children of adolescent mothers different from those of adult mothers? Answer the question given the following information: Context: To study breastfeeding during the first year of life and the kind of complementary food provided at one year of life to children of adolescent mothers. To compare these data with breastfeeding and complementary food received by children of adult mothers. Context: A dual cohort was performed. Children were selected from the files of CAISM/UNICAMP and assessed when they were one year old. This study consisted of 122 children born from adolescent mothers and 123 children born from adult mothers--full-term births, birthweight was 2,500 g or higher. When the children were one year old, the mothers were interviewed at home or at CIPED/UNICAMP. The results were compared using the chi-square test and the Fisher's test; alpha=5%; the Kaplan-Meier method was used to analyze the duration of breastfeeding and the Wilcoxon test (Breslow) to compare the exclusive, predominant, full and total breastfeeding curves. Context: 94.3% of children of adolescent mothers and 95.9% of children of adult mothers left the maternity hospital being breastfed (p=0.544). The median exclusive breastfeeding duration for both groups was 90 days. After completing one year, 35.3% and 28.5% of children of adolescent and adult mothers, respectively, continued breastfeeding (p=0.254): only breastfeeding 11.5% vs. 8.9% and mixed feeding 23.8% vs. 19.5% (p=0.519). Meat intake by children of adolescent mothers was lower than that of children of adult mothers (13.9% vs. 26.0%; Fisher's test: p=0.031). With regard to egg intake, 11.5% vs. 19.5% of children of adolescent mothers and adult mothers did not eat egg but the results suggested that the egg intake of children of adolescent mothers was higher (p=0.082). Think step by step to answer my question. [/INST] Duration and pattern of breastfeeding were similar between children of adolescent mothers and of adult mothers. The complementary nutrition was similar, except for a lower intake of meat and a higher intake of eggs among the children of adolescent mothers.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does violence in the emotional relationships make STD/AIDS prevention more difficult? Answer the question given the following information: Context: To identify violent situations in the daily life of adolescents and young people of low-income communities; to establish a relation between the use of drugs and STD/AIDS risk behavior; and to verify if violence in the emotional relationships between adolescents and young people make the STD/AIDS prevention more difficult. Context: Epidemiological study with adolescents and young people of two neighborhoods in the city of Rio de Janeiro, based on the results obtained from a structured questionnaire that dealt with subjects' profile, information about the family, use of drugs, daily violent situations, sexual experience, among others. For the present article, only the variables that dealt with aggressiveness, use of drugs, sexual risk behavior and violence in the emotional relationships were analyzed. The association between the variable "I used a condom the last time I had sex" and the questions that indicated violent or non-violent attitudes in emotional relationships received special attention. Context: A total of 1,041 young people aged 14-22 years old took part in the study, 53.6% of them were female. A statistically significant relation was observed between not using condoms (p<0.05) and the categorical variables revealing aggressiveness in emotional relations. Think step by step to answer my question. [/INST] The study showed that there is an important association between violence in the emotional relationships and the inconsistent use of condoms in the group studied. Therefore, preventive measures should be taken regarding youth behavior that involves the risk of STD/AIDS infection, associated with campaigns against violence.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is low antiepileptic drug dose effective in long-term seizure-free patients? Answer the question given the following information: Context: To investigate the value of leaving seizure-free patients on low-dose medication. Context: This was an exploratory prospective randomized study conducted at our University Hospital. We evaluated the frequency of seizure recurrence and its risk factors following complete or partial antiepileptic drug (AED) withdrawal in seizure free patients for at least two years with focal, secondarily generalized and undetermined generalized epilepsies. For this reason, patients were divided into two groups: Group 1 (complete AED withdrawal), and Group 2 (partial AED withdrawal). Partial AED withdrawal was established as a reduction of 50% of the initial dose. Medication was tapered off slowly on both groups. Follow-up period was 24 months. Context: Ninety-four patients were followed up: 45 were assigned to complete (Group 1) AED withdrawal and 49 to partial (Group 2) AED withdrawal. Seizure recurrence frequency after two years follow-up were 34.04% in group 1 and 32.69% in Group 2. Survival analysis showed that the probability of remaining seizure free at 6, 12, 18 and 24 months after randomization did not differ between the two groups (p = 0.8). Group 1: 0.89, 0.80, 0.71 and 0.69; group 2: 0.86, 0.82, 0.75 and 0.71. The analysis of risk factors for seizure recurrence showed that more than 10 seizures prior to seizure control was a significant predictive factor for recurrence after AED withdrawal (hazard ratio = 2.73). Think step by step to answer my question. [/INST] Leaving seizure free patients on low AED dose did not reduce the risk for seizure recurrence. That is, once the decision of AED withdrawal has been established, it should be complete.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Parental perception of waiting time and its influence on parental satisfaction in an urban pediatric emergency department: are parents accurate in determining waiting time? Answer the question given the following information: Context: The objective of this study was to determine whether parental perception of waiting time in an urban pediatric emergency department (ED) is accurate and whether the actual waiting times or their perception of waiting times impact on parental satisfaction. Context: A prospective convenience sample study in which the on-duty emergency physicians randomly administered a questionnaire at the time of the ED visit was used. During a 3-week period from December 15, 1999, through January 7, 2000, 500 parents or legal guardians of children who visited our ED were questioned about their perceived waiting time, and the responses were compared with the actual waiting time. The parents or guardians were also asked if they were satisfied with the waiting time. Context: The majority (84%) of parents overestimated waiting time in the ED (median difference, 26 min; interquartile range, 9-50 min). Parents with perceived or actual waiting times that exceeded 2 hours were significantly more likely to be dissatisfied than parents with actual or perceived waiting times that were 1 hour or less (P<0.001). Satisfaction was not related to the age (P = 0.35), sex (P = 0.30), race/ethnicity (P = 0.90), or mode of arrival (P = 0.28). Think step by step to answer my question. [/INST] Parents tend to overestimate waiting time. Both perceived and actual waiting times that exceed 2 hours were associated with parental dissatisfaction. ED administrators may need to keep this in mind when arranging ED staffing patterns to match peak patient hours to achieve optimal parental satisfaction.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do poison center guidelines adversely affect patient outcomes as triage referral values increase? Answer the question given the following information: Context: The purpose of this study was to determine whether patient outcomes were adversely affected as healthcare referral values increased for two common poisonings: acute, unintentional acetaminophen (APAP) poisonings and acute, unintentional iron (Fe) poisonings. We hypothesized that symptom rates would increase with high referral values. Context: Qualifying 1997 exposures were separated by substance (APAP or Fe) and then further stratified into three healthcare referral value ranges. Symptomatic and asymptomatic patients were totaled for each stratum. Expected vs. observed distributions of symptomatic and asymptomatic patients across triage referral strata for a given substance and treatment location were compared using chi-square test for independence. The Wilcoxon-Mann-Whitney test was used to compare the distribution of patients across referral strata for home vs. healthcare facility locations for a specific substance. Context: There were no statistically significant differences in the distribution of symptomatic patients within referral value strata for APAP or for Fe. There was also no difference in distribution of symptomatic patients across strata when comparing home vs. healthcare facility for APAP and Fe. Think step by step to answer my question. [/INST] Referral values as high as 201 mg/kg for APAP and 61 mg/kg for Fe do not appear to adversely affect patient outcomes.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is [18F]-2-fluoro-2-deoxy-d-glucose (FDG) scintigraphy with non-dedicated positron emission tomography useful in the diagnostic management of suspected metastatic thyroid carcinoma in patients with no detectable radioiodine uptake? Answer the question given the following information: Context: Dedifferentiation of thyroid cancer leads to an inability of thyroid cells to concentrate iodine. In these cases, imaging methods that allow an accurate detection of recurrence and/or metastases at an early stage are essential for an adequate management of patients. Positron emission tomography using [18F]-2-fluoro-2-deoxy-d-glucose and a dedicated (dPET-FDG) or non-dedicated (nPET-FDG) camera has been suggested as a potential tool for the detection of tumour foci. Context: This prospective study was undertaken to evaluate nPET-FDG in 51 consecutive patients (18 men, 33 women) with differentiated thyroid cancer (33 papillary, 11 follicular, four insular and three oncocytic (Hurthle-cell) thyroid carcinomas). Selection criteria were high thyroglobulin (Tg) levels (>10 ng/ml off-levothyroxine treatment) and no detectable radioiodine uptake, on a whole body scan performed with a high dose, in the absence of iodine contamination. Context: Results were interpreted in terms of assumed presence of tumoral tIssue. Sensitivity of nPET-FDG was similar to that of conventional imaging modalities (67%). False negative nPET-FDG (n=16) were observed mostly in cases of micro-lesions (lymph nodes or lung metastases). Conversely, nPET-FDG identified new tumoral sites in 11 cases. Better sensitivity was found for nPET-FDG in patients with Tg levels higher than 15 microg/l (P<0.05). On a patient basis, results of nPET-FDG were equivalent to that of dPET-FDG. Finally, nPET-FDG changed treatment strategy in seven patients. Think step by step to answer my question. [/INST] nPET-FDG has a high sensitivity for the detection of tumour sites in patients when pathological iodine uptake cannot be demonstrated and appears to be a useful method in patients with elevated Tg levels, especially when dedicated PET is either unavailable or impractical.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do patients with schizophrenia consciously recollect emotional events better than neutral events? Answer the question given the following information: Context: The influence of the emotional valence of words on conscious awareness was assessed in patients with schizophrenia. Context: The remember/know procedure was used to test 24 patients with schizophrenia and 24 normal comparison subjects. Context: Patients' "remember" responses and conscious recollection were more frequent for emotional words than for neutral words. In contrast, the levels of "know" responses and familiarity were independent of emotional words. Think step by step to answer my question. [/INST] Patients with schizophrenia consciously recollected emotional words better than neutral words.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are impairments of action monitoring and executive control true dissociative dysfunctions in patients with schizophrenia? Answer the question given the following information: Context: Impaired self-monitoring is considered a critical deficit of schizophrenia. The authors asked whether this is a specific and isolable impairment or is part of a global disturbance of cognitive and attentional functions. Context: Internal monitoring of erroneous actions, as well as three components of attentional control (conflict resolution, set switching, and preparatory attention) were assessed during performance of a single task by eight high-functioning patients with schizophrenia and eight comparison subjects. Context: The patients exhibited no significant dysfunction of attentional control during task performance. In contrast, their ability to correct errors without external feedback and, by inference, to self-monitor their actions was markedly compromised. Think step by step to answer my question. [/INST] This finding suggests that dysfunction of self-monitoring in schizophrenia does not necessarily reflect a general decline in cognitive function but is evidence of disproportionately pronounced impairment of action monitoring, which may be mediated by a distinct subsystem within the brain's executive attention networks.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is HbA(1c) affected by glycemic instability? Answer the question given the following information: Context: HbA(1c) is a standard clinical assessment of glycemia and the basis of most data relating glycemic control to complications. It remains unclear, however, whether HbA(1c) is affected by glycemic variation and mean glycemia. Context: To test this question, we analyzed the statistical relationship between HbA(1c) levels and glycemic variability as measured by self-monitoring of blood glucose (SMBG). The records of 256 subjects were studied. SMBG data for the preceding 3 months were downloaded, and HbA(1c) was measured by ion-exchange high-performance liquid chromatography. Simple- and random-effects linear regression models were used to assess the independent contributions of mean blood glucose (BG) and SD of BG to HbA(1c), after adjusting for the mean BG. Context: Mean +/- SD for HbA(1c) was 7.66 +/- 1.11% and for BG was 8.5 +/- 1.9 mmol/l (153.3 +/- 34.9 mg/dl); SD of BG for individual subjects was 3.5 mmol/l (63.3 mg/dl), varying from 0.4 mmol/l (8.1 mg/dl; very stable glycemia) to 8.4 mmol/l (152.5 mg/dl; very unstable glycemia). A close correlation between mean BG and HbA(1c) was demonstrated (r = 0.62). Also, within-subject SD of BG correlated with HbA(1c) (r = 0.375), indicating that people with poorer glycemic control had higher BG variance. After adjusting for mean BG in a linear regression model, however, the effect of the within-subject SD of BG on the HbA(1c) was insignificant. Several further analyses confirmed the strength of the observation. Think step by step to answer my question. [/INST] HbA(1c) reflects mean glycemia and is not meaningfully affected by glycemic instability after adjusting for mean BG.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Moderate alcohol consumption, estrogen replacement therapy, and physical activity are associated with increased insulin sensitivity: is abdominal adiposity the mediator? Answer the question given the following information: Context: To investigate 1). associations between environmental factors (alcohol consumption, hormone replacement therapy [HRT], and physical activity) and insulin resistance and secretion,independent of genetic influences; 2). the contribution of abdominal adiposity to these relationships; and 3). whether gene-environment interactions mediate these associations. Context: Reported effects of lifestyle factors on insulin resistance and secretion are inconsistent, possibly due to difficulty in dissecting environmental from genetic influences and to confounding by adiposity. We examined these relationships in 798 nondiabetic female twins. Insulin resistance and secretion were estimated by modified homeostasis model assessment (HOMA-R' and HOMA-beta', respectively). Percent total body fat and percent central abdominal fat (CAF) were measured by dual-energy X-ray absorptiometry. Context: All categories of alcohol consumption were associated with lower insulin levels and HOMA-beta' than abstinence. Only moderate alcohol consumers (11-20 units/week) had lower HOMA-R' than abstainers (-0.16 +/- 0.09 vs. 0.14 +/- 0.13 SD, P = 0.048). This difference was attenuated after controlling for percent CAF (P = 0.57), which was lower in moderate drinkers. Controlling for genetic and smoking effects in cotwin case-control analysis, monozygotic pairs discordant for alcohol consumption had greater within-pair differences in HOMA-R' than concordant pairs (P = 0.02). Postmenopausal women using estrogen-only HRT had lower HOMA-R' than non-HRT users (-0.33 +/- 0.16 vs. 0.17 +/- 0.08 SD, P = 0.003), even after controlling for percent CAF. Lower fasting glucose levels and insulin resistance and secretion indexes in physically active subjects were partly explained by lower abdominal adiposity. Think step by step to answer my question. [/INST] Moderate alcohol consumption, estrogen replacement, and physical activity are associated with increased insulin sensitivity in female twins. The favorable effects of moderate alcohol consumption and physical activity on insulin sensitivity are partly mediated by lower abdominal adiposity.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Low insulin sensitivity (S(i) = 0) in diabetic and nondiabetic subjects in the insulin resistance atherosclerosis study: is it associated with components of the metabolic syndrome and nontraditional risk factors? Answer the question given the following information: Context: To determine the meaning of S(i) = 0 derived from the frequently sampled intravenous glucose tolerance test. Context: The issue of assessing insulin resistance in large studies is important because the most definitive method ("gold standard"), the hyperinsulinemic-euglycemic clamp, is expensive and invasive. The frequently sampled intravenous glucose tolerance test (FSIGTT) has been widely used, but in insulin-resistant subjects (especially diabetic subjects), it yields considerable numbers of subjects whose S(i) is zero. The interpretation of an S(i) equaling zero is unknown. Context: -To address this issue, we examined 1482 subjects from the Insulin Resistance Atherosclerosis Study (IRAS) using an insulin-modified FSIGTT and minimal model calculation of S(i). The proportion of insulin-resistant subjects (S(i)<1.61 x 10(-4) [min(-1). microU(-1) x ml(-1)] based on the median of the nondiabetic population) was 38.6% in subjects with normal glucose tolerance (NGT), 74% in subjects with impaired glucose tolerance (IGT), and 92% in subjects with type 2 diabetes. The proportion of subjects with S(i) = 0 was 2.2% in subjects with NGT, 13.2% in subjects with IGT, and 35.7% in subjects with type 2 diabetes. In subjects with IGT, those with S(i) = 0 had significantly lower HDL cholesterol levels and higher BMI, waist circumference, fibrinogen, plasminogen-activator inhibitor 1 (PAI-1), C-reactive protein (CRP), and 2-h insulin levels than insulin-resistant subjects with S(i)>0. In type 2 diabetes, subjects with S(i) = 0 had significantly greater BMI and waist circumference and higher triglyceride, PAI-1, CRP, fibrinogen, and fasting and 2-h insulin levels than insulin-resistant subjects with S(i)>0. In addition, diabetic subjects with S(i) = 0 had more metabolic disorders related to the insulin resistance syndrome than diabetic insulin-resistant subjects with S(i)>0. Think step by step to answer my question. [/INST] We found very few subjects with S(i) = 0 among subjects with NGT and few subjects with S(i) = 0 among subjects with IGT. In contrast, S(i) = 0 was common in subjects with diabetes. Subjects with S(i) = 0 tended to have more features of the insulin resistance syndrome than other insulin-resistant subjects with S(i)>0, as would be expected of subjects with almost no insulin-mediated glucose disposal, thus suggesting that subjects with S(i) = 0 are correctly classified as being very insulin resistant rather than having failed the minimal model program.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Prevalence of measles susceptibility among health care workers in a UK hospital. Does the UK need to introduce a measles policy for its health care workers? Answer the question given the following information: Context: First, to determine the prevalence of measles non-immunity in a group of health care workers (HCW), and secondly, to investigate what pre-employment screening for measles is carried out by NHS occupational health departments. Context: Two hundred and eighteen HCWs with patient contact on the medical wards at Addenbrooke's hospital provided an oral fluid sample and answered a questionnaire. A postal survey of Association of National Health Occupational Physicians Society (ANHOPS) members was conducted to assess whether UK NHS Trusts identify measles non-immune individuals. Context: Of the HCWs tested, 3.3% of were found to be non-immune to measles (both oral fluid and confirmatory serum sample were measles IgG negative). Less than one third of a sample of 80 NHS occupational health departments enquired about measles immunity. Think step by step to answer my question. [/INST] The prevalence of measles non-immune health care workers is low, but with a fall in uptake of MMR immunization and increased likelihood of measles outbreaks, it is important to identify these at-risk individuals. Serum testing is the most reliable method to use. Oral fluid testing and history of measles disease or vaccination are unreliable methods of identifying non-immune individuals. To achieve complete immunity, it is cost-effective to screen and then offer immunization. NHS trusts vary greatly in their measles policies for health care workers.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does influenza vaccination increase consultations, corticosteroid prescriptions, or exacerbations in subjects with asthma or chronic obstructive pulmonary disease? Answer the question given the following information: Context: Concern over the safety of influenza vaccination in individuals with obstructive airways disease has contributed to suboptimal rates of vaccine uptake in this group. We investigated the safety of influenza vaccine in older people with asthma or chronic obstructive pulmonary disease (COPD) in a cohort from the UK General Practice Research Database (GPRD). Context: A population based cohort study of 12,000 individuals with asthma or COPD from 432 general practices was conducted. Incidence rate ratios (IRR) were calculated for asthma or COPD diagnoses, prescriptions for oral corticosteroids, and acute exacerbations on the day of vaccination and on days 1-2 and 3-14 after vaccination compared with other time periods in the influenza season. Context: The IRRs for asthma or COPD diagnoses and oral corticosteroid prescriptions were increased on the day of vaccination (for example, the IRR for oral corticosteroid prescriptions for subjects with asthma during the 1992-3 influenza season was 8.24 (95% confidence interval 5.54 to 12.26)). However, there was no consistent increase in the IRR of any of the outcomes on days 1-2 or 3-14 after vaccination, and most of these IRRs were close to 1. Rates of exacerbation were low and showed no consistent statistically significant increase during any risk periods. Think step by step to answer my question. [/INST] Older people with asthma or COPD commonly have diagnoses recorded or prescriptions for oral corticosteroids given on the day of influenza vaccination, but there is no increased risk of adverse acute outcomes in the first 2 weeks after vaccination. Our findings strongly suggest that influenza vaccination is safe in this population.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can a self-management programme delivered by a community pharmacist improve asthma control? Answer the question given the following information: Context: No randomised studies have addressed whether self-management for asthma can be successfully delivered by community pharmacists. Most randomised trials of asthma self-management have recruited participants from secondary care; there is uncertainty regarding its effectiveness in primary care. A randomised controlled study was undertaken to determine whether a community pharmacist could improve asthma control using self-management advice for individuals recruited during attendance at a community pharmacy. Context: Twenty four adults attending a community pharmacy in Tower Hamlets, east London for routine asthma medication were randomised into two groups: the intervention group received self-management advice from the pharmacist with weekly telephone follow up for 3 months and the control group received no input from the pharmacist. Participants self-completed the North of England asthma symptom scale at baseline and 3 months later. Context: The groups were well matched at baseline for demographic characteristics and mean (SD) symptom scores (26.3 (4.8) and 27.8 (3.7) in the intervention and control groups, respectively). Symptom scores improved in the intervention group and marginally worsened in the control group to 20.3 (4.2) and 28.1 (3.5), respectively (p<0.001; difference adjusted for baseline scores=7.0 (95% CI 4.4 to 9.5). Think step by step to answer my question. [/INST] A self-management programme delivered by a community pharmacist can improve asthma control in individuals recruited at a community pharmacy. Further studies should attempt to confirm these findings using larger samples and a wider range of outcome measures.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Building a better quality measure: are some patients with 'poor quality' actually getting good care? Answer the question given the following information: Context: National performance measures monitor the proportion of diabetic patients with low-density lipoprotein (LDL) levels>/=130 mg/dL, but such simple intermediate outcomes measure poor control, not necessarily poor care. "Tightly linked" quality measures define good quality either by a good intermediate outcome (LDL<130 mg/dL) or by evidence of appropriate responses to poor control (eg, starting or optimizing medications for high LDL or not doing so in the face of contraindications). Context: We examined hyperlipidemia therapy for patients with diabetes to determine the relative accuracy of quality assessment using simple intermediate outcome versus tightly linked quality measures. Context: Retrospective longitudinal cohort. Context: A total of 1154 diabetic patients with an LDL test done between October 1, 1998, and March 31, 1999, in 2 large VA facilities. Context: LDL levels, medication treatment, and explanations for poor quality. Context: Although 27% (307 of 1154) of patients had an LDL>/=130 mg/dL using the simple intermediate outcome measure, only 13% (148 of 1154) were classified as having substandard quality using the tightly linked measure. Among the 159 reclassified to adequate quality, 117 had lipid-lowering medication started or increased within 6 months of an LDL>/=130 mg/dL, 8 were already on high-dose medication, 12 had a repeat LDL<130 mg/dL, and 22 had contraindications to treatment. Think step by step to answer my question. [/INST] Simple intermediate outcome measures can be an inaccurate reflection of true quality of care, and many patients classified as having substandard quality by "poor control" might actually be receiving good quality of care.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does the ownership of the admitting hospital make a difference? Answer the question given the following information: Context: Concerns have been expressed about quality of for-profit hospitals and their use of expensive technologies. Context: To determine differences in mortality after admission for acute myocardial infarction (AMI) and in the use of low- and high-tech services for AMI among for-profit, public, and private nonprofit hospitals. Context: Cooperative Cardiovascular Project data for 129,092 Medicare patients admitted for AMI from 1994 to 1995. Context: Mortality at 30 days and 1 year postadmission; use of aspirin, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers at discharge, thrombolytic therapy, catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft (CABG) compared by ownership. Context: Mortality rates at 30 days and at 1 year at for-profit hospitals were no different from those at public and private nonprofit hospitals. Without patient illness variables, nonprofit hospitals had lower mortality rates at 30 days (relative risk [RR], 0.95; 95% confidence interval [CI], 0.91-0.99) and at 1 year (RR, 0.96; 95% CI, 0.93-0.99) than did for-profit hospitals, but there was no difference in mortality between public and for-profit hospitals. Beneficiaries at nonprofit hospitals were more likely to receive aspirin (RR, 1.04; 95% CI, 1.03-1.05) and ACE inhibitors (RR, 1.05; 95% CI, 1.02-1.08) than at for-profit hospitals, but had lower rates of PTCA (RR, 0.91; 95% CI, 0.86-0.96) and CABG (RR, 0.93; 95% CI, 0.86-1.00). Think step by step to answer my question. [/INST] Although outcomes did not vary by ownership, for-profit hospitals were more likely to use expensive, high-tech procedures. This pattern appears to be the result of for-profit hospitals' propensity to locate in areas with demand for high-tech care for AMI.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Primary gastric Burkitt lymphoma in childhood: associated with Helicobacter pylori? Answer the question given the following information: Context: This retrospective study was designed to estimate the incidence of primary gastric non-Hodgkin lymphoma (NHL) in childhood and the possible association with Helicobacter pylori (H. pylori). Context: We reviewed and analyzed the charts of 135 patients with NHL that were diagnosed and treated in a single oncology unit during the last 20 years. Context: Only two patients, 5 and 12 years old, with primary gastric NHL were found. Upper gastroduodenal endoscopy detected an ulcer in the lesser curvature of the body of the stomach, in both cases. Endoscopy revealed a moderate chronic gastritis in the antrum of both patients that was H. pylori associated in one of them who also suffered from chronic gastritis. Biopsy specimens demonstrated infiltration by Burkitt lymphoma (BL). The two patients received chemotherapy for 6 months. Additionally, one of the two patients received a triple therapy regimen with bismuth, amoxicillin, and metronidazole for H. pylori. Fifteen and six years later they are in complete remission, free of symptoms. Think step by step to answer my question. [/INST] Primary gastric NHL in childhood is rare. It was found in fewer than 2% of our NHL patients. The temporal relationship between the H. pylori infection and BL suggest a causative link between these two events.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Undetermined deaths: are they suicides? Answer the question given the following information: Context: The group of undetermined deaths was compared to other death categories with respect to sex, age, marital status, and month of death of the deceased. A total yearly number of 18.508 deaths in Slovenia in 2001 was analyzed. Context: Significantly more men died in fatal traffic accidents and committed suicide than from undetermined causes. Persons dying in fatal traffic accidents and committing suicides were significantly younger than those dying from undetermined causes of death, whereas persons dying from remaining causes of death were older. The marital status profiles of persons dying from undetermined causes and those committing suicides were similar. Also, undetermined deaths and suicides were both more likely to occur in April and May. Think step by step to answer my question. [/INST] Underestimation of actual number of suicides could be assumed, given the similarities with the group of undetermined deaths in both seasonality and marital status. As some differences were obtained between the two groups in sex and age, we may conclude that some cases of older women suicides are concealed within the undetermined deaths group.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the high frequency of Caesarean sections in a highly specialized gyneco-obstetric hospital justifiable? Answer the question given the following information: Context: To determine if the high proportion of cesarean section performed at Obstetrics and Gynecology number 3 Hospital of the Medical Center "La Raza", IMSS (HGO3) is justified. Context: We carried out a cross sectional study of 300 patients who underwent cesarean section during a period of 35 consecutive days, from October to November 2001. We reviewed their clinical expedients and went to additional direct interrogatory. The studied variables were the number and indications of cesarean section; if they were programmed or urgent events and if the indication of surgery was related with perinatal outcome. Context: We used descriptive statistics with frequencies and percentages in statistics program SPSS10. We found high incidence of prematurity (38.3%), pregestational and gestational maternal diseases (66%) and urgent indication of surgery (60.7%). Think step by step to answer my question. [/INST] The incidence of cesarean section in similar third level concentration hospitals in this country ranks from 20 to 40%. At HGO3 it was 72.51% in the last year (2001). This suggests that pregnancy comorbidity seen at this hospital, may be proportionally larger than in other similar units, because two thirds of patients had a high risk pregnancy and, if not, they had an obstetric or fetal justification for cesarean section in 80% of cases.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is adherence to drug treatment correlated with health-related quality of life? Answer the question given the following information: Context: Adherence to drug treatment and health-related quality of life (HRQL) are two distinct concepts. Generally one would expect a positive relationship between the two. Context: The purpose of this study was to assess the relationship between adherence and HRQL. Context: HRQL was measured using the physical and mental summary measures of the RAND-12 (PHC-12, MHC-12), the SF-12 (PCS-12, MCS-12), HUI-2 and HUI-3. Adherence was assessed using Morisky's instrument. Three longitudinal datasets were used. One dataset included 100 hypertensive patients. Another dataset covered 199 high risk community-dwelling individuals. The third dataset consisted of 365 elderly patients. Spearman's correlation coefficients were used to assess association. Subgroup analyses by type of medication and inter-temporal analyses were also performed. Context: Correlation between adherence and PHC-12 ranged from 0.08 (p = 0.26) to 0.22 (p<0.01). Correlations between adherence and MHC-12 ranged from 0.11 (p = 0.11) to 0.15 (p<0.01). Similar results were observed using HUI-2, HUI-3, and SF-12 as well as by type of medication and in the lagged analyses. Think step by step to answer my question. [/INST] Correlations between HRQL and adherence were positive but typically weak or negligible in magnitude.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are reciprocal changes a consequence of "ischemia at a distance" or merely a benign electrical phenomenon? Answer the question given the following information: Context: The aim of the present study was to investigate whether ST segment depression in precordial leads at the time of acute inferior myocardial infarction represents a reciprocal change rather than concurrent anterior wall ischemia on the surface electrocardiography. Context: The mechanism of reciprocal ST segment depression during acute myocardial infarction is controversial. "Ischemia at a distance" or a benign electrical phenomenon has been implicated in numerous reports. Pulsed-wave tissue Doppler (PWTD) echocardiography can be used to examine the regional diastolic motion of the left ventricular myocardial wall and may allow the detection of ischemic segments. Context: We evaluated regional myocardial ischemia using PWTD echocardiography in 48 patients with a first inferior wall myocardial infarction. The left ventricle was divided into 16 segments. PWTD echocardiographic velocities were obtained from each left ventricular segments. Context: Reciprocal ST segment depression was present in 35 patients (Group 1) but not in the remaining 13 patients (Group 2). There were no significant differences between groups 1 and 2 with respect to systolic (S) (7.4 +/- 1.1 vs 6.8 +/- 0.9 cm/s; P>0.05), early (E) (10.5 +/- 2 vs 9.4 +/- 1.2 cm/s; P>0.05), and late (A) (9.5 +/- 3.2 vs 8.5 +/- 2.3 cm/s; P>0.05) diastolic waves peak velocities, E/A ratio 1.1 +/- 0.2 vs 1.1 +/- 0.1; P>0.05), Ewave deceleration time (DT) (92 +/- 17 vs 101 +/- 16 ms; P>0.05) and regional relaxation time (RT) (82 +/- 19 vs 93 +/- 21 ms; P>0.05) in anterior wall (basal levels), which correspond to reciprocal ST segment depression on electrocardiography. According to E/A ratio detected by PWTD echocardiography in anterior wall and anterior septum, patients with reciprocal ST segment depression were also divided into two groups: Group A, with E/A ratio>1; Group B, with E/A ratio<1. Among the 35 patients with reciprocal ST segment depression, anterior wall ischemia was present in 10 patients and absent in 25 patients, whereas anterior septal ischemia was present 12 patients and absent in 23 patients. Think step by step to answer my question. [/INST] Reciprocal ST segment depression during the early phases of inferior infarction is an electrical reflection of primary ST segment elevation in the area of infarction.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is obesity a risk factor for cirrhosis-related death or hospitalization? Answer the question given the following information: Context: Our aim was to determine whether increased body mass index (BMI) in the general population is associated with cirrhosis-related death or hospitalization. Context: Participants included 11,465 persons aged 25-74 years without evidence of cirrhosis at entry into the study, or during the first 5 years of follow-up, who subsequently were followed-up for a mean of 12.9 years. The BMI was used to categorize participants into normal-weight (BMI<25 kg/m(2), N = 5752), overweight (BMI 25 to<30 kg/m(2), N = 3774), and obese categories (BMI>/= 30 kg/m(2), N = 1939). Context: Cirrhosis resulted in death or hospitalization of 89 participants during 150,233 person-years of follow-up (0.59/1000 person-years). Cirrhosis-related deaths or hospitalizations were more common in obese persons (0.81/1000 person-years, adjusted hazard ratio 1.69, 95% confidence interval [CI] 1.0-3.0) and in overweight persons (0.71/1000 person-years, adjusted hazard ratio 1.16, 95% CI 0.7-1.9) compared with normal-weight persons (0.45/1000 person-years). Among persons who did not consume alcohol, there was a strong association between obesity (adjusted hazard ratio 4.1, 95% CI 1.4-11.4) or being overweight (adjusted hazard ratio 1.93, 95% CI 0.7-5.3) and cirrhosis-related death or hospitalization. In contrast, this association was weaker among persons who consumed up to 0.3 alcoholic drinks/day (adjusted hazard ratio 2.48, 95% CI 0.7-8.4 for obesity; adjusted hazard ratio 1.31, 95% CI 0.4-4.2 for overweight) and no association was identified among those who consumed more than 0.3 alcoholic drinks/day. Think step by step to answer my question. [/INST] Obesity appears to be a risk factor for cirrhosis-related death or hospitalization among persons who consume little or no alcohol.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Restoration of locomotion in paraplegics with aid of autologous bypass grafts for direct neurotisation of muscles by upper motor neurons--the future: surgery of the spinal cord? Answer the question given the following information: Context: Paraplegia means a lifelong sentence of sensory loss, paralysis and dependence. Complete spinal cord lesions cannot heal up to now despite intensive experimental research, remarkable efforts and recent achievements in bio-technology and re-engineering. Traumatic paraplegia due to spinal cord injury (SCI) is a quite frequent condition and related to the socio-economical situation of the population. It is experienced disproportionately by young people. The rise in gunshot wounds is dramatic. SCI has appeared refractory to treatment. Context: Since 1980 G.A.B. had tried surgical repair of the spinal cord (SC) after experimental bisection in rats, and since 1993 research was done on monkeys (macaca fascicularis) to be closer to human physiology. The sciatic nerve was removed and used as an autologous graft from the lateral bundle of the spinal cord (tractus corticospinalis ventro lateralis) to the three muscles of both legs being known to be most important for locomotion: M. gluteus maximus, M. gluteus medius and M. quadriceps femoris. The first fruitful transplantation in a human being was performed in July 2000. Context: The results in rats were promising and fulfilled the requirements of the American Task Force of the National Institute of Neurological and Communicative Disorders and Stroke of the US. The results in monkeys confirmed the paradigm so that we performed the first operation in a young lady suffering for four months from complete SC lesion T9 after approval by the ethical committee. First voluntary movements of the connected muscles after 17 months. 27 months after op she was able to walk up to 60 steps with the help of a walker and to climb steps in the water. Improvement is still continuing. Context: SCI has appeared refractory to any kind of treatment. Compensatory strategies are still experimental in human beings. Autologous nerve grafts from the spinal cord tissue (the lateral spinal bundle) connected to peripheral muscle nerves seem promising in paraplegics. But the physiology is still unclear when the glutamatergic upper motor neuron connected to motor end-plates (cholinergic) does work like in our patient. Think step by step to answer my question. [/INST] Further studies in primates and paraplegic patients are necessary to clarify the bypass grafting of the SC to muscle groups distal to the complete SCI to restore locomotion.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Night-time frequency, sleep disturbance and general health-related quality of life: is there a relation? Answer the question given the following information: Context: We conducted a community-based study to determine the relationship among night-time frequency, sleep disturbance and general health-related quality of life (GHQL). Context: A total of 2271 participants, men and women, aged 41-70 and randomly selected in three Japanese towns completed a postal questionnaire survey. This questionnaire included: the International Prostate Symptom Score, the overall incontinence score of the International Consultation of Incontinence Questionnaire Short Form for lower urinary tract symptoms, the Pittsburg Sleep Quality Index for sleep problems, the Medical Outcome Study Short Form-8 for GHQL, and medical history of disease, cigarette smoking, and alcohol consumption. A multiple regression model was used for statistical analysis, and P<0.05 was considered significant. Context: Although night-time frequency by itself was closely associated with most aspects of GHQL, this association disappeared in four domains (general health perception, vitality, mental health and emotional role) and in the two summary scores of the Medical Outcome Study Short Form-8 after inclusion of the influence of sleep problems represented by the total score on the Pittsburg Sleep Quality Index. However, three domains (physical function, physical role, and social function) remained significantly associated with night-time frequency. Sleep problems were by far the worst risk factor for the deterioration of GHQL. Think step by step to answer my question. [/INST] Night-time frequency appeared to be associated with GHQL mainly by affecting sleep conditions, a symptom that independently influenced some aspects of GHQL.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are voiding symptoms really associated with abnormal urodynamic voiding parameters in women? Answer the question given the following information: Context: To examine the relationship between voiding symptoms and objective measurements of voiding dysfunction. Context: We prospectively collected data from 116 consecutive women attending for urodynamic investigations. Symptoms of voiding dysfunction and objective voiding parameters including uroflowmetry and post-void residual volume were evaluated. Context: Sixteen (14%) patients reported a symptom of straining, 21 (18%) double voiding, 32 (27%) post-micturition dribbling, 10 (8%) poor stream and 34 (29%) incomplete emptying. Using receiver-operator curves we were unable to determine a cut-off value for flow or residual volume where symptoms became more prevalent. Poor stream was, however, a good predictor for a residual volume of>100 mL and>150 mL. Strain predicted a residual volume of>100 and>150 mL and it correlated with maximum flow rate<15 mL/s. The other three symptoms did not correlate with any of the cut-off values. Think step by step to answer my question. [/INST] Poor steam and strain are weakly predictive of abnormal voiding function.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is it possible to predict the procedural time of endoscopic submucosal dissection for early gastric cancer? Answer the question given the following information: Context: Endoscopic submucosal dissection (ESD) has been expected to be a possible curative treatment, especially for node-negative early gastric cancer (EGC). We investigated the influential factors on the procedural time of gastric ESD with a Flex knife for the estimation. Context: In 222 intestinal-type EGC resected by ESD experts with established techniques, age, sex, location, circumference, gross type, tumor size, tumor depth, ulcerative findings, the period of ESD, the operator, and the experience of the operator were retrospectively analyzed. Predictors with a significant difference, as determined by multivariate analysis, were used to compose a predictive formula of procedural time. Context: Location, gross type, tumor depth, ulcerative findings, and tumor size were considered influential factors on the procedural time by univariate analysis. Location in the upper-third of the stomach, presence of ulcerative findings, and>20 mm in size were independent factors, as determined by multivariate analysis. Procedural time (min) was nearly equal to the maximal tumor size (mm) multiplied by 2.5, and an additional 40 min was required if the tumor was located in the upper-third of the stomach or had ulcerative findings (in both situations, an additional 80 min was needed). Think step by step to answer my question. [/INST] The procedural time of ESD with a Flex knife for EGC can be predicted by tumor size, location, and existence of ulcerative findings. The estimation of procedural time may be very useful to determine the operation schedule.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: The activation peptide of thrombin-activatable fibrinolysis inhibitor: a role in activity and stability of the enzyme? Answer the question given the following information: Context: Thrombin-activatable fibrinolysis inhibitor (TAFI) is a 56-kDa procarboxypeptidase. Proteolytic enzymes activate TAFI into TAFIa, an inhibitor of fibrinolysis, by cleaving off the N-terminal activation peptide (amino acids 1-92), from the enzyme moiety. Activated TAFI is unstable, with a half-life of approximately 10 min at 37 degrees C. So far, it is unknown whether the activation peptide is released or remains attached to the catalytic domain, and whether it influences TAFIa's properties. The current study was performed to clarify these issues. Context: TAFI was activated, and the activity and half-life of the enzyme were determined in the presence and absence of the activation peptide. Context: TAFIa was active both before and after removal of the activation peptide, and the half-life of TAFIa was identical in the two preparations. Furthermore, we observed that intrinsically inactivated TAFIa (TAFIai) aggregated into large, insoluble complexes that could be removed by centrifugation. Think step by step to answer my question. [/INST] The data presented in this article show that the activation peptide of TAFI is not required for TAFIa activity and that the activation peptide has no effect on the stability of the enzyme. These results are in favour of a model in which the activation peptide solely stabilizes the structure of the proenzyme. After activation of TAFI and subsequent breakage of interactions between the activation peptide and the catalytic domain, the activation peptide is no longer capable of performing this stabilizing task, and the integrity of the catalytic domain is lost rapidly. The resulting TAFIai is more prone to proteolysis and aggregation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the action taken by Catalonian primary care doctors adequate in view of the insufficient reduction in blood pressure levels in hypertensive patients? Answer the question given the following information: Context: To determine the attitude to therapy of primary care staff in view of the lack of reduction in blood pressure. To describe the most commonly used antihypertensives. Context: Descriptive, longitudinal, retrospective study during the year 2001. Context: Primary care, Spain. Context: We analysed 990 hypertensive patients from 12 health centres picked from the 31 participants in the DISEHTAC-1996 study. Context: Age, sex, weight, and height were analysed, along with blood pressure values throughout the year 2001, therapeutic attitude (increase/replacement/combination) with poor control (more than 2 consecutive visits with blood pressure>139 and/or 89 mm Hg), screening and prevalence of cardiovascular risk factors (CVRF), and drugs used. Context: There were 58.9% females; mean age: 65.4 (13.01) years, and 43.8% received 2 or more antihypertensives. The most common antihypertensives prescribed were diuretics (47.6%), and angiotensin-converting enzyme (ACE) inhibitors plus diuretics was the most used combination (22.1%). When there was poor control, some change in treatment was made in 76.8% (95% confidence interval [CI], 73.6-80) of cases. The most common was a combination of drugs (49.6%). The expected action was more frequent in those over 65 years and with a grade I of arterial hypertension (systolic blood pressure [SBP]between 140-150 and diastolic blood pressure [DBP] between 90-99 mm Hg (P<.001). Think step by step to answer my question. [/INST] Combined therapy is used in almost half of hypertensive patients, with the most common action being a drug combination.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Nothing new under the heavens: MIH in the past? Answer the question given the following information: Context: Dentitions of 45 sub-adults were examined using standard macroscopic methods and systematically recorded. A total of 557 teeth were examined with a *5 lens and photographed. Ages of the individuals were estimated from their dental crown and root development stages and not from charts that combine tooth eruption with development stages. The dental age of the individual and the approximate age of onset of enamel defects was then calculated on the basis of the chronological sequence of incremental deposition and calcification of the enamel matrix. Affected enamel was graded macroscopically as: - Mild:<30% of the tooth's enamel surface area visibly disrupted (this encompasses the entire range reported in most other studies), Moderate: 31-49% of the tooth's enamel surface area visibly disrupted and Severe:>50% of the tooth's enamel surface area visibly disrupted. Context: Of the total number of individuals 41 (93.2%) showed signs of enamel developmental dysplasia or MIH, 28 of them showing moderate or severe lesions of molars, primary or permanent (63.6% of the sample). Incisors and canines, though surviving much less often, showed episodes of linear hypoplasia. Think step by step to answer my question. [/INST] The extensive lesions seen on many of the molars displayed cuspal enamel hypoplasia (CEH). Many of these teeth also exhibited Molar Incisal Hypomineralisation (MIH).</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Pancreatic injury in damage control laparotomies: Is pancreatic resection safe during the initial laparotomy? Answer the question given the following information: Context: While damage control (DC) techniques such as the rapid control of exsanguinating haemorrhage and gastrointestinal contamination have improved survival in severely injured patients, the optimal pancreatic injury management strategy in these critically injured patients requiring DC is uncertain. We sought to characterise pancreatic injury patterns and outcomes to better determine optimal initial operative management in the DC population. Context: A two-centre, retrospective review of all patients who sustained pancreatic injury requiring DC in two urban trauma centres during 1997-2004 revealed 42 patients. Demographics and clinical characteristics were analysed. Study groups based on operative management (pack+/-drain vs. resection) were compared with respect to clinical characteristics and hospital outcomes. Context: The 42 patients analysed were primarily young (32.8+/-16.2 years) males (38/42, 90.5%) who suffered penetrating (30/42, 71.5%) injuries of the pancreas and other abdominal organs (41/42, 97.6%). Of the 12 patients who underwent an initial pancreatic resection (11 distal pancreatectomies, 1 pancreaticoduodenectomy), all distal pancreatectomies were performed in entirety during the initial laparotomy while pancreaticoduodenectomy reconstruction was delayed until subsequent laparotomy. Comparing the pack+/-drain and resection groups, no difference in mechanism, vascular injury, shock, ISS, or complications was revealed. Mortality was substantial (packing only, 70%; packing with drainage, 25%, distal pancreatectomy, 55%, pancreaticoduodenectomy, 0%) in the study population. Think step by step to answer my question. [/INST] The presence of shock or major vascular injury dictates the extent of pancreatic operative intervention. While pancreatic resection may be required in selected damage control patients, packing with pancreatic drainage effectively controls both haemorrhage and abdominal contamination in patients with life-threatening physiological parameters and may lead to improved survival. Increased mortality rates in patients who were packed without drainage suggest that packing without drainage is ineffective and should be abandoned.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: N-terminal pro-brain natriuretic peptide in systemic sclerosis: a new cornerstone of cardiovascular assessment? Answer the question given the following information: Context: Cardiac involvement, a common and often fatal complication of systemic sclerosis (SSc), is currently detected by standard echocardiography enhanced by tissue Doppler echocardiography (TDE). Context: The performance of the biomarker of cardiovascular disease, N-terminal pro-brain natriuretic peptide (NT-proBNP), in the detection of cardiac involvement by SSc was examined. Context: A total of 69 consecutive patients with SSc (mean (SD) age 56 (13) years, 56 women) were prospectively studied with standard echocardiography and TDE measurements of longitudinal mitral and tricuspid annular velocities. Plasma NT-proBNP was measured in all patients. Context: Overall, 18 patients had manifestations of cardiac involvement, of whom 7 had depressed left ventricular and 8 depressed right ventricular myocardial contractility, and 8 had elevated systolic pulmonary arterial pressure. Patients with reduced contractility had increased mean (SD) NT-proBNP (704 (878) pg/ml versus 118 (112) pg/ml in patients with normal myocardial contractility, p<0.001). Similarly, NT-proBNP was higher in patients with (607 (758) pg/ml) than in patients without (96 (78) pg/ml) manifestations of overall cardiac involvement (p<0.001). Receiver operating characteristic analysis showed NT-proBNP reliably detected depressed myocardial contractility and overall cardiac involvement (area under the curve 0.905 (95% CI 0.814 to 0.996) and 0.935 (95% CI 0.871 to 0.996), respectively). Considering patients with SSc with normal echocardiography and TDE as controls, and using a 125 pg/ml cut-off concentration, sensitivity and specificity were 92% and 71% in the detection of depressed myocardial contractility, and 94% and 78% for overall cardiac involvement. Think step by step to answer my question. [/INST] NT-proBNP reliably detected the presence of cardiac involvement and appears to be a very useful marker to risk stratify patients presenting with SSc.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Epidemiological surveillance of mycoplasmas belonging to the 'Mycoplasma mycoides' cluster: is DGGE fingerprinting of 16S rRNA genes suitable? Answer the question given the following information: Context: The analysis by Denaturing Gradient Gel Electrophoresis (DGGE) of the PCR-amplified V3 region of 16S rRNA gene was previously shown to detect and differentiate a large number of human and animal mycoplasmas. In this study, we further assessed the suitability of the technique for epidemiological surveillance of mycoplasmas belonging to the 'Mycoplasma mycoides' cluster, a phylogenetic group that includes major ruminant pathogens. Context: The V3 region of 16S rRNA genes from approx. 50 field strains was amplified and analysed by DGGE. Detection and identification results were compared with the ones obtained by antigenic testing and sequence analysis. Think step by step to answer my question. [/INST] The DGGE technique is robust and valuable as a first-line test, but the patterns obtained for strains belonging to the 'M. mycoides' cluster were too variable within a taxon and in contrast too conserved between taxa to allow an unequivocal identification of isolates without further analysis.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does leisure time physical activity in early pregnancy protect against pre-eclampsia? Answer the question given the following information: Context: To examine the association between physical activity in early pregnancy and risk of pre-eclampsia. Context: Prospective cohort. Context: Denmark. Context: A total of 85,139 pregnant Danish women, recruited between 1996 and 2002. Context: The authors assessed leisure time physical activity in first trimester by a telephone interview and categorised women a priori into seven groups: 0 (reference), 1-44, 45-74, 75-149, 150-269, 270-419 and 420+ minutes/week. Pre-eclampsia diagnoses were extracted from the Danish National Patient Registry. A number of potential confounders were adjusted for by logistic regression. Context: Pre-eclampsia and severe pre-eclampsia. Context: The two highest physical activity levels were associated with increased risk of severe pre-eclampsia compared with the nonexercising group, with adjusted odds ratios of 1.65 (95% CI: 1.11-2.43) and 1.78 (95% CI: 1.07-2.95), whereas more moderate levels of physical activity (1-270 minutes/week) had no statistically significant association with risk of pre-eclampsia (total n = 85,139). Think step by step to answer my question. [/INST] We were unable to document a protective effect of leisure time physical activity against pre-eclampsia. Our data even suggest that leisure time physical activity exceeding 270 minutes/week in first trimester may increase risk of severe pre-eclampsia.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is TrpM5 a reliable marker for chemosensory cells? Answer the question given the following information: Context: In the past, ciliated receptor neurons, basal cells, and supporting cells were considered the principal components of the main olfactory epithelium. Several studies reported the presence of microvillous cells but their function is unknown. A recent report showed cells in the main olfactory epithelium that express the transient receptor potential channel TrpM5 claiming that these cells are chemosensory and that TrpM5 is an intrinsic signaling component of mammalian chemosensory organs. We asked whether the TrpM5-positive cells in the olfactory epithelium are microvillous and whether they belong to a chemosensory system, i.e. are olfactory neurons or trigeminally-innervated solitary chemosensory cells. Context: We investigated the main olfactory epithelium of mice at the light and electron microscopic level and describe several subpopulations of microvillous cells. The ultrastructure of the microvillous cells reveals at least three morphologically different types two of which express the TrpM5 channel. None of these cells have an axon that projects to the olfactory bulb. Tests with a large panel of cell markers indicate that the TrpM5-positive cells are not sensory since they express neither neuronal markers nor are contacted by trigeminal nerve fibers. Think step by step to answer my question. [/INST] We conclude that TrpM5 is not a reliable marker for chemosensory cells. The TrpM5-positive cells of the olfactory epithelium are microvillous and may be chemoresponsive albeit not part of the sensory apparatus. Activity of these microvillous cells may however influence functionality of local elements of the olfactory system.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do proton-pump inhibitors increase the risk for nosocomial pneumonia in a medical intensive care unit? Answer the question given the following information: Context: The aim of this study was to determine whether the use of gastric acid-suppressive agents increases the risk of nosocomial pneumonia (NP) in a medical intensive care unit population. Context: Retrospective cohort study in a medical intensive care unit of a 554-bed, university-affiliated, academic medical center. Context: A total of 924 medical records were included in the database during the study period of which 787 patients were included in the study. Out of this cohort,104 patients (13.2%) eventually developed a NP. The risk for patients who received proton-pump inhibitors (adjusted hazard ratio [AHR] 0.63; 95% CI 0.39-1.01) was not significantly different than in non exposed patients. Variables most strongly associated with NP were the administration of sedatives or neuromuscular blockers for at least 2 consecutive days (AHR 3.39;95% CI 1.99-5.75), an Acute Physiology and Chronic Health Evaluation II (APACHE II) severity score greater than 15 (AHR, 3.34; 95% CI 1.82-6.50), and presence of a central venous catheter (AHR, 1.76; 95% CI 1.12-2.76). Think step by step to answer my question. [/INST] Prior use of a proton-pump inhibitor did not correlate with a significant increase in the risk of developing NP. This risk was higher with the administration of sedatives or neuromuscular blockers, increased disease severity, and placement of a central venous catheter.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: A tale of two countries--the United States and Japan: are differences in health due to differences in overweight? Answer the question given the following information: Context: Despite similar standards of living and health care systems for older persons, there are marked differences in the relative health of the elderly populations in the United States (US) and Japan. We explore the association of overweight and obesity with these health disparities. Context: Data on older adults from the US National Health Interview Survey (1994) and the Longitudinal Study of Aging II (1994) were compared to similar data from the 1999-2001 Nihon University Japanese Longitudinal Study of Aging. Regression analyses for the 2 countries were conducted to examine the correlates of being overweight and obese, and the relationships of overweight and obesity with activities of daily living functioning, heart disease, arthritis, and diabetes. Context: The prevalence of overweight and obesity is higher in the US than in Japan, as is the prevalence of heart disease, diabetes, arthritis, and functioning problems. Education level and marital status are predictors of overweight for older Americans but not for older Japanese people. Health behaviors affect weight in all groups. The prevalence of functioning problems and disease are more likely to be associated with being overweight in US men and women than in Japanese women, and are not associated with being overweight in Japanese men. Think step by step to answer my question. [/INST] Despite similar standards of living and health care systems for older persons, the conditions associated with poor health differ in the US and Japan. Being overweight or obese appears to be related to more functioning problems and arthritis in the US than in Japan.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is there a distinct form of developmental dyslexia in children with specific language impairment? Answer the question given the following information: Context: The aim of this study was to identify quantitative and qualitative differences between the reading and writing skills of children with developmental dyslexia and those of dyslexic children with a specific language impairment (SLI). Context: It is suggested that although the etiology of developmental dyslexia and SLI may be diverse, dyslexic children with SLI and their language-intact peers are comparable on a behavioral level. Context: Three groups of second-grade children were compared on reading and writing tests with single words and nonwords: 15 dyslexic children with a history of SLI (SLI group), 15 dyslexic children with a typical pattern of language development (non-SLI group), and a control group of 30 children with no clinical history of learning disabilities or communication disorders. Context: Analysis of the results revealed the performances of both SLI and non-SLI dyslexic groups to be comparable in terms of speed, accuracy, and error typology. Think step by step to answer my question. [/INST] This study confirms that there are parallels between dyslexic children with language disorders and their dyslexic peers with intact language skills, at least in terms of their performance on reading and writing tests.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Idiopathic subarachnoid hemorrhage and venous drainage: are they related? Answer the question given the following information: Context: In the past, several possible explanations for idiopathic subarachnoid hemorrhage (ISAH) have been proposed; however, neuroimaging studies have never provided conclusive data about the structural cause of the bleeding. The aim of this study is to determine whether there are anatomic differences in the deep cerebral venous drainage in patients with ISAH compared with those with aneurysmal subarachnoid hemorrhage (ASAH) and those without intracranial hemorrhage. Context: We reviewed the venous phase of carotid digital angiograms of 100 consecutive patients who had a final diagnosis of ISAH. We also analyzed the angiograms of a control group of 112 patients with ASAH and the angiograms of a nonhemorrhagic group of 25 patients having incidental aneurysms. The anatomic variants of the basal vein of Rosenthal (BVR) on both sides were classified into the following types: Type A (normal continuous), in which the BVR is continuous with the deep middle cerebral veins and drains mainly into the vein of Galen; Type B (normal discontinuous), in which there is discontinuous venous drainage, anterior to the uncal vein and posterior to the vein of Galen; and Type C (primitive), which drains mainly to veins other than the vein of Galen. We calculated the proportions to analyze the differences in the type of venous drainage between patients with ISAH, patients with ASAH, and patients without hemorrhage. chi2 statistics were used to search for differences. Context: Types A and C venous drainage were present in 23.8 and 32.3%, respectively, of patients with ISAH compared with 58.7 and 15.4%, respectively, in the ASAH group and 57.5 and 5%, respectively, in the nonhemorrhagic group (P<0.001). A primitive variant was present in at least 1 hemisphere in 38 patients with ISAH (41.8% of the cases) compared with 24 patients with ASAH (21.4%) and 2 patients (8%) in the nonhemorrhagic group (P<0.001). Think step by step to answer my question. [/INST] In patients with ISAH, deep cerebral venous drainage more commonly drains directly into dural sinuses instead of via the vein of Galen compared with patients with ASAH and patients without intracranial hemorrhage. The way in which this venous configuration might influence bleeding remains unknown.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the treatment response in elderly patients with rheumatoid arthritis diminished? Answer the question given the following information: Context: With increasing age DMARD and TNF-alpha-Inhibitors are less frequently used. The goal of this work was to investigate whether the therapeutic response in elderly patients with rheumatoid arthritis (RA) is diminished. Context: In total, 192 patients admitted to hospital because of active RA were prospectively studied. The improvements in disease activity (RADAI), pain and function (FFbH) three months after release were measured and compared between two age groups. Context: Patients<65 and>or =65 years of age (n=104 and 88, mean age of 52+/-10 and 72+/-5.6 years, respectively) showed comparable improvements of disease activity and pain in the complete group as well as in those who received newly administered DMARD or TNF-alpha-inhibitors (71.2% and 62.6%, respectively, for the two groups). A significant difference was demonstrated for the change in function: While patients<65 years of age in the mean had a moderate improvement of the FFbH, this could not be shown for the older patients (p=0.04). A close correlation of the improvements of RADAI and FFbH could be shown for the younger patients only. Think step by step to answer my question. [/INST] DMARD or TNF-alpha-inhibitors improve disease activity and pain in elderly patients with RA no less than in younger patients. However, in contrast to the younger patients, the older patients profit less in terms of functional impairment.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Magnetic toys: forbidden for pediatric patients with certain programmable shunt valves? Answer the question given the following information: Context: Inadvertent adjustments and malfunctions of programmable valves have been reported in cases in which patients have encountered powerful electromagnetic fields such as those involved in magnetic resonance imaging, but the potential effects of magnetic toys on programmable valves are not well known. Context: The magnetic properties of nine toy magnets were examined. To calculate the effect of a single magnet over a distance, the magnetic flux density was directly measured using a calibrated Hall probe at seven different positions between 0 and 120 mm from the magnet. Strata II small (Medtronic Inc.), Codman Hakim (Codman&Shurtleff), and Polaris (Sophysa) programmable valves were then tested to determine the effects of the toy magnets on each valve type. Context: The maximal flux density of different magnetic toys differed between 17 and 540 mT, inversely proportional to the distance between toy and measurement instrument. Alterations to Strata and Codman valve settings could be effected with all the magnetic toys. The distances that still led to an alteration of the valve settings differed from 10 to 50 mm (Strata), compared with 5 to 30 mm (Codman). Valve settings of Polaris could not be altered by any toy at any distance due to its architecture with two magnets adjusted in opposite directions. Think step by step to answer my question. [/INST] This is the first report describing changes in the pressure setting of some adjustable valves caused by magnetic toys in close contact. Parents, surgeons, neurologists, pediatric oncologists, and paramedics should be informed about the potential dangers of magnetic toys to prevent unwanted changes to pressure settings.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does the expression of cyclin E, pRb, and p21 correlate with prognosis in gastric adenocarcinoma? Answer the question given the following information: Context: Cyclin E is a protein that plays a key role in the G1 -->S transition of the normal cell cycle. The product of retinoblastoma gene (pRb) is the master regulator of entry into the cell cycle and p21 protein is a cyclin-dependent kinase inhibitor that disturbs the progression through the cell cycle. The expression of these proteins, among many others, is being deregulated in tumorogenesis. The aim of this study was to investigate whether cyclin E, pRb, and p21 can be used as prognostic indicators in gastric cancer. Context: Fifty-six patients with gastric adenocarcinoma, who underwent curative resection, constituted the group of our study. The immunohistochemical expression of cyclin E, pRb, and p21 proteins was examined and correlated with clinical-pathological parameters and survival. Context: Positive cyclin E immunostaining was observed in 23 tumors (41.1%). It was associated with intestinal Lauren classification (P=0.003), nodal infiltration (P=0.0025), size of the tumor>5 cm (P=0.032), and lymphatic (P=0.042) and vascular invasion (P= 0.0029). Nevertheless, the survival of patients with positive cyclin E tumors was not significantly shorter than that of negative patients. Positive pRb immunostaining was found in 24 (42.9%) cases and it was associated with the absence of Helicobacter pylori (P=0.044), whereas positive p21 immunostaining was found in 21 tumors (37.5%) and it was associated with less depth of gastric wall infiltration (P=0.001), the absence of lymphatic (P=0.019) and vascular infiltration (P=0.024), and the absence of liver metastasis (P=0.044). Cyclin E expression was associated with pRb expression (P=0.023), but was correlated inversely with p21 expression (P=0.009). The survival of patients with pRb-positive tumors and the survival of patients with p21-positive tumors were significantly longer than that of negative patients (P= 0.0044 and P<0.001, respectively). Think step by step to answer my question. [/INST] The expression of cyclin E could not predict the survival in this series of patients with gastric cancer, whereas the expression of pRb and p21 was associated with a favorable prognosis.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Synaptic plasticity: the new explanation of visceral hypersensitivity in rats with Trichinella spiralis infection? Answer the question given the following information: Context: Synaptic plasticity plays an important role in affecting the intensity of visceral reflex. It may also be involved in the development of visceral hypersensitivity. The aim of this study was to investigate the role of synaptic plasticity on visceral hypersensitivity of rats infected by Trichinella spiralis. Context: Thirty male Sprague-Dawley (SD) rats were randomly divided into control, acute, and chronic infection groups, and were investigated at 1 week after adaptive feeding and at 2 and 8 weeks post infection (PI) by oral administration of 1 ml phosphate-buffered saline (PBS) containing 8,000 Trichinella spiralis larvae. Visceral sensitivity was evaluated by electromyography (EMG) recording during colorectal distension. Intestinal inflammation was observed by hematoxylin-eosin (HE) staining. Synaptic ultrastructure parameters, such as postsynaptic density (PSD) length, synaptic cleft, and number of synaptic vesicles, were examined by transmission electron microscopy (TEM). The expression of protein associated with synaptic plasticity, including postsynaptic density-95 (PSD-95), synaptophysin, calbindin-28 K, N-methyl-D-aspartate receptor-1 (NMDA-R1), alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid receptor (AMPA-R), and glial cell line-derived neurotrophic factor (GDNF), were analyzed by Western blot. Context: (1) Visceral hypersensitivity was noted in the chronic infection group, although the inflammation was nearly eliminated (P<0.05). Severe inflammation and downregulation of visceral sensitivity were observed in the acute infection group (P<0.05). (2) There were many more synaptic vesicles and longer PSD in the chronic infection group than in the control group (P<0.05, respectively). However, in comparison with control rats, disappearance of mitochondria cristae in the synapses, and decrease of synaptic vesicles and length of PSD were observed in the acute infection group. There was no significant difference in width of synaptic cleft among the three groups. (3) Compared with the control, the expression of proteins associated with synaptic plasticity was significantly upregulated during chronic infection phase (P<0.05), and downregulated during acute infection phase. Think step by step to answer my question. [/INST] Synaptic plasticity was observed in SD rats infected by Trichinella spiralis and was associated with visceral sensitivity, which suggests that it may play an important role in the formation of visceral hypersensitivity.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: A survey of patient advocates within the National Cancer Institute's Prostate Cancer SPORE Program: who are they? Answer the question given the following information: Context: Interacting with patients, researchers, and administrators, patient advocates have a unique vantage point. Yet, few prior studies have sought to understand these individuals or to seek their opinions on cancer issues. Context: A survey to address the foregoing was developed and mailed to advocates within the National Cancer Institute's Prostate Cancer SPORE Program. Context: A total of 10 of 19 advocates responded. All were men, most were retired, and all had faced a diagnosis of prostate cancer. Two major themes emerged: (1) the importance of patient education in promoting informed clinical decision-making and (2) a perceived need for patient-centered research by providers and educators. Think step by step to answer my question. [/INST] Prostate cancer patient advocates provide a broad range of opinions on the spectrum of cancer care. Similar studies among advocates involved in other malignancies may be worthwhile.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Selective enamel etching reconsidered: better than etch-and-rinse and self-etch? Answer the question given the following information: Context: This study evaluated the marginal quality of differently bonded direct resin composite restorations in enamel and dentin, before and after thermomechanical loading (TML). Special attention was focussed on the performance of selective enamel etching, etch-and-rinse, and self-etching adhesives. Context: Eighty MO cavities with proximal margins beneath the cementoenamel junction were prepared in extracted human third molars. Direct resin composite restorations (Tetric EvoCeram, n=8) were placed with 4-step selective enamel etching (Syntac SE), 4-step etch-and-rinse (Syntac ER), 2-step etch-and-rinse (XP Bond, Scotchbond 1 XT/Single Bond Plus), 2-step self-etching (AdheSE, Clearfil SE Bond), 2-step self-etching with selective enamel etching (AdheSE SE, Clearfil SE Bond SE), and 2-step self-etching with etch-and-rinse (AdheSE TE, Clearfil SE Bond TE). Marginal gaps were analyzed using epoxy resin replicas under a scanning electron microscope at 200X magnification. Context: Initially, high percentages of gap-free margins were identified for all adhesives. After TML, the results were as follows: (A) Enamel margins: When phosphoric acid was used on enamel, results were constantly higher (approximately 90%) compared with two-step self-etchin adhesives (approximately 70%; p<0.05). (B) Dentin margins: No statistical differences were found when etch-and-rinse and selective etch approaches were compared (59% to 64%; p>0.05). When self-etching adhesives were used as per manufacturers' directions, dentin margins exhibited the best marginal quality (74% to 82%; p<0.05). When self-etching adhesives were used under etch-and-rinse conditions, marginal quality in dentin was significantly reduced to 35% to 42% (p<0.05). Think step by step to answer my question. [/INST] Enamel bonding was generally more effective with phosphoric-acid etching. Enamel bonding performance of 2-step self-etching adhesives was improved when phosphoric acid was applied on enamel selectively.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do children with ADHD and/or PDD-NOS differ in reactivity of alpha/theta ERD/ERS to manipulations of cognitive load and stimulus relevance? Answer the question given the following information: Context: We examined whether the method of event-related (de-)synchronization (ERD/ERS) revealed differential effects of selective attention and working memory load in children (8-11 years) with pervasive developmental disorder - not otherwise specified (PDD-NOS) or attention-deficit/hyperactivity disorder (ADHD). Context: Fifteen healthy controls and three equally large groups of children with symptoms of PDD-NOS, ADHD or both (PDD/HD) performed a visual selective memory search task. The EEG was recorded from which occipital alpha and frontal theta were derived. Context: The effects of the overall task manipulations of task load, relevance and target/nontarget were clearly present in the overall analyses of alpha and theta ERD/ERS. However, no significant differences with respect to these manipulations existed between any of the subject groups. Think step by step to answer my question. [/INST] The results supply no evidence for a distinction in information processing abilities of selective attention and working memory as reflected by alpha and theta ERD/ERS between children diagnosed with either ADHD, PDD-NOS or healthy controls.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do increased training requirements in gastrointestinal endoscopy and advanced laparoscopy necessitate a paradigm shift? Answer the question given the following information: Context: Many modifications to the traditional residency model contribute to the ongoing paradigm shift in surgical education; yet, the frequency and manner by which such changes occur at various institutions is less clear. To address this issue, our study examined the variability in endoscopy and laparoscopy training, the potential impact of new requirements, and opinions of Program Directors in Surgery (PDs). Context: A 22-item online survey was sent to 251 PDs in the United States. Appropriate parametric tests determined significance. Context: In all, 105 (42%) PDs responded. No difference existed in response rates among university (56.2%), university-affiliated/community (30.5%), or community (13.3%) program types (p = 0.970). Surgeons alone (46.7%) conducted most endoscopy training with a trend toward multidisciplinary teams (43.8%). A combination of fellowship-trained minimally invasive surgeons and other surgeon types (66.7%) commonly provided laparoscopy training. For adequate endoscopy experience in the future, most PDs (74.3%) plan to require a formal flexible endoscopy rotation (p<0.001). For laparoscopy, PDs intend for more minimally invasive surgery (59%) as well as colon and rectal surgery (53.4%) rotations (both p<0.001). Respondents feel residents will perform diagnostic endoscopy (86.7%) and basic laparoscopy (100%) safely on graduation. Fewer PDs confirm graduates will safely practice therapeutic endoscopy (12.4%) and advanced laparoscopy (52.4%). PDs believe increased requirements for endoscopy and laparoscopy will improve procedural competency (79% and 92.4%, respectively) and strengthen the fields of surgical endoscopy and minimally invasive surgery (55.2% and 68.6%, respectively). Less believe new requirements necessitate redesign of cognitive and technical skills curricula (33.3% endoscopy, 28.6% laparoscopy; p = 0.018). A national surgical education curriculum should be a required component of resident training, according to 79% of PDs. Think step by step to answer my question. [/INST] PDs employ and may implement varied tools to meet the increased requirements in endoscopy and laparoscopy. With such variability in educational methodology, establishment of a national surgical education curriculum is very important to most PDs.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does training novices to criteria and does rapid acquisition of skills on laparoscopic simulators have predictive validity or are we just playing video games? Answer the question given the following information: Context: To determine whether LapSim training (version 3.0; Surgical Science Ltd, Göteborg, Sweden) to criteria for novice PGY1 surgical residents had predictive validity for improvement in the performance of laparoscopic cholecystectomy. Context: In all, 21 PGY1 residents performed laparoscopic cholecystectomies in pigs after minimal training; their performance was evaluated by skilled laparoscopic surgeons using the validated tool GOALS (global operative assessment of laparoscopic operative skills: depth perception, bimanual dexterity, efficiency, tissue handling, and overall competence). From the group, 10 residents trained to competency on the LapSim Basic Skills Programs (camera navigation, instrument navigation, coordination, grasping, lifting and grasping, cutting, and clip applying). All 21 PGY1 residents again performed laparoscopic cholecystectomies on pigs; their performance was again evaluated by skilled laparoscopic surgeons using GOALS. Additionally, we studied the rate of learning to determine whether the slow or fast learners on the LapSim performed equivalently when performing actual cholecystectomies in pigs. Finally, 6 categorical residents were tracked, and their clinical performance on all of the laparoscopic cholecystectomies in which they were "surgeon, junior" was prospectively evaluated using the GOALS criteria. Context: We found a statistical improvement of depth perception in the operative performance of cholecystectomies in pigs in the group trained on the LapSim. In the other 4 domains, a trend toward improvement was observed. No correlation between being a fast learner and the ultimate skill was demonstrated in the clinical performance of laparoscopic cholecystectomies. We did find that the fast learners on LapSim all were past or current video game players ("gamers"); however, that background did not translate into better clinical performance. Think step by step to answer my question. [/INST] Using current criteria, we doubt that the time and effort spent training novice PGY1 Surgical Residents on the basic LapSim training programs is justified, as such training to competence lacks predictive validity in most domains of the GOALS program. We are investigating 2 other approaches: more difficult training exercises using the LapSim system and an entirely different approach using haptic technology (ProMis; Haptica Ltd., Ireland), which uses real instruments, with training on realistic 3-dimensional models with real rather than simulated cutting, sewing, and dissection. Although experienced video gamers achieve competency faster than nongamers on LapSim programs, that skill set does not translate into improved clinical performance.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Improving outcomes on the ABS Certifying Examination: can monthly mock orals do it? Answer the question given the following information: Context: First-time pass rates on the American Board of Surgery Certifying Examination (ABSCE) have now become one of the standards of excellence to evaluate residency programs. Our residency program started monthly simulated and critiqued (verbal, written, and video) oral examinations (MSCE) in 2003. The current study explores the outcomes of this intervention. Context: We evaluated ABSCE performance of 48 residents who graduated from a large academic/community program between the years 2001 and 2006 though a prospective study with historical controls. Residents were divided into 2 groups: The intervention group comprised the 2003 to 2006 classes, which underwent MSCE; the historical control group spanned the 2001 and 2002 classes, which did not undergo MSCE. Results in the ABSCE were compared between groups using the Fisher exact test. In addition, the intervention group was queried in relation to the most important aspects of the MSCE as a learning experience through a structured questionnaire. Context: A statistically significant improvement (p = 0.038) in ABSCE first-time pass rates was noted in the intervention group. Examinees unanimously asserted they had been helped by the MSCE. Improvements in clinical reasoning and promotion of self-study were the most often cited benefits of the MSCE. Think step by step to answer my question. [/INST] Monthly simulated and critiqued oral examinations improved the first-time pass rate of the American Board of Surgery Certifying Examination. Additional perceived benefits of this intervention included improvements in clinical reasoning and promotion of self-study.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does antioxidant system adaptive response alleviate related oxidative damage with long term bed rest? Answer the question given the following information: Context: The aim of the study was to evidence oxidative damage and erythrocyte antioxidant enzyme activities during long term bed rest (LTBR) and recovery, while verifying the prophylactic effects of resistance exercise on LTBR-induced oxidative damage. Context: 11 healthy male participated in the study. Nutrient intakes were monitored. Assessments occurred during LTBR (60th and 90th day) and 90 days after the end. Context: LTBR induced only a slight decrease in total thiol protein (SH) group concentrations. Glutathione peroxidase (GPx) activity was upregulated during LTBR and down regulated after recovery suggesting that hypokinesia induces an oxidative stress. These effects where not correlated to antioxidant intake as nutritional density is preserved. Lipoperoxidative markers stay unchanged. Think step by step to answer my question. [/INST] Exercise alleviates hypokinesia outcomes by preserving glutathione reductase activity with minor effect on hypokinesia-induced antioxidant response and oxidative stress which both exhibit a high magnitude inter-individual variability. Return to initial physical activity allows biomarkers to return to initial values marking the end of the stress. Hypokinetic situations should be considered as an oxidative stressful situation requiring exercise and nutritional strategies.</s>