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<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Management of heart failure among very old persons living in long-term care: has the voice of trials spread? Answer the question given the following information: Context: Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail. Context: Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model. Context: The mean age of the population was 84.9 +/- 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities. Think step by step to answer my question. [/INST] Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does hysteroscopy facilitate tumor cell dissemination? Answer the question given the following information: Context: In several case reports, distension and irrigation of the uterine cavity during fluid hysteroscopy was suspected to cause tumor cell dissemination into the abdominal cavity in patients with endometrial carcinoma. It was the aim of this study to compare the incidence of positive peritoneal cytology in patients who underwent dilatation and curettage (D&C) with or without previous hysteroscopy. Context: The authors conducted a multicentric, retrospective cohort analysis. One hundred thirteen consecutive patients with endometrial carcinoma treated between 1996 and 1997 were included. Endometrial carcinoma had to be limited to the inner half or less than the inner half of the myometrium (pathologic Stage IA,B). Positive peritoneal cytology was obtained during staging laparotomy. Patients underwent D&C either with or without prior diagnostic fluid hysteroscopy. No selection or randomization was applied to the two groups. Positive peritoneal cytology, defined as malignant or suspicious, was considered the primary statistical endpoint. Context: Peritoneal cytology was suspicious or positive in 10 of 113 patients (9%). The presence of suspicious or positive peritoneal cytology was associated with a history of hysteroscopy (P = 0.04) but not with myometrial invasion (P = 0.57), histologic subtype (P = 1.00) or grade (r = 0.16, P = 0.10), or the time between D&C and staging laparotomy (r = 0.04, P = 0.66). Think step by step to answer my question. [/INST] Based on the limited extent of endometrial carcinoma in the current analysis, our data strongly suggest dissemination of endometrial carcinoma cells after fluid hysteroscopy. Determining whether a positive peritoneal cytology affects the prognoses of patients without further evidence of extrauterine disease will require longer follow-up.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Sympathetic skin response in diabetic children: do diabetic children have diabetic neuropathy? Answer the question given the following information: Context: Abnormal sympathetic skin response (SSR) has been reported in adult patients with diabetic neuropathy. In addition, other studies have revealed abnormal SSR in diabetic patients not having autonomic symptoms and autonomic dysfunctions. These findings have been only obtained from adult patients. There have been few reports on the autonomic functions in diabetic children. Accordingly, it is not clear whether the autonomic neuropathy occurs in diabetic children. The aim of the present study is to clear autonomic function in children with insulin-dependent diabetes mellitus by SSR. Context: The SSR was measured in 28 normal healthy children and in eight patients with IDDM not having symptoms of dysautonomia. The SSR was elicited using 10 stimuli on programmed Nihonkoden Neuropack Sigma model machine. Following a single electrical stimulation, four SSR were recorded in both the palms and the soles simultaneously. Context: The SSR were simultaneously obtained in 100% of the two groups. The amplitudes in the palms and soles were not significantly different between the two groups. The mean and shortest latency in the soles were significantly longer in the IDDM group than in the control group (P<0.01). None of the measurements of SSR revealed correlation with duration of diabetes and onset of illness. Think step by step to answer my question. [/INST] Diabetic neuropathy may not have occurred in young patients having shorter duration of illness. Conversely, assuming that prolonged latency is abnormal, it may even have occurred in them. Follow up on these patients with prolonged latencies would be required.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are the newer antidepressant drugs as effective as established physical treatments? Answer the question given the following information: Context: The aim of this study was to determine, in a clinical panel sample, the extent to which patients with depression (and melancholic and non-melancholic subtypes) judged the effectiveness of previously received antidepressant treatments, particularly the comparative effectiveness of the older and newer antidepressant drugs. Context: Twenty-seven Australasian psychiatrists assessed 341 non-psychotic depressed patients and rated the extent to which previous antidepressant treatments had been effective. Patients were assigned to 'melancholic' and residual 'non-melancholic' categories by two processes (DSM-IV decision rules, and a cluster analysis-derived allocation) and treatment effectiveness examined within each category. Context: Electroconvulsive therapy (both bilateral and unilateral) was judged as highly effective by both melancholic and non-melancholic patients. Antipsychotic medication similarly rated highly (but was judged as more effective by the non-melancholic than melancholic patients). The tricyclics and irreversible monoamine oxidase inhibitors (MAOIs) were rated as more effective by the whole sample than several newer antidepressant classes (including the selective serotonin re-uptake inhibitors [SSRIs], venlafaxine, mianserin and moclobemide), whether effectiveness was examined dimensionally or categorically. Comparison of the overall tricyclic and SSRI classes indicated that any superior tricyclic effectiveness was specific to the melancholic subjects. Think step by step to answer my question. [/INST] Despite methodological limitations intrinsic to such clinical panel data, the judged greater effectiveness of the older antidepressants (tricyclics and irreversible MAOIs) for melancholic depression is of importance. If valid, such data are of intrinsic clinical relevance but also have the potential to inform us about the neurobiological determinants of 'melancholia' and pharmacological actions which contribute to its effective treatment.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does syndrome X exist in hypertensive elderly persons with impaired glycemic control? Answer the question given the following information: Context: This report focuses on the glycemic state in relation to insulin and lipid levels of a cohort of elderly hypertensive persons to estimate the prevalence of syndrome X. Context: A cross-sectional study was performed at the University of Tennessee, Memphis, and the General Clinical Research Center (GCRC) on 95 participants in the Trial of Nonpharmacologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study. A standard oral glucose tolerance test (OGTT) with insulin and C-peptide levels and a fasting lipid profile were obtained. Context: In this sample of healthy elderly participants with hypertension who were taking an antihypertensive medication, 43 (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had impaired glucose tolerance (IGT), and 11 (11.6%) had undiagnosed non-insulin-dependent diabetes mellitus (NIDDM). Fasting hyperinsulinemia occurred in only one participant, who was in the IGT group. Hypertriglyceridemia and low high density lipoprotein (HDL) occurred in four persons, none of whom had hyperinsulinemia. Persons in the NIDDM and IGT groups had decreased beta cell function compared to persons in the NGT group, but did not have increased peripheral insulin resistance as estimated from the OGTT data. Think step by step to answer my question. [/INST] Our data demonstrated that in this cohort of elderly hypertensive participants with a high prevalence of central obesity, impaired glycemic control was common, but was not associated with fasting hyperinsulinemia or peripheral insulin resistance. Furthermore, we conclude that syndrome X essentially did not occur in these participants and postulate that the primary etiology for their impaired glycemic control is beta cell dysfunction. Further research is needed to elucidate these relationships.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Fish allergy: is cross-reactivity among fish species relevant? Answer the question given the following information: Context: Allergic reactions to fish are a common cause of food allergy in many areas of the world where fish is a major source of protein. Although different species of fish may be consumed, possible cross-reactivity has received limited investigation. Context: The aim of this study was to assess potential cross-reactivity to different species of fish species using double-blind, placebo-controlled food challenges (DBPCFC) in fish-allergic adults and to compare skin test and RAST reactivity with the challenge response. Context: Nine skin prick test and/or RAST-positive adult individuals with histories of an immediate-type reaction following fish ingestion were challenged with different fish species using double-blind, placebo-controlled food challenge. Context: Of a total of 19 double-blind, placebo-controlled fish challenges performed, 14 challenges (74%) resulted in the induction of objective signs that were consistent with an IgE-mediated response. The most common sign observed was emesis (37%); the most prevalent subjective symptoms reported were compatible with the oral allergy syndrome (84%). Three subjects reacted to at least three fish species and one subject reacted to two fish species tested. In regard to the positive challenges, predictive accuracy of skin prick test and RAST was 84% and 78%, respectively. Think step by step to answer my question. [/INST] Our results indicate that clinically relevant cross-reactivity among various species of fish may exist. Advising fish-allergic subjects to avoid all fish species should be emphasized until a species can be proven safe to eat by provocative challenge.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do eosinophil counts correlate differently with asthma severity by symptoms versus peak flow rate? Answer the question given the following information: Context: Discrepancy in asthmatic assessment by symptoms and peak flow rate (PFR) is a frequent dilemma. Currently, total peripheral eosinophil count (TPEC) is under study for asthma evaluation. Context: To explore the correlation between TPEC and asthma severity assessed by symptoms alone versus symptoms and PFR. Context: Adults asthmatics were selected from the Asthma Clinic. Severity assessment was based on two methods: symptoms alone or symptoms and PFR. Expiratory PFR was recorded by a Wright peak flow meter. Severity levels included mild intermittent, mild persistent, moderate persistent, and severe persistent. Total peripheral eosinophil count was performed on a Celldyn-3500 counter. Data was analyzed for statistical significance. Context: Sixty asthmatics aged 15 to 70 years (mean = 34 years), of which 68.3% were female, were studied. Severity levels differed between the two assessment methods in 45% of the cases and showed a predominance of the moderate persistent type. Total peripheral eosinophil count ranged between 22 and 2470 cells/mm3 (mean = 520 +/- SD = 393) and eosinophilia was found in 50% of the cases. Total peripheral eosinophil count showed a high positive correlation with increased asthma severity level assessed by history alone (r = 0.460, P<.001); more than by history and PFR (r = 0.328, P<.05). Think step by step to answer my question. [/INST] The discrepancy between symptoms and PFR is confirmed by these results. A reliable objective parameter in asthma assessment is a continuous challenge. This study advocates the possible supplementation of TPEC as another objective parameter that might help in selecting the appropriate severity level in asthmatics.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do immunoassays differentially detect different acidity glycoforms of FSH? Answer the question given the following information: Context: The possibility of the carbohydrate residues of glycoproteins affecting their recognition in immunoassays is an important and unresolved issue. This study looked for evidence of differential recognition of FSH glycoform preparations, of variable isoelectric point (pI) and known molarity, using three routine assays employing different antibody configurations. Context: Seven glycoform preparations with differing pI bands (between 3.8 and 5.5) were produced by isoelectric focusing of recombinant human FSH and the molecular weights determined by mass spectroscopy. Three concentrations of each glycoform were assayed and the results expressed relative to unfractionated material. From the relative responses, recognition differences between the assay methods and between the glycoform preparations were investigated. Context: Three routine assays were employed: the commercially available Amerlite(R) enzyme immunoassay and Delfia(R) immunofluorometric assay, together with an in-house competitive two-site radioimmunoassay (RIA). Context: Overall, the three assays gave the same relative responses for equivalent glycoforms, with the only exceptions involving small differences between some assay pairs for the fractions at the extremes of the pI range investigated. Within each assay type, differences (P<0.05) of up to 33% existed between glycoforms of different pI, however, these differences showed no patterns or trends across the entire acidity range examined. Think step by step to answer my question. [/INST] Between the assay methods investigated in this study, few differences exist in the recognition of individual pI bands of FSH when expressed relative to a common unfractionated standard. Differences were apparent in the recognition of the different acidity glycoforms within each assay method, however, these were small and unlikely to be of clinical significance.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is high peritoneal transport rate an independent risk factor for CAPD mortality? Answer the question given the following information: Context: Is high peritoneal transport rate an independent risk factor for CAPD mortality? Context: Patients with high peritoneal transport display the lowest serum albumin (SAlb) and the highest peritoneal protein loss. An association between high peritoneal membrane permeability and diabetes mellitus (DM) has been suggested. As malnutrition, hypoalbuminemia, and DM cause high mortality, it is probable that a high peritoneal transport rate is associated with high mortality on continuous ambulatory peritoneal dialysis (CAPD). The aim of the study was to identify whether a high peritoneal transport rate is an independent risk factor for mortality on CAPD. Context: We included 167 patients with a peritoneal equilibration test that was performed between January 1994 and July 1997. The endpoint was the patient's status (alive, dead, or lost) in December 1997. Survival analysis was done by the Kaplan-Meier method and multivariate Cox proportional-hazard model. Context: DM was significantly more frequent in the high (H) peritoneal transport type (20 out of 33) and was less frequent in the low (L) transport group (3 out of 18). SAlb (g/dL) was significantly lower as the peritoneal transport type was higher [H 2.7 +/- 0.5, high average (HA) 2.9 +/- 0.7, low average (LA) 3.2 +/- 0.6, and L 3.6 +/- 0.5]. Serum creatinine (SCr) was significantly higher in the L transport type (12.0 +/- 4.3 mg/dL) than in the other transport groups (H 8.7 +/- 3.1, HA 8.6 +/- 3.7, and LA 9.6 +/- 4.5). No other differences were found between peritoneal transport types. In the univariate analysis, high peritoneal transport rate, DM, low SCr, low SAlb, and older age significantly predicted mortality. However, in the multivariate analysis (chi2 = 40.55, P<0.0001), only DM (b = 1.34, P = 0.0001), low SCr (b = -0.11, P = 0.02), and high peritoneal transport rate (b = 2.6, P = 0.06) were shown as mortality risk factors. Think step by step to answer my question. [/INST] DM was the most important risk factor for mortality on CAPD. A high peritoneal transport rate also predicted mortality, yet its role seems to be related to the presence of DM. The role of higher SCr predicting a better survival might have been associated with a better nutritional status. Hypoalbuminemia, previously shown as risk factor for mortality, did not play an important role in this study, probably because of its collinearity with DM.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Expression of CD44 in uterine cervical squamous neoplasia: a predictor of microinvasion? Answer the question given the following information: Context: CD44, an integral membrane glycoprotein, may have an important role in early tumorigenesis, specifically, facilitating early tumor progression. Reports of the expression of CD44 in early uterine cervical squamous carcinogenesis are conflicting. We examined the expression of CD44 in microinvasive carcinoma of the cervix (MIC), as yet unreported, and compared it to that in cervical intraepithelial neoplasia (CIN) 1 and CIN 3 to further elucidate its role in early squamous carcinogenesis. Context: Seventeen cases of CIN 1, 24 cases of CIN 3, and 20 cases of MIC were stained with antibodies to CD44s, CD44v5, and CD44v6. Only membranous staining was considered positive. Context: Positive membranous staining (>50% cells) was observed in 97% of cases of CIN 1 using all three antibodies. In CIN 3, positive staining was seen more often with CD44v6 (18/24) and CD44v5 (19/24) than with CD44s (6/24). Expression of CD44v6 was retained more often in MIC (16/20) compared with CD44s (3/20) and CD44v5 (9/20). Those cases of CIN 3 and MIC that failed to meet our criteria for positive staining showed either heterogeneous or absent staining. Think step by step to answer my question. [/INST] There is a qualitative and quantitative reduction in expression of CD44 in MIC and CIN 3 compared with CIN 1. Down-regulation of CD44 variants may occur later in neoplastic progression than CD44s. This pattern may reflect their important biological function in early progression by cervical cancer cells. Patchy and heterogeneous staining in more advanced lesions limits the usefulness of CD44 and its variants in the assessment of microinvasion.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Was the decreasing trend in hospital mortality from heart failure attributable to improved hospital care? Answer the question given the following information: Context: To assess the trend in risk-adjusted hospital mortality from heart failure. Context: Oregon hospital discharge data from 1991 through 1995 were analyzed. Context: A total of 29,530 hospitalizations because of heart failure in elderly patients (age>or = 65 years) were identified from International Classification of Diseases, 9th Revision, codes 428.0-428.9. The logistic regression and life table analyses were used to assess the risk-adjusted trend in hospital mortality from heart failure. Context: From 1991 through 1995, 1757 (5.9%) patients with heart failure died in the hospital; 920 (52.4%) of them died within 3 days. The percentage of patients discharged to skilled nursing facilities increased from 6.1% in 1991 to 9.8% in 1995 (P value for trend<.001), whereas the percentage of patients discharged directly to home decreased from 69.2% in 1991 to 62.4% in 1995 (P value for trend<.001). The mean length of stay decreased from 5.15 days in 1991 to 3.97 days in 1995. The age- and sex-standardized mortality rate decreased by 33.8% from 7.4 in 1991 to 4.8 in 1995 (P value for trend<.01). Additional adjustment for comorbidity using multiple logistic regression revealed a greater reduction of 41.0% in the mortality rate (odds ratio = 0.59; 95% confidence interval = 0.50, 0.69) and a reduction of 46.0% in the 3-day mortality rate (odds ratio = 0.54; 95% confidence interval = 0.43, 0.67) across the 5-year period. Life table analysis showed consistently lower cumulative mortality rates during the first week after admission in 1995 compared with those in 1991 (P<.001). Think step by step to answer my question. [/INST] There was a decreasing trend over time in the risk-adjusted hospital mortality rates from heart failure, which was not an artifact of decreasing length of stay. Our findings raised the possibility of improved hospital care for heart failure in Oregon.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is a third-trimester antibody screen in Rh+ women necessary? Answer the question given the following information: Context: To determine the need for routine third-trimester antibody screening in Rh+ women. Context: An analytic case-control study. Context: We identified Rh+ pregnant women who had received prenatal care and retrospectively analyzed their laboratory data. Patients were grouped into those with a positive third-trimester antibody screen (cases) and those with a negative third-trimester screen (controls). Because entry into a group was decided by the investigators, it could not be randomized. We reviewed the maternal medical records for antibody identification and final pregnancy outcome. We also reviewed the neonatal medical records for evidence of direct Coombs-positive cord blood, anemia, need for transfusion or phototherapy, other medical complications, and death. Context: Using a computerized laboratory database from 2 teaching hospitals, we identified 10,581 obstetric patients who underwent routine first- and third-trimester antibody screening between 1988 and 1997. Of these, 1233 patients were Rh- and 9348 were Rh+. Among the Rh+ patients, 178 (1.9%) had 1 or more atypical antibodies at the first-trimester screen, and 53 (0.6%) had a positive third-trimester antibody screen despite a negative first-trimester screen. Although 6 of these 53 patients (0.06% of the study population) had clinically relevant antibodies for hemolytic disease of the new-born, no significant neonatal sequelae occurred among these 6 patients. Think step by step to answer my question. [/INST] Based on the patient and hospital records studied, a repeat third-trimester antibody screen for Rh+ patients is clinically and economically unjustified. Eliminating this laboratory test from clinical practice will not adversely affect pregnancy outcomes and will decrease the costs of prenatal care.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do nursing home residents make greater demands on GPs? Answer the question given the following information: Context: The number of people residing in nursing homes has increased. General practitioners (GPs) receive an increased capitation fee for elderly patients in recognition of their higher consultation rate. However, there is no distinction between elderly patients residing in nursing homes and those in the community.AIM: To determine whether nursing home residents receive greater general practice input than people residing in the community. Context: Prospective comparative study of all 345 residents of eight nursing homes in Glasgow and a 2:1 age, sex, and GP matched comparison group residing in the community. A comparison of contacts with primary care over three months in terms of frequency, nature, length, and outcome was carried out. Context: Nursing home residents received more total contacts with primary care staff (P<0.0001) and more face-to-face consultations with GPs (P<0.0001). They were more likely to be seen as an emergency (P<0.01) but were no more likely to be referred to hospital, and were less likely to be followed-up by their GP (P<0.0001). Although individual consultations with nursing home residents were shorter than those with the community group (P<0.0001), the overall time spent consulting with them was longer (P<0.001). This equated to an additional 28 minutes of time per patient per annum. Some of this time would have been offset by less time spent travelling, since 61% of nursing home consultations were done during the same visit as other consultations, compared with only 3% of community consultations (P<0.0001). Think step by step to answer my question. [/INST] Our study suggests that nursing home residents do require a greater input from general practice than people of the same age and sex who are residing in the community. While consideration may be given to greater financial reimbursement of GPs who provide medical care to nursing home residents, consideration should also be given to restructuring the medical cover for nursing home residents. This would result in a greater scope for proactive and preventive interventions and for consulting with several patients during one visit.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does teaching during a general practice consultation affect patient care? Answer the question given the following information: Context: General practice differs from hospital medicine in the personal nature of the doctor-patient relationship and in the need to address social and psychological issues as well as physical problems. Recent changes in undergraduate medical education have resulted in more teaching and learning taking place in general practitioner (GP) surgeries.AIM: To explore patients' experiences of attending a surgery with a medical student present. Context: A questionnaire was designed, based on semi-structured interviews. Questionnaires were posted to patients who had attended teaching surgeries in London and Newcastle-upon-Tyne. Context: Four hundred and eighty questionnaires were sent; of these, 335 suitable for analysis were returned. The response rate in Newcastle was 79%, and in London 60%. Ninety-five per cent of responders agreed that patients have an important role in teaching medical students. Patients reported learning more and having more time to talk, however, up to 10% of responders left the consultation without saying what they wanted to say and 30% found it more difficult to talk about personal matters. Think step by step to answer my question. [/INST] The presence of a student has a complex effect on the general practice consultation. Future developments in medical education need to be evaluated in terms of how patient care is affected as well as meeting educational aims.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are postal questionnaire surveys of reported activity valid? Answer the question given the following information: Context: Postal questionnaire surveys are commonly used in general practice and often ask about self-reported activity. The validity of this approach is unknown.AIM: To explore the criterion validity of questions asking about self-reported activity in a self-completion questionnaire. Context: A comparison was made between (a) the self-reported actions of all general practitioner (GP) principals in 51 general practices randomly selected within the nine family health services authorities of the former northern regional health authority, and (b) the contents of the medical records (case notes and computerized records) of patients classified as hypertensive from a 1 in 7 random sample of all patients registered in these practices and aged between 65 and 80. Data were gathered from the GPs by self-completion postal questionnaires. Six comparisons were made for two groups of items: first, target and achieved blood pressure; secondly, patient's weight, smoking status, alcohol consumption, exercise and salt intake. The frequency with which the data items were recorded in patient records was compared with the GPs' self-reported frequency of performing the actions. Context: No relationship was found between achieved blood pressure and stated target levels. For each of the other actions, more than half of the responders reported that they usually or always performed the activity. For four of these (smoking, weight, alcohol and exercise), a significant association was noted, but the size of this varied considerably. Think step by step to answer my question. [/INST] There is a variable relationship between what responders report that they do in self-completion questionnaires, and what they actually do as judged by the contents of their patients' medical records. In the absence of prior, knowledge of the validity of questions on reported activity, or of concurrent attempts to establish their validity, the questions should not be asked.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Underestimation of the small residual damage when measuring DNA double-strand breaks (DSB): is the repair of radiation-induced DSB complete? Answer the question given the following information: Context: To overcome the underestimation of the small residual damage when measuring DNA double-strand breaks (DSB) as fraction of activity released (FAR) by pulsed-field gel electrophoresis. Context: The techniques used to assess DNA damage (e.g. pulsed-field gel electrophoresis, neutral elution, comet assay) do not directly measure the number of DSB. The Blöcher model can be used to express data as DSB after irradiation at 4 degrees C by calculating the distribution of all radiation-induced DNA fragments as a function of their size. We have used this model to measure the residual DSB (irradiation at 4 degrees C followed by incubation at 37 degrees C) in untransformed human fibroblasts. Context: The DSB induction rate after irradiation at 4 degrees C was 39.1+/-2.0 Gy(-1). The DSB repair rate obtained after doses of 10 to 80 Gy followed by repair times of 0 to 24 h was expressed as unrepaired DSB calculated from the Blöcher formula. All the damage appeared to be repaired at 24h when the data were expressed as FAR, whereas 15% of DSB remained unrepaired. The DSB repair rate and the chromosome break repair rate assessed by premature condensation chromosome (PCC) techniques were similar. Think step by step to answer my question. [/INST] The expression of repair data in terms of FAR dramatically underestimates the amount of unrepaired DNA damage. The Blöcher model that takes into account the size distribution of radiation-induced DNA fragments should therefore be used to avoid this bias. Applied to a normal human fibroblast cell line, this model shows that DSB repair is never complete.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Contracting for quality: does length matter? Answer the question given the following information: Context: To examine whether longer-term contracts for health services will shift attention away from concern for finance and activity levels and towards the achievement of better quality services. Context: Analysis of 288 contracts from the British National Health Service (NHS) and 12 semi-structured interviews with staff from provider (NHS hospital trusts) and purchaser (health authorities) organisations. Context: No relationship was found between the duration of a contract and the duration of service specifications or quality frameworks. The annual contracting cycle is concerned largely with ensuring that all parties stay within activity targets and financial constraints, and this is unlikely to be affected by a shift to longer-term contracts. The setting of standards and initiatives to improve quality is largely independent of the contracting process and the duration of contracts, and relies on relationships rather than contracts. Think step by step to answer my question. [/INST] It is optimistic to expect longer-term contracts automatically to produce a greater focus on quality and the incentives needed to ensure that improvements in quality are delivered. However, this may not matter as issues of quality are being addressed more appropriately in the British NHS through a variety of other routes.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is radiation therapy a preferred alternative to surgery for squamous cell carcinoma of the base of tongue? Answer the question given the following information: Context: To evaluate irradiation alone for treatment of base-of-tongue cancer. Context: Two hundred seventeen patients with squamous cell carcinoma of the base of tongue were treated with radiation alone and had follow-up for>/= 2 years. Context: Local control rates at 5 years were as follows: T1, 96%; T2, 91%; T3, 81%; and T4, 38%. Multivariate analysis revealed that T stage (P =.0001) and overall treatment time (P =.0006) significantly influenced local control. The 5-year rates of local-regional control were as follows: I, 100%; II, 100%; III, 83%; IVA, 64%; and IVB, 65%. Multivariate analysis revealed that the following parameters significantly affect the probability of this end point: T stage (P =.0001), overall treatment time (P =.0001), overall stage (P =.0131), and addition of a neck dissection (P =.0021). The rates of absolute and cause-specific survival at 5 years were as follows: I, 50% and 100%; II, 81% and 100%; III, 65% and 76%; IVA, 42% and 56%; and IVB, 44% and 52%. Severe radiation complications developed in eight patients (4%). Think step by step to answer my question. [/INST] The likelihood of cure after external-beam irradiation was related to stage, overall treatment time, and addition of a planned neck dissection. The local-regional control rates and survival rates after radiation therapy were comparable to those after surgery, and the morbidity associated with irradiation was less.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Section of the sublingual frenulum. Are the indications correct? Answer the question given the following information: Context: To see the relationship of the lingual frenum with speech and other oral functions, evaluating the surgical indications and the results of frenectomy. Context: In 1997 we operated 72 children with sublingual frenulum, a telephone questionnaire to the mothers of these patients was done, obtaining data about: age at surgery, professional reasons for referral, preoperative findings, pre-post operative speech therapy, place of surgery and type of anesthesia and mother's impression about the final result. Context: Fifty valid questionnaires were obtained, the mean age at frenectomy was 3.03 years, 38% of children were sent due to speech problems, 60% due to some degree of tongue-tie and 2% due to dentofacial developmental anomalies. In 70% the patients were sent by a pediatrician and in 14% by a speech therapist. In 20% preoperative speech therapy was done and postoperatively in 30%. In 48% of cases, aged less than 2 years, speech was not possible to be evaluated. In the 11 cases with questionable results, a multidisciplinary reevaluation showed 7 cases with lingual dysfunction and poor tongue control, 4 cases with deglutitory anomalies and 3 cases with orofacial occlusal problems secondary to lingual dysfunction or altered oral habits. Think step by step to answer my question. [/INST] The presence of a nondisturbing lingual frenulum does not justify its surgical section, the frenectomy is indicated only in presence of altered oro-lingual functions caused by the tongue-tie such as: speech problems, errors of bite and deglutition, lingual dysfunction and anomalous oral habits.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Physician education and report cards: do they make the grade? Answer the question given the following information: Context: We sought to determine whether tailored educational interventions call improve the quality of care, as measured by the provision of preventive care services recommended by the US Preventive Services Task Force, as well as lead to better patient satisfaction. Context: We performed a randomized controlled study among 41 primary care physicians who cared for 1,810 randomly selected patients aged 65 to 75 years old at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California. All physicians received ongoing education. Physicians randomly assigned to the comprehensive intervention group also received peer-comparison feedback and academic detailing. Baseline and postintervention (2 to 2.5 years later) surveys examining the provision of preventive care and patient satisfaction were performed and medical records were reviewed. Context: Based on the results of patient surveys, there were significant improvements over time in the provision of preventive care in both the education and the comprehensive intervention groups for influenza immunization (79% versus 89%, P<0.01, and 80% versus 91%, P<0.01), pneumococcal immunization (42% versus 73%, P<0.01 and 34% versus 73%, P<0.01), and tetanus immunization (64% versus 72%, P<0.01, and 59% versus 79%, P<0.01). Mammography (90% versus 80%, P<0.01) and clinical breast examination (85% versus 79%, P<0.05) scores worsened in the education only group but not in the comprehensive intervention group. However, there were few differences in rates of preventive services between the groups at the end of the study, and the improvements in preventive care were not confirmed by medical record review. Patient satisfaction scores improved significantly in the comprehensive intervention group (by 0.06 points on a 1 to 5 scale, P = 0.02) but not in the education only group (by 0.02 points, P = 0.42); however, the improvement was not significantly greater in the comprehensive intervention group (P = 0.20). Think step by step to answer my question. [/INST] A physician-targeted approach of education, peer-comparison feedback, and academic detailing has modest effects on patient satisfaction and possibly on the offering of selected preventive care services. The lack of agreement between patient reports and medical records review raises concerns about current methods of ascertaining compliance with guidelines for preventive care.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: In-house referral: a primary care alternative to immediate secondary care referral? Answer the question given the following information: Context: Methods are needed to ensure that those patients referred from primary to secondary care are those most likely to benefit. In-house referral is the referral of a patient by a general practitioner to another general practitioner within the same practice for a second opinion on the need for secondary care referral. Context: To describe whether in-house referral is practical and acceptable to patients, and the health outcomes for patients. Context: Practices were randomized into an intervention or a control group. In intervention practices, patients with certain conditions who were about to be referred to secondary care were referred in-house. If the second clinician agreed referral was appropriate the patient was referred on to secondary care. In control practices patients were referred in the usual fashion. Patient satisfaction and health status was measured at the time of referral, 6 months and one year. Context: Eight intervention and seven control practices took part. For the 177 patients referred in-house, 109 (61%) were judged to need referral on to secondary care. For patient satisfaction, the only difference between the groups studied was that at 12 months patients who had been referred in-house reported themselves as being more satisfied than those referred directly to hospital. For health status, the only difference found was that at the time of referral, patients who had been referred in-house and judged to need hospital referral reported themselves as being less able on the 'Physical function' subscale of the SF-36 than patients who were referred in-house and judged to not need hospital referral. Think step by step to answer my question. [/INST] In-house referral is acceptable to patients and provides a straightforward method of addressing uncertainty over the need for referral from primary to secondary care.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do better quality consultations result in better health? Answer the question given the following information: Context: In theory, a positive relationship is expected between the quality of a consultation and a patient's subsequent health status. However, such a relationship has not yet been firmly established in daily practice. Context: We aimed to study the relationship between the quality of the first consultation in a new episode of non-acute abdominal complaints and subsequent health status of patients in general practice. Context: Quality scores for 743 consultations were calculated on the basis of review criteria developed by expert panels. Functional health status was measured by the SIP (Sickness Impact Profile) at baseline, and at 1 and 6 months after the consultation. Multilevel regression analysis was used to examine the relationship between the quality of consultations and health status, and to identify factors of influence on this relationship. Context: In the majority of these patients (97%) health status improved regardless of consultation quality. In patients with malignant disease, and chronic colitis, however, an association between consultation quality and subsequent health status was found: in those with a high consultation quality score (>66-percentile) the health status deteriorated in the first month but improved over the following 5 months; in those with a low consultation quality score (<33-percentile) it deteriorated continuously. Think step by step to answer my question. [/INST] For the great majority of patients we found no relation between the quality of consultation and health status. However, for a very small subgroup of patients there is proof of benefit from better quality consultations.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Development of a computer clinical instruction program. Is the game worth the candle? Answer the question given the following information: Context: Use of computers in medicine, as tools for information and education, is increasing. Many computer-assisted learning tools have been marketed. For clinician-teachers, computer-assisted learning offers interesting possibilities. Is this educational technology within the reach of family physicians? Context: To describe development of a computer-based learning tool and to suggest indications for its use. Context: A team of clinician-teachers and information technologists developed a tool called Didacticiel sur l'Aviseur to train family physicians and family medicine residents on a clinical decision-making tool called l'Aviseur pharmacothérapeutique, which consists of a database and nine search functions. The Didacticiel in turn consists of an interactive guided tour, a series of exercises with formative evaluation and feedback, a real-time test with a final evaluation, and an integrated, multidimensional project evaluation program. Think step by step to answer my question. [/INST] Developing a computerized learning tool is a worthwhile investment if the content has longevity; the learning process is highly interactive; there is a market for the product; and the tool is developed by a team of experienced, committed information technologists.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can sonographic signs predict long-term results of laparoscopic cholecystectomy? Answer the question given the following information: Context: To determine whether sonographic signs of the gallbladder can predict the long-term outcome of laparoscopic cholecystectomy (LC). Context: All 346 patients, who underwent LC at our institution between January 1, 1993 and March 1, 1996, were interviewed using a structured questionnaire on the persistence of pre-operative abdominal symptoms. Patients without a sonographic examination 6 months prior to surgery were excluded. Sonographic parameters, scored on the pre-operative examination, were evaluated by univariate analysis using the relief of abdominal symptoms as a dependent variable. Context: The response rate of correctly returned questionnaires was 68%. The follow-up ranged from 14-53 months. Fourteen percent (18/133) of all patients reported persistence of abdominal complaints after cholecystectomy. Grit in the gallbladder on the pre-operative ultrasound examination was significantly associated with a higher relative risk (RR) for persistence of pre-operative abdominal symptoms (RR 4.5, 95% confidence intervals (CI) 2.0-10.1). The presence of echogenic bile (RR 1.9, 95% CI 0.8-4.9), gallbladder distention (RR 1.9, 95% CI 0.6-5.7), and gallbladder wall thickening (RR 1.5, 95% CI 0.5-4.1) were associated with the persistence of symptoms. A contracted gallbladder (RR 0.6, 95% CI 0.4-1.1) and stone impaction (RR 0.44, 95% CI 0.1-1.8) were associated with the relief of abdominal symptoms. None of these sonographic signs reached significance. There was no difference in the post-operative symptoms rate between patients with a laparoscopic cholecystectomy and those who were converted to an open cholecystectomy. Think step by step to answer my question. [/INST] This retrospective study showed that the sonographic sign of grit in the gallbladder is associated with a high relative risk for persistent abdominal symptoms after cholecystectomy. These findings will be re-evaluated in a prospective study to estimate the definitive clinical importance.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Jugular phlebectasia in children: is it rare or ignored? Answer the question given the following information: Context: Phlebectasia of the jugular veins is a venous anomaly that usually presents in children as a soft cystic swelling in the neck during straining. The purpose of this report is to discuss the differential diagnosis, the methods of imaging, the mode of treatment, and to demonstrate some factors that have made us believe that the condition may not be an actual rarity but rather has been ignored. Context: Eight cases of unilateral internal jugular phlebectasia were treated surgically (ie, excision of the dilated portion of the vein) from 1987 to 1998. The age of the patients ranged from 3 to 14 years. There were 3 girls and 5 boys. The lesions were right sided in 6, and left sided in 2 children. The patients underwent surgery after comparative ultrasonographic confirmation of the diagnosis. Furthermore, the authors prepared a simple questionnaire for evaluating the level of knowledge about this lesion among the related specialists. One hundred ten physicians were asked to describe the jugular phlebectasia and its ideal treatment. Context: All of the patients were discharged from the hospital 24 hours after surgery. Follow-up periods ranged from 6 months to 6 years and no complaints were noted at the time of most recent visits. Our questionnaire results showed that 96% of 73 pediatricians, 37% of 22 otorhinolaryngologists, and 40% of 15 pediatric surgeons did not know what the jugular phlebectasia was. Think step by step to answer my question. [/INST] Color Doppler sonography alone is sufficient for the diagnosis of jugular phlebectasia. The authors recommend surgical excision in asymptomatic cases for cosmetic and psychological purposes. The rarity of the lesion may be caused by a lack of knowledge among the related physicians and the tendency of reporting only surgical results.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Alcoholics' selective attention to alcohol stimuli: automated processing? Answer the question given the following information: Context: This study investigated alcoholics' selective attention to alcohol words in a version of the Stroop color-naming task. Context: Alcoholic subjects (n = 23) and nonalcoholic control subjects (n = 23) identified the color of Stroop versions of alcohol, emotional, neutral and color words. Manual reaction times (RTs), skin conductance responses (SCRs) and heart rate (HR) were recorded. Context: Alcoholics showed overall longer RTs than controls while both groups were slower in responding to the incongruent color words than to the other words. Alcoholics showed longer RTs to both alcohol (1522.7 milliseconds [ms]) and emotional words (1523.7 ms) than to neutral words (1450.8 ms) which suggests that the content of these words interfered with the ability to attend to the color of the words. There was also a negative correlation (r = -.41) between RT and response accuracy to alcohol words for the alcoholics, reflecting that the longer time the alcoholics used to respond to the color of the alcohol words, the more incorrect their responses were. The alcoholics also showed significantly greater SCRs to alcohol words (0.16 microSiemens) than to any of the other words (ranging from 0.04-0.08 microSiemens), probably reflecting the emotional significance of the alcohol words. Finally, the alcoholics evidenced smaller HR acceleration to alcohol (1.9 delta bpm) compared to neutral (2.8 delta bpm), which could be related to difficulties alcoholics experience in terminating their attention to the alcohol words. Think step by step to answer my question. [/INST] These findings indicate that it is difficult for alcoholics to regulate their attention to alcohol stimuli, suggesting that alcoholics' processing of alcohol information is automated.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Alcohol effects on movement-related potentials: a measure of impulsivity? Answer the question given the following information: Context: To assess the effects of acute alcohol intoxication on lateralized readiness potential (LRP), a central measure of movement-related brain activity, and the potential association of such effects with personality measures. Context: Male volunteers (N = 12) alternated responding hands during a "go/no go" verbal recognition task across all four sessions of the balanced placebo design in which beverage content (either juice only or a vodka and juice mixture that raised the average blood alcohol concentration to 0.045%) was crossed with instructions as to beverage content. Context: Whereas the instructions had no effect on behavioral (response accuracy and reaction time) and physiological (LRP) measures, alcohol decreased reaction times adjusted for psychometer speed. As expected, large LRPs were recorded on "go" trials and were not affected by the beverage. However, the "no go" words that did not require and did not evoke motor responses, also evoked significant LRPs under alcohol but not placebo. Since only trials with correct responses and correct abstentions from responses were included in the averages, the motor preparation was not completed and was terminated before the motor response on "no go" trials. Similarly, there was a decrease in spectral power of the movement-related mu-rhythm on "no go" trials under alcohol. Think step by step to answer my question. [/INST] Alcohol may result in disinhibition such that the "response execution" process is activated based on very preliminary stimulus evaluation. This alcohol-induced brain activity signaling premature motor preparation exhibited correlation trends with personality traits related to impulsivity, hyperactivity and antisocial tendencies, thus concurring with other evidence that indicates commonalities between alcoholism and impulsivity, disinhibition and antisocial behaviors. The LRP on "no go" trials could potentially be used as a psychological index of the impulsiveness induced by alcohol intoxication.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Lower frequency of focal lip sialadenitis (focus score) in smoking patients. Can tobacco diminish the salivary gland involvement as judged by histological examination and anti-SSA/Ro and anti-SSB/La antibodies in Sjögren's syndrome? Answer the question given the following information: Context: Prospectively collected computer database information was previously assessed on a cohort of 300 patients who fulfilled the Copenhagen classification criteria for primary Sjögren's syndrome. Analysis of the clinical data showed that patients who smoked had a decreased lower lip salivary gland focus score (p<0.05). The aim of this original report is to describe the tobacco habits in patients with primary Sjögren's syndrome or stomatitis sicca only and to determine if there is a correlation between smoking habits and focus score in lower lip biopsies as well as ciculating autoantibodies and IgG. Context: All living patients with primary Sjögren's syndrome or stomatitis sicca only, who were still in contact with the Sjögren's Syndrome Research Centre were asked to fill in a detailed questionnaire concerning present and past smoking habits, which was compared with smoking habits in a sex and age matched control group (n=3700) from the general population. In addition, the patients previous lower lip biopsies were blindly re-evaluated and divided by the presence of focus score (focus score = number of lymphocyte foci per 4 mm(2) glandular tissue) into those being normal (focus score</= 1) or abnormal (focus score>1). Furthermore the cohort was divided into three groups; 10-45, 46-60 and>/= 61 years of age. Finally the focus score was related to the smoking habits. Seroimmunological (ANA; anti-SSA/Ro antibodies; anti-SSB/La antibodies; IgM-RF and IgG) samples were analysed routinely. Context: The questionnaire was answered by 98% (n=355) of the cohort and the percentage of current smokers, former smokers and historical non-smokers at the time of lower lip biopsy was not statistically different from that of the control group. Cigarette smoking at the time of lower lip biopsy is associated with lower risk of abnormal focus score (p<0.001; odds ratio 0.29, 95%CI 0.16 to 0.50). The odds ratio for having focal sialadenitis (focus score>1) compared with having a non-focal sialadenitis or normal biopsy (focus score</= 1) was decreased in all three age groups (10-45: odds ratio 0.27, 95%CI 0.11 to 0.71; 46-60: odds ratio 0.22, 95%CI 0. 08 to 0.59; and>/= 61: odds ratio 0.36, 95%CI 0.10 to 1.43) although there was only statistical significance in the two younger age groups. Moreover, among current smokers at the time of the lower lip biopsy there was a decreasing odds ratio for an abnormal lip focus score with increasing number of cigarettes smoked per week (p trend 0.00). In the group of former smokers, which included patients that had stopped smoking up to 30 years ago, the results were in between those of the smokers and the historical non-smokers (odds ratio 0.57, 95%CI 0.34 to 0.97, compared with never smokers). Present or past smoking did not correlate with the function of the salivary glands as judged by unstimulated whole sialometry, stimulated whole sialometry or salivary gland scintigraphy. Among former smokers, the median time lapse between the first symptom of primary Sjögren's syndrome and the performance of the lower lip biopsy was approximately half as long as the median time lapse between smoking cessation and biopsy (8 versus 15 years). Hence, symptoms of Sjögren's syndrome are unlikely to have had a significant influence on smoking habits at the time of the biopsy. Among the seroimmunological results only anti-SSA/Ro and anti-SSB/La antibodies reached statistical significance in a manner similar to the way smoking influenced the focus score in lower lip biopsies. On the other hand the level of significance was consistently more pronounced for the influence of smoking on the focus score than for the influence on anti-SSA/Ro and anti-SSB/La autoantibodies. Think step by step to answer my question. [/INST] This is believed to be the first report showing that cigarette smoking is negatively associated with focal sialadenitis-focus score>1-in lower lip biopsy in patients with primary Sjögren's syndrome. Furthermore, tobacco seems to decrea</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is routine procaine spirit application necessary in the care of episiotomy wound? Answer the question given the following information: Context: A randomised controlled trial to investigate the usefulness of local application of procaine spirit versus cleansing with water for care of episiotomy wound after normal vaginal delivery was conducted in 100 women. Context: Fifty women entered the study arm and 50 entered the control arm of the study. Women in the two arms were similar in their demographic and obstetric characteristics. Context: The pain scores on a verbal analogue scale was highest (score = 2.5) on Day 1 of the delivery. This was the same in women in both arms. The number of paracetamol tablets consumed was also low and was similar in both groups of women. By the fourteenth day of delivery, all the women were pain-free and the wound had healed well. It was noted that all the women maintained a high standard of perineal hygiene with a mean of 5 washes a day. Think step by step to answer my question. [/INST] It is concluded that in a woman with normal vaginal delivery, local application of procaine spirit is unnecessary in the care of a routine episiotomy wound.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is it necessary to biopsy the obvious? Answer the question given the following information: Context: The radiologist and oncologist are often confident that biopsy will confirm their suspicion of recurrent disease, but a biopsy is performed to confirm the histologic diagnosis before beginning or altering therapy. We have examined data to determine how often the biopsied lesion represents recurrent disease from the primary tumor or is an instance of new cancer, and whether recurrent disease can be predicted. Context: We reviewed the medical and imaging records of 253 patients who underwent CT-guided biopsy of an abdominal or pelvic lesion between 1993 and 1996. Sixty-nine of the 253 patients had a previously diagnosed primary tumor and were being examined for possible tumor recurrence or metastasis. The images of these 69 patients were analyzed to determine if the pattern of disease was typical of recurrence or metastasis. Context: In 55 of the 69 patients, the pattern was judged to be typical of metastatic or recurrent disease. Biopsy confirmed this suspicion in all 55 patients. In 14 of the 69 patients, the pattern of spread was judged not to be typical of recurrence or metastasis. These 14 patients were found to have a new primary tumor (n = 4), benign processes (n = 2), and recurrences (n = 8). Think step by step to answer my question. [/INST] Of the patients for whom radiographic findings suggested recurrence, we found no patients in whom a new primary tumor would have been missed if biopsy had been avoided. Data should now be acquired prospectively to determine whether it may be prudent to make treatment decisions on the basis of imaging findings alone, without histologic confirmation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Improving the recognition and management of depression: is there a role for physician education? Answer the question given the following information: Context: Many patients who visit primary care physicians suffer from depression, but physicians may miss the diagnosis or undertreat these patients. Improving physicians' communication skills pertaining to diagnosing and managing depression may lead to better outcomes. Context: We performed a randomized controlled trial involving 49 primary care physicians to determine the effect of the Depression Education Program on their knowledge of depression and their behavior toward depressed patients. After randomization, physicians in the intervention group completed the Depression Education Program, which consists of 2 4-hour interactive workshops that combine lectures, discussion, audiotape review, and role-playing. Between sessions, physicians audiotaped an interview with one of their patients. Two to 6 weeks following the intervention program, physicians completed a knowledge test and received office visits from 2 unannounced people acting as standardized patients with major depression. These "patients" completed a checklist and scales. Logistic and linear regression were used to control for sex, specialty, and suspicion that the patient was a standardized patient. Context: For both standardized patients, more intervention physicians than control physicians asked about stresses at home, and they also scored higher on the Participatory Decision-Making scale. During the office visits of one of the standardized patients, more intervention physicians asked about at least 5 criteria for major depression (82% and 38%, P = .006), discussed the possibility of depression (96% and 65%, P = .049), scheduled a return visit within 2 weeks (67% and 33%, P = .004), and scored higher than control physicians on the Patient Satisfaction scale (40.3 and 35.5, P = .014). Think step by step to answer my question. [/INST] The Depression Education Program changed physicians' behavior and may be an important component in the efforts to improve the care of depressed patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is acculturation a risk factor for early smoking initiation among Chinese American minors? Answer the question given the following information: Context: To determine the extent to which Chinese American and white minors differ in age of smoking initiation, and to determine the effect of acculturation on smoking initiation. Context: Cross-sectional telephone surveys. Context: Stratified random samples of the state of California, United States. Context: 347 Chinese American and 10 129 white adolescents aged 12 through 17 years, from the California Tobacco Survey (1990-93) and the California Youth Tobacco Survey (1994-96). Context: Hazards (risk) of smoking initiation by age, smoking initiation rate, cumulative smoking rate, mean age of smoking initiation, and acculturation status. Context: Life table methods, proportional hazards models, and chi(2) tests. Context: The risk of smoking initiation by age among Chinese American minors was about a third of that among white minors. The risk for Chinese Americans continued to rise even in later adolescence, in contrast to that for whites, which slowed after 15 years of age. Acculturation was associated significantly with smoking onset among Chinese Americans. Acculturation, smoking among social network members, attitudes toward smoking, and perceived benefits of smoking were associated with the difference in hazards of smoking onset between Chinese American minors and their white counterparts. Think step by step to answer my question. [/INST] Chinese American adolescents had a lower level and a different pattern of smoking onset than white adolescents. Levels of acculturation and other known risk factors were associated with the hazards of smoking initiation among Chinese American minors and with the difference in smoking initiation between the Chinese and white adolescents. Tobacco prevention policies, strategies, and programmes for ethnically diverse populations should take acculturation factors into account.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Decrease in asthma mortality rate in Israel from 1991-1995: is it related to increased use of inhaled corticosteroids? Answer the question given the following information: Context: Asthma mortality rates (AMRs) during the last several decades increased in many countries with developed medical services, including Israel. The reasons for this trend were never established. Recent data suggested that this trend is changing. Context: We sought to compare the AMR in Israel during 1991-1995 with that of the previous decade and to investigate a possible correlation between mortality rates and use of inhaled corticosteroids (ICSs) and beta(2)-agonists. Context: Statistical data on the AMR in Israel during 1981-1995 were extracted. Data were analyzed for 5- and 10-year periods (1981-1990) and compared with a 5-year period (1991-1995). Data on ICS and beta(2)-agonist sales were extracted from the marketing companies' official reports. Context: The mean AMR per 100,000 population per year during 1981-1990 in the 5- to 34-year-old group was 0.393 +/- 0.055 and decreased to 0.202 +/- 0. 046 during the 1991-1995 period (P =.03). There was no significant difference between changes in mean AMR in the 35- to 64-year-old or in the 5- to 64-year-old group during the same periods (4.568 vs 4. 063 and 2.480 vs 2.133). The mean ICS unit sales rates (per 100,000 population per year) between 1982-1990 and 1991-1995 were 21.70 and 190.45, respectively (P<.05). The correlation between ICS sales and AMR was -0.631 (P =.016). Sales of beta(2)-agonists did not change significantly during the study period. Think step by step to answer my question. [/INST] We identified a trend of decreased AMRs in Israel during 1991-1995. The decline in AMRs paralleled the increase in ICS sales, whereas the sales of inhaled beta(2)-agonists did not change significantly. One may speculate that the decrease in AMR may be the result of better anti-inflammatory treatment, as reflected by the increased use of ICSs. The feasibility of reducing AMRs in a country such as Israel, with low AMRs to start with, by improving medical treatment is encouraging.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: A 10-year national trend study of alcohol consumption, 1984-1995: is the period of declining drinking over? Answer the question given the following information: Context: Data from the 1984, 1990, and 1995 National Alcohol Surveys were used to investigate whether declines shown previously in drinking and heavy drinking across many demographic subgroups have continued. Context: Three alcohol consumption indicators--current drinking (vs abstaining), weekly drinking, and weekly heavy drinking (5 or more drinks in a day)--were assessed for the total US population and for demographic subgroups. Context: Rates of current drinking, weekly drinking, and frequent heavy drinking, previously reported to have decreased between the 1984 and 1990 surveys, remained unchanged between 1990 and 1995. Separate analyses for each beverage type (beer, wine, and spirits) and most demographic subgroups revealed similar temporal patterns. Think step by step to answer my question. [/INST] Alcohol consumption levels, declining since the early 1980s, may reach a minimum by the 21st century. Consumption levels should be monitored carefully over the next few years in the event that long-term alcohol consumption trends may be shifting.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Should cocaine-abusing, buprenorphine-maintained patients receive auricular acupuncture? Answer the question given the following information: Context: Buprenophrine is a synthetic opioid with micro-agonist properties currently pending Food and Drug Administration (FDA) approval as a maintenance agent for treating heroin-addicted individuals. Unlike methadone, a widely used opioid maintenance agent, buprenorphine is a kappa-receptor antagonist. Research linking the effects of acupuncture to the release of dynorphin, the endogenous ligand for the kappa-receptor, raised the possibility that buprenorphine may block acupuncture's effects. In this study, we sought to gather preliminary data on this issue in order to guide the clinical care of cocaine-abusing, buprenorphine-maintained patients. Context: Between-group analysis comparing buprenorphine- and methadone-maintained patients on ratings of acute effects after a single session of auricular acupuncture. Context: Thirty-four (34) cocaine-abusing, opioid-dependent patients, eighteen (18) maintained on buprenorphine, and sixteen (16) maintained on methadone. Context: A single, 40-minute session of auricular acupuncture; four needles were inserted in each auricle. Context: Acute effect ratings in four domains: pain, de qi sensations, relaxation effects, subjective experiences. Context: There were no significant differences in acute-effects ratings between the two groups. Patients in both groups reported positive effects. Think step by step to answer my question. [/INST] These preliminary findings are consistent with the interpretation that buprenorphine does not block auricular acupuncture, supporting the provisional recommendation that cocaine-abusing patients maintained on buprenorphine should not be excluded from receiving auricular acupuncture or from participating in clinical studies of this treatment modality. Further, controlled research on this issue, with clinical outcomes, is needed.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Duodenojejunitis: is it idiopathic or is it Henoch-Schönlein purpura without the purpura? Answer the question given the following information: Context: Henoch-Schönlein purpura is a small-vessel vasculitic disease that most often affects the skin. Gastrointestinal manifestations have been well described, including duodenojejunal inflammation (DJI). Context: Four children with DJI and clinical features of HSP are described, in whom the rash was either not present or appeared atypically late in the illness. Context: The characteristic rash did not develop in three children, and it developed much later in one. The patients (three boys and one girl) were aged between 7 and 9 years (mean, 7.5 years). Growth characteristics were normal. In all patients, pain occurred acutely with colicky abdominal pain in the spring or fall of the year, and all stools were positive for occult blood. No infectious cause was identified. Upper gastrointestinal endoscopic examinations demonstrated significant visual and histologic duodenitis in a pattern consistent with previous reports in children with known HSP. Factor XIII activity was absent. Immunoglobulin A levels were increased in three of four children. All children made a prompt recovery with the administration of intravenous glucocorticoids. In one child, the characteristic rash of HSP developed 18 weeks after the initial examination. Think step by step to answer my question. [/INST] Duodenojejunal inflammation may be the primary manifestation of HSP, even in the absence of the characteristic rash.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is health-related quality of life among older, chronically ill patients associated with unplanned readmission to hospital? Answer the question given the following information: Context: Assessment of health-related quality of life (HRQL) is being used increasingly to assess the impact of treatment. Context: To determine if HRQL, assessed shortly after acute hospitalisation, is associated with readmission to hospital. Context: In a prospective, longitudinal study, 163 chronically ill, medical and surgical patients (mean age 67.0+/-16.3 years) discharged to home following acute hospitalisation were studied. HRQL was assessed at one month post-hospital discharge using the MOS 36-Item Short-Form Health Survey (SF-36). Patients were followed-up for six months thereafter to determine subsequent incidence of unplanned readmission. Context: HRQL as measured by the eight health dimensions of the SF-36, for the entire cohort, was lower relative to age and gender matched norms for the local population (p<0.01). During study follow-up, 47 (35%) patients had an unplanned readmission and one patient died. Patients who had an unplanned readmission demonstrated both significantly lower physical (32.2+/-9.8 vs 38.6+/-10.1: p<0.001) and mental (45.1+/-12.7 vs 49.9+/-12.3: p=0.03) health component scores in comparison to the remainder of the cohort. On multivariate analysis, independent correlates of unplanned readmission were: 1) presence of formal home assistance (OR 6.4: p<0.01), 2)>or =five prescribed medications (OR 2.4: p=0.04), 3)>or =two admissions in the six months before follow-up (OR 4.3: p<0.01) and 4) an SF-36 physical component score of<or =40 (OR 2.2: p=0.05). Think step by step to answer my question. [/INST] In this cohort of predominantly older and chronically ill patients recently discharged from acute hospital care, relatively lower SF-36 physical health component scores were independently associated with an increased risk of subsequent unplanned readmission.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Internet-based home asthma telemonitoring: can patients handle the technology? Answer the question given the following information: Context: To evaluate the validity of spirometry self-testing during home telemonitoring and to assess the acceptance of an Internet-based home asthma telemonitoring system by asthma patients. Context: We studied an Internet-based telemonitoring system that collected spirometry data and symptom reports from asthma patients' homes for review by physicians in the medical center's clinical information system. After a 40-min training session, patients completed an electronic diary and performed spirometry testing twice daily on their own from their homes for 3 weeks. A medical professional visited each patient by the end of the third week of monitoring, 10 to 40 min after the patient had performed self-testing, and asked the patient to perform the spirometry test again under his supervision. We evaluated the validity of self-testing and surveyed the patients attitude toward the technology using a standardized questionnaire. Context: Telemonitoring was conducted in patients' homes in a low-income inner city area. Context: Thirty-one consecutive asthma patients without regard to computer experience. Context: Thirty-one asthma patients completed 3 weeks of monitoring. A paired t test showed no difference between unsupervised and supervised home spirometry self-testing. The variability of FVC (4.1%), FEV(1) (3. 7%), peak expiratory flow (7.9%), and other spirometric indexes in our study was similar to the within-subject variability reported by other researchers. Despite the fact that the majority of the patients (71%) had no computer experience, they indicated that the self-testing was "not complicated at all" or only "slightly complicated." The majority of patients (87.1%) were strongly interested in using home asthma telemonitoring in the future. Think step by step to answer my question. [/INST] Spirometry self-testing by asthma patients during telemonitoring is valid and comparable to those tests collected under the supervision of a trained medical professional. Internet-based home asthma telemonitoring can be successfully implemented in a group of patients with no computer background.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is rest or exercise hypertension a cause of a false-positive exercise test? Answer the question given the following information: Context: To determine if a history of hypertension or an exaggerated rise in exercise systolic BP is associated with a false-positive exercise ECG. Context: Retrospective analysis of the associations between exercise-induced ST-segment depression and a history of hypertension, exercise systolic BP, and several other clinical and exercise test variables. Among 20,097 patients referred for exercise tomographic thallium imaging in a nuclear cardiology laboratory at a tertiary care center, 1,873 patients met inclusion criteria for this study, which included no history of myocardial infarction or coronary artery revascularization, a normal resting ECG, and normal exercise thallium images. Context: False-positive ST-segment depression occurred in 20% of the population. A history of hypertension was actually associated with a lower likelihood of ST-segment depression (odds ratio, 0.70; 95% confidence interval [CI], 0.55 to 0.89; p = 0. 004). A higher peak exercise systolic BP was associated with a higher likelihood of ST-segment depression (odds ratio, 1.08 for each 10-mm Hg increase in systolic BP; 95% CI, 1.03 to 1.14; p<0. 001). However, the association between peak exercise systolic BP and ST-segment depression was so weak that this measurement could not be predictive in the individual patient (R(2) = 0.2%). For every 20-mm Hg increase in peak exercise systolic BP, the percentage of patients with ST-segment depression increased by only 3%. Think step by step to answer my question. [/INST] In patients with normal resting ECGs, we conclude the following: (1) a history of hypertension is not a cause of a false-positive exercise test, and (2) higher exercise systolic BP is a significant but weak predictor of ST-segment depression.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Pancreatitis during therapy of acute myeloid leukemia: cytarabine related? Answer the question given the following information: Context: Acute pancreatitis in acute myeloid leukemia (AML) has been rarely associated with cytarabine therapy. This report attempts to characterize this toxicity. Context: Criteria for pancreatitis was prospectively defined. Seven patients with pancreatitis were identified from an AML database and a clinical study at two tertiary care centers (n = 134). Their records were retrospectively reviewed. Context: Seven patients with pancreatitis complicating AML therapy were identified. Median age was 36 (range 25-73) years. Median amylase was 184 (range 77-552) U/l and median lipase was 1026 (range 630-6087) U/l. The patients had received high dose bolus cytarabine (2 g/m2 i.v. bolus every 12 hours; n = 2), and continuous infusion cytarabine followed by high-dose cytarabine (100 mg/m2 i.v. CI days 1-7 then 2 g/m2 i.v. bolus every 12 hours days 8-10; n = 2), or standard dose continuous infusion cytarabine (200 mg/m2/d; n = 3) prior to developing pancreatitis. Pancreatitis occurred at a median of 10 days following day one of cytarabine administration with resolution at a median of 11 days after initial diagnosis. Six patients did not suffer major complications. One patient died of causes unrelated to pancreatitis. Five of six patients was rechallenged and all remained free of pancreatitis. One patient subsequently did develop pancreatitis on a later rechallenge. Think step by step to answer my question. [/INST] Pancreatitis in the setting of AML therapy may be an infrequent and self-limited toxicity of cytarabine. A schedule dependent toxicity with cytarabine was not identified.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Pediatric residents' telephone triage experience: do parents really follow telephone advice? Answer the question given the following information: Context: A previous study showed that calls received by our continuity clinic residents were similar to those in private practice. However, that study did not address the compliance of the parents to the advice given. Context: To determine parents' compliance to after-hours telephone advice given by pediatric residents in a continuity clinic. Context: Advice given during initial telephone contact of 493 after-hours telephone calls was categorized into 3 groups: only telephone advice, appointment the next day, or immediate visit to the emergency department (ED). Follow-up telephone calls were made to all families 3 to 7 days after initial contact to determine compliance with the advice given. Context: Pediatric resident continuity clinic of a tertiary hospital in Augusta, Georgia. Context: Children registered in the pediatric resident continuity clinic. Context: Overall, 412 (83.6%) of 493 caregivers followed the telephone advice that residents gave them. Of the 270 callers only given telephone advice, 244 (90.4%) followed the advice, 15 (5.6%) went to the ED, and 11 (4.1%) made an appointment for the next day. Of the 112 patients instructed to make an appointment, 82 (73.2%) reported at the scheduled time, 18 (16.1%) improved and did not come to the appointment, and 1 (.9%) reported worsened symptoms and went to the ED. When a visit to the ED was recommended, 86 (93.5%) of 92 complied, 2 (2.2%) improved and did not come, 1 (1.1%) had transportation problems, and 3 (3.3%) did not think an ED visit was warranted. Think step by step to answer my question. [/INST] If an after-hours line is used by caregivers, they are more likely to follow the recommendations given by pediatric residents in a tertiary center.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Organizational and financial characteristics of health plans: are they related to primary care performance? Answer the question given the following information: Context: Primary care performance has been shown to differ under different models of health care delivery, even among various models of managed care. Pervasive changes in our nation's health care delivery systems, including the emergence of new forms of managed care, compel more current data. Context: To compare the primary care received by patients in each of 5 models of managed care (managed indemnity, point of service, network-model health maintenance organization [HMO], group-model HMO, and staff-model HMO) and identify specific characteristics of health plans associated with performance differences. Context: Cross-sectional observational study of Massachusetts adults who reported having a regular personal physician and for whom plan-type was known (n = 6018). Participants completed a validated questionnaire measuring 7 defining characteristics of primary care. Senior health plan executives provided information about financial and nonfinancial features of the plan's contractual arrangements with physicians. Context: The managed indemnity system performed most favorably, with the highest adjusted mean scores for 8 of 10 measures (P<.05). Point of service and network-model HMO performance equaled the indemnity system on many measures. Staff-model HMOs performed least favorably, with adjusted mean scores that were lowest or statistically equivalent to the lowest score on all 10 scales. Among network-model HMOs, several features of the plan's contractual arrangement with physicians (ie, capitated physician payment, extensive use of clinical practice guidelines, financial incentives concerning patient satisfaction) were significantly associated with performance (P<.05). Think step by step to answer my question. [/INST] With US employers and purchasers having largely rejected traditional indemnity insurance as unaffordable, the results suggest that the current momentum toward open-model managed care plans is consistent with goals for high-quality primary care, but that the effects of specific financial and nonfinancial incentives used by plans must continue to be examined.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are genetic influences on peptic ulcer dependent or independent of genetic influences for Helicobacter pylori infection? Answer the question given the following information: Context: Genetic factors play a role or roles in the etiology of peptic ulcer disease and the acquisition of Helicobacter pylori infection. Context: To evaluate the relative importance of genetic and environmental influences as well as the importance of H. pylori on peptic ulcer disease. Context: Cross-sectional study on monozygotic (MZ) and dizygotic (DZ) twins, reared apart or together. Context: Twins of the subregistry of the Swedish Twin Registry included in the Swedish Adoption/Twin Study of Aging. Context: Peptic ulcer disease and H. pylori status were assessed in MZ and DZ twin pairs reared apart or together. A total of 258 twin pairs had information regarding H. pylori status and history of peptic ulcer. Helicobacter pylori status was assessed as the presence of anti-H. pylori IgG. Context: The intraclass correlations for peptic ulcer disease for MZ twins reared apart and together and DZ twins reared apart and together were 0.67, 0.65, 0.22, and 0.35, respectively, which indicates that genetic effects are important for liability to peptic ulcer. The correlation coefficient for MZ twins reared apart (0.67) provides the best single estimate of the relative importance of genetic effects (heritability) for variation in liability to peptic ulcer disease, and structural model fitting analyses confirmed this result (heritability, 62%). The cross-twin cross-trait correlations for MZ and DZ twins were examined to determine whether genetic effects for peptic ulcer were shared with or independent of genetic influences for H. pylori. The cross-correlations for MZ and DZ twins were almost identical (0.25 and 0.29, respectively), suggesting that familial environmental rather than genetic influences mediate the association between peptic ulcer disease and H. pylori infection. Think step by step to answer my question. [/INST] Genetic influences are of moderate importance for liability to peptic ulcer disease. Genetic influences for peptic ulcer are independent of genetic influences important for acquiring H. pylori infection.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does eradication of Helicobacter pylori alone heal duodenal ulcers? Answer the question given the following information: Context: Eradication of Helicobacter pylori infection prevents duodenal ulcer (DU) relapse, but it remains uncertain whether eradication of H. pylori alone heals duodenal ulceration.AIM: To test the hypothesis that eradication of H. pylori infection is accompanied by healing of duodenal ulcer. Context: A total of 115 consecutive patients with endoscopically confirmed H. pylori-infected duodenal ulcer were randomly assigned to one of two groups. Group BTC patients received a 1-week course of colloidal bismuth subcitrate 220 mg b.d., tinidazole 500 mg b.d., clarithromycin 250 mg b.d. Group OBTC patients received omeprazole 20 mg daily for 4 weeks with the BTC regimen during the first week. Endoscopy with antral biopsies and 13C-urea breath test (UBT) were performed before and 4 weeks after completion of the 7-day triple or quadruple therapy. Context: Eight patients dropped out (four in BTC and four in OBTC). Duodenal ulcer healing rates on an intention-to-treat basis in BTC and OBTC were 86% (95% CI: 77-95%) and 90% (95% CI: 82-98%), respectively. The eradication rates of H. pylori on an intention-to-treat basis in BTC and OBTC were 88% (95% CI: 79-96%) and 91% (95% CI: 84-99%), respectively. There were no statistically significant differences in ulcer healing rates and eradication rates between these two groups (P>0.05). Epigastric pain resolved more rapidly in patients assigned to OBTC compared with those assigned to BTC. Both of the two regimens were well tolerated with only minor side-effects (3% of the 115 patients) and the compliance was good. Think step by step to answer my question. [/INST] BTC is a very effective H. pylori eradication regimen. Almost all duodenal ulcers heal spontaneously after cure of H. pylori infection using a 1-week low-dose bismuth-based triple therapy. Treating duodenal ulcer with simultaneous administration of omeprazole achieves ulcer pain relief more rapidly.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Diversion colitis in children: an iatrogenic appendix vermiformis? Answer the question given the following information: Context: Diversion colitis (DC) is a localized, relatively benign, iatrogenic condition which occurs in almost 100% of diverted colonic segments in patients who undergo ileostomy/colostomy for various reasons. The aim of this study was to establish histological features of DC in children. Context: Twenty-three cases of DC following colostomy for Hirschsprung's disease in young children were analysed. The distinguishing features included prominent follicular lymphoid hyperplasia (100%), chronic mucosal inflammation (100%), accompanied by a variable degree of acute inflammation (78%) and Paneth cell metaplasia (26%). Less frequent histological findings were as follows: mild goblet cell depletion (22%), foci of cryptitis (13%), crypt abscesses (13%) and mild architectural distortion (22%). A previously unrecognized feature was the presence of mucosal aggregates of eosinophils, found in 43% of cases. A striking similarity between the normal appearance of the vermiform appendix and pathological features in DC was noted and the possible relationship between the two is discussed. Think step by step to answer my question. [/INST] Histological features of DC in children are very similar to those described in adults. They should help to distinguish it from ulcerative colitis and Hirschsprung's-associated enterocolitis in order to prevent inappropriate therapy and follow-up. There are many similarities between DC and the normal appendix vermiformis.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Raising research awareness among midwives and nurses: does it work? Answer the question given the following information: Context: The primary aim of the study was to evaluate the effectiveness of two approaches to increase research awareness among midwives and nurses. Context: Quasi-experimental with the attitudes of staff in the two groups being measured at two points (January and October 1997). Context: All midwives and nurses working in four clinical areas in an acute NHS Trust. The intervention arm of the study involved all midwives and nurses in the Clinical Directorate of Obstetrics and Gynaecology, while the control arm involved all nurses working in a specialist oncology and haematology unit and in the children's directorate. Context: The Joint Ethics Committee considered approval unnecessary because the study involved staff and not patients. Context: Data were collected by self-complete questionnaires. Context: A programme of education with policy and practice interventions targeted at ward sisters. Context: Staff attitudes to, knowledge of, and level of involvement in, research. Context: The study demonstrated a significant increase in both knowledge and use of research resources. Following the programme of education, staff in the intervention group were significantly more likely to use resources associated with research utilization and to report that they had read a research paper within the last month. Context: The time scale of the intervention was restricted by the funding available; a significant Hawthorne effect was evident with both groups showing an increase in knowledge; the pragmatic nature of the study meant that it was not possible to randomize the study groups; the scale of the study did not permit an economic evaluation. Think step by step to answer my question. [/INST] The introduction of clinical governance challenges healthcare providers to improve the care they deliver. There are huge opportunities for Trusts to invest in developing staff knowledge and use of research. However, staff will only seize these opportunities if there is an appropriate, enabling environment--an environment that delivers intensive interventions and is sensitive to the wider structural factors in the NHS affecting staff morale and commitment. In the absence of this environment, what may be seen as opportunities to managers may be regarded as just another burden by staff.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Delivery of primary care to women. Do women's health centers do it better? Answer the question given the following information: Context: Women's health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women's health center compared with those at a general medicine clinic. Context: Cross-sectional survey. Context: University hospital-affiliated women's health and general internal medicine clinics. Context: An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic. Context: Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women's health center. Women's health center users (n = 357) were more likely than general medicine clinic users ( n = 349) to prefer a female provider ( 57% vs 32%, p =.0001) and to have sought care at the clinic because of its focus on women's health (49% vs 17%, p =. 0001). After adjusting for age and self-assessed health status, women's health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI]1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2.6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction. Think step by step to answer my question. [/INST] These results suggest that, at least in this setting, women's health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women's health centers, the quality of general preventive care may be better in general medical clinics.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Analysis of failures after whole abdominal irradiation in gastrointestinal lymphomas. Is prophylactic irradiation of inguinal lymph nodes required? Answer the question given the following information: Context: To evaluate failures and to investigate the need for prophylactic inclusion of the inguinal lymph nodes in case of whole abdominal irradiation in gastrointestinal lymphoma. Context: In October 1992 a prospective study on primary gastrointestinal lymphoma was initiated to evaluate management strategies. Treatment consisted either of conservative management comprehending radiotherapy +/- chemotherapy or radio-/chemotherapy sequential to primary surgery, depending on the physician's decision. Until November 1996, 382 patients were enrolled. Out of them we analyzed 92 patients who received a whole abdominal irradiation, in 21 cases with prophylactic inclusion, in 71 cases without inclusion of inguinal lymph nodes. Context: After a median follow-up time of 36 months in 92 patients with whole abdominal irradiation 9 patients developed relapse of gastrointestinal lymphoma (8 local failures, 1 distant failure). In these cases the analysis of radiation therapy shows low tumor doses or small field sizes. No significant difference in the relapse rates is shown between the 21 patients with inclusion of the inguinal lymph nodes in the abdominal radiation fields (3 recurrences approximately equal to 14.3%) and the 71 patients without enclosure of the inguinal lymph nodes (6 recurrences approximately equal to 8.5%). Think step by step to answer my question. [/INST] General prophylactic enclosure of the inguinal lymph nodes in the case of whole abdominal irradiation in gastrointestinal lymphoma seems to be unnecessary.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Loco-regional block in ophthalmic surgery: single drug or drug combination with hyaluronidase? Answer the question given the following information: Context: The aim of this study is the comparison between the use of bupivacaine alone and a mixture of bupivacaine, mepivacaine and hyaluronidase in both retrobulbar and peribulbar blockades for eye surgery. Three hundred ninety-nine consecutive adult patients scheduled for cataract surgery with regional anaesthesia were included in this prospective, randomized and partially blind study. Peribulbar blockade was performed on 199 patients (group P). Ninety-nine of them received a mixture of local anaesthetics and hyaluronidase (sub-group M), while 100 received bupivacaine alone (sub-group B). Retrobulbar blockade was performed on 200 patients (group R): 100 of them received the mixture with hyaluronidase (sub-group M), while 100 received bupivacaine (sub-group B). The interval between anaesthesia and motor blockade (onset time), the presence of residual ocular movements, the need of further anaesthesia, the quality of anaesthesia, the ocular tone, the length of anaesthesia and possible complications were registered. Context: Retrobulbar blockade has the only advantage of a shorter onset time, while peribulbar blockade shows a longer anaesthetic effect. Mixture with hyaluronidase (the sub-group M) has a shorter onset time, a lesser need of further anaesthesia, fewer residual ocular movements and a better quality of anaesthesia. Think step by step to answer my question. [/INST] Local anaesthetics mixture with hyaluronidase associated with peribulbar blockade presents the advantages of rapidity, duration and better quality without the risks of retrobulbar blockade side effects.</s>