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Answer the question based on the following context: Health care reform is dramatically changing the practice and delivery of medical care. The goal of this investigation was to examine gastroenterology trainees' outlook on the impact of health care reform on training programs. A 24-question survey was mailed in February 1996 to 780 GI fellows obtained from the comprehensive American College of Gastroenterology (ACG) database. A total of 362 fellows responded (46%): 85% were male, 57% Caucasian, 75% married, and 86% were university-based. Ninety-six percent of fellows believed that health care reform is adversely affecting the quality of health care and 94.1% felt that it was adversely affecting fellowship training. Eighty-eight percent expressed concern over the impact of health care reform on practice opportunities. Only 9% of fellows reported that their training program had established a specific educational program addressing health care reform, whereas 83% of fellows felt that their program should do so.
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Question: The impact of health care reform on gastroenterology fellows: are training programs preparing them for the future?
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Gastroenterology fellows are concerned about the impact of health care reform on the quality of care and the quality of their fellowship training. Trainees believe that programs are not providing sufficient education to help them respond to the changes in health care.
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Answer the question based on the following context: To study whether nitric oxide (NO) affects the CBF response to hypoxic and carbon monoxide (CO) hypoxia. We incrementally reduced arterial oxygen content in rats, by decreasing the concentration of inspired oxygen (20 rats) or by repeated CO inhalation (20 rats), and measured local CBF using the hydrogen clearance method. Ten animals of each group received 80 mg/kg NO synthase (NOS) inhibitor N-monomethyl-L-arginine intravenously prior to hypoxia, while 10 rats served as controls. Inhibition of NOS decreased mean CBF by 30% and increased cerebrovascular resistance by 70%. Under hypoxic hypoxia, mean oxygen reactivity of CBF (relative change of CBF to a change of arterial oxygen content) was 7.8%/vol% in control animals and 3.3%/vol% after NOS inhibition (P<0.02). Under CO hypoxia, mean oxygen reactivity was 7.3%/vol% in control animals and 5.1%/vol% after NOS inhibition (P<0.05). Inhibition of NOS diminished significantly the cerebral vasodilatory response during hypoxic hypoxia (P<0.05) but only to a lesser extent during CO hypoxia.
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Question: Does NO regulate the cerebral blood flow response in hypoxia?
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These observations suggest that NO is involved in cerebral oxygen vasoreactivity, particularly in severe hypoxia.
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Answer the question based on the following context: This study examined whether heightened cardiovascular reactivity and low socioeconomic status had synergistic effects on the progression of carotid atherosclerosis in a population of eastern Finnish men. Data from the Kuopio Ischemic Heart Disease Risk Factor Study were used to measure 4-year progression of intima-media thickness in 882 men according to cardiovascular reactivity and socioeconomic status. Associations were examined in relation to risk factors and were stratified by baseline levels of atherosclerosis and prevalent ischemic heart disease. The effect of reactivity on atherosclerotic progression depended on socioeconomic status. Men who had heightened cardiovascular responsiveness to stress and were born into poor families, received little education, or had low incomes had the greatest atherosclerotic progression.
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Question: Does low socioeconomic status potentiate the effects of heightened cardiovascular responses to stress on the progression of carotid atherosclerosis?
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An understanding of associations between individual risk factors and disease should be based on etiologic hypotheses that are conceived at the population level and involve fundamental social and economic causes of disease. This study demonstrates how examining the interaction of an individual biological predisposition will low socioeconomic status over the life course is etiologically informative for understanding the progression of atherosclerotic vascular disease.
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Answer the question based on the following context: Mortality rates from breast cancer are approximately 25% higher for women in the northeastern United States than for women in the South or West. This study examined the hypothesis that the elevation is due to decreased survival rather than increased incidence. Data on breast cancer incidence, treatment, and mortality were reviewed. The elevated mortality in the Northeast is apparent only in older women. For women aged 65 years and older, breast cancer mortality is 26% higher in New England than in the South, while incidence is only 3% higher. Breast cancer mortality for older women by state correlates poorly with incidence (r = 0.28).
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Question: Geographic variations in breast cancer mortality: do higher rates imply elevated incidence or poorer survival?
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Those seeking to explain the excess breast cancer mortality in the Northeast should assess survival and should examine differences in cancer control practices that affect survival.
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Answer the question based on the following context: The purpose of this study was to analyze duration of coverage among new Medicaid enrollees. The 1991 Survey of Income and Program Participation was used to examined the duration of coverage for individuals who did not have Medicaid in January 1991 and obtained coverage by May 1993. Of new Medicaid enrollees, 38% (90% confidence interval [CI] = 34%, 42%) remained covered 1 year later; 26% (90% CI = 21%, 31%) remained covered at 28 months. Of those older than 65 years, 54% (90% CI = 31%, 77%) retained Medicaid for 28 months, vs 20% (90% CI = 14%, 26%) of children. Of people who lost Medicaid, 54% (90% CI = 31%, 77%) had no insurance the following month.
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Question: Can Medicaid managed care provide continuity of care to new Medicaid enrollees?
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Almost two thirds of new Medicaid recipients lose coverage within 12 months. It is unlikely that Medicaid managed care will enhance continuity of care for new recipients.
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Answer the question based on the following context: To determine whether disease specific characteristics, reflecting clinical disease severity, add to the explanation of mobility limitations in patients with specific chronic diseases. Cross sectional study of survey data from community dwelling elderly people, aged 55-85 years, in the Netherlands. The additional explanation of mobility limitations by disease specific characteristics was examined by logistic regression analyses on data from 2830 community dwelling elderly people. In the total sample, chronic non-specific lung disease, cardiac disease, peripheral atherosclerosis, diabetes mellitus, stroke, arthritis and cancer (the index diseases), were all independently associated with mobility limitations. Adjusted for age, sex, comorbidity, and medical treatment disease specific characteristics that explain the association between disease and mobility mostly reflect decreased endurance capacity (shortness of breath and disturbed night rest in chronic non-specific lung disease, angina pectoris and congestive heart failure in cardiac disease), or are directly related to mobility function (stiffness and lower body complaints in arthritis). For atherosclerosis and diabetes mellitus, disease specific characteristics did not add to the explanation of mobility limitations.
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Question: Do disease specific characteristics add to the explanation of mobility limitations in patients with different chronic diseases?
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The results provide evidence that, to obtain more detailed information about the differential impact of chronic diseases on mobility, disease specific characteristics are important to take into account.
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Answer the question based on the following context: To investigate longterm pain and disability subsequent to a tibial shaft fracture treated conservatively. Subjects who had sustained a tibial shaft fracture more than 27 years ago were compared with those who had not. 572 fracture patients (identified from the records of the plaster room) aged over 16 at the time of injury were contracted and were compared with 2285 randomly selected subjects matched for age, sex, and general practice. Self reported knee pain; self reported GP's diagnosis of osteoarthritis; ability to climb stairs, walk 100 yards, to bend, kneel, or stoop; and SF-36 physical functioning score. Subjects were reviewed between 27 and 41 years after tibial shaft fracture (mean 35 years). Fracture patients were more likely to suffer chronic knee pain (odds ratio 1.23; 95% confidence interval (CI) 1.00, 1.51) and report being given a diagnosis of osteoarthritis by their GP (odds ratio 1.46; 95% CI 1.08, 1.97). The ability to climb stairs, walk 100 yards, and bend, kneel, or stoop was less in the fracture group than the other subjects. The SF-36 physical function score was significantly lower in the fracture group.
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Question: Conservatively managed tibial shaft fractures in Nottingham, UK: are pain, osteoarthritis, and disability long-term complications?
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More than 27 years after a tibial shaft fracture, subjects have more knee pain than the rest of the population. They also have greater difficulty performing everyday physical activities. The excess morbidity may be due to injury factors or treatment factors, and further research is needed to investigate this important association further.
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Answer the question based on the following context: To establish whether there is a relationship between tobacco industry support of basic research and the conclusions drawn by the authors of that research. A sample of 91 papers investigating the effects of tobacco or nicotine use upon cognitive performance was analyzed to see if the pattern of conclusions drawn by researchers acknowledging tobacco industry support differed from the pattern of conclusions drawn by researchers not acknowledging tobacco industry support. Scientists acknowledging tobacco industry support reported typically that nicotine or smoking improved cognitive performance while researchers not reporting the financial support of the tobacco industry were more nearly split on their conclusions.
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Question: Research into smoking or nicotine and human cognitive performance: does the source of funding make a difference?
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While it is only possible to speculate on the possible reasons, the existence of a possible bias in the published literature according to funding source must be given serious consideration.
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Answer the question based on the following context: To compare the prices of cocaine powder and crack cocaine in the United States. Retail prices for crack and powder cocaine are compared for 14 US cities between 1986 and 1991 using regression analysis and t-tests. Prices are estimated from the United States Drug Enforcement Administration's System to Retrieve Information from Drug Evidence (STRIDE) database. On average, crack is neither more nor less expensive per pure unit than powder cocaine. Prices are not equal in every city in every year, but crack is equally likely to be more or less expensive, and the differences are not large relative to variation in prices of both forms of cocaine between cities and over time.
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Question: Is crack cheaper than (powder) cocaine?
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Crack has been widely believed to be cheaper than powder cocaine, and this "fact" has been used to help explain why US drug problems worsened in the 1980s. However, crack is not, in fact, cheaper per pure unit than powder cocaine. Other explanations must be sought for why crack spread so rapidly relative to powder cocaine.
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Answer the question based on the following context: Accurate and timely diagnosis of hemorrhagic and nonhemorrhagic strokes helps in patient management. Neuroimaging studies are useful in diagnosis and distinction of hemorrhagic (HS) and nonhemorrhagic (NHS) strokes. The use of clinical variables, such as Siriraj stroke scores (SSS), has shown good sensitivity, specificity and predictive values (distinguishing stroke types). The aim of our study was to evaluate the use of SSS in a U.S. population and assess whether it could aid to expedite treatment decisions. Levels of consciousness, vomiting, headache and atheroma markers used in SSS were applied to patients who met the criteria for stroke. Of the 302 patients identified, the SSS classified 254 with sensitivity of 36% (HS) and 90% (NHS) and positive predictive values of 77% and 61%, respectively.
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Question: Can a clinical score aid in early diagnosis and treatment of various stroke syndromes?
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Our results suggest that SSS is not reliable in distinguishing stroke types (in a US population). Definite neuroimaging studies are needed prior to thrombolytic therapy.
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Answer the question based on the following context: Whether the genetic influences are distinct for generalized and localization-related epilepsies or whether some susceptibility genes raise the risk for both types of epilepsy is uncertain. To evaluate genetic heterogeneity in epilepsy. We used Cox proportional hazards analysis to compute rate ratios (RRs) for generalized and localization-related idiopathic or cryptogenic epilepsy in the first-degree relatives of 1498 adult probands with idiopathic or cryptogenic epilepsy ascertained from voluntary organizations. The reference group comprised the first-degree relatives of 362 probands from the same study with postnatal symptomatic epilepsy in whom the genetic contributions appear to be minimal. In the parents and siblings, the risk for all idiopathic or cryptogenic epilepsy was greater if the proband's epilepsy was generalized than if it was localization-related (RR, 4.7 vs 2.4). However, in the parents and siblings of each group of probands, the increased risk was not restricted to the same type of epilepsy as in the proband. The results differed in offspring, with a greater risk for all types of epilepsy if the proband's epilepsy was localization-related than if it was generalized (RR, 4.2 vs 1.6) and a greater risk for localization-related epilepsy than for generalized epilepsy (RR, 7.8 vs 1.8) if the proband's epilepsy was localization-related.
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Question: Are generalized and localization-related epilepsies genetically distinct?
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These findings in parents and siblings suggest that some susceptibility genotypes raise the risk for both generalized and localization-related epilepsies but are more common in persons affected with generalized epilepsy. The different findings in offspring may reflect a different influence on susceptibility in that subgroup.
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Answer the question based on the following context: Alopecia areata (AA) is hypothesized to be an organ-specific autoimmune disease mediated by T cells directed to the hair follicle. Genetic susceptibility may be conferred by HLA, and an environmental trigger, such as a viral infection, is suspected. The incidence of AA in the population is estimated to be 1.7%, with an average of one in four patients having a positive family history. Our purpose was to examine the concordance rate of AA among identical versus fraternal twins and the correlation between stress, cytomegalovirus (CMV) infection, and disease. Families with AA were solicited from dermatologists in the United States and through a Website on the Internet. HLA class 2 typing and identification of CMV early and late genes were performed by polymerase chain reaction (PCR) on genomic peripheral blood DNA. Serum antibodies for CMV were determined by enzyme-linked immunosorbent assay. From 114 families, we identified 11 sets of monozygotic twins and 3 sets of dizygotic twins. The concordance rate was 55% for monozygotic twins and 0% for fraternal twins. Most identical twins were male. The severity of the AA phenotype varied and appeared most severe in the first affected twin. Five of 24 twins were CMV seropositive but CMV DNA was not detected in blood lymphocytes of any of the subjects when studied after the onset of AA. The presence of AA in twins was not correlated with evidence of CMV.
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Question: Alopecia areata and cytomegalovirus infection in twins: genes versus environment?
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A 55% concordance rate in identical twins and AA occurring in families support a genetic component as well as possible environmental triggers that remain unknown.
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Answer the question based on the following context: To study the influence of hepatitis C virus (HCV) co-infection on clinical and immunological evolution of HIV-infected patients. A longitudinal study of HIV-infected individuals with or without HCV infection, identified at the Infectious Diseases Department of Dijon University Hospital and enrolled in a historical cohort, was performed. One hundred and nineteen HIV-infected people co-infected with HCV and 119 matched individuals infected with HIV alone were included in the cohort (median participation time 3 years; range, 2 months to 11.5 years). Clinical progression was defined as one or more of the following: a 30% decrease in the Karnofsky index; a 20% loss of body weight; an AIDS-defining illness (for non-AIDS patients); death (except by accident, suicide or overdose). Immunological progression was defined as a 50% decrease in the initial CD4 T-cell count (for patients with an initial count>100 x 10(6) cells/l). Effects of HCV co-infection were evaluated using Kaplan-Meier survival analysis and significance was tested using univariate (log-rank and Peto's tests) and multivariate methods (Cox's model). In univariate analysis, immunological progression was not statistically different between the HCV-positive group and the HCV-negative group, whereas clinical progression was significantly faster in HCV-positive patients (P<0.005, log-rank test). In a multivariate Cox model, clinical progression remained significantly associated with infection by HCV [hazard ratio (HR), 1.64; 95% confidence interval (CI), 1.06-2.55; P<0.05]. Stratified multivariable analysis retained HCV as a significant prognostic factor of clinical progression (HR, 10.9; 95% CI, 1.09-109.3; P<0.05) and immunological progression (HR, 2.31; 95% CI, 1.16-4.62; P<0.02) for patients with an initial CD4 count above 600 x 10(6) cells/l.
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Question: Does hepatitis C virus co-infection accelerate clinical and immunological evolution of HIV-infected patients?
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Clinical progression is more rapid in HIV-HCV co-infected patients than in HIV-seropositive patients are not infected by HCV. The prognostic value of HCV infection for both clinical and immunological progression is significant at early stages of HIV infection. These findings may argue for active management of hepatitis C infection in co-infected individuals, especially for asymptomatic patients whose CD4 count is above 600 x 10(6) cells/l, to predict and prevent accelerated progression of HCV and HIV diseases.
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Answer the question based on the following context: Many researchers have speculated that markers of malnutrition such as albumin, prealbumin, cholesterol, and transferrin are influenced by inflammation. The mechanism of this interaction has not been well understood. This was a prospective cross-sectional study. We evaluated 72 male patients older than 60 years admitted to a geriatric rehabilitation unit. Subjects with severe hepatic or renal diseases were excluded. We measured body mass index, caloric intake, serum albumin, prealbumin, cholesterol, transferrin, hemoglobin, and total lymphocyte count. To detect inflammation, we measured C-reactive protein, Westergren sedimentation rate, fibrinogen, and cytokines including tumor necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), IL-6, IL-2, and the soluble IL-2 receptor. Soluble IL-2 receptor was negatively associated with albumin (r = -.479, p<.0001), prealbumin (r = -.520, p =<.0001), cholesterol (r = -.487, p = .0001), transferrin (r = -.455, p = .0002), and hemoglobin (r = -.371, p = .002). TNF-alpha, IL-1 beta, IL-6, and IL-2 were not associated with these measures.
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Question: Is malnutrition overdiagnosed in older hospitalized patients?
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Inflammation increases the incidence of hypoalbuminemia and hypocholesterolemia, potentially leading to overdiagnosis of malnutrition. We suggest that albumin, cholesterol, prealbumin, and transferrin be used with caution when assessing the nutritional status of older hospitalized patients. In the future, soluble IL-2 receptor levels might be used to correct for the impact of inflammation on these markers of malnutrition.
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Answer the question based on the following context: Our objective was to assess the educational benefits of a formal pathology rotation during an obstetrics and gynecology residency program and to determine the utility of this information in clinical practice. In this descriptive study, the benefits of a 2-month rotation in pathology for obstetrics and gynecology residents were analyzed. A computerized listing of surgical cases processed by each resident was sent to the obstetrics and gynecology program director. Our resident accessioned 5.4% of the total pathology cases processed each month. Reports from previous residents (over a 17-year period) and from program directors at the annual educational retreat indicate that such information was not relevant to our graduates in their clinical practice.
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Question: Formal pathology rotation during obstetrics and gynecology residency: is it beneficial?
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A formal pathology rotation for obstetric residents can improve knowledge base, but the usefulness of this knowledge in clinical practice is dubious.
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Answer the question based on the following context: Previous researchers have reported that newspapers were useful adjuncts to unintentional injury surveillance efforts in a nearby southern state. The current study sought to determine whether newspaper accounts of intentional injuries could provide a reliable source of primary or secondary surveillance data. Newspaper accounts of assaults, homicides, suicides, and rapes occurring in Jefferson County, Alabama, between January 1, 1991, and December 31, 1991, were compared with similar data from official governmental agencies whose responsibility it is to investigate and/or document the occurrence, details, and characteristics of violent events resulting in death or injury. Newspapers greatly underreported suicides, rapes, and assaults, and reported firearms-related incidents in numbers that substantially exceeded their actual occurrence.
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Question: Are newspapers a viable source for intentional injury surveillance data?
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Much information of potential value for injury surveillance purposes appears to be excluded from newspapers by editorial process and policy. Thus, newspapers are neither a valid nor reliable source for intentional injury surveillance purposes.
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Answer the question based on the following context: Children with a question of occult head injury are routinely hospitalized despite having both normal central nervous system (CNS) and computed tomographic (CT) scan examinations. We determined the incidence of significant CNS morbidity after occult head injury to determine whether or not hospital admission was necessary in children after minimal head trauma. We reviewed the records of children admitted to a level I trauma center with a question of closed head injury, an initial Glasgow Coma Scale equal to 15, a normal neurologic exam, and a normal head CT scan. Children with associated injuries requiring admission were excluded. The endpoints were deterioration in CNS exam, new CT findings, and the need for a prolonged hospital stay. Sixty-two patients were studied with a mean age of 7 years (range, 1 month to 15 years), and 65% were male. The primary mechanisms of injury were fall (45%) and vehicular crash (23%). The mean injury severity score was 4 +/- 2. The mean length of stay was 1.2 days (range, 1 to 3 days). Prolonged hospitalization occurred in 9 patients (15%). No child developed significant CNS sequelae warranting hospital admission. Total charges for these hospitalizations were $177 874.
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Question: Minimal head trauma in children revisited: is routine hospitalization required?
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Children undergoing emergency department work-up of occult head injury, who have a normal CNS exam and a normal head CT scan, do not seem to be at risk for significant CNS sequelae. These patients can be discharged home with parental supervision and avoid unnecessary and costly hospitalization.
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Answer the question based on the following context: To determine whether sexual and nonsexual childhood abuse are risk factors for early adolescent sexual activity and pregnancy. DESIGN; Cross-sectional study. Prenatal clinic within an inner-city teaching hospital from June 1990 to August 1991. One thousand twenty-six primiparous, African-American women enrolled in a randomized clinical trial of nurse home visitation. Four measures of child abuse were used: sexual abuse, incidents of physical abuse, any major physical abuse, and emotional abuse. The outcome measures were age of first consensual coitus and age of first pregnancy. After adjustments for household income, parental separation, urban residence, age of menarche, and teen smoking, sexual abuse during childhood was associated with younger age at first coitus (7.2 months; 95% confidence interval [CI], 2.6 to 11.7 months) and younger age at first pregnancy (9.7 months; 95% CI, 3.0 to 16.3 months). Incidents of physical abuse showed minimal effect on age at first coitus (1.2 days per incident; 95% CI, 0.5 to 1.9 days) and no effect on age of first pregnancy. A history of major physical abuse or emotional abuse showed no effect on age of first coitus or first pregnancy.
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Question: Does child abuse predict adolescent pregnancy?
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Child sexual abuse, but not child physical or emotional abuse, seems to be a risk factor for earlier pregnancy among African-American adolescents.
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Answer the question based on the following context: The etiology of sudden hearing loss is not yet known. The most common mechanism of sudden hearing loss would appear to be impaired cochlear blood circulation. Tobacco smoking causes changes in hemostasis and raises the body's need for oxygen because of carbon monoxide, one component of the smoke which blocks a part of the hemoglobin. 297 patients (76 smokers, 99 former smokers, and 122 non smokers) who were treated because of sudden hearing loss in the hospital in the last 5 years were queried about their smoking habits. We asked the patients to complete a questionnaire in order to get more reliable answers. We explored the kind of tobacco, the number of cigarettes or cigars per day, the age at onset of smoking, the number and rate of recurrence of sudden hearing loss, the result of the treatment of a former sudden hearing loss (if there was one), the characteristics of tinnitus, the possibility of stopping smoking, and the significance of tobacco smoking as reflected in health policy. Tobacco smoking does not increase the overall risk of sudden hearing loss. The incidence of smokers in the population of the region and the incidence of smokers among patients with sudden hearing loss is equal. But the average age of the smoking patients is significantly lower than the average age of non smokers and former smokers. Smokers have a higher rate of recurrence of a sudden hearing loss. The result of treatment of former sudden hearing loss is worse in smoking patients.
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Question: Is there a correlation between sudden deafness and smoking?
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There is no obvious relation between the risk of sudden hearing loss and tobacco smoking.
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Answer the question based on the following context: To review the practice in two hospitals with differing protocols in the timing of seminal analysis after vasectomy. The results from 245 vasectomies carried out at Hospital A, where semen was assessed 3 months after vasectomy, were reviewed and compared with those from 100 consecutive vasectomies at Hospital B, where semen was assessed 6 months after vasectomy. The results of seminal analysis at Hospital A were also audited after changing to the 6-month protocol. The patients' preferences for the timing of seminal analysis were also obtained. Of the 245 patients at Hospital A, 58 (24%) failed to provide samples, leaving 187 (76%) for evaluation; 528 samples were examined (mean 2.8 per patient, range 1-13). The first sample was positive in 36 (19.3%) and the second positive in 10 (5.3%), the first being negative. Four (2%) patients had persistent spermatozoa at 6 months, one subsequently undergoing exploration. Thirty-one (17%) patients provided further samples despite providing two consecutive clear ones. At Hospital B, 24 (24%) patients failed to provide samples; 10 (13%) patients had persistent spermatozoa at 6 months and live spermatozoa were detected in one patient's samples. All eventually produced clear samples, with none requiring exploration. After changing the protocol, 87 vasectomies were performed, with 18 (21%) patients failing to provide samples; seven (10%) of the samples collected showed occasional nonmotile spermatozoa at 6 months in either the first, second or both samples, with all samples clear by 8 months after vasectomy.
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Question: Is the timing of post-vasectomy seminal analysis important?
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The complete disappearance of spermatozoa after vasectomy takes longer than is generally believed and we therefore suggest that given adequate counselling, seminal analysis 6 months after vasectomy is cost-effective and in the patient's interest.
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Answer the question based on the following context: The incidence of perioperative bradyarrhythmias in patients with bifascicular or left bundle branch block (LBBB) and the influence of an additional first-degree atrioventricular (A-V) block has not been evaluated with 24-h Holter electrocardiographic monitoring. Therefore the authors assessed the rate of block progression and bradyarrhythmia in these patients. Patients (n = 106) with asymptomatic bifascicular block or LBBB with or without an additional first-degree A-V block scheduled for surgery under general or regional anesthesia were enrolled prospectively. Three patients were excluded. Of the 103 remaining, 56 had a normal P-R interval and 47 had a prolonged one. Holter monitoring (CM2, CM5) was applied to each patient just before induction of anesthesia and was performed for 24 h. The primary endpoint of the study was the occurrence of block progression. As secondary endpoints, bradycardias<40 beats/min with hemodynamic compromise (systolic blood pressure<90 mmHg) or asystoles>5 s were defined. Block progression to second-degree A-V block and consecutive cardiac arrest occurred in one case of LBBB without a prolonged P-R interval Severe bradyarrhythmias with hypotension developed in another eight patients: asystoles>5 s occurred in two cases and six patients had bradycardias<40/min. Pharmacotherapy was successful in these eight patients. There was no significant difference for severe bradyarrhythmias associated with hemodynamic compromise between patients with and without P-R prolongation (P = 1.00).
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Question: Perioperative risk of bradyarrhythmias in patients with asymptomatic chronic bifascicular block or left bundle branch block: does an additional first-degree atrioventricular block make any difference?
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In patients with chronic bifascicular block or LBBB, perioperative progression to complete heart block is rare. However, the rate of bradyarrhythmias with hemodynamic compromise proved to be relevant. Because an additional first-degree A-V block did not increase the incidence of severe bradyarrhythmias and pharmacotherapy by itself was successful in nearly all cases, routine prophylactic insertion of a temporary pacemaker in such patients should be questioned.
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Answer the question based on the following context: Calcium produces constriction in isolated coronary vessels and in the coronary circulation of isolated hearts, but the importance of this mechanism in vivo remains controversial. The left anterior descending coronary arteries of 20 anesthetized dogs whose chests had been opened were perfused at 80 mmHg. Myocardial segmental shortening was measured with ultrasonic crystals and coronary blood flow with a Doppler flow transducer. The coronary arteriovenous oxygen difference was determined and used to calculate myocardial oxygen consumption and the myocardial oxygen extraction ratio. The myocardial oxygen extraction ratio served as an index of effectiveness of metabolic vasodilation. Data were obtained during intracoronary infusions of CaCl2 (5, 10, and 15 mg/min) and compared with those during intracoronary infusions of dobutamine (2.5, 5.0, and 10.0 microg/min). CaCl2 caused dose-dependent increases in segmental shortening, accompanied by proportional increases in myocardial oxygen consumption. Although CaCl2 also increased coronary blood flow, these increases were less than proportional to those in myocardial oxygen consumption, and therefore the myocardial oxygen extraction ratio increased. Dobutamine caused dose-dependent increases in segmental shortening and myocardial oxygen consumption that were similar in magnitude to those caused by CaCl2. In contrast to CaCl2, however, the accompanying increases in coronary blood flow were proportional to the increases in myocardial oxygen consumption, with the result that the myocardial oxygen extraction ratio remained constant.
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Question: Is calcium a coronary vasoconstrictor in vivo?
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Calcium has a coronary vasoconstricting effect and a positive inotropic effect in vivo. This vasoconstricting effect impairs coupling of coronary blood flow to the augmented myocardial oxygen demand by metabolic vascular control mechanisms. Dobutamine is an inotropic agent with no apparent direct action on coronary resistance vessels in vivo.
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Answer the question based on the following context: Acute scrotum in the pediatric age is mainly related to surgical causes. Spermatic cord torsion and inguinoscrotal hernia must be ruled out first, because of the possible ischemic damage to gonadal tissue and therefore surgery is sometimes performed directly, thus representing also a diagnostic tool. Spermatic cord torsion is found in two age ranges, namely: the neonatal period, where it usually represents the evolution of an intrauterine process, and the peripubertal period, which is more frequent. An unquestionable and prompt diagnosis is particularly needed because of the extreme sensitivity of gonadal tissue to ischemia. In this particular field, color and power Doppler US, depicting gonadal flow, have greatly increased diagnostic imaging capabilities, which were previously limited to B-mode US. We examined 19 peripubertal patients with the diagnosis of spermatic cord torsion made on the basis of B-mode US and then confirmed with color Doppler. We found two signs which can be considered highly suggestive of spermatic cord torsion: the spiral twist of spermatic vessels and the peculiar extent of reactive hydrocele, caused by the bell clapper anomaly of the vaginal sac.
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Question: Does B-mode ultrasound still have a role in the diagnosis of spermatic cord torsion?
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The above US patterns are very helpful to diagnose spermatic cord torsion.
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Answer the question based on the following context: African-American adolescents have the highest rates of sexually transmitted diseases (STDs) of any racial/ethnic group of adolescents. The objective of this study was to determine the degree to which racial/ethnic differences in sexual behaviors account for African-American adolescents' higher rates of STDs. A secondary analysis of data collected as part of the Youth Risk Behavior Survey supplement to the 1992 National Health Interview Survey was conducted. The sample included 5,189 nationally representative civilian noninstitutionalized sexually experienced United States adolescents 14 to 21 years of age. The age- and sex-adjusted odds ratio (OR) for a reported history of an STD for African-American adolescents was 3.86 (95% confidence interval [CI] = 1.57, 9.50). The STD risk for African-American youth increased with the adjustment for other sociodemographic factors (OR = 4.13; CI = 1.71, 9.99) and decreased with the adjustment for sexual behaviors (OR = 3.67; CI = 1.55,8.66).
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Question: Do differences in sexual behaviors account for the racial/ethnic differences in adolescents' self-reported history of a sexually transmitted disease?
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Differences in sexual behaviors do not fully account for African-American adolescents' increased risk for STDs. Interventions designed to reduce sexual risk taking among African-American adolescents may not ameliorate racial/ethnic differences in rates of STDs.
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Answer the question based on the following context: There are conflicting opinions on whether to recommend spermicides containing nonoxynol-9 for prevention of sexually transmitted diseases, including human immunodeficiency virus (HIV). To systematically review and summarize the medical literature on the effect of spermicides containing nonoxynol-9 on prevention of gonorrhea, chlamydial infection, and HIV. Meta-analysis. Potential articles were identified through computerized literature searches. Articles were included if the design was clinical trial, cohort, case-control, or cross-sectional; original outcome data were presented for gonorrhea, chlamydial infection, or HIV; and spermicides containing nonoxynol-9 were used separately from other barrier methods. Study characteristics including design, population, spermicide dose, and delivery method were abstracted. Relative risks (RR) and 95% confidence intervals (CI) were determined from information published in the study or from study authors. Summary risk estimates were computed for clinical trials. Twelve eligible articles were identified, including six clinical trials and six observational studies. Eleven articles evaluated gonorrhea; each found a reduced risk of infection with spermicide use. Among six clinical trials, the summary RR was 0.62 (95% CI, 0.49-0.78). The five articles evaluating chlamydial infection also found significant reduction among spermicide users, with the four clinical trials having a summary RR of 0.75 (95% CI, 0.62-0.91). The degree of spermicidal protection against gonorrhea and chlamydial infection did not differ materially among studies with different study designs or spermicidal preparations (i.e., sponge, gel, suppository, or film). Three studies evaluated degree of protection according to consistency of use and found stronger protection with more consistent use. The two studies on spermicidal prevention of HIV had contrasting results: An observational study found a significant protective effect (RR = 0.1), whereas a clinical trial found a nonsignificantly increased risk (RR = 1.7).
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Question: Do spermicides containing nonoxynol-9 prevent sexually transmitted infections?
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Nonoxynol-9-containing spermicides have an appreciable protective effect against both gonorrhea and chlamydial infection, and wider use of spermicides might substantially reduce the incidence of these diseases. However, insufficient data exist to judge their effect on HIV transmission, and more research on the effect of nonoxynol-9 on HIV transmission is urgently needed to make evidence-based clinical decisions and public health recommendations in the future.
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Answer the question based on the following context: This study sought to examine whether passive smoking is associated with endothelial dysfunction in the coronary arteries. Long-term exposure to cigarette smoking has been reported to suppress endothelium-dependent arterial dilation in humans. Endothelial dysfunction is an early feature of atherogenesis, and the impairment of acetylcholine (ACh)-induced coronary artery dilation indicates coronary endothelial dysfunction. We studied 38 women (40 to 60 years old) who had no known risk factors for coronary artery disease other than tobacco smoking: 11 nonsmokers who had never smoked and had never been regularly exposed to environmental tobacco smoke; 19 passive smokers with self-reported histories of exposure to environmental tobacco smoke of>or = 1 h/day for>or = 10 years; and 8 active smokers. We examined the response of the epicardial coronary artery diameters (proximal and distal segments of the left anterior descending [LAD] and left circumflex [LCx]coronary arteries) to the intracoronary injection of ACh into the left coronary artery by means of quantitative coronary angiography. ACh significantly dilated the distal segment in nonsmokers (percent change from baseline diameter: LAD 13.7+/-3.4%, p<0.05; LCx 18.8+/-2.9%, p<0.01) but not the proximal segment (LAD 7.4+/-3.5%; LCx 3.1+/-5.0%). ACh significantly constricted all segments of the left coronary artery in passive smokers (LAD: proximal -20.3+/-3.7%, p<0.05; distal -22.3+/-4.1%, p<0.01; LCx: proximal -20.8+/-3.1%, p<0.05; distal -17.3+/-2.9%, p<0.01) and active smokers (LAD: proximal -14.8+/-3.4%, p<0.05; distal -27.2+/-6.0%, p<0.01; LCx: proximal -14.5+/-6.6%, p<0.05; distal -22.4+/-4.0%, p<0.01). Thus, ACh constricted most coronary arteries in both passive and active smokers and dilated the coronary arteries in nonsmokers.
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Question: Does passive smoking impair endothelium-dependent coronary artery dilation in women?
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Impairment of ACh-induced coronary artery dilation, indicating coronary endothelial dysfunction, may occur diffusely in passive smokers as well as in active smokers.
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Answer the question based on the following context: This study examined whether enhancing standard aftercare with an outreach case management intervention would improve patients' quality of life. A sample of 292 patients discharged from an inpatient psychiatry service at an urban general hospital were randomly assigned either to an intervention group (N = 147), which received outreach case management services in addition to standard aftercare service, or to a control group (N = 145), which received only standard aftercare services. The follow-up period was 15 to 52 months. Individuals in both groups were reinterviewed by an independent research team about 21.6 months after discharge. The groups were compared using 39 measures of quality of life. The interviews elicited information about patients' physical well-being and competence in performing activities of daily living; their emotional well-being as shown in emotional expressiveness, sadness, suicidal thoughts, and substance abuse; and their interpersonal relationships, living arrangements, friendships, income maintenance, and employment. No difference was found between the groups on any of the quality-of-life variables.
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Question: Does outreach case management improve patients' quality of life?
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Outreach case management was not associated with improved quality of life.
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Answer the question based on the following context: To investigate whether the protective efficacy of bacille Calmette-Guérin (BCG) against tuberculosis decreases with time since vaccination. A quantitative review of all 10 randomized trials of BCG against tuberculosis in purified protein derivative (PPD)-negative individuals, that presented data for discrete periods. For each trial, we derived log rate ratios for the annual change in the efficacy of BCG. We also compared efficacy in the first two years, and the first 10 years, to that in the rest of the trial. There was considerable heterogeneity between trials in the annual change in the efficacy of BCG. In seven efficacy decreased overtime, while in three it increased. Average annual change in efficacy was not related to overall efficacy. Efficacy also varied between trials in the first two years after vaccination, at more than two years after vaccination and in the first ten years after vaccination. However the variation in efficacy between trials more than 10 years after vaccination was not statistically significant (P = 0.26). We therefore calculated that the average efficacy more than 10 years after vaccination was 14% (95% confidence interval -9% to 32%).
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Question: Does the efficacy of BCG decline with time since vaccination?
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BCG protection can wane with time since vaccination. There is no good evidence that BCG provides protection more than 10 years after vaccination.
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Answer the question based on the following context: To determine whether medical students were prepared to assess risk and counsel patients about prevention of HIV infection, and whether HIV-related experience produced better knowledge and counseling skills. In 1995, students at four North Carolina medical schools interviewed a standardized patient portraying a young woman concerned about HIV infection. The standardized patient recorded whether students asked risk-behavior questions and provided risk-reduction advice. A 21-item questionnaire assessed the students' knowledge of HIV testing and prevention. Students indicated whether they had had experience in educational settings related to HIV or STDs. 415 students completed both the patient interview and the questionnaire. Many failed to ask the patient about several HIV-risk behaviors. Although nearly all (98%) inquired about condom use, fewer than two thirds asked about the patient's history of STDs, number of sexual partners, or specific sexual practices. Most students advised the patient to use condoms. The average score on the knowledge test was 79%; 70% of students confused anonymous with confidential testing, more than half overestimated the risk of HIV transmission from a needle stick, and nearly one in ten did not know how to use a condom. Educational exposures did not produce significantly better risk assessment, counseling information, or knowledge scores.
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Question: Are medical students ready to provide HIV-prevention counseling?
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A majority of experienced medical students did not assess several important risk factors of a patient concerned about HIV infection, and many would have provided incorrect information related to HIV testing and prevention of infection. Patient contact in traditional clinical settings did not influence prevention knowledge or behavior. More innovative methods are needed to train students in HIV-infection prevention and counseling.
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Answer the question based on the following context: Hepatic resection for multiple hepatocellular carcinomas (HCCs) involving both lobes of the liver is rarely recommended because of high operative risks and low radicality. Thus the justification of hepatic resection for bilobar multicentric HCC remains undefined. Two hundred eleven patients with HCC, who underwent curative hepatic resection, were studied retrospectively. The patients were divided into two groups. Group A consisted of 39 patients with bilobar (both sides of Cantlie's line) multicentric HCCs. Group B consisted of 172 patients with HCC with solitary or unilobar lesions. The backgrounds and resectional results of patients in groups A and B were compared. Patients in group A usually required multiple separate liver resections and a longer operative time. However, the operative blood loss, amount of blood transfused, and operative morbidity and mortality rates were not significantly different. Patients in group A showed higher incidences of associated satellite nodules, microscopic vascular invasion, and a lack of capsules. The 6-year disease-free and actuarial survival rates of patients in groups A and B were 30.5% and 41.8% (p = 0.17) and 42.9% and 51.4% (p = 0.12), respectively. For patients in group A the presence of satellite nodules in any resected tumor was the only independent unfavorable feature that influenced the actuarial survival rate after multivariate analysis.
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Question: Hepatic resection for bilobar multicentric hepatocellular carcinoma: is it justified?
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Liver resection is justified for bilobar multicentric HCCs in selected patients, if the tumors can be totally resected. Postoperative adjuvant therapies should be considered when satellite nodules are present in any resected tumor.
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Answer the question based on the following context: There have been several case reports of unexpected gallbladder cancer diagnosed after laparoscopic cholecystectomy (LC) being associated with fatal recurrence of cancer in the abdominal wall. Therefore there is a risk that LC might worsen the prognosis of gallbladder cancer. The objective of this study was to examine the frequency of recurrence of cancer in the abdominal wall and the prognosis of patients with unexpected gallbladder cancer diagnosed after LC. A clinicopathologic study was performed on 30 patients with postoperatively diagnosed gall-bladder cancer among 3566 patients undergoing LC at 19 institutions. The cumulative survival rate was compared with that reported for gallbladder cancer diagnosed after open cholecystectomy. Recurrence of cancer in the abdominal wall occurred in three patients, and two of them died. The 3-year survival rate was 100% for early gallbladder cancer and 70% for advanced tumors. These results were comparable to the 3-year survival rates for gallbladder cancer diagnosed after open cholecystectomy.
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Question: Is laparoscopic cholecystectomy hazardous for gallbladder cancer?
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The incidence of recurrence of cancer in the abdominal wall was increased, but the medium-term prognosis was not worsened by laparoscopy. It does not appear necessary to exclude patients with cholecystitis or gallbladder wall hypertrophy from undergoing laparoscopic procedures on the grounds that they might have gallbladder cancer.
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Answer the question based on the following context: To analyze the effects of epidural analgesia for labor when dystocia occurs. Retrospective cohort study. Academic health center. 641 low risk, nulliparous women in spontaneous labor. 406 (63%) women received epidurals analgesia and 253 (37%) did not. Sixty women (9.4%) required an abdominal delivery for dystocia. Women receiving epidural analgesia were more likely to be white, receive care from an attending physician, need labor augmentation, and deliver a heavier infant. Multivariate analysis identified five variables predictive of dystocia and abdominal delivery: pitocin augmentation odds ratio (O.R.) = 3.9 (2.0 to 7.6), duration of labor more than 20 hours O.R. = 2.4 (1.3 to 4.4), high epidural dose O.R. = 2.2 (1.2 to 4.1), birthweight over 4,000 grams O.R. = 2.0 (1.0 to 4.2), and early placement of epidural O.R. = 1. 9 (1.0 to 3.5). Repeating the regression after excluding the 20 women who developed abnormal labor prior to epidural placement (18 of 20 women had protracted dilatation) demonstrated that pitocin augmentation O.R. = 4.0 (1.8 to 4.), high epidural dose O.R. = 3.0 (1.9 to 6.2), duration of labor greater than 20 hours O.R. = 2.7 (1.3 to 5.7), and birthweight over 4,000 grams O.R. = 2.1 (0. 9 to 4.8) were associated with dystocia.
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Question: Does epidural analgesia cause dystocia?
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Epidural analgesia appears to be a marker of abnormal labor rather than a cause of dystocia. High concentration anesthetics and epinephrine should be avoided, as they may influence labor. Randomized, controlled trials of this technique will be difficult to do; our work should reassure patients and their clinicians that epidural analgesia does not adversely affect labor.
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Answer the question based on the following context: Soluble adhesion molecules are considered to be markers of inflammation, endothelial activation, or damage. This study was designed to assess whether adhesion molecules are specifically altered in patients undergoing cardiac surgical procedures. Three groups of 20 patients each were prospectively studied: patients undergoing elective coronary artery bypass grafting; patients scheduled for a Whipple pancreatoduodenectomy; and patients undergoing elective pneumonectomy for lung cancer. Plasma levels of soluble adhesion molecules (endothelial leukocyte adhesion molecule-1, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and granule membrane protein 140) were measured from arterial blood samples after induction of anesthesia (baseline), at the end of the operation, 2 hours and 5 hours after operation, and on the morning of the first postoperative day. Duration of operation was longest in the group having a Whipple operation (289 +/- 50 minutes) and did not differ between the other two groups. Plasma levels of all measured adhesion molecules at baseline were within normal ranges. After cardiopulmonary bypass, levels of adhesion molecules were significantly increased in the cardiac surgical patients (soluble endothelial leukocyte adhesion molecule-1, from 38 +/- 11 ng/mL at baseline to 68 +/- 12 ng/mL; soluble intercellular adhesion molecule-1, from 241 +/- 50 ng/mL to 498 +/- 78 ng/mL; and granule membrane protein 140, from 69 +/- 12 ng/mL to 150 +/- 25 ng/mL). On the morning of the first postoperative day, all levels had returned to baseline except that of soluble vascular cell adhesion molecule-1, which was still elevated (p<0.05). In both the other groups, concentrations of adhesion molecules remained almost unchanged.
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Question: Are circulating adhesion molecules specifically changed in cardiac surgical patients?
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Cardiac operation was associated with increased plasma levels of soluble adhesion molecules, a finding indicating endothelial activation or dysfunction. In contrast, in patients undergoing complex, long-lasting abdominal or lung operations, soluble adhesion molecules remained unchanged. Activation of proinflammatory cascades, ischemia/reperfusion phenomenon, and microcirculatory dysfunction appear to be the most likely reasons for this difference between groups. Whether modulation of adhesion molecules may influence organ function after cardiopulmonary bypass remains to be elucidated in further studies.
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Answer the question based on the following context: Health-affecting psychosocial problems are inherent in general practice, present among one-third of the patients and constituting between 3 and 13% of reasons for encounter. Such problems are not always presented, and often overlooked by the doctors. We aimed to describe the frequency of psychosocial problems presented to the doctor by patients with somatic reasons for encounter, as a proportion of the patients' existing health-affecting problems, and to explore whether characteristics of the doctor, the patient, their relationship or reason for encounter influence the presentation of problems. A questionnaire survey of 1401 consecutive patients visiting 89 Norwegian GPs mapped the prevalence of nine commonly occurring psychosocial problems and the frequency by which they were disclosed during the consultation. From 21% (loneliness) to 59% (occupational stress) of problems were disclosed to the doctors. Reason for encounter was the only factor to influence the disclosure from male patients, while reason for encounter, educational level and income source of the patient, gender of the doctor, and the doctor's previous general knowledge of the patient influenced the disclosure from female patients.
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Question: Psychosocial problems presented by patients with somatic reasons for encounter: tip of the iceberg?
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Less than half of health-affecting psychosocial problems are disclosed to GPs by patients with somatic reasons for encounter. Occupational stress is disclosed more often than other psychosocial problems. Female patients disclose non-occupational problems more often than male patients, especially if they know the doctor or if the doctor is a woman. Symptoms from the musculoskeletal system are the reasons for encounter most often preceding the disclosure of psychosocial problems.
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Answer the question based on the following context: To determine whether the increase in frequency of cesarean section is associated with a decreased incidence of major birth trauma. A retrospective cohort study was performed evaluating all neonatal cases of major birth trauma from January 1989 to December 1994. Major birth trauma was defined as peripheral plexus or nerve injuries, fractures, or lacerations. The data were grouped into two mutually exclusive periods (January 1989 to December 1990 vs January 1991 to December 1994) in which a significant difference in the cesarean section rate was known. Of 17,957 deliveries during the period, 141 cases of birth trauma occurred. One hundred thirty-seven of the 141 medical records were available for review, and 116 were classified as having had major birth trauma and were included in the study. The overall incidence of major birth trauma was 6.5/1000 deliveries. During the two-year period (January 1989 to December 1990), 18.3% of deliveries were by cesarean section and the major birth trauma rate was 8.4/1000 deliveries. During the following 4 years, the cesarean section rate was 22.3% and the major birth trauma rate was 5.3/1000 deliveries. Significant differences in the birth trauma chi(2) = 6.12, p = 0.013) and cesarean section (chi(2) = 40.80, p<0.001) rates were observed. Controlling for the mode of delivery lessened the association between time period and birth trauma incidence (chi(2)MH = 3.28, p = 0.07). A significant decrease in the occurrence of major birth trauma in neonates delivered by cesarean section in the later period was discovered (relative risk = 0.46, 95% confidence interval 0.22 to 0.97). This decrease appeared to be mediated by a decrease in total lacerations between the periods (chi(2) = 11.76, p<0.001), because the rates of other types of major birth trauma did not differ in neonates delivered by cesarean section or the vaginal route.
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Question: Does cesarean section decrease the incidence of major birth trauma?
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With a 4% increase in rate of cesarean section at our institution, a significant decrease in the occurrence of major birth trauma was observed. This finding cannot be explained by a decreased risk of neonatal trauma in patients delivering vaginally, but rather by a decreased risk of neonatal trauma at cesarean section during the latter period.
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Answer the question based on the following context: I.v. lipid emulsions contain vitamin K in substantial quantities and in 1989, we therfore stopped supplying vitamin K1 to patients receiving home parenteral nutrition (HPN). Nine patients (group I) receiving HPN before 1989 (10 mg i.v. vitamin K1 supplementation weekly until 1989, which was discontinued thereafter) and six patients with an initial low plasma vitamin K1 concentration (related to their malabsorption) (group II) receiving HPN after 1989 were studied. Prothrombin time (PT), plasma vitamin K1 concentration, and vitamin K1, content in lipid emulsions were measured throughout the period of HPN. All lipid emulsions, except for Eurolip 20% and Clinoleic 20% (Baxter SA, Maurepas, France) contained vitamin K1, with concentration ranges from 179 +/- 39 to 353 +/- 78 ng/L. Group I patients had an initial high plasma vitamin K1 concentration due to the vitamin K1 supplementation. After this supplementation was discontinued, plasma vitamin K1 decreased and remained in normal ranges with a normal PT. Throughout the HPN period after 1989, patients received 255 +/- 104 micrograms of vitamin K1 weekly through lipid emulsions. The PT and plasma vitamin K1 concentrations in group II patients were restored by lipid emulsions, which contained 418 +/- 143 micrograms/wk of vitamin K1.
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Question: Is vitamin K1 supplementation necessary in long-term parenteral nutrition?
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In patients receiving i.v. lipids (except for Eurolip and Clinoleic), a normal vitamin K1 status can be maintained during long-term HPN without vitamin K1 supplementation. However, vitamin K supplementation cannot be abandoned until the vitamin K content of emulsions is standardized by manufacturers. A weekly supply of 250 to 400 micrograms of vitamin K1 is enough to maintain and even restore a normal vitamin K1 status in HPN.
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Answer the question based on the following context: Because there is no consensus regarding the necessity of imaging the cervical spine of patients who sustain a gunshot wound to the cranium, the cervical spinal radiographs of 53 consecutive patients with gunshot wounds to the cranium admitted to Hermann Hospital, a Level I trauma center, from January of 1993 to January of 1996, were reviewed. The cervical spine radiographs of all 53 patients were negative.
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Question: Is cervical spine imaging indicated in gunshot wounds to the cranium?
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Cervical spine injury is not associated with gunshot wound to the cranium. Therefore, patient management decisions/procedures, including endotracheal intubation, should not be delayed pending cervical spine imaging.
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Answer the question based on the following context: The etiology of Wells' syndrome or eosinophilic cellulitis is unknown. Various triggering factors, such as myeloproliferative disorders, lymphoma, infections/infestations, insect bites and drugs have been reported. In 1979, Wells was the first who pointed out some common features of eosinophilic cellulitis and skin lesions in toxocariasis. We report 2 patients who exhibited the characteristic clinical and histological features of Wells's syndrome together with elevated antibody titers to the excretory-secretory antigen of Toxocara canis. In both patients, the skin lesions disappeared after oral albendazole treatment and no recurrences were observed. The clinical response was followed by a normalization of the Toxocara antibody titer. In contrast, a patient with eczematoid skin lesions, eosinophilia and an elevated Toxocara antibody titer did not benefit from albendazole treatment despite serological normalization.
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Question: Toxocariasis and Wells' syndrome: a causal relationship?
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Taken together, these cases lend support to a causal relationship of Toxocara in selected patients with Wells' syndrome.
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Answer the question based on the following context: Borrelia burgdorferi, the causative agent of Lyme disease, has never been isolated from a patient thought to have acquired Lyme disease in any southeastern state. To investigate 14 cases of an erythema migrans (EM)-like rash illness that occurred during 2 summers at an outdoor camp in central North Carolina in an effort to determine the etiologic, epidemiological, and clinical aspects of this illness. Using active surveillance, we identified cases of clinically diagnosed EM in residents and staff of the camp. We collected clinical and demographic information; history of exposure to ticks; acute and convalescent serum antibodies to B. burgdorferi, Rickettsia rickettsii, and Ehrlichia chaffeensis; and cultures for spirochetes from biopsy specimens of skin lesions. Serum samples from a group of residents and staff who did not develop rashes were tested for the same antibodies. We speciated ticks removed from people and collected from vegetation. We identified 14 cases of EM-like rash illness during the 2 summers. Of the 14 case-patients, 10 had associated mild systemic symptoms and 1 had documented fever. All 14 case-patients had removed attached ticks, and 8 remembered having removed a tick from the site where the rash developed a median of 12 days earlier (range, 2-21 days). One tick removed from the site where a rash later developed was identified as Amblyomma americanum, the Lone Star tick; 97% of ticks collected from vegetation and 95% of ticks removed from people were A. americanum. No spirochetes were isolated from skin biopsy specimens. Paired serum samples from 13 case-patients did not show diagnostic antibody responses to B. burgdorferi or other tick-borne pathogens.
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Question: Erythema migrans-like rash illness at a camp in North Carolina: a new tick-borne disease?
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This investigation suggests the existence of a new tick-associated rash illness. We suspect that the disease agent is carried by A. americanum ticks. In the southern United States, EM-like rash illness should no longer be considered definitive evidence of early Lyme disease.
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Answer the question based on the following context: This retrospective review was conducted to determine if delay in the start of radiotherapy after definitive breast surgery had any detrimental effect on local recurrence or disease-free survival in node-negative breast cancer patients. A total of 568 patients with T1-T2, N0 breast cancer were treated with breast-conserving surgery and breast irradiation, without adjuvant systemic therapy between January 1, 1985 and December 31, 1992, at the London Regional Cancer Centre. Adjuvant breast irradiation consisted either of 50 Gy in 25 fractions or 40 Gy in 15 or 16 fractions, followed by a boost of 10 Gy or 12.5 Gy to the lumpectomy site. The time intervals from definitive breast surgery to breast irradiation used for analysis were 0-8 weeks (201 patients),>8-12 weeks (235 patients),>1216 weeks (91 patients), and>16 weeks (41 patients). The time intervals of 0-12 weeks (436 patients) and>12 weeks (132 patients) were also analyzed. Kaplan-Meier estimates of time to local recurrence and disease-free survival rates were calculated. The association between surgery-radiotherapy interval, age (<or = 40,>40 years), tumor size (<or = 2,>2cm), Scharf-Bloom-Richardson (SBR) grade, resection margins, lymphatic vessel invasion, extensive intraductal component, and local recurrence and disease-free survival were investigated using Cox regression techniques. Median follow-up was 63.5 months. Patients in all 4 time intervals were similar in terms of age and pathologic features. There was no statistically significant difference between the 4 groups in local recurrence or disease-free survival with surgery-radiotherapy interval (p = 0.189 and p = 0.413, respectively). The 5-year freedom from local relapse was 95.4%. The crude local recurrence rate was 6.9% (7.8% for 436 patients treated within 12 weeks (median follow-up 67 months) and 3.8% for 132 patients treated>12 weeks from surgery (median follow-up 52 months). In a stepwise multivariable Cox regression model for disease-free survival, allowing for entry of known risk factors, tumour size (p<0.001), grade (p<0.001), and age (p = 0.048) entered the model, but the surgery-radiotherapy interval did not enter the model.
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Question: Does delay in breast irradiation following conservative breast surgery in node-negative breast cancer patients have an impact on risk of recurrence?
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This retrospective study suggests that delay in start of breast irradiation beyond 12 and up to 16 weeks does not increase the risk of recurrence in node-negative breast cancer patients. The certainty of these results are limited by the retrospective nature of this analysis and the lack of information concerning the late local failure rate.
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Answer the question based on the following context: The sex ratio of 1.06:1, the ratio of male to female births, has declined over the past decades. Recent reports from a number of industrialized countries indicate that the proportion of males born has significantly decreased, while some male reproductive tract disorders have increased. To examine the evidence for declines in the male proportion at birth and suspected causes for this decline, and to determine whether altered sex ratio can be considered a sentinel health event. Birth records were analyzed from national statistical agencies. Published analyses of trends in ratio of males to females at birth and studies of sex determinants evaluating epidemiological and endocrinological factors. Proportion of males born: 1950-1994 in Denmark; 1950-1994 in the Netherlands; 1970-1990 in Canada; and 1970-1990 in the United States. Since 1950, significant declines in the proportion of males born have been reported in Denmark and the Netherlands. Similar declines have been reported for Canada and the United States since 1970 and parallel declines also have occurred in Sweden, Germany, Norway, and Finland. In Denmark, the proportion of males declined from 0.515 in 1950 to 0.513 in 1994. In the Netherlands, the proportion of males declined from 0.516 in 1950 to 0.513 in 1994. Similar declines in the proportion of males born in Canada and the United States are equivalent to a shift from male to female births of 8600 and 38000 births, respectively. Known and hypothesized risk factors for reduced sex ratio at birth cannot fully account for recent trends.
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Question: Reduced ratio of male to female births in several industrial countries: a sentinel health indicator?
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Patterns of reduced sex ratio need to be carefully assessed to determine whether they are occurring more generally, whether temporal or spatial variations are evident, and whether they constitute a sentinel health event.
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Answer the question based on the following context: The objective of this national survey was to describe the routine use of procedures and technologies in Canadian hospitals providing maternity care, and to determine the extent to which current use was consistent with the existing evidence and recommended guidelines for maternal and newborn care. Representatives of 572 hospitals providing maternity care across Canada were sent questionnaires in the spring and summer of 1993; 523 (91.4%) responded. The primary outcome measures consisted of the self-reported use of obstetric procedures and technologies (perineal shaves, enemas/suppositories, intravenous infusions, initial and continuous electronic fetal heart monitoring, episiotomy rates). Hospitals were grouped according to location, size (number of live births per year), and university affiliation status. The hospitals in the Prairie provinces, in Quebec, and in the Atlantic provinces were significantly less likely than those in Ontario to restrict their use of perineal shaves and enemas to women on admission in labor. Small hospitals were significantly more likely than large hospitals (>1000 live births) to restrict their use of intravenous infusions, and initial and continuous electronic fetal monitoring. The university-affiliated and nonteaching hospitals were significantly less likely than the university teaching hospitals to have episiotomy rates of less than 40 percent for primiparous women. Small hospitals were more likely than large hospitals to report episiotomy rates of less than 20 percent for multiparous women.
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Question: A national survey of use of obstetric procedures and technologies in Canadian hospitals: routine or based on existing evidence?
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Considerable variations occur in the routine use of obstetric procedures and technologies in Canadian hospitals providing maternity care, according to hospital location, size, and university affiliation status. Despite the existing evidence suggesting that the routine use of these practices and procedures is both unnecessary and potentially harmful, a significant number of Canadian hospitals continued to use them routinely in 1993.
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Answer the question based on the following context: The aim of this study was to assess the feasibility of the use of "willingness to pay" as a measure of the benefits of intrapartum care. A questionnaire was mailed to 150 pregnant women booking at Aberdeen Maternity Hospital in the northeast of Scotland, giving information on options for intrapartum care compiled from a recent randomized trial of care in a midwife-managed delivery unit versus care in a consultant-led labor ward. Women were asked which type of care they preferred and what would be their maximum willingness to pay for their preferred option. Data were also collected on demographic and clinical characteristics. Most women (55%) expressed a preference for care in a midwives unit. However, strength of preference, as reflected in willingness to pay, was greater among those in the smaller group, who expressed a preference for care in a consultant-led labor ward. The willingness-to-pay results were not associated with ability to pay.
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Question: Willingness to pay: a method for measuring preferences for maternity care?
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These data should be used together with cost data to decide on provision of care. Given the strength of preference of the minority group, and if the cost implications are not too great, a flexible service that takes account of women's wishes should be provided, even if this goes against the trend for care of those at low risk. By analyzing choice of care by income groups and social class groupings, it is possible to examine whether willingness-to-pay results are associated with indicators of ability to pay. In this case, they were not. Willingness to pay has an advantage in allowing respondents to account for more than just health gain when valuing different types of care.
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Answer the question based on the following context: In Western countries during the 1960s and 1970s, sore nipples and insufficient milk were common problems that made it hard for mothers to maintain breastfeeding for long. This study investigated the relationship of breastfeeding problems to nursing behavior and pacifier use. Fifty-two healthy mother-infant pairs with breastfeeding problems were referred for observation of nursing behavior to a breastfeeding clinic at the Department of Pediatrics of Malmö General Hospital, Malmö, Sweden, from August 1987 to July 1989. The infants ranged in age from 1 to 17 weeks. A faulty nursing pattern was corrected as necessary. Forty mother-infant pairs with no breastfeeding problems provided a control group. In most cases the nursing problems were related to incorrect sucking technique. The difference in technique of the study group compared with the control group was significant (p = 0.0001). The continuation of breastfeeding was poorer if the infant already had become used to bottle-feeding. Pacifier use was more common in conjunction with breastfeeding problems and in cases with a faulty superficial nipple-sucking technique.
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Question: Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles?
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Breastfeeding problems may be prevented by the adoption of hospital routines that do not interfere with the start of breastfeeding and by the avoidance of extensive use of pacifiers.
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Answer the question based on the following context: Unstable angina pectoris often leads to acute myocardial infarction. Since lipid peroxidation is thought to be causally related to chronic and acute events in atherosclerosis and coronary artery disease, we measured lipid peroxidation products and vitamin E in 100 patients with coronary artery disease and compared them to a matched control group. 50 consecutive patients with stable angina pectoris (SAP) and 50 consecutive patients with unstable angina pectoris (UAP) were studied and compared to 100 clinically healthy individuals. In addition to conventional lipid and lipoprotein analysis, malondialdehydes were measured as thiobarbituric acid reactive substances (TBARS). Lipid hydroperoxides were assayed with the colorimetric methylene blue method. alpha-Tocopherol was quantitated by HPLC after extraction of serum with hexane-ethanol. In the patient group conjugated dienes were also measured. As expected, patients had significantly higher cholesterol, triglyceride LDL-C and Lp(a) values and lower HDL-C values than controls. When patients were divided into groups with SAP and UAP respectively, peroxides and TBARS were significantly higher in the latter group as compared to patients with SAP and to controls. Conjugated dienes were also significantly higher in patients with UAP as compared to patients with SAP. Total plasma alpha-tocopherol was comparable in all three groups, whereas the alpha-tocopherol content per LDL particle was lowest in patients with UAP, followed by patients with SAP and then controls.
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Question: Is oxidative stress causally linked to unstable angina pectoris?
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It is concluded that lipid peroxidation parameters are increased in patients with UAP and discriminate SAP from UAP patients.
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Answer the question based on the following context: Thirty five neonates were classified, at the time of blood sampling, into three groups: unstable ventilated; stable ventilated; and stable non-ventilated. A modification of an extraction method for pAVP was developed for use in studies on very small babies, and sampling methods were compared. The pAVP (median, range) was similar in the ventilated (1.85 pmol/l, 0.5 to 3.4) and non-ventilated (2.0, 0.5 to 2.6) stable babies, but was significantly higher (5.7, 1.1 to 25) in the unstable group. There was an inverse correlation between systolic blood pressure and pAVP concentration.
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Question: Does positive pressure ventilation increase arginine vasopressin in preterm neonates?
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This study shows that in preterm neonates pAVP concentration is affected by the clinical condition and blood pressure, but not by treatment with IPPV.
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Answer the question based on the following context: To evaluate whether isolated Horner's syndrome presenting in the first year of life warrants investigation. Retrospective review of 23 children presenting with Horner's syndrome in the first year of life. In 16 patients (70%) no cause was identified. Birth trauma was the most common identifiable cause (four patients). Twenty one children (91%) had urinary vanillylmandelic acid (VMA) measured and 13 patients (57%) underwent either computed tomography or magnetic resonance imaging of the chest and neck. These investigations revealed previously undisclosed pathology in only two--one ganglioneuroma of the left pulmonary apex and one cervical neuroblastoma. A further patient was known to have abdominal neuroblastoma before presenting with Horner's syndrome. There were no cases of Horner's syndrome occurring after cardiothoracic surgery. Long term follow up of the patients (mean 9.3 years) has not revealed further pathology.
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Question: Does Horner's syndrome in infancy require investigation?
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Routine diagnostic imaging of isolated Horner's syndrome in infancy is unnecessary. Infants should be examined for cervical or abdominal masses and involvement of other cranial nerves. If the Horner's syndrome is truly isolated then urinary VMA levels and follow up in conjunction with a paediatrician should detect any cases associated with neuroblastoma. Further investigation is warranted if the Horner's syndrome is acquired or associated with other signs such as increasing heterochromia, a cervical mass, or cranial nerve palsies.
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Answer the question based on the following context: The clinical audit method based on a retrospective analysis of medical files can be used to assess hospital health care. The reliability of the results obtained depends on the validity of the data in the file and its completeness. The aim of this work was to assess the quality of this information source. The simplified ANDEM/ANAES from was proposed to 47 medical information departments of public and private hospitals participating in the public health care service in the Provence-Alples-Côte d'Azur region. The audit was conducted on a sample of hospital stays during a regular 6-month quality control assessment of hospital health care activity. Analysis of the 467 forms returned by 39 hospitals, showed that the quality of medical file recordings should be improved as a large amount of data or important documents were missing: reason for hospitalization (recorded on 74.1% of files), operation report (found in 83.2% of files) and discharge summary (found in 66.6% of files).
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Question: Can medical files be used to audit hospital health care?
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Clinical audits would be compromised in certain hospitals by the use of medical files. Efforts to improve the quality of hospital medical files should be a priority.
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Answer the question based on the following context: To characterise the appetite control in habitual high fat (HF) and low fat (LF) phenotypes. Four treatment conditions for each subject group in a fully repeated 2 x 2 x 2 measures design. The Human Appetite Research Unit at Leeds University, Psychology Department. Eight lean HF (mean % fat intake-46.7% daily energy) and eight lean LF (mean % fat intake - 29.9% daily energy) were recruited from the staff/student population of Leeds University. All subjects were provided with either a low (2129 kJ) or high (3801 kJ) energy meal at midday and the capacity for compensation was later measured by nutrient challenge (ad libitum consumption of either high fat or high CHO foods). Satiation and satiety were assessed by changes in energy and nutrient intakes, hunger, fullness and food preferences. The energy and nutrient manipulations gave rise to different levels in the rated intensity of hunger between HF and LF (P<0.01). HF rated their baseline hunger at a higher level than LF, and the nutrient induced changes in hunger had a much greater amplitude. HF consumed significantly more energy from the high fat meals than from the high CHO meals (P<0.05); this effect was not observed in LF. HF ate more energy and a greater weight of the high fat foods but less energy and smaller weight of the high CHO foods than did the LF. HF rated the high fat and high CHO foods equally satisfying, tasty and filling, whereas LF indicated a preference for high CHO foods (P<0.05).
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Question: Are high-fat and low-fat consumers distinct phenotypes?
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The appetite control in habitual high and low fat consumers is different. HF 'passively overconsume' fat whereas this effect is weak in LF. The HF ate a constant weight of food whereas LF ate a more constant level of energy. HF could not distinguish between high and low fat foods suggesting that they were intrinsically insensitive or 'taste adapted' whereas LF were fat sensitive. The clear differences disclosed in response to signals generated by the characteristics of ingested food (weight, energy, nutrient composition, taste) suggest that habitual high and low fat consumers can be regarded as distinct behavioural phenotypes. The different styles of appetite control could arise from: (a) intrinsic physiological differences, or (b) a system which is adapted to deal with a particular type of diet.
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Answer the question based on the following context: Many veterans who were involved in the Persian Gulf theater of operations have had a variety of unexplained physical complaints, collectively called the Gulf War syndrome or similar names. There has been much debate on the issue and numerous publications, both in the medical and the lay press. A method for examining urinary sediment that was developed in an effort to identify nonculturable bacteria has been used in Gulf War veterans and was the basis for intensive antimicrobial therapy in many of them. We evaluated eight Gulf War veterans with complaints compatible with Gulf War syndrome. Subjects were from various parts of the United States. A detailed history and physical examination were performed. Urine was obtained before and after prostatic massage (men) or before and after pelvic examinations (women) and was tested by a previously described microscopic method as well as by culture and conventional Gram stain. Age- and sex-matched healthy control subjects were tested similarly and concurrently. Two female Gulf War veterans had findings of Candida albicans and Klebsiella pneumoniae by conventional culture. The same organism types were seen both by the special method and by conventional Gram stain. All other subjects and controls were completely indistinguishable.
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Question: Does examination of urinary sediment identify individuals with Gulf War syndrome?
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Examining the urinary sediment by this elaborate method does not differentiate persons with Gulf War syndrome from normal, healthy control subjects who were never in the Persian Gulf area.
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Answer the question based on the following context: To assess the function of the pylorus after pylorus-preserving pancreaticoduodenectomy (PPPD) done for periampullary or pancreatic cancer. Prospective, observational controlled clinical study. Teaching hospital, Italy. 17 patients who had undergone PPPD, and 15 healthy control subjects. Endoscopy to check for gastritis and marginal ulcers and 24 h-pH monitoring and 99mTc HIDA scintigraphy to detect jejunogastric reflux. Scintigraphy was also used to evaluate gastric and jejunal transit after a solid meal labelled with 99mTc colloid sulphur. Signs of delayed gastric emptying, jejunogastric reflux and gastric outlet obstruction in the short and long term. In the early postoperative period only 1 patient had delayed gastric emptying. In the long term, two patients had symptoms of dyspepsia and 8/11 showed alkaline reflux with persistent gastric pH more than 4 for more than 12 hours; 3 had histological signs of gastritis. There was no difference in gastric emptying compared with controls, but three patients had prolonged emptying time (T1/2 more than 85 minutes). Endoscopy findings correlated with pH monitoring results.
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Question: Is pyloric function preserved in pylorus-preserving pancreaticoduodenectomy?
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After PPPD, most patients have abnormal pyloric function, but it is clinically evident in only a small proportion.
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Answer the question based on the following context: It has been reported that severe cryptogenic chronic hepatitis may be a subgroup of autoimmune hepatitis. The aims of this study were to investigate the clinical features, liver function tests, human leukocyte antigens and response to immunosuppressive therapy in severe cryptogenic chronic hepatitis, and to compare the findings in such patients with those in patients with autoimmune hepatitis. History of alcohol and hepatotoxic drug intake, markers of metabolic liver disease, autoantibodies (antinuclear antibody, smooth muscle antibody, antibody to liver/kidney microsome type 1), and viral markers (HBsAg, HBV DNA, anti-HCV, HCV RNA) were negative in all severe cryptogenic chronic hepatitis patients (histological activity index>9 and alanine aminotransferase level>2 x normal). Fifteen cryptogenic patients (13 women; mean age, 33 +/- 16 years) and seven autoimmune patients (seven women; mean age, 28 +/- 3.9 years; five type 1; two type 2a) received prednisolone and azathioprine for at least 2 years. Cryptogenic chronic hepatitis patients were similar to patients with autoimmune hepatitis with respect to age, sex, clinical presentation, liver function tests and Knodell scores at admission. HLA phenotype frequencies were comparable between cryptogenic and autoimmune groups: BW6 (77% vs. 100%), DR4 (62% vs. 57%), and HLA B8 (15% vs. 43%). The rates of complete and partial remissions achieved during therapy were 87% vs. 57% and 13% vs. 29%, respectively (p>0.05).
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Question: Is severe cryptogenic chronic hepatitis similar to autoimmune hepatitis?
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The clinical, biochemical and HLA phenotypic features, and the responsiveness to immunosuppressive therapy in severe cryptogenic chronic hepatitis support the idea that it may be an autoimmune liver disease similar to autoimmune hepatitis.
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Answer the question based on the following context: Leptin, an adipose tissue-derived signalling factor encoded by the obese gene has been shown to be present as a 16-kDa protein in the blood of mice and humans. Resistance to leptin occurs in human obesity. Leptin has also been shown to associate with plasma insulin concentrations and there is currently considerable debate about the potential link between insulin resistance and resistance to leptin. In non-pregnant individuals, circulating leptin concentrations associate strongly with both total body fat mass and body mass index (BMI). In normal human pregnancy, the maternal fat stores increase to a peak in the late second trimester, before declining towards term as fat stores are mobilized to support the rapidly growing fetus. Insulin resistance increases during late pregnancy and is believed to be further enhanced in pregnancies complicated by pre-eclampsia. The aim of this study was to examine if leptin levels were altered in pregnancy and, if so, whether the pattern of change in circulating leptin related to previously established changes in fasting insulin concentrations or fat mass. We measured third trimester plasma leptin concentrations in 12 uncomplicated pregnant women, nine women with pre-eclampsia matched for age and booking BMI, and 18 non-pregnant women similarly matched. We also examined the longitudinal course of leptin concentrations occurring throughout gestation (from 10 weeks gestation and at five week intervals thereafter), in five normal pregnancies and two women with gestational-onset diabetes. Leptin concentrations were significantly higher in the normal pregnant women (37.1 microg/L, [15.4-117.0], geometric mean, [range]; p=0.049), and women with pre-eclampsia (45.3 microg/L, [21.3-98.4]; p=0.001), than in non-pregnant controls (17.85 microg/L, [1.3-36.5]), however, there was no significant difference between uncomplicated and pre-eclamptic pregnancies (p=0.22). On examination of the longitudinal course of leptin concentrations occurring throughout gestation, in all seven women plasma leptin concentrations initially increased relative to booking (10 weeks) concentrations, but did so by varying amounts (ranging between 30-233%). Significantly, however, in all seven women plasma leptin concentrations peaked at around 20-30 weeks of gestation before declining towards term.
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Question: Leptin levels in pregnancy: marker for fat accumulation and mobilization?
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On the basis of these observations, we postulate that plasma leptin levels increase significantly in human pregnancies and that the pattern of change in circulating leptin parallels the process of fat accumulation and mobilization.
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Answer the question based on the following context: Our purpose was to determine whether the identification of subtle anomalies further improves Down syndrome detection over standard ultrasonographic biometry and the detection of gross morphologic defects. The screening efficiency of clinodactyly, dilated renal pelvis (>or =4 mm), echogenic bowel, mild ventriculomegaly (>or =10 to 15 mm), and two-vessel cord was determined prospectively in midtrimester fetuses at amniocentesis. The screening efficiency of increased nuchal thickness and shortened long-bone length (standard biometry) and gross morphologic defects was determined for comparison. Multiple backward stepwise regression analysis was used to determine which subtle anomalies significantly correlated with Down syndrome detection rate and whether they increased Down syndrome detection over that with standard biometry and morphologic defects. Although all subtle anomalies except two-vessel cord correlated with the presence of Down syndrome on univariate analysis, only echogenic bowel (Wald chi2 = 15.0211, p = 0.0001) and clinodactyly (Wald chi2 = 9.4273, p = 0.002) persisted in regression analysis of the subtle anomaly group. When either of the above-described anomalies was present, the detection rate for Down syndrome was 28.6%, p<0.00001. For the combination of standard biometry (either increased nuchal thickness or short humerus) or gross anatomic defect, Down syndrome detection rate was 53.3% (p<0.00000001). This increased to 63.2% (p<0.00000001) when subtle anatomic defects (either echogenic bowel or clinodactyly) were included in the definition of an abnormal sonogram.
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Question: Subtle ultrasonographic anomalies: do they improve the Down syndrome detection rate?
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Subtle anomalies, of which echogenic bowel and clinodactyly are the most significant, further increase Down syndrome screening efficiency over standard biometry or the finding of gross anatomic defect. Our data appear to support the addition of subtle anomaly findings to ultrasonographic screening for Down syndrome.
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Answer the question based on the following context: Our purpose was to determine the significance of finding an isolated clubfoot on a prenatal sonogram. All fetuses found to have an isolated congenital clubfoot over a 9-year period were retrospectively identified. Fetuses with associated anomalies were excluded. Review of medical records for obstetric and neonatal outcome and pathologic and cytogenic results were tabulated. Eighty-seven fetuses were identified from our database as having isolated clubfoot on prenatal ultrasonography, with complete follow-up available for 68 fetuses. Sixty of the 68 fetuses were confirmed as having clubfoot after delivery (false-positive rate = 11.8%). The male/female ratio was 2:1. Four fetuses (5.9%) had abnormal karyotypes: 47,XXY, 47,XXX, trisomy 18, and trisomy 21. Nine fetuses had hip or other limb abnormalities noted after birth. Other anomalies not detected until delivery included a unilateral undescended testis, ventriculoseptal defects (n = 2), hypospadias (n = 2), early renal dysplasia, mild posterior urethral valves, and a two-vessel cord. Five of the 68 patients (including those with aneuploidy) had pregnancy terminations. Eleven patients were delivered preterm.
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Question: The significance of prenatally identified isolated clubfoot: is amniocentesis indicated?
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Karyotypic evaluation is recommended when isolated clubfoot is identified on prenatal sonogram because other subtle associated malformations may not be detected ultrasonographically in the early second trimester.
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Answer the question based on the following context: The purpose of this study was to investigate the popular belief that the incidence of odontogenic cellulitis is weather-related. Two meteorologic parameters were examined: temperature and atmospheric pressure. To test the hypothesis being studied, a retrospective cohort study design was used. Medical reports of all patients with serious odontogenic cellulitis who were treated at the Salpêtrière University Hospital between January 1, 1995, and December 31, 1995, (a total of 301 cases) were evaluated in relation to the weather. Hypothesizing that the incidence of odontogenic cellulitis was constant over a period of 1 year, the authors calculated the probability of observed incidence for each month over a 12-month period. The mean number of cases of odontogenic cellulitis (+/- standard error of the mean) for days on which (1) the temperature was within the same 2 degrees -C (3.6 degrees -F) interval and (2) the atmospheric pressure was within the same 3-hPa (2.25-mmHg) interval was also calculated. When the monthly incidence of odontogenic cellulitis and either the average temperature or the average atmospheric pressure for each month were examined together, fluctuation in the former seemed to be independent of the latter. Similarly, when we calculated the mean number of cases of odontogenic cellulitis for several intervals of temperature and atmospheric pressure without taking the calendar into account, no direct relationship could be observed.
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Question: Do temperature and atmospheric pressure affect the incidence of serious odontogenic infection?
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The results of the study suggest that the occurrence of odontogenic cellulitis is not influenced by the weather, at least insofar as weather is measured by temperature and atmospheric pressure.
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Answer the question based on the following context: Our purpose was to evaluate the ability of FDG PET to differentiate recurrent tumor from posttherapy radiation necrosis. MR images, PET scans, and medical records of 84 consecutive patients with a history of a treated intracranial neoplasm were evaluated retrospectively. In all patients, recurrent tumor or radiation necrosis was suggested by clinical or MR findings. Metabolic activity of the PET abnormality was compared qualitatively with normal contralateral gray and white matter. PET findings were confirmed histologically in 31 patients. With contralateral white matter as the standard of comparison, the PET scan sensitivity and specificity were found to be 86% and 22%, respectively. With contralateral gray matter as the reference standard, the sensitivity and specificity became 73% and 56%, respectively. Overall, nearly one third of the patients would have been treated inappropriately in either scheme had the PET scan been the sole determinant of therapy.
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Question: Differentiating recurrent tumor from radiation necrosis: time for re-evaluation of positron emission tomography?
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Our data suggest that the ability of FDG PET to differentiate recurrent tumor from radiation necrosis is limited. Both false-positive and false-negative PET scan results contributed to unacceptably low sensitivity and specificity values.
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Answer the question based on the following context: Coronary artery bypass graft surgery (CABG) compared with percutaneous coronary intervention (PCI) reduces mortality in patients with diabetes mellitus. However, prior trials compared CABG with balloon angioplasty or older generation stents, and it is not known if the gap between CABG and PCI can be reduced by newer generation drug-eluting stents. PUBMED/EMBASE/CENTRAL search for randomized trials comparing mode of revascularization in patients with diabetes mellitus. Primary outcome was all-cause mortality. Secondary outcomes were myocardial infarction, repeat revascularization, and stroke. Mixed treatment comparison analyses were performed using a random-effects Poisson regression model. Sixty-eight randomized trials that enrolled 24 015 diabetic patients with a total of 71 595 patient-years of follow-up satisfied our inclusion criteria. When compared with CABG (reference rate ratio [RR]=1.0), PCI with paclitaxel-eluting stent (RR=1.57 [1.15-2.19]) or sirolimus-eluting stent (RR=1.43 [1.06-1.97]) was associated with an increase in mortality. However, PCI with cobalt-chromium everolimus-eluting stent (RR=1.11 [0.67-1.84]) was not associated with a statistically significant increase in mortality. When compared with CABG, there was excess repeat revascularization with PCI, which progressively declined from plain old balloon angioplasty (341% increase) to bare metal stent (218% increase) to paclitaxel-eluting stent (81% increase) and to sirolimus-eluting stent (47% increase). However, for PCI with cobalt-chromium everolimus-eluting stent (RR=1.31 [0.74-2.29]), the excess repeat revascularization was not statistically significant although the point estimate favored CABG. CABG was associated with numerically higher stroke.
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Question: Outcomes with coronary artery bypass graft surgery versus percutaneous coronary intervention for patients with diabetes mellitus: can newer generation drug-eluting stents bridge the gap?
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In patients with diabetes mellitus, evidence from indirect comparison shows similar mortality between CABG and PCI using cobalt-chromium everolimus-eluting stent. CABG was associated with numerically excess stroke and PCI with cobalt-chromium everolimus-eluting stent with numerically increased repeat revascularization. This hypothesis needs to be tested in future trials.
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Answer the question based on the following context: Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic cause of chronic kidney disease (CKD) in adults. It is associated with both inter- and intra- familial variability, which can be explained by genetic heterogeneity, modifier genes and a genetic background. NGAL, a 25-kDa protein released from tubular cells after harmful stimuli, is a new biomarker. Recent studies suggest a possible role for NGAL in CKD. The aim of this study was to investigate NGAL in the context of genotype-phenotype correlation in ADPKD. We measured plasma NGAL, creatinine (Cr), and urea in 18 ADPKD patients on dialysis (PKD1_TRS), 29 of their relatives with CKD stage II-III (PKD1_AMB), 33 wild-type relatives (PKD1_WT), 12 subjects in CKD stage II-III with confirmed mutation in PKD2 and 30 healthy controls (CTR). Cr, urea and CysC were measured according to standard methods. Plasma NGAL was measured using point-of-care test. Estimated glomerular filtration rate (eGFR) was calculated with a 4-variable standardized-MDRD formula. Plasma NGAL, CysC, Cr and urea levels in PKD1_TRS were significantly higher than CTR (all with p<0,001). PKD1_TRS pts had significantly higher NGAL, CysC, Cr and Urea levels compared to PKD1_AMB and PKD1_WT. PKD1_AMB pts had higher NGAL, CysC, Urea and Cr levels compared to PKD1_WT relatives. NGAL CysC, Cr and urea values were similar between PKD1_WT and CTR (p>0.05). NGAL levels were not significantly different in ADPKD patients in CKD stage II-III with mutation in PKD1 or PKD2 (86 pg/mL, IQR 60-109 vs 82 pg/mL,IQR 63-169). NGAL correlated well (all with p<0.001) with CysC (r=0.95), Cr (r=0.89), urea (r=0.76) and inversely with eGFR (r=-0.81). A strong correlation between CysC and residual renal function was observed (CysC/eGFR: r=-0.86; CysC/Cr: r=0.7; CysC/Urea: r=0.79, all with p<0.001).
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Question: Genotype-phenotype correlation in ADPKD: a possible role for NGAL?
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This is the first study to evaluate plasma NGAL in the context of genotype-phenotype correlation. In ADPKD, NGAL levels were higher in patients already on Renal Replacement Therapy (RRT) compared to their affected relatives not on RRT. WT relatives had normal NGAL and CysC levels: these could be considered a better CTR group because they share the same genetic background with ADPKD subjects. No differences were found in NGAL levels between PKD1 and PKD2 patients in CKD stage II-III. Furthermore, the results indicate that NGAL correlates closely with renal function and CysC levels.
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Answer the question based on the following context: Developmental dysplasia of the hip (DDH) is rarely encountered in the native sub-Saharan African population. We present a retrospective review of the incidence of symptomatic DDH in Malawi and a systematic review of the role of back-carrying as a potential influence of prevalence in this population group. We retrospectively reviewed the diagnosis and management of all infants seen at the Beit CURE International Hospital, Malawi and its mobile clinics, from November 2002 to September 2012. In addition, methodical review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist and algorithm was performed. A total of 40,683 children aged less than 16 years were managed at our institute over a 10-year period, of which 9842 children underwent surgery. No infant presented with, or underwent surgical intervention, for symptomatic DDH.
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Question: Back-carrying infants to prevent developmental hip dysplasia and its sequelae: is a new public health initiative needed?
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The majority of mothers in Malawi back-carry their infants during the first 2 to 24 months of life, in a position that is similar to that of the Pavlik harness. We believe this to be the prime reason for the low incidence of DDH in the country. In addition, there is established evidence indicating that swaddling, the opposite position to back-carrying, causes an increase in the incidence of DDH. There is a need for the establishment of a large clinical trial into back-carrying and prevention of DDH in non-African population groups.
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Answer the question based on the following context: To evaluate the training needs and awareness of childhood sexual abuse amongst clinical staff taking cervical screening samples in one inner city primary care trust. Studies exploring sexual abuse and nonparticipation in cervical screening have demonstrated that women can experience re-traumatisation if care during examinations is insensitive to their particular needs. This was a mixed methods, service evaluation in three phases. A literature review, a questionnaire to cervical screening staff in an inner city primary care trust and a focus group of four staff drawn from questionnaire respondents to explore themes raised in the questionnaire data. Data analysis of both quantitative and qualitative data showed that clinical staff underestimated the frequency of childhood sexual abuse although they were aware of the difficulties and reluctance some women experience undergoing gynaecological examinations. When women did disclose childhood sexual abuse or when staff suspected a history of childhood sexual abuse, staff reported feeling unsure of how they should proceed. There was no support or clinical supervision, and unmet training needs were identified.
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Question: Cervical screening and the aftermath of childhood sexual abuse: are clinical staff trained to recognise and manage the effect this has on their patients?
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Nurses expressed anxiety around the potential of the screening test to cause more harm than good and at their inability to provide more help than listening. Staff wanted support and further training after completing their cervical screening training course to assist in their provision of sensitive care to patients who have experienced childhood sexual abuse.
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Answer the question based on the following context: This study explored the relationship between propensity for conscious control of movement (assessed by the Movement-Specific Reinvestment Scale) and self-reported knee pain. Cross-sectional study. General population. Adults aged 18 to 55 years of age. Participants completed the movement-specific reinvestment scale and a self-report questionnaire on knee pain at the same time on one occasion. Data was collected on 101 adults of whom 34 (33.7%) self-reported knee pain. Mean scores on the conscious motor processing subscale of the movement-specific reinvestment scale, but not the movement self-consciousness subscale, were significantly higher for participants who reported knee pain within the previous year compared with those who did not (mean difference 3.03; t-test 2.66, df = 97, P = 0.009; 95% confidence interval (CI) 0.77 to 5.30). The association between self-reported knee pain and propensity for conscious motor processing was still observed, even after controlling for movement self-consciousness subscale scores, age, gender and body mass index (adjusted odds ratio 1.16, 95% CI 1.04 to 1.30).
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Question: Do people who consciously attend to their movements have more self-reported knee pain?
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Propensity for conscious control of movement may play a role in knee pain.
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Answer the question based on the following context: Rates of disability pension are greatly increased among people with low education. This study examines the extent to which associations between education and disability pensions might be explained by differences in working conditions. Information on individuals at age 13 years was used to assess confounding of associations. Two nationally representative samples of men and women born in 1948 and 1953 in Sweden (22 889 participants in total) were linked to information from social insurance records on cause (musculoskeletal, psychiatric, and other) and date (from 1986-2008) of disability pension. Education data were obtained from administrative records. Occupation data were used for measurement of physical strain at work and job control. Data on paternal education, ambition to study, and intellectual performance were collected in school. Women were found to have higher rates of disability pension than men, regardless of diagnosis, whereas men had a steeper increase in disability pension by declining educational level. Adjustment of associations for paternal education, ambition to study, and intellectual performance at age 13 had a considerable attenuating effect, also when disability pension with a musculoskeletal diagnosis was the outcome. Despite this, high physical strain at work and low job control both contributed to explain the associations between low education and disability pensions in multivariable models.
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Question: Do working conditions explain the increased risks of disability pension among men and women with low education?
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Working conditions seem to partly explain the increased rate of disability pension among men and women with lower education even though this association does reflect considerable selection effects based on factors already present in late childhood.
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Answer the question based on the following context: In public hospitals, the work-up and surgery for patients with appendicitis is predominantly performed by surgical registrars, whereas in private hospitals, it is performed by consultants. This study aims to demonstrate the difference, if any, in the demographics, work-up, management and complication rate of patients in these two groups. This was a retrospective review of all patients who underwent laparoscopic appendicectomy at a major public hospital and major private hospital over the same 13 months. Data included demographics, admission details, work-up, length of stay, time to surgery, histology and complications. Fisher's exact test and the unpaired t-test were performed to look at the statistical difference between these two groups. Total laparoscopic appendicectomies were 164 (public) and 105 (private). Median waiting times to operation were 13 and 9.5 h, respectively. Histological findings of appendicitis/neoplasia/normal appendix were 83.5/3.0/13.4% and 81.9/1.9/16.2%. Histological findings of gangrene or perforation were 26.2% and 11.6% (P = 0.0081). The proportion of those who had surgery more than 24 h after admission was 12.2% and 4.8% (P = 0.0517). Rates of pelvic collection were 1.2% and 1.9% (P = 0.6448), wound infection rates were 2.4% and 1.9% (P = 1) and overall complication rates were 7.3% and 8.6% (P = 0.8165). Mean operative time was 49.79 min for consultants and 67.98 min for registrars (P<0.0001).
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Question: Laparoscopic appendicectomy: an operation for all trainees but does the learning curve continue into consultanthood?
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Consultants are faster at laparoscopic appendicectomies than registrars. A consultant lead service in a private hospital has earlier operation times and less patients ending up with gangrenous or perforated appendicitis but does not alter complication rates.
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Answer the question based on the following context: Enteroviruses are seasonally prevalent each year in Southeast Asia. Elevated C-reactive protein (CRP) levels have been noted in minor populations of patients, and antibiotics may be prescribed under the impression of a suspected bacterial infection. This prescription might be inappropriate, resulting in further bacterial resistance and medical expense. The aim of this study was to delineate how effective antibiotics are for children suffering from enterovirus infection complicated with a high CRP level. The medical records of children hospitalized between January 2008 and December 2012 with herpangina or hand, foot and mouth disease were reviewed retrospectively. The children enrolled were divided into three groups, A, B, and C, by CRP level, which were<40, 40-80, and ≥ 80 mg/l, respectively. A case-control study of group C divided into subgroups according to the prescription of antibiotics for at least 24h during the admission was conducted for further analysis. A total 3566 cases were identified; 214 were in group C and 71.0% of them received a prescription for antibiotics. There was a linear trend between a relatively higher CRP level and a higher proportion of antibiotics prescribed in the three groups (p=0.001). In the case-control study, there were no significant differences in age, sex, mean CRP, or febrile days. However, a relatively longer stay of hospitalization was recorded in the subgroup with an antibiotic prescription (p=0.020).
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Question: Are antibiotics beneficial to children suffering from enterovirus infection complicated with a high C-reactive protein level?
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The present study indicated that antibiotics might not be beneficial in treating these patients, even those with a high CRP level. Clinicians should be more prudent in antibiotic use when no obvious evidence of bacterial infection is found.
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Answer the question based on the following context: Mast cell tryptase has recently been reported to be involved in atherosclerotic plaque destabilization. However, the results of these reports are conflicting. The aim of this study was to characterize the role of tryptase as a prognostic marker of patient cardiovascular complexity in acute coronary syndrome (ACS). Furthermore, its association with an angiographic scoring system [defined by the SYNergy between percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent and the cardiac surgery (SYNTAX) score] was examined. The serum tryptase was measured at admission in 65 consecutive ACS patients and in 35 healthy controls. In the patients with ACS, a composite measure of clinical and angiographic patient cardiovascular complexity was indicated by two of the following: clinical adverse events at hospitalization, at least 2 epicardial coronary arteries involved in the atherosclerotic disease, more than 1 stent implanted or more than 2 coronary artery disease risk factors. The tryptase measurements were lower in patients without the composite measure (p<0.0005). Linear regression showed a significant relationship between tryptase levels and the SYNTAX score (SX-score). Conversely, high-sensitivity troponin values did not correlate with either the composite outcome or the SX-score. The predictive accuracy of serum tryptase for the composite outcome was set at the cut-off point of 5.22 ng/ml (sensitivity 81% and specificity 95.7%).
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Question: Serum tryptase: a new biomarker in patients with acute coronary syndrome?
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In ACS patients, serum tryptase levels at admission may predict patient cardiovascular complexity more reliably than currently known biomarkers. Further studies are needed to demonstrate the long-term prognostic role of this biomarker in ACS.
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Answer the question based on the following context: Inflammatory myofibroblastic tumors (IMFTs) are uncommon neoplasms of the central nervous system (CNS) of intermediate grade biologic potential. Anaplastic lymphoma kinase (ALK-1), a diagnostic marker of anaplastic large cell lymphoma, is also expressed in a subset of IMFTs and appears to have prognostic significance. Though, few studies have evaluated expression of ALK-1 in IMFTs of the CNS. This retrospective study was undertaken to evaluate the expression of ALK-1 expression in IMFT of CNS by immunohistochemistry and correlate with the clinical, radiological and pathologic features. Five cases diagnosed as IMFT/inflammatory pseudotumour/plasma cell granuloma, diagnosed in CNS over 10 year period (1998-2007) were retrieved from the archives of Department of Neuropathology of a tertiary referral center. The clinical profile and imaging features were collected from the case records. Hematoxylin and eosin stained sections were reviewed with immunohistochemistry for smooth muscle actin (SMA), vimentin, desmin, ALK-1, p53, MIB-1, CD68, leukocyte common antigen, CD3, and CD20. All five cases of IMFTs presented as dural-based space occupying or en-plaque lesions. Histologically, four cases had combined plasma cell granuloma-fibrous histiocytoma morphology, and one had fibrous histiocytoma-like morphology. Immunohistochemically, SMA was strongly positive in spindle cell component of the tumors confirming diagnosis. ALK-1 expression could not be detected by immunohistochemistry in any of the cases.
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Question: Absence of anaplastic lymphoma kinase-1 expression in inflammatory myofibroblastic tumors of the central nervous system: does it signify a different nosologic entity from its systemic counterpart?
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Further studies analyzing ALK-1 gene mutation and rearrangements are required to determine pathogenetic role, if any, in CNS IMFTs.
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Answer the question based on the following context: Achievement of euvolemia is a fundamental challenge in the peritoneal dialysis (PD) population. Bioimpedance spectroscopy (BIS) is one of the best techniques for routine assessment of hydration status (HS) in PD, but in recent years, the role of brain natriuretic peptides (BNP) in the assessment of volume status has gained interest. The aim of this study was to investigate the relation between BNP and volume status as measured by BIS in PD patients and to assess how these variables correlate according to the time that a patient has been on PD. We prospectively studied 68 PD patients from whom measurements of BNP and assessments of HS by BIS were performed every 3 months. Three groups were defined based on HS: group A, measurements of HS<-1.1 liters (underhydrated); group B, measurements of HS between -1.1 and +1.1 liters (normohydrated), and group C, measurements of HS>+1.1 liters (overhydrated). Measurements were also separated according to the time on PD (<6 vs. ≥6 months). Correlation between HS and BNP was performed using Spearman's correlation. We performed a total of 478 measurements of HS and BNP. There was a statistically significant difference in BNP (p<0.001) among three HS groups, with higher levels of BNP detected in overhydrated patients. We found a positive correlation between HS and BNP (rs = 0.28; p<0.001) that seemed stronger in the first 6 months on PD (rs = 0.42; p = 0.006).
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Question: Is brain natriuretic peptide a reliable biomarker of hydration status in all peritoneal dialysis patients?
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BNP correlated positively with fluid overload measured by HS, and this correlation was stronger in the first 6 months on PD.
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Answer the question based on the following context: Cytoblocks (CBs), or cell blocks, provide additional morphological detail and a platform for immunocytochemistry (ICC) in cytopathology. The Cellient(™) system produces CBs in 45 minutes using methanol fixation, compared with traditional CBs, which require overnight formalin fixation. This study compares Cellient and traditional CB methods in terms of cellularity, morphology and immunoreactivity, evaluates the potential to add formalin fixation to the Cellient method for ICC studies and determines the optimal sectioning depth for maximal cellularity in Cellient CBs. One hundred and sixty CBs were prepared from 40 cytology samples (32 malignant, eight benign) using four processing methods: (A) traditional; (B) Cellient (methanol fixation); (C) Cellient using additional formalin fixation for 30 minutes; (D) Cellient using additional formalin fixation for 60 minutes. Haematoxylin and eosin-stained sections were assessed for cellularity and morphology. ICC was assessed on 14 cases with a panel of antibodies. Three additional Cellient samples were serially sectioned to determine the optimal sectioning depth. Scoring was performed by two independent, blinded reviewers. For malignant cases, morphology was superior with Cellient relative to traditional CBs (P < 0.001). Cellularity was comparable across all methods. ICC was excellent in all groups and the addition of formalin at any stage during the Cellient process did not influence the staining quality. Serial sectioning through Cellient CBs showed optimum cellularity at 30-40 μm with at least 27 sections obtainable.
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Question: Automated Cellient(™) cytoblocks: better, stronger, faster?
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Cellient CBs provide superior morphology to traditional CBs and, if required, formalin fixation may be added to the Cellient process for ICC. Optimal Cellient CB cellularity is achieved at 30-40 μm, which will impact on the handling of cases in daily practice.
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Answer the question based on the following context: Pharmacotherapy with vitamin K antagonists (VKA) and low-molecular-weight heparins (LMWH) is a major cost driver in the treatment of venous thromboembolism (VTE). Major representatives of anticoagulants in Europe include: acenocoumarol and warfarin (VKA), enoxaparin, dalteparin, nadroparin, reviparin, parnaparin and bemiparin (LMWH). Aim of this report is to measure and critically assess the utilization of anticoagulants and other resources used in the out-patient treatment of VTE in Poland. To confront the findings with available scientific evidence on pharmacological and clinical properties of anticoagulants. The perspectives of the National Health Fund (NHF) and the patients were adopted, descriptive statistics methods were used. The data were gathered at the NHF and the clinic specialized in treatment of coagulation disorders. Non-pharmacological costs of treatment were for the NHF 1.6 times higher with VKA than with LMWH. Daily cost of pharmacotherapy with LMWH turned out higher than with VKA (234 times for the NHF, 42 times per patient). Within both LMWH and VKA the reimbursement due for the daily doses of a particular medication altered in the manner inversely proportional to the level of patient co-payment. Utilization of long-marketed and cheap VKA was dominated by LMWH, when assessed both through the monetary measures and by the actual volume of sales. Pharmaceutical reimbursement policy favored the more expensive equivalents among VKA and LMWH, whereas in the financial terms the patients were far better off when remaining on a more expensive alternative.
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Question: Are pharmacological properties of anticoagulants reflected in pharmaceutical pricing and reimbursement policy?
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The pharmaceutical pricing and reimbursement policy of the state should be more closely related to the pharmacological properties of anticoagulants.
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Answer the question based on the following context: Sleep disturbances are frequently observed in rheumatic diseases including systemic lupus erythematosus (SLE). This study aimed at evaluating the prevalence of insomnia, poor sleep quality and their determinants in a cohort of SLE patients. Eighty-one consecutive SLE female patients were evaluated in a cross-sectional study. The Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), the Beck Depression Inventory (BDI) and the Self-rating Anxiety Scale (SAS) were administered. Patients with previous diagnosis of obstructive sleep apnea or restless legs syndrome were excluded. Fifty-three women with hypertension (without SLE) were enrolled as control group (H). In the SLE cohort poor sleep quality (65.4% vs 39.6%, p<0.01) and difficulty in maintaining sleep and/or early morning awakening (65.4% vs 22.6%, p<0.001), but not insomnia (33.3% vs 22.6%, p = ns), were more prevalent than in H. Depressive symptoms were present in 34.6% of SLE vs 13.2% H patients (p<0.001) while state anxiety was more common in H patients (H 35.8% vs SLE 17.3%, p<0.005). SLE was associated with a 2.5-times higher probability of presenting poor sleep quality in comparison to H (OR 2.5 [CI 1.21-5.16]). After adjusting for confounders, both depressive symptoms (OR 4.4, [1.4-14.3]) and use of immunosuppressive drugs (OR 4.3 [CI 1.3-14.8]) were significantly associated with poor sleep quality in SLE patients. Furthermore, poor sleep quality was not associated either with disease duration or activity.
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Question: Poor sleep quality in systemic lupus erythematosus: does it depend on depressive symptoms?
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In a cohort of SLE women, insomnia and poor sleep quality, especially difficulties in maintaining sleep, were common. Depressive symptoms might be responsible for the higher prevalence of poor sleep quality in SLE.
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Answer the question based on the following context: From June 2011 to April 2013, 99 patients who were diagnosed with GC or adenocarcinoma of the gastroesophageal junction (type II or III) and needed surgical management were enrolled. They all underwent gastrectomy by the same operators [35 undergoing total gastrectomy (TG) plus Roux-en-Y reconstruction, 34 distal gastrectomy (DG) plus Billroth I reconstruction, and 30 proximal gastrectomy (PG) plus gastroesophagostomy]. We collected and analyzed their gastrointestinal juice and tissues from the pre-operational day to the 5(th) day post-operation, and 6 mo post-surgery. Gastric pH was detected with a precise acidity meter. Gastric juice contents including potassium, sodium and bicarbonate ions, urea nitrogen, direct and indirect bilirubin, and bile acid were detected using Automatic Biochemical Analyzer. Data regarding tumor size, histological type, tumor penetration and tumor-node-metastasis (TNM) stage were obtained from the pathological records. Reflux symptoms pre- and 6 mo post-gastrectomy were evaluated by reflux disease questionnaire (RDQ) and gastroesophageal reflux disease questionnaire (GERD-Q). SPSS 16.0 was applied to analyze the data. Before surgery, gastric pH was higher than the threshold of hypoacidity (4.25 ± 1.45 vs 3.5, P = 0.000), and significantly affected by age, tumor size and differentiation grade, and potassium and bicarbonate ions; advanced malignancies were accompanied with higher pH compared with early ones (4.49 ± 1.31 vs 3.66 ± 1.61, P = 0.008). After operation, gastric pH in all groups was of weak-acidity and significantly higher than that pre-gastrectomy; on days 3-5, comparisons of gastric pH were similar between the 3 groups. Six months later, gastric pH was comparable to that on days 3-5; older patients were accompanied with higher total bilirubin level, indicating more serious reflux (r = 0.238, P = 0.018); the TG and PG groups had higher RDQ (TG vs DG: 15.80 ± 5.06 vs 12.26 ± 2.14, P = 0.000; PG vs DG: 15.37 ± 3.49 vs 12.26 ± 2.14, P = 0.000) and GERD-Q scores (TG vs DG: 10.54 ± 3.16 vs 9.15 ± 2.27, P = 0.039; PG vs DG: 11.00 ± 2.07 vs 9.15 ± 2.27, P = 0.001) compared with the DG group; all gastric juice contents except potassium ion significantly rose; reflux symptom was significantly associated with patient's body mass index, direct and indirect bilirubin, and total bile acid, while pH played no role.
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Question: Should peri-gastrectomy gastric acidity be our focus among gastric cancer patients?
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Acidity is not an important factor causing unfitness among GC patients. There is no need to further alkalify gastrointestinal juice both pre- and post-gastrectomy.
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Answer the question based on the following context: Disproportionate access to unhealthy foods in poor or minority neighborhoods may be a primary determinant of obesity disparities. We investigated whether fast-food access varies by Census block group (CBG) percent black and poverty. We measured the average driving distance from each CBG population-weighted centroid to the five closest top ten fast-food chains and CBG percent black and percent below poverty. Among 209,091 CBGs analyzed (95.1% of all US CBGs), CBG percent black was positively associated with fast-food access controlling for population density and percent poverty (average distance to fast-food was 3.56 miles closer (95% CI: -3.64, -3.48) in CBGs with the highest versus lowest quartile of percentage of black residents). Poverty was not independently associated with fast-food access. The relationship between fast-food access and race was stronger in CBGs with higher levels of poverty (p for interaction<0.0001).
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Question: Do minority and poor neighborhoods have higher access to fast-food restaurants in the United States?
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Predominantly black neighborhoods had higher access to fast-food while poverty was not an independent predictor of fast-food access.
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Answer the question based on the following context: A substantial number of children exposed to gestational opioids have neurodevelopmental, behavioral and cognitive problems. Opioids are not neuroteratogens but whether they affect the developing brain in more subtle ways (for example, volume loss) is unclear. We aimed to determine the feasibility of using magnetic resonance imaging (MRI) to assess volumetric changes in healthy opioid-exposed infants. Observational pilot cohort study conducted in two maternity hospitals in New South Wales, Australia. Maternal history and neonatal urine and meconium screens were obtained to confirm drug exposure. Volumetric analysis of MRI scans was performed with the ITK-snap program. Scans for 16 infants (mean (s.d.) gestational age: 40.9 (1.5) weeks, birth weight: 3022.5 (476.6) g, head circumference (HC): 33.7 (1.5 cm)) were analyzed. Six (37.5%) infants had HC<25th percentile. Fourteen mothers used methadone, four used buprenorphine and 11 used more than one opioid (including heroin, seven). All scans were structurally normal whole brain volumes (357.4 (63.8)) and basal ganglia (14.5 (3.5)) ml were significantly smaller than population means (425.4 (4.8), 17.1 (4.4) ml, respectively) but lateral ventricular volumes (3.5 (1.8) ml) were larger than population values (2.1(1.5)) ml.
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Question: Do maternal opioids reduce neonatal regional brain volumes?
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Our pilot study suggests that brain volumes of opioid-exposed babies may be smaller than population means and that specific regions, for example, basal ganglia, that are involved in neurotransmission, may be particularly affected. Larger studies including correlation with neurodevelopmental outcomes are warranted to substantiate this finding.
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Answer the question based on the following context: A physician's advice is among the strongest predictors of efforts toward weight management made by obese patients, yet only a minority receives such advice. One contributor could be the physician's failure to recognize true obesity. The objectives of this study were to assess physicians' ability to recognize obesity and to identify factors associated with recognition and documentation of obesity. Internal medicine residents and attending physicians at three academic urban primary care clinics and their adult patients participated in a study using recognition and documentation of patient obesity as the main measures. A total of 52 physicians completed weight assessments for 400 patients. The mean patient age was 51 years, 56% were women, 77% were Hispanic, and 67% had one or more obesity-related comorbidity. There were 192 (48%) patients, of whom 66% were correctly identified by physicians as being obese, 86% of those with a body mass index (BMI) ≥ 35, but only 49% of those with a BMI of 30 to 34.9 (P<0.0001). Fewer obese Hispanic patients were identified than were non-Hispanic patients (62% vs 76%; P = 0.03). No physician characteristics were significantly associated with recognition of obesity. Physicians documented obesity as a problem for 51% of patients. Attending physicians documented obesity more frequently than did residents (64% vs 43%, odds ratio 2.5, 95% confidence interval 1.3-4.6) and normal-weight physicians documented obesity more frequently than overweight physicians (58% vs 41%, odds ratio 2.0, 95% confidence interval 1.0-4.0). Documentation was more common for patients with a BMI ≥ 35 and for non-Hispanics. Documentation was not more common for patients with obesity-related comorbidities.
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Question: Do physicians underrecognize obesity?
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Physicians have difficulty recognizing obesity unless patients' BMI is ≥ 35. Training physicians to recognize true obesity may increase rates of documentation, a first step toward treatment.
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Answer the question based on the following context: Many aspects in the management of acute upper gastrointestinal bleeding rely on pre-esophagogastroduodenoscopy (EGD) stratification of patients likely to exhibit high-risk stigmata (HRS); however, data predicting the presence of HRS are lacking. To determine clinical and laboratory predictors of HRS at the index EGD in patients presenting with acute upper gastrointestinal bleeding using retrospective data from a validated national database - the Canadian Registry in Upper Gastrointestinal Bleeding and Endoscopy registry. methods: Relevant clinical and laboratory parameters were evaluated. HRS was defined as spurting, oozing, nonbleeding visible vessel or adherent clot after vigorous irrigation. Multivariable modelling was used to identify predictors of HRS including age, sex, hematemesis, use of antiplatelet agents, American Society of Anesthesiologists (ASA) classification, nasogastric tube aspirate, hemoglobin level and elapsed time from the onset of bleeding to EGD. Of the 1677 patients (mean [± SD] age 66.2 ± 16.8 years; 38.3% female), 28.7% had hematemesis, 57.8% had an ASA score of 3 to 5, and the mean hemoglobin level was 96.8 ± 27.3 g⁄L. The mean time from presentation to endoscopy was 22.2 ± 37.5 h. The best fitting multivariable model included the following significant predictors: ASA score 3 to 5 (OR 2.16 [95% CI 1.71 to 2.74]), a shorter time to endoscopy (OR 0.99 [95% CI 0.98 to 0.99]) and a lower initial hemoglobin level (OR 0.99 [95% CI 0.99 to 0.99]).
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Question: Can the presence of endoscopic high-risk stigmata be predicted before endoscopy?
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A higher ASA score, a shorter time to endoscopy and lower initial hemoglobin level all significantly predicted the presence of endoscopic HRS. These criteria could be used to improve the optimal selection of patients requiring more urgent endoscopy.
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Answer the question based on the following context: Physical activity is mandatory if patients are to remain healthy and independent after stroke. Maintenance of motor function, tone, grip strength, balance, mobility, gait, independence in personal and instrumental activities of daily living, health-related quality-of-life and an active lifestyle 4 years post-stroke. A prospective randomized controlled trial. Four years post-stroke, 37 of the 75 participating persons were eligible for follow-up; 19 (54.3%) from the intensive exercise group and 18 (45%) from the regular exercise group. Both groups were performing equally well with no significant differences in total scores on the BI (p = 0.3), MAS (p = 0.4), BBS (p = 0.1), TUG (p = 0.08), 6MWT (p = 0.1), bilateral grip strength (affected hand, p = 0.8; non-affected hand, p = 0.9) nor in the items of NHP (p > 0.005). Independence in performing the IADL was 40%, while 60% had help from relatives or community-based services.
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Question: Physiotherapy and physical functioning post-stroke: exercise habits and functioning 4 years later?
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This longitudinal study shows that persons with stroke in two groups with different exercise regimes during the first year after stroke did not differ in long-term outcomes. Both groups maintained function and had a relatively active life style 4 years after the acute incident. The results underline the importance of follow-up testing and encouragement to exercise, to motivate and sustain physical activity patterns, to maintain physical function, not only in the acute but also in the chronic phase of stroke.
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Answer the question based on the following context: Despite numerous evidence-based guidelines (EBGs) being developed to manage the symptom burden associated with cancer and chemotherapy, there is a paucity of research exploring their efficacy. The aim of this study was to explore the effect of implementing EBGs to reduce the symptom burden and psychological distress of cancer patients requiring outpatient chemotherapy at an acute, tertiary care public hospital in Western Australia. The study was conducted in 2 populations and stages, using action research to promote change. Stage 1 assessed prevalence; in stage 2, specific EBGs were implemented. Symptom prevalence, severity, and bother were determined at baseline and 1 week and 1 month after initial chemotherapy, to allow comparison between stages. Stage 2 participants did better at managing feeling low (odds ratio, 2.33; 95% confidence interval, 1.47-3.70; P<.001) and vomiting (odds ratio, 2.37; 95% confidence interval, 1.13-4.97; P = .022). Bother was greater in stage 2 at baseline for vomiting (P = .040), pain (P = .017), feeling tired (P = .038), feeling anxious or worried (P = .001), and feeling low (P = .024). By 1 month, only feeling anxious or worried (P = .023) and feeling low (P = .006) differed. Severity was greater in stage 2 at baseline for pain (P = .025) and feeling anxious or worried (P = .008). By 1 month, only feeling anxious or worried (P = .010) differed.
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Question: Evidence-Based Self-care Guidelines for People Receiving Chemotherapy: Do They Reduce Symptom Burden and Psychological Distress?
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Effective self-care strategies to manage the adverse effects of chemotherapy should be evidence based but individualized, as our findings suggest; for some, focusing on their symptoms may not always be beneficial.
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Answer the question based on the following context: The use of intravenous regional anesthesia (IVRA) is limited by pain resulting from the application of tourniquets and postoperative pain. To assess the efficacy of low-level laser therapy added to IVRA for improving pain related to surgical fixation of distal radius fractures. The present double-blinded, placebo-controlled, randomized clinical trial involved 48 patients who were undergoing surgical fixation of distal radius fractures. Participants were randomly assigned to either an intervention group (n=24), who received 808 nm laser irradiation as 4 J⁄point for 20 s over ipsilateral three nerve roots in the cervical region corresponding to C5-C8 vertebrae, and 808 nm laser irradiation as 0.1 J⁄cm2 for 5 min in a tangential scanning mode over the affected extremity; or a control group (n=24), who underwent the same protocol and timing of laser probe application with the laser switched off. Both groups received the same IVRA protocol using 2% lidocaine. The mean visual analogue scale scores were significantly lower in the laser-assisted group than in the lidocaine-only group on all measurements during and after operation (P<0.05). The mean time to the first need for fentanyl administration during the operation was longer in the laser group (P=0.04). The total amount of fentanyl administered to patients was significantly lower in the laser-assisted group (P=0.003). The laser group needed significantly less pethidine for pain relief (P=0.001) and at a later time (P=0.002) compared with the lidocaine-only group. There was no difference between the groups in terms of mean arterial pressure and heart rate.
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Question: Does low-level laser therapy enhance the efficacy of intravenous regional anesthesia?
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The addition of gallium-aluminum-arsenide laser irradiation to intravenous regional anesthesia is safe, and reduces pain during and after the operation.
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Answer the question based on the following context: To evaluate whether or not children with displaced proximal humerus fractures are more likely to have attention deficit and hyperactivity disorder (ADHD). Between January 2010 and February 2013, we retrospectively evaluated 42 children with proximal humerus fractures. Requirements for inclusion were an open epiphyseal plate and a non-pathological fracture of the proximal humerus. Fractures were classified according to Salter-Harris, Neer and Horwitz. Following orthopaedic examination, all of the children were consulted to child psychiatry department of our hospital. Orthopaedic examination included a detailed physical examination; the assessment of the overall shoulder functions using the Constant score. Diagnostic and Statistical Manual of Mental Disorders, Text Revisions (DSM-IV-TR) were used for psychiatric examination. 9 of the 42 children with proximal humerus fractures consulted to child psychiatry were put ADHD diagnoses (21 %). Of the remaining 33 children without ADHD diagnosis, 5 children were operated; percentage of surgery was 15%. We found statistically significant difference between the rates of ADHD diagnosed children with proximal humerus fractures and ADHD diagnoses in normal population (p<0.01). There was also statistically significant difference between operation rates of children with or without ADHD diagnosis (55 % vs. 15 %) (p<0,01).
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Question: Is attention deficit and hyperactivity disorder a risk factor for sustaining fractures of proximal humerus?
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ADHD can be accepted as a risk factor for sustaining high energy trauma and rate of ADHD children who were operated was significantly more than normal children. This might be due to more displaced, open fractures or polytrauma - higher energy trauma- they sustained. Deciding on the treatment method, surgery may be treatment of choice in certain children with severely displaced, irreducable, fractures or polytrauma with accompanying ADHD due to the potential difficulties during follow up period.
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Answer the question based on the following context: Recent literature in ovarian cancer suggests differences in surgical outcomes depending on operative start time. We sought to examine the effects of operative start time on surgical outcomes for patients undergoing minimally invasive surgery for endometrial cancer. A retrospective review was conducted of patients undergoing minimally invasive surgery for endometrial cancer at a single institution between 2000 and 2011. Surgical and oncologic outcomes were compared between patients with an operative start time before noon and those with a surgical start time after noon. A total of 380 patients were included in the study (245 with start times before noon and 135 with start times after noon). There was no difference in age (p=0.57), number of prior surgeries (p=0.28), medical comorbidities (p=0.19), or surgical complexity of the case (p=0.43). Patients with surgery starting before noon had lower median BMI than those beginning after noon, 31.2 vs. 35.3 respectively (p=0.01). No significant differences were observed for intraoperative complications (4.4% of patients after noon vs. 3.7% of patients before noon, p=0.79), estimated blood loss (median 100 cc vs. 100 cc, p=0.75), blood transfusion rates (7.4% vs. 8.2%, p=0.85), and conversion to laparotomy (12.6% vs. 7.4%, p=0.10). There was no difference in operative times between the two groups (198 min vs. 216.5 min, p=0.10). There was no association between operative start time and postoperative non-infectious complications (11.9% vs. 11.0%, p=0.87), or postoperative infections (17.8% vs. 12.3%, p=0.78). Length of hospital stay was longer for surgeries starting after noon (median 2 days vs. 1 day, p=0.005). No differences were observed in rates of cancer recurrence (12.6% vs. 8.8%, p=0.39), recurrence-free survival (p=0.97), or overall survival (p=0.94).
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Question: Minimally invasive surgery for endometrial cancer: does operative start time impact surgical and oncologic outcomes?
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Our results indicate equivalent surgical outcomes and no increased risk of postoperative complications regardless of operative start time in minimally invasive endometrial cancer staging, despite longer length of hospital stay for surgeries beginning after noon.
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Answer the question based on the following context: The primary purpose of this study is to explore primary care physicians' (PCPs') knowledge, attitudes and self-reported activities provided to patients for smoking cessation. The secondary purpose is to identify the relationships between physician-related characteristics and knowledge, attitudes and self-reported activities for smoking cessation. A national cross-sectional web survey was conducted in Italy from April through September 2012. 722 PCPs completed the questionnaire. The great majority indicated the correct proportion of smokers among patients with lung cancer, the smoking abstention required for risk reduction after smoking cessation, and tobacco as a known major risk factor for chronic obstructive pulmonary disease (COPD), whereas 28.7% knew the Fagerstrom test for the assessment of nicotine dependence. Almost all PCPs reported that they ask all patients if they smoke, inform about the dangers of smoking and recommend to quit smoking, whereas prescription of recommended drugs for smoking cessation varied from 37.7% for nicotine replacement therapy to 4.9% for varenicline.
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Question: Are primary care physicians prepared to assist patients for smoking cessation?
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Despite a positive attitude, Italian PCPs are not prepared to deliver effective interventions for smoking cessation in their patients.
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Answer the question based on the following context: Nowadays, capsule endoscopy (CE) is the first-line procedure after negative upper and lower gastrointestinal (GI) endoscopy for obscure gastrointestinal bleeding (OGIB). Approximately, two-thirds of patients undergoing CE for OGIB will have a small-bowel abnormality. However, several patients who underwent CE for OGIB had the source of their blood loss in the stomach or in the colon. The aim of the present study is to determine the incidence of bleeding lesions missed by the previous gastroscopy/colonoscopy with CE and to evaluate the indication to repeat a new complete endoscopic workup in subjects related to a tertiary center for obscure bleeding before CE. We prospectively reviewed data from 637/1008 patients underwent to CE for obscure bleeding in our tertiary center after performing negative gastroscopy and colonoscopy. CE revealed a definite or likely cause of bleeding in stomach in 138/637 patients (yield 21.7%) and in the colon in 41 patients (yield 6.4%) with a previous negative gastroscopy and colonoscopy, respectively. The lesions found were outside the small bowel in only 54/637 (8.5%) patients. In 111/138 patients, CE found lesions both in stomach and small bowel (small-bowel erosions in 54, AVMs in 45, active small-bowel bleeding in 4, neoplastic lesions in 3 and distal ileum AVMs in 5 patients). In 24/41 (58.5%) patients, CE found lesions both in small bowel and colon (multiple small-bowel erosions in 15; AVMs in 8 and neoplastic lesion in 1 patients. All patients underwent endoscopic therapy or surgery for their nonsmall-bowel lesions.
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Question: Obscure recurrent gastrointestinal bleeding: a revealed mystery?
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Lesions in upper or lower GI tract have been missed in about 28% of patients submitted to CE for obscure bleeding. CE may play an important role in identifying lesions missed at conventional endoscopy.
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Answer the question based on the following context: Application to otolaryngology-head and neck surgery residency is highly competitive, and the interview process strives to select qualified applicants with a high aptitude for the specialty. Commonly employed criteria for applicant selection have failed to show correlation with proficiency during residency training. We evaluate the correlation between the results of a surgical aptitude test administered to otolaryngology resident applicants and their performance during residency. Retrospective study at an academic otolaryngology-head and neck surgery residency program. Between 2007 and 2013, 224 resident applicants participated in a previously described surgical aptitude test administered at a microvascular surgical station. The composite score and attitudinal scores for 24 consecutive residents who matched at our institution were recorded, and their residency performance was analyzed by faculty survey on a five-point scale. The composite and attitudinal scores were analyzed for correlation with residency performance score by regression analysis. Twenty-four residents were evaluated for overall quality as a clinician by eight faculty members who were blinded to the results of surgical aptitude testing. The results of these surveys showed good inter-rater reliability. Both the overall aptitude test scores and the subset attitudinal score showed reliability in predicting performance during residency training.
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Question: Still under the microscope: can a surgical aptitude test predict otolaryngology resident performance?
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The goal of the residency selection process is to evaluate the candidate's potential for success in residency and beyond. The results of this study suggest that a simple-to-administer clinical skills test may have predictive value for success in residency and clinician quality.
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Answer the question based on the following context: To evaluate whether first, second, and third-trimester maternal serum hepcidin levels are different in pregnancies with and without adverse pregnancy outcomes (APO). A 165 nullipar pregnant women were included in this prospective cohort study. Serum hepcidin, ferritin, IL-6, C-reactive protein (CRP) and Hb values were measured at 11-14, 24-28, and 30-34 weeks of gestation. The relation between these parameters and APO and neonatal outcomes were investigated. Preterm delivery, intrauterine growth restriction, pre-eclampsia, gestational hypertension and placental abruption were determined as adverse pregnancy outcomes. The risk of APO was three times higher in women with high IL-6 levels in the second trimester. High hepcidin levels in the second trimester were associated with a 1.6 times increased risk of APO. Newborns of women with high IL-6 levels in the third trimester had a 1.6-fold increased risk of neonatal complications. High ferritin levels in the third trimester were associated with minimally increased risk of neonatal complications.
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Question: Do the first, second and third trimester maternal serum hepcidin concentrations clarify obstetric complications?
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Mean serum hepcidin levels were similar in all pregnant women, however, elevated second trimester serum hepcidin and IL-6 levels were associated with a higher risk of APO and high third trimester hepcidin, ferritin and IL-6 levels were associated with higher risk of neonatal complications.
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Answer the question based on the following context: Research on diet and nutrition of patients with depression show that their eating habits are frequently irrational and result in the inconsistent supply of nutrients, especially vitamins and minerals, the deficiency of which leads to nervous system dysfunction.AIM: The aim of the study was to evaluate the content of selected vitamins and minerals in daily food rations of patients suffering from recurrent depressive disorders. The study involved a group of 69 people (54 women and 15 men, aged 18-65 years, mean age of women 45.7 +/- 12.2 years, men 46.0 +/- 12.2 years), treated for recurrent depressive disorders. A questionnaire designed in the Department of Dietetics and Clinical Nutrition, Medical University of Bialystok was used to collect dietary data. The quantitative assessment of eating habits used a 24-hour diet recall including 3 weekdays and 1 weekend day. The study showed that the supply of most nutrients assessed was inconsistent with recommendations.
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Question: Does the usual dietary intake of patients with depression require vitamin-mineral supplementation?
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The results indicate that the need for vitamin-mineral supplementation should be considered individually. Nutritional education related to the proper choice of groups of food products is indicated at the time of clinical improvement to ensure the optimum supply of vitamins and minerals.
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Answer the question based on the following context: To test whether three different intensive programs of treatment for neurotic and personality disorders are effective in decreasing neurotic symptoms and traits of neurotic personality and whether there are differences between them in clinical outcome. The sample consisted of 105 patients (83% female, mean age 35) diagnosed with neurosis and personality disorders that were treated in three therapeutic wards under routine inpatient conditions. The therapeutic programs are designed for patients with neurotic and personality disorders. They consist of 6-12 weeks of approximately 5 hours of eclectic group treatment (group psychotherapy, psychodrama, psychoeducation etc.). Participants filled in Symptoms' Questionnaire KS-II, and Neurotic Personality Questionnaire KON-2006 at the beginning and at the end of the course of psychotherapy. The treatment proved to be effective in diminishing neurotic symptoms (d Cohen = 0.56). More detailed analysis revealed that there was a significant interaction between the three analysed therapeutic wards and the effectiveness (12 = 0.09). The treatments offered in two institutions were effective (d Cohen = 0.80) while one of the programs did not lead to significant improvement of the patients. None of the therapeutic wards proved to be effective in changing the neurotic personality traits.
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Question: Differences in effectiveness of intensive programs of treatment for neurotic and personality disorders. Is it worth to monitor the effectiveness of the therapeutic team?
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There are significant differences in effectiveness of the intensive programs of treatment for neurotic and personality disorders. In the light of the literature, one can assume that the differences are more connected with the characteristics of therapeutic teams than with the methods used. The need for standard methods of effectiveness monitoring is discussed.
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Answer the question based on the following context: The association between excess body weight and colorectal cancer screening is not well established. The purpose of this analysis was to explore, in the context of patients receiving navigation, whether obesity influences receipt of screening colonoscopy among lower-income Latinos and African Americans. This sub-analysis was conducted among Latinos and African American participants who received patient navigation and had complete body mass index (BMI) data (n = 520). Cross-sectional survey data were collected at baseline among individuals 50 years and older who were referred by their primary care providers for a colonoscopy at Mount Sinai's Primary Care Clinic. BMI was based on height and weight data from chart review at baseline, and colonoscopy completion status was collected at 1 year post-baseline. The mean BMI of the sample was 31.17 kg/m(2), with over half (53 %) of the sample categorized as obese. Rates of colonoscopy screening were high (~80 %), regardless of weight status. Adjusting for age, gender, race/ethnicity, family history of colorectal cancer, smoking status, comorbid conditions, income, marital status, insurance, and education, obesity status was not significantly associated with screening behavior among the entire sample (adjusted OR 0.81, CI 0.49-1.32, p = 0.39) or among stratified race/ethnicity and gender groups.
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Question: Is obesity associated with colorectal cancer screening for African American and Latino individuals in the context of patient navigation?
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These findings suggest that obesity may not negatively influence receipt of colonoscopy screening in the context of patient navigation among minority participants. Further studies are needed to determine whether this finding will be observed in other populations, with and without the assistance of a patient navigator.
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Answer the question based on the following context: Fetal growth restriction (FGR) is a key cause of adverse pregnancy outcome where maternal and fetal factors are identified as contributing to this condition. Idiopathic FGR is associated with altered vascular endothelial cell functions. Decorin (DCN) has important roles in the regulation of endothelial cell functions in vascular environments. DCN expression is reduced in FGR. The objectives were to determine the functional consequences of reduced DCN in a human microvascular endothelial cell line model (HMVEC), and to determine downstream targets of DCN and their expression in primary placental microvascular endothelial cells (PLECs) from control and FGR-affected placentae. Short-interference RNA was used to reduce DCN expression in HMVECs and the effect on proliferation, angiogenesis and thrombin generation was determined. A Growth Factor PCR Array was used to identify downstream targets of DCN. The expression of target genes in control and FGR PLECs was performed. DCN reduction decreased proliferation and angiogenesis but increased thrombin generation with no effect on apoptosis. The array identified three targets of DCN: FGF17, IL18 and MSTN. Validation of target genes confirmed decreased expression of VEGFA, MMP9, EGFR1, IGFR1 and PLGF in HMVECs and PLECs from control and FGR pregnancies.
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Question: Altered decorin leads to disrupted endothelial cell function: a possible mechanism in the pathogenesis of fetal growth restriction?
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Reduction of DCN in vascular endothelial cells leads to disrupted cell functions. The targets of DCN include genes that play important roles in angiogenesis and cellular growth. Therefore, differential expression of these may contribute to the pathogenesis of FGR and disease states in other microvascular circulations.
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Answer the question based on the following context: As Botox(®)/filler use has increased in recent years, a growing number of nonaesthetic health professionals have emerged to perform these procedures. Since studies have shown that patients identify training as the most important factor in considering these procedures, this study seeks to summarize the perspective of plastic surgeons regarding these paradigm shifts. In the summer of 2013, an eight-question survey was sent to members of ISAPS, ASAPS, and ASPS (approximately 26,113 plastic surgeons globally). Two questions assessed practice location and membership affiliation and six questions assessed various healthcare practitioners' capability to administer Botox, fillers, and vaccines (control). Healthcare practitioners included plastic surgeons and dermatologists, gynecologists, dentists, nurses in plastic surgery and dermatology, or nurses in other fields. On three e-mail notifications, 14,184 plastic surgeons opened the survey and 882 responded: 36.6 % from North America, 29.1 % from Europe, 12.9 % from South America, 10.1 % from Asia, 4.5 % from the Middle East, 3.4 % from Australia, 1.9 % from Africa, and 1.6 % from Central America. Seventy-seven percent believed nurses were not as capable as plastic surgeons in administering Botox; 81 % felt the same for fillers. Conversely, 84 % agreed that nurses were as capable as plastic surgeons in administering vaccines. Plastic surgeons ranked nurses in other fields (48 %) as most capable in administering vaccines, then plastic surgeons (42 %), nurses of plastic surgeons (9 %), gynecologists (1 %), and dentists (<1 %). When asked about Botox/fillers, responders ranked plastic surgeons (98 %) most capable, then nurses in plastic surgery (2 %), gynecologists (<1 %), dentists (<1 %), and nurses in other fields (<1 %). When asked to rank according to patient perception, the order remained the same.
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Question: Are nurse injectors the new norm?
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Based on responses from over 880 plastic surgeons from around the world, plastic surgeons consider themselves and dermatologists the most capable injectors. However, they still believe nurses in other fields to be the most capable of administering vaccines. This dichotomy may define the role of various practitioners in an increasingly more competitive injectable environment to improve patient satisfaction and outcomes. Given that the majority of growth in cosmetic injectables is being driven by providers other than plastic surgeons and dermatologists, further clarification on training requirements and practice guidelines may be necessary to ensure a consistent, reproducible experience for the patient.
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Answer the question based on the following context: Our goal was to test whether short-term intermittent hypobaric hypoxia (IHH) at a level well tolerated by healthy humans could, in combination with muscle electro-stimulation (ME), mobilize circulating progenitor cells (CPC) and increase their concentration in peripheral circulation. Nine healthy male subjects were subjected, as the active group (HME), to a protocol involving IHH plus ME. IHH exposure consisted of four, three-hour sessions at a barometric pressure of 540 hPa (equivalent to an altitude of 5000 m). These sessions took place on four consecutive days. ME was applied in two separate 20-minute periods during each IHH session. Blood samples were obtained from an antecubital vein on three consecutive days immediately before the experiment, and then 24 h, 48 h, 4 days, 7 days and 14 days after the last day of hypoxic exposure. Four months later a control study was carried out involving seven of the original subjects (CG), who underwent the same protocol of blood samples but without receiving any special stimulus. In comparison with the CG the HME group showed only a non-significant increase in the number of CPC CD34+ cells on the fourth day after the combined IHH and ME treatment.
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Question: Combined intermittent hypobaric hypoxia and muscle electro-stimulation: a method to increase circulating progenitor cell concentration?
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CPC levels oscillated across the study period and provide no firm evidence to support an increased CPC count after IHH plus ME, although it is not possible to know if this slight increase observed is physiologically relevant. Further studies are required to understand CPC dynamics and the physiology and physiopathology of the hypoxic stimulus.
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Answer the question based on the following context: The two North Atlantic eel species, the European and the American eel, represent an ideal system in which to study parallel selection patterns due to their sister species status and the presence of ongoing gene flow. A panel of 80 coding-gene SNPs previously analyzed in American eel was used to genotype European eel individuals (glass eels) from 8 sampling locations across the species distribution. We tested for single-generation signatures of spatially varying selection in European eel by searching for elevated genetic differentiation using FST-based outlier tests and by testing for significant associations between allele frequencies and environmental variables. We found signatures of possible selection at a total of 11 coding-gene SNPs. Candidate genes for local selection constituted mainly genes with a major role in metabolism as well as defense genes. Contrary to what has been found for American eel, only 2 SNPs in our study correlated with differences in temperature, which suggests that other explanatory variables may play a role. None of the genes found to be associated with explanatory variables in European eel showed any correlations with environmental factors in the previous study in American eel.
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Question: Do North Atlantic eels show parallel patterns of spatially varying selection?
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The different signatures of selection between species could be due to distinct selective pressures associated with the much longer larval migration for European eel relative to American eel. The lack of parallel selection in North Atlantic eels could also be due to most phenotypic traits being polygenic, thus reducing the likelihood of selection acting on the same genes in both species.
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Answer the question based on the following context: Rehabilitation of impaired cognitive functions begins to be considered a standard component of medical care after acquired brain injury. Indeed, many evidences support the effectiveness of the two major categories of techniques, i.e. the traditional and computer-assisted ones, which are widely used in cognitive rehabilitative treatment. Aim of this study is to evaluate the effects of pc - cognitive training in brain injury patients. We studied 35 subjects (randomly divided into two groups), affected by traumatic or vascular brain injury, having attended from January 2010 to December 2012 the Laboratory of Robotic and Cognitive Rehabilitation of IRCCS Neurolesi of Messina. Cognitive impairment was investigated through psychometric battery, administered before (T0) and two months (T1) after the cognitive pc-training, which was performed only by the experimental group, in addition to conventional treatment. Statistical analysis was performed using Wilcoxon test with a p < 0.01. At time T0, all patients showed language deficits and cognitive alterations in visual attention and memory abilities. After the rehabilitation program we noted a global improvement in both the groups. However, at T1, the experimental group showed a greater cognitive improvement than the control group, with significant differences in nearly all the neuropsychological tests performed.
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Question: Is computer-assisted training effective in improving rehabilitative outcomes after brain injury?
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Our data suggest that cognitive pc-training may be a promising methodology to optimize the rehabilitation outcomes following brain injury.
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Answer the question based on the following context: Using data from the Hong Kong Mr and Ms Os study, we validated the SARC-F against 3 consensus definitions of sarcopenia from Europe, Asia, and an international group, and compared the ability of all 4 measures to predict 4-year physical limitation, walking speed, and repeated chair stands. Prospective cohort study. Hong Kong community. Four thousand men and women living in the community. A questionnaire regarding ability to carry a heavy load, walking, rising from a chair, climbing stairs, and falls frequency was administered. These questions were used to calculate the SARC-F score. Measurements, including appendicular muscle mass, were taken using dual-energy X-ray, grip strength using a dynamometer, 6-m gait speed, and time taken for repeated chair stand. Classification using the SARC-F score was compared using consensus panel criteria from international, European, and Asian sarcopenia working groups. The performance of all 4 methods was compared by examining the predictive ability for 4-year outcomes using ROC curve. The SARC-F has excellent specificity but poor sensitivity for sarcopenia classification; however, all 4 methods have comparable but modest predictive power for 4-year physical limitation.
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Question: Validating the SARC-F: a suitable community screening tool for sarcopenia?
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The SARC-F may be considered a suitable tool for community screening for sarcopenia.
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Answer the question based on the following context: The patient-centered medical home has gained much traction. Little is known about the relationship between the model and specific health care processes for chronic diseases such as diabetes. This study assesses the impact of features of a medical home on diabetes care. A cross-sectional survey of 540 patients with Medicaid (Medi-Cal) health insurance and type 2 diabetes in Los Angeles County was performed. The Primary Care Assessment Tools was used to measure seven features of medical-home performance. The response rate of the patient survey was 68.9%. Patient-reported medical-home performance averaged a score of 2.85 ± 0.29 (on a 1-4 scale, with 4 equaling the best care). Patients who received more timely and thorough diabetes care reported higher medical-home performance in every feature except for the comprehensiveness-services available. For example, the first-contact access feature score was higher among patients who had an HbA1c test in the past 6 months versus those who did not (2.38 vs. 2.25; P<0.05). Before and after adjusting for sociodemographics and health status, total medical-home performance was positively associated with each diabetes care measure. A 1-point increase in total medical-home score was associated with 4.53 higher odds of an HbA1c test in the past 6 months and 1.88 higher odds of an eye exam in the past year.
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Question: Do experiences consistent with a medical-home model improve diabetes care measures reported by adult Medicaid patients?
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Features consistent with higher medical-home performance are associated with improvements in patient-reported diabetes care process measures, even in this low socioeconomic status setting. The patient-centered medical-home model may help in caring for people with type 2 diabetes.
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Answer the question based on the following context: Within an Australian context, the medium to long-term health impacts of climate change are likely to be wide, varied and amplify many existing disorders and health inequities. How the health system responds to these challenges will be best considered in the context of existing health facilities and services. This paper provides a snapshot of the understanding that Australian health planners have of the potential health impacts of climate change. The first author interviewed (n=16) health service planners from five Australian states and territories using an interpretivist paradigm. All interviews were digitally recorded, key components transcribed and thematically analysed. Results indicate that the majority of participants were aware of climate change but not of its potential health impacts. Despite this, most planners were of the opinion that they would need to plan for the health impacts of climate change on the community.
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Question: Is enough attention given to climate change in health service planning?
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With the best available evidence pointing towards there being significant health impacts as a result of climate change, now is the time to undertake proactive service planning that address market failures within the health system. If considered planning is not undertaken then Australian health system can only deal with climate change in an expensive ad hoc, crisis management manner. Without meeting the challenges of climate change to the health system head on, Australia will remain unprepared for the health impacts of climate change with negative consequences for the health of the Australian population.
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Answer the question based on the following context: The outcomes of emergent laparoscopic cholecystectomy (LC) for acute cholecystitis have not been documented in the low-volume, resource-poor Caribbean setting. This study was carried out in a low-resource setting across three islands in the Anglophone Caribbean. The records of all consecutive patients who had emergency LC for acute cholecystitis over 82 months were examined. The data were extracted and analysed using SPSS version 14. There were 74 patients with acute cholecystitis at a mean age of 45 (SD 11.8) years. The mean duration of operation was 99 (SD 45) min. There were 3 (4.1%) conversions and 6 (8.1%) complications. No bile duct injuries or deaths were recorded. There was more morbidity in patients with complicated disease, longer mean operation times and longer mean intervals between admission and operation.
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Question: Is emergent laparoscopic cholecystectomy for acute cholecystitis safe in a low volume resource poor setting?
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Emergent LC for acute cholecystitis is effective and safe in a low-volume setting in the Caribbean. However, the operations are technically demanding and should be performed by trained laparoscopic surgeons.
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Answer the question based on the following context: The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) guidelines on chronic kidney disease (CKD) introduced risk classes for adverse outcome based on estimated glomerular filtration rate (eGFR) and albuminuria categories (low-LR, moderately-MR, high-HR, very high risk-VHR). We aimed to investigate if such risk stratification is suitable in kidney transplant (KTx) recipients. This single-center prospective study enrolled 231 prevalent KTx recipients [36 (34-48) years, 62 % male, eGFR 53.7 (50.9-56.4) mL/min]. The patients were stratified in risk classes in January 2011; clinical and laboratory data were collected every 6 months till June 2013. Individual slope of linear regression of all eGFR and time-averaged proteinuria (TAP) were computed. The composite endpoint was defined as>30 % decline in eGFR from 6 months after KTx to June 2013, dialysis initiation or death. Fifty-one patients reached the endpoint. They were younger, more often female, donor specific anti-HLA antibodies positive, noncompliant and smokers. TAP was 4 time greater (p<0.0001) and eGFR abruptly declined [eGFR slope: -3.17 (-4.13 to -2.21) vs. 0.81 (0.45-1.3) mL/min per year, p<0.0001] in the endpoint group. At baseline: 36 % LR, 23 % MR, 23 % HR and 18 % VHR, without differences between the groups. In the binary logistic regression model, VHR as compared to the other risk classes was an independent risk factor for poorer outcome. The final model also included female gender, cardiovascular events, smoking, GFR slope and BK virus infection.
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Question: Does the KDIGO CKD risk stratification based on GFR and proteinuria predict kidney graft failure?
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Risk group stratification according to KDIGO guideline on CKD may prove useful in predicting graft outcome, but this should be confirmed in larger cohorts.
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Answer the question based on the following context: Eighteen patients with chronic periodontitis (CP), 20 patients with generalized aggressive periodontitis (G-AgP), 20 patients with gingivitis, and 18 healthy subjects were included in the study. Periodontal parameters including probing depth, clinical attachment level, papilla bleeding index, and plaque index were assessed in all study subjects. GCF proteinase 3 and cathepsin C levels were analyzed by ELISA. GCF proteinase 3 total amount was significantly higher in diseased groups compared to control group, after adjusting age (P<0.05). No differences were found in GCF cathepsin C levels among the study groups (P>0.05). Periodontal parameters of sampling sites were positively correlated with GCF proteinase 3 total amounts (P<0.01) but not with cathepsin C total amounts (P>0.05).
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Question: Are proteinase 3 and cathepsin C enzymes related to pathogenesis of periodontitis?
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Elevated levels of GCF proteinase 3 in CP, G-AgP, and gingivitis might suggest that proteinase 3 plays a role during inflammatory periodontal events in host response. However, cathepsin C in GCF does not seem to have an effect on the pathogenesis of periodontal diseases.
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Answer the question based on the following context: Category II fetal heart rate (FHR) tracings are considered indeterminate; thus, improved risk stratification of category II FHR tracings is needed. We estimated whether the presence of meconium increased the risk of adverse neonatal outcomes. This study was conducted within a prospective cohort of 5000 women with singleton pregnancies who were admitted in labor at term. Pregnancies with category II FHR in the 60 minutes before delivery were included. FHR data were extracted by trained nurses who were blinded to clinical outcome. The exposure was the presence of meconium. The primary outcome was a composite neonatal morbidity defined as ≥1 of the following: neonatal death, neurologic morbidity, respiratory morbidity, hypotension that required treatment, and sepsis. Secondary outcomes were nursery admission, cord pH, 5-minute Apgar score, and components of the composite. Logistic regression was used to adjust for confounders. Of the 3257 women with category II FHR tracings, 693 women (21.3%) had meconium, and 2564 women (78.7%) did not. Meconium was associated with higher risk of the composite morbidity (adjusted odds ratio, 2.49; 95% confidence interval, 1.78-3.48) and increased risks of the secondary outcomes. The associations remained significant when infants with meconium aspiration syndrome were excluded. Thick meconium was associated significantly with the composite morbidity.
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Question: Interpreting category II fetal heart rate tracings: does meconium matter?
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The presence of meconium is associated with an increased risk of neonatal morbidity in women with category II FHR pattern. This clinical factor may assist clinicians in managing category II FHR patterns in labor.
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