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Answer the question based on the following context: Frontofacial monobloc advancement (FFMBA) is a powerful but high-risk procedure to correct both exorbitism and impaired airways of faciocraniosynostosis. One hundred and five children with faciocraniosynostosis (mean 4.9 years, 7 months-14 years) were evaluated prospectively after FFMBA and quadruple internal distraction. The advancement was started at day 5 (0.5 mm/day). Mean follow-up was 61 months (maximum 10.5 years). Relapse was evaluated by the comparison between the evaluation at the time of removal of distractors and 6 months later. Seventy-six patients (72%) completed their distraction uneventfully in the initial period. - One death at D1 from acute tonsillar herniation before beginning of distraction. - Cerebrospinal fluid leaks managed conservatively (11 patients) and with transient lumbar drainage (eight patients). - Revision surgery (dysfunction/infection) of distraction devices (nine patients, subsequently four completed the distraction). Ninety-nine out of 104 patients finally completed their distraction, resulting in exorbitism correction. Respiratory impairment, when present, was corrected and class I occlusal relationship was obtained in 77% of the cases. Reossification was limited at the orbital level but relapse could be prevented by a retention phase of 6 months. Pfeiffer syndrome, previous surgeries, and surgery before 18 months of age were risk factors.
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Question: Faciocraniosynostosis: monobloc frontofacial osteotomy replacing the two-stage strategy?
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Internal distraction allows early correction of respiratory impairment and exorbitism of faciocraniosynostosis. In order to limit the risks, we advise: - Preliminary craniovertebral junction decompression if needed - Four devices to customize the distraction - Double pericranial flap to seal the anterior cranial fossa - Systematical external transient drainage if CSF leak - Slow rate of distraction (0.5 mm/day) - Long consolidation phase (6 months).
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Answer the question based on the following context: Mastectomy with axillary lymph node dissection (ALND) represents the gold standard in the treatment of male breast carcinoma. Recently, data have emerged supporting that sentinel lymph node biopsy (SNB) may be feasible in selected patients. The aim of this study was to analyze the safety and prognostic reliability of SNB in male patients with breast carcinoma and clinically negative axilla. During a 10-year period (2000-2010), 11 men with mean age 66.1 years (range 34-84) diagnosed with breast carcinoma were retrospectively included to our study. All patients underwent SNB. Regardless of the SNB results, completion axillary clearance was conducted in all cases. SNB detection rate was 100%, while the mean number of sentinel nodes removed was 1.5 +/- 0.7 (range 1-2). Frozen section analysis revealed a negative sentinel node in four out of 11 patients (36.4%). Independently of these results, all patients underwent completion ALND. The overall false-negative rate, defined as the percentage of all node-positive tumors in which the SNB was negative, was 0%.
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Question: Sentinel node biopsy in male breast carcinoma: is the "female" approach justified?
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The current study indicates that SNB may be feasible in selected male individuals with breast carcinoma. The technique may reduce the morbidity related to dissection of the axilla; prospective multicenter trials are needed in order to define the exact criteria for wider application of this technique.
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Answer the question based on the following context: Over two-thirds of UK medical schools are augmenting their selection procedures for medical students by using the United Kingdom Clinical Aptitude Test (UKCAT), which employs tests of cognitive and non-cognitive personal qualities, but clear evidence of the tests' predictive validity is lacking. This study explores whether academic performance and professional behaviours that are important in a health professional context can be predicted by these measures, when taken before or very early in the medical course. This prospective cohort study follows the progress of the entire student cohort who entered Hull York Medical School in September 2007, having taken the UKCAT cognitive tests in 2006 and the non-cognitive tests a year later. This paper reports on the students' first and second academic years of study. The main outcome measures were regular, repeated tutor assessment of individual students' interpersonal skills and professional behaviour, and annual examination performance in the three domains of recall and application of knowledge, evaluation of data, and communication and practical clinical skills. The relationships between non-cognitive test scores, cognitive test scores, tutor assessments and examination results were explored using the Pearson product-moment correlations for each group of data; the data for students obtaining the top and bottom 20% of the summative examination results were compared using Analysis of Variance. Personal qualities measured by non-cognitive tests showed a number of statistically significant relationships with ratings of behaviour made by tutors, with performance in each year's objective structured clinical examinations (OSCEs), and with themed written summative examination marks in each year. Cognitive ability scores were also significantly related to each year's examination results, but seldom to professional behaviours. The top 20% of examination achievers could be differentiated from the bottom 20% on both non-cognitive and cognitive measures.
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Question: Can personal qualities of medical students predict in-course examination success and professional behaviour?
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This study shows numerous significant relationships between both cognitive and non-cognitive test scores, academic examination scores and indicators of professional behaviours in medical students. This suggests that measurement of non-cognitive personal qualities in applicants to medical school could make a useful contribution to selection and admission decisions. Further research is required in larger representative groups, and with more refined predictor measures and behavioural assessment methods, to establish beyond doubt the incremental validity of such measures over conventional cognitive assessments.
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Answer the question based on the following context: Our primary objective was to determine whether vibroacoustic stimulation (VAS) decreases time to fetal reactivity in the antenatal testing unit (ATU) of a tertiary care center. We performed a prospective, quality assurance initiative to determine whether VAS could increase the efficiency of our ATU. On pre-specified "VAS days," VAS was applied for 3 s, if the non-stress test was non-reactive in the first 10 min. Generalized estimating equations models were used to account for within subject correlation due to multiple appointments per patient. VAS use was associated with a 3.76-min reduction in time to reactivity (21.79 vs 25.55, p = 0.011) and a 56% reduction in the need for a biophysical profile (OR: 0.44, 95% CI: 0.21-0.90). Overall, however, we found no significant decrease in time spent on the monitor or in the ATU.
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Question: Can vibroacoustic stimulation improve the efficiency of a tertiary care antenatal testing unit?
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Compliance with a strict VAS protocol may improve the efficiency of increasingly busy ATUs.
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Answer the question based on the following context: It has been suggested that prescription of amoxicillin plus metronidazole in the context of periodontal therapy should be limited to patients with specific microbiologic profiles, especially those testing positive for Aggregatibacter actinomycetemcomitans. The main purpose of this analysis is to determine if patients positive for A. actinomycetemcomitans with moderate to advanced periodontitis benefit specifically from amoxicillin plus metronidazole given as an adjunct to full-mouth scaling and root planing. This is a double-masked, placebo-controlled, randomized longitudinal study including 41 participants who were positive for A. actinomycetemcomitans and 41 participants who were negative for A. actinomycetemcomitans. All 82 patients received full-mouth periodontal debridement performed within 48 hours. Patients then received either systemic antibiotics (375 mg amoxicillin and 500 mg metronidazole, three times daily) or placebo for 7 days. The primary outcome variable was persistence of sites with a probing depth (PD)>4 mm and bleeding on probing (BOP) at the 3-month reevaluation. Using multilevel logistic regression, the effect of the antibiotics was analyzed according to the following factors (interaction effect): A. actinomycetemcomitans-positive or -negative at baseline, sex, age, smoking, tooth being a molar, and interdental location. At reevaluation, participants in the test group had significantly fewer sites with a persisting PD>4 mm and BOP than control patients (P<0.01). Being A. actinomycetemcomitans-positive or -negative did not change the effect of the antibiotics. Patients benefited from the antibiotics irrespective of sex, age, or smoking status. Molars benefited significantly more from the antibiotics than non-molars (P for interaction effect = 0.03).
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Question: Are there specific benefits of amoxicillin plus metronidazole in Aggregatibacter actinomycetemcomitans-associated periodontitis?
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Patients who were positive for A. actinomycetemcomitans had no specific benefit from amoxicillin plus metronidazole. Sites on molars benefited significantly more from the antibiotics than non-molar sites.
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Answer the question based on the following context: To determine the effectiveness of implementation of a prevention programme via mobile phone text messaging in enhancing knowledge, attitudes and practice concerning iodine deficiency and iodized salt consumption. In a randomized controlled trial, participants were subjected to a brief tele-educational support regarding iodine deficiency and the importance of iodized salt consumption. The intervention group received daily text messages via mobile phone for 6 weeks. Knowledge, attitude and practice scores, urinary iodine concentration and salt iodine content were assessed at baseline and 8 weeks after the intervention. Participants were recruited from health-care centres in Tehran, the capital city of Iran. For the present study 205 females aged ≥18 years were randomly assigned to the intervention (n 95) and control (n 110) groups. A significant difference was found in median knowledge scores between the intervention and control groups at follow-up (P = 0.004). There was also a significant difference in median attitude scores between the intervention and control groups (P = 0.02). The intervention group did not differ significantly in median practice score, urinary iodine concentration and salt iodine content from the control group.
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Question: Does a text messaging intervention improve knowledge, attitudes and practice regarding iodine deficiency and iodized salt consumption?
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Text messaging interventions are effective in improving individuals' knowledge and attitudes regarding preventive health-care topics.
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Answer the question based on the following context: To examine: (i) the association between home availability of fruit and vegetables and children’s fruit and vegetable intake; (ii) the association between parental perception of the local food shopping environment and the home availability of fruit and vegetables; and (iii) whether the home availability of fruit and vegetables mediates the association between parental perception of the local food environment and children’s fruit and vegetable consumption. Cross-sectional study. A total of ninety-one primary schools in the Netherlands. In total 1501 primary caregivers completed a questionnaire to measure children’s fruit and vegetable consumption, home availability of fruit and vegetables, parental perceptions of the local food shopping environment (price, quality and availability), the child’s socio-economic status, the child’s ethnicity and maternal height and weight. The home availability of fruit and vegetables was positively associated with children’s fruit and vegetable intake (P,0?01 and P,0?001, respectively). Negative parental perceptions of the local food shopping environment were associated with less fruit available at home (P,0?05, P,0?01 and P,0?05 for price, quality and availability of fruit, respectively). No significant associations were found between parental perception of the local food shopping environment and children’s fruit and vegetable consumption. We found no evidence that home availability of fruit and vegetables mediates the association between parental perception of the local food environment and children’s fruit and vegetable intake.
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Question: Is there an association between the home food environment, the local food shopping environment and children's fruit and vegetable intake?
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Interventions focusing on improving the home availability of fruit and vegetables may help to increase children’s fruit and vegetable consumption. However, more data are required on factors influencing the home availability of fruit and vegetables.
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Answer the question based on the following context: The present study investigates the changes and tracking of dietary behaviours in Norwegian 11-year-olds and examines the association between parental education and dietary tracking over a time period of 20 months. Longitudinal data from the Norwegian HEalth In Adolescents (HEIA) cohort study followed up at three time points (2007-2009). Intakes of fruits, vegetables and snacks were assessed by frequency and intakes of sugar-sweetened soft drinks and squash were assessed by frequency and amount. Tracking of dietary behaviours was assessed by adolescents' relative position in rank over time and Cohen's kappa was used to measure tracking coefficients. Multinomial logistic regression analyses were performed to assess the association between parental education and the tracking of dietary behaviours. In total, 885 adolescents from the HEIA cohort study participated by answering Internet-based questionnaires at three time points. The results indicated that boys and girls maintained their relative position in rank of dietary intake over time, when grouped by baseline consumption. Fair to moderate tracking coefficients of dietary variables were observed. An inverse association was found between parental education and stability of soft drink and squash consumption during the 20 months.
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Question: Does tracking of dietary behaviours differ by parental education in children during the transition into adolescence?
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The observed tracking pattern indicates the importance of promoting healthy dietary behaviours at an even earlier age. Furthermore, interventions should focus particularly on adolescents from families with low parental education and their consumption of sugar-sweetened beverages.
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Answer the question based on the following context: Spontaneous reporting of adverse drug reactions (ADR) is fundamental to drug safety surveillance (pharmacovigilance) and assessment of benefit/risk ratio. However, under-reporting remains the limit of the system. The aim of this study was to assess the effect of regular visits of an Assistant in Clinical Research (CRA) on the improvement of ADR reporting in non-university hospitals. We set up an ADR report collecting system that involved regular visits in non-university hospitals, We began the visits in 2006 in 2 areas (Haute Garonne and Gers), extended to 4 other areas in 2009. We compared the reporting rate (number of reports/number of beds) of total ADRs reported by non-university hospitals in these areas before (one year) and after the start of CRA visits. A total 2831 of reports were collected by the CRA: 40% were "serious" including two deaths. The results suggest an increase of 100% of the rate of reporting of ADRs.
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Question: Could we improve notification of adverse drugs reactions in hospital?
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This study shows that regular visits increases the number of ADRs reported by non-university hospitals. Further assessment of this procedure is necessary for long term evaluation of its effectiveness.
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Answer the question based on the following context: Cerebral white matter lesions (WML), evident on CT and MRI brain scans, are histopathologically heterogeneous but associated with vascular risk factors and thought mainly to indicate ischemic damage. There has been disagreement over their clinical prognostic value in predicting conversion from mild cognitive impairment (MCI) to dementia. We scrutinised and rated CT and MRI brain scans for degree of WML in a memory clinic cohort of 129 patients with at least 1 year of follow-up. We examined the relationship between WML severity and time until conversion to dementia for all MCI patients and for amnestic (aMCI) and non-amnestic (naMCI) subgroups separately. Five-year outcome data were available for 87 (67%) of the 129 patients. The proportion of patients converting to dementia was 25% at 1 year and 76% at 5 years. Patients with aMCI converted to dementia significantly earlier than those with naMCI. WML severity was not associated with time to conversion to dementia for either MCI patients in general or aMCI patients in particular. Among naMCI patients, there was a tendency for those with a low degree of WML to survive without dementia for longer than those with a high degree of WML. However, this was not statistically significant.
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Question: Do cerebral white matter lesions influence the rate of progression from mild cognitive impairment to dementia?
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MCI subtype is a significant independent predictor of conversion to dementia, with aMCI patients having higher risk than naMCI for conversion throughout the 5-year follow-up period. WML severity does not influence conversion to dementia for aMCI but might accelerate progression in naMCI.
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Answer the question based on the following context: Chronic pain is the leading cause of disability in developed countries. Prevalence is linked with socio-economic position (SEP), but little is known about the influence of SEP on disabling pain over the life course. We have investigated the influence of different life course trajectories of SEP on disabling pain ('pain interference') in postal surveys of adults aged ≥50 years sampled from the general population of adults registered with three UK general practices. Current pain interference was measured using the dichotomized 36-item Short-Form (SF-36) health survey. Three recalled SEP measures (age left school, longest job and current/most recent job) were dichotomized into low SEP (left school at or before minimum school leaving age; reported routine or manual occupations) and high SEP, from which eight life course SEP trajectories were constructed. Associations of (i) eight SEP trajectories and (ii) three individual SEP measures adjusted for each other, with pain interference, adjusted for potential confounders, were calculated using logistic regression. A total of 2533 individuals provided data on all three SEP measures. A consistently low life course SEP trajectory was significantly associated with current pain interference compared with a high trajectory [odds ratio (OR) = 2.76, 95% confidence interval (CI): 2.19-3.47], even after adjustment for age and gender. Further adjustment reduced the association but it remained significant (OR = 2.04; 95% CI: 1.55-2.68). In the model with individual measures, low age left school (OR = 1.45; 95% CI: 1.15-1.82) and manual longest job (OR = 1.47; 95% CI: 1.13-1.91) were independently associated with pain interference.
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Question: Does life course socio-economic position influence chronic disabling pain in older adults?
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Our results highlight the potential for reducing chronic disabling pain in later life by addressing inequalities in both childhood education and adult occupational opportunities.
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Answer the question based on the following context: NTIS has been described for more than 30 years. However, only few studies focused on the relationship between NTIS and CD. The incidence, underlying pathogenesis, clinical outcomes, and correlation with other inflammatory disease severity and nutritional variables of NTIS in CD have not been completely established. Prospectively, 44 CD patients were enrolled. Medical records and various laboratory values (including thyroidal, nutritional, and inflammatory variables) were collected in all participants. The incidence of NTIS in CD was 36.4%. Albumin, Acute Physiology and Chronic Health Evaluation II score, and Crohn's Disease Activity Index score in NTIS group were statistically different from those in euthyroid group. A decreased sum activity of deiodinases and a reduced ratio of TT4/FT4 were observed in NTIS group. Duration of hospitalization was significantly longer for NTIS patients than euthyroid patients. Albumin was confirmed as a protective factor of NTIS in CD. Receiver operating characteristic curve analysis demonstrated the differentiating capacity of albumin, suggesting 37.6 g/L as optimal cut-off value with sensitivity and specificity of 81.3% and 79.2%, respectively.
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Question: Nonthyroidal illness syndrome: is it far away from Crohn's disease?
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NTIS was a common complication in CD. NTIS patients showed worse nutrition status and clinical outcome, and more critical disease activity and severity compared with euthyroid patients. A hypodeiodination condition and a potential thyroid-hormone-binding dysfunction may play a role in the etiology of NTIS in CD. Albumin was a meaningful protective and distinguishing marker of NTIS in CD.
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Answer the question based on the following context: Some epidemiological data are available on the association between sleep duration and sleep quality, sleep complaints, and the aging related cognitive impairment in the elderly. In this study we examined a large sample of healthy elderly subjects to assess the relationship between sleep quality, subjective cognitive complaints, and neuropsychological performance. A total of 272 elderly subjects (mean age 74.8 ± 1.1 years) were recruited from a population-based cross-sectional study on aging and cardiovascular morbidity. All subjects filled in self-assessment questionnaires evaluating cognitive function, anxiety, depression, sleep-related parameters, and the Pittsburgh Sleep Quality Index (PSQI). Ambulatory polygraphy and extensive neuropsychological tests were also performed. Based on the total PSQI score, subjects were classified as good sleepers (GS, PSQI<5, n=116) and poor sleepers (PS, PSQI≥5, n=156). Poor sleep did not affect the subjective cognitive function score, subjective cognitive impairment being mainly related to anxiety, depression, and sleep medication intake. No significant differences were seen between GS and PS in any of the objective cognitive function tests except for the Trail Making Test A (TMA-A), processing speed being longer in the PS group (p<0.001). Neither the presence of sleep-related breathing disorders nor gender affected cognitive performance.
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Question: Does subjective sleep affect cognitive function in healthy elderly subjects?
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Our results suggest that in healthy elderly subjects, subjective sleep quality and duration did not significantly affect subjective and objective cognitive performances, except the attention level, for that the interference of sleep medication should be considered.
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Answer the question based on the following context: Providing informal care has been linked with poor health but has not previously been studied across a whole population. We aimed to study the association between informal care provision and self-reported poor health. We used data from the UK 2001 Census. The relationship between informal caregiving and poor health was modelled using logistic regression, adjusting for age, sex, marital status, ethnicity, economic activity and educational attainment. We included 44,465,833 individuals free from permanent sickness or disability. 5,451,902 (12.3%) participants reported providing informal care to another person. There was an association between provision of informal caregiving and self-reported poor health; OR 1.100, 95% CI 1.096 to 1.103. This association remained after adjustment for age, sex, ethnic group, marital status, economic activity and educational attainment. The association also increased with the amount of care provided (hours per week).
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Question: Is informal caregiving independently associated with poor health?
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Around one in eight of the UK population reports that he or she is an informal caregiver. This activity is associated with poor health, particularly in those providing over 20 h care per week.
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Answer the question based on the following context: This study aims to investigate direct and indirect pathways of family flexibility, social support, and family communication on health-related quality of life (HRQOL) for Chinese- and Korean-American breast cancer survivors (BCS). A total of 157 Chinese (n = 86)- and Korean-American (n = 71) BCS were recruited from the California Cancer Surveillance Program and area hospitals in Los Angeles County. The present study was guided by the Resiliency Model of Family Stress, Adjustment, and Adaptation. Structural equation modeling demonstrated that (1) family communication was directly associated with HRQOL for both groups; (2) family flexibility was indirectly associated with HRQOL through family communication for Korean-Americans only; (3) social support mediated the relationship between family flexibility and family communication for Chinese-Americans only; and (4) acculturation was directly related to social support for both groups. Multigroup analysis demonstrated that the structural paths were equivalent between Chinese- and Korean-American BCS, although statistical differences in baseline parameters were noted.
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Question: Is family functioning and communication associated with health-related quality of life for Chinese- and Korean-American breast cancer survivors?
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Our findings suggest that family communication impacts HRQOL among Asian-American BCS. Our results show that while there are commonalities in family characteristics among Asian-Americans, specific ethnic variations also exist. Therefore, specific cultural and familial contexts should be assessed to better inform interventions to enhance family communication strategies and improve HRQOL.
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Answer the question based on the following context: Probe-based confocal laser endomicroscopy (pCLE) has enabled in vivo histopathology by obtaining high resolution images of the mucosal layers of the gastrointestinal tract. For indeterminate bile duct strictures, biopsy, cytologic brushing and needle aspiration have low levels of diagnostic accuracy.AIM: The objective of this multi-center pilot study was to assess the interobserver agreement in interpretation of pCLE imaging. Twenty-five de-identified pCLE video clips of indeterminate biliary strictures were sent to 6 observers at 5 institutions. Miami Classification was used to standardize image interpretation. Seven variables were assessed for interobserver agreement using the Fleiss kappa statistic which included: presence of thick (>20 μm) or thin (<20 μm) dark or white bands, dark clumps, epithelium including glandular structures, interstitial fluorescein leakage, ease of interpretation, and final diagnosis. Based on operator experience, observers were categorized into 3 categories of experience (Category 1: 0-10; Category 2: 11-20; Category 3:>21 cases). Upon stratification, Category 1 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.277, κ = -0.079, κ = -0.025, κ = -0.066, κ = 0.128, κ = 0.088), and for the final diagnosis variable, the agreement was slight (κ = 0.033). Category 2 and 3 interobserver agreement ranged from "Poor" to "Fair" (κ = 0.211, κ = 0.181, κ = 0.347, κ = 0.238, κ = -0.050, κ = 0.092), and for the final diagnosis variable, the agreement was slight (κ = 0.195).
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Question: Interpretation of probe-based confocal laser endomicroscopy of indeterminate biliary strictures: is there any interobserver agreement?
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The overall interobserver agreement for pCLE image interpretation in indeterminate biliary strictures ranges from poor to fair. Interpretation criteria as well as training require further standardization toward improving inter-rater reliability.
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Answer the question based on the following context: There is no evidence regarding restaging of patients with locally advanced rectal cancer after a long course of neoadjuvant radiotherapy with or without chemotherapy. This study evaluated the value of restaging with chest and abdominal computed tomographic (CT) scan after radiotherapy. Between January 2000 and December 2010, all newly diagnosed patients in our tertiary referral hospital, who underwent a long course of radiotherapy for locally advanced rectal cancer, were analyzed. Patients were only included if they had chest and abdominal imaging before and after radiotherapy treatment. A total of 153 patients who met the inclusion criteria and were treated with curative intent were included. A change in treatment strategy due to new findings on the CT scan after radiotherapy was observed in 18 (12%) of 153 patients. Twelve patients (8%) were spared rectal surgery due to progressive metastatic disease.
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Question: Is restaging with chest and abdominal CT scan after neoadjuvant chemoradiotherapy for locally advanced rectal cancer necessary?
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Restaging with a chest and abdominal CT scan after radiotherapy for locally advanced rectal cancer is advisable because additional findings may alter the treatment strategy.
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Answer the question based on the following context: There are conflicting reports in the literature regarding the prognostic influence of pregnancy on patients with papillary thyroid carcinoma (PTC), and there is no literature on specific microRNA (miRNA) profiles of PTC in the context of pregnancy. We aim to examine clinically if pregnancy is an adverse factor in PTC, and if pregnancy-associated PTC are biologically different from those in nonpregnant women in terms of their miRNA profiles. Women diagnosed with PTC during or soon after pregnancy were recruited into the pregnancy group. Age-matched nonpregnant females were recruited into the nonpregnancy group. MiRNA microarray was performed on PTC tissue of pregnant patients (10), nonpregnant patients (10), and normal thyroids (5). There were 6 differentially expressed miRNAs from the microarray comparisons validated with RT-PCR. There were 24 patients in the clinical pregnancy group and 30 in the nonpregnancy group. Tumors from the pregnancy group were significantly larger and showed more regional lymph node metastases. The microarray data showed a total of 27 miRNAs that were potential differentiators of PTC tissue samples from pregnant and nonpregnant patients. Of the 6 selected for validation, no significant difference in expression was found.
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Question: Papillary thyroid carcinoma in pregnancy: a variant of the disease?
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Our clinical data suggests that PTC during pregnancy may be more locoregionally aggressive. However, no difference in survival or recurrence is demonstrated. The miRNA profiles of the pregnancy-associated PTC have not been shown to be different to the nonpregnancy counterparts. This likely suggests that the differences seen clinically are related to patient factors rather than the disease itself.
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Answer the question based on the following context: The relation between vitamin B-6 intake and colorectal cancer risk remains uncertain. We prospectively evaluated whether a higher vitamin B-6 intake in the remote past is more strongly associated with a lower risk of colorectal cancer than is an intake in the recent past in the Nurses' Health Study and the Health Professionals Follow-Up Study. We assessed vitamin B-6 intake every 4 y by using validated food-frequency questionnaires and followed 86,440 women and 44,410 men for ≤28 y. Cox proportional hazards regression was used to estimate multivariable RRs and 95% CIs. The total vitamin B-6 intake was significantly associated with an ∼20-30% lower risk of colorectal cancer in age-adjusted results, but this association became attenuated and nonsignificant after additional adjustment for nondietary and dietary factors. When the highest to lowest quintiles of cumulative total vitamin B-6 intake were compared, RRs (95% CIs) for colorectal cancer were 0.99 (0.80, 1.24; P-trend = 0.55) for women and 0.95 (0.73, 1.23; P-trend = 0.75) for men. For the same comparison, RRs were 0.92 (0.73, 1.16) for total vitamin B-6 intake 0-4 y before diagnosis, 0.99 (0.78, 1.26) for intake 4-8 y before diagnosis, 0.92 (0.71, 1.21) for intake 8-12 y before diagnosis, and 0.93 (0.69, 1.26) for intake 12-16 y before diagnosis in women. Corresponding RRs for men were 0.86 (0.63, 1.17), 0.96 (0.70, 1.32), 0.90 (0.63, 1.29), and 1.16 (0.75, 1.79). Results did not differ by cancer subsite, source of vitamin B-6 (food or supplement), alcohol consumption, or folate intake.
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Question: Prospective cohort studies of vitamin B-6 intake and colorectal cancer incidence: modification by time?
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Our data do not support a strong role of adulthood vitamin B-6 intake in colorectal carcinogenesis in these US health professionals.
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Answer the question based on the following context: Maltreatment and torture during custody is still an important problem in many countries. Both national and international regulations and the Istanbul Protocol are of great importance in terms of elimination of maltreatment and torture. In this study, we evaluated whether examinations for custody of immigrants were performed in accordance with the Istanbul Protocol. We retrospectively evaluated reports of forensic examinations for custody of 100 immigrants in Van-Çaldıran Government Hospital in 2009. Data about nationality, age, gender, examination date, referring department, examination findings and departments to which the reports were submitted were collected. Fifty percent of the immigrants were Iranian and they were aged between 11 and 62 years. Ninety-nine immigrants were men and one was woman. Data about history of arrest were missing in forensic reports about all immigrants. Data about signs of trauma were present only for seven immigrants. Ninety-three immigrants were reported to have no signs of trauma. None of the immigrants underwent psychiatric examination. All forensic reports were found to be submitted to the police personally. Whether the immigrants were examined before or after the custody was not clear in the reports.
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Question: Medical forensic examination of detained immigrants: is the Istanbul Protocol followed?
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Evaluation of the data showed that none of the forensic examinations were performed in accordance with the Istanbul Protocol. It can be recommended that the protocol should be incorporated into the curricula for undergraduate, graduate and in-service training programmes in order to improve relevant forensic practices.
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Answer the question based on the following context: Thirty-six patients with HCC underwent caudate lobectomy at a single tertiary referral center between January 1995 and June 2010. In this series, left-sided, right-sided and bilateral approaches were used. The outcomes of patients who underwent isolated caudate lobectomy or caudate lobectomy combined with an additional partial hepatectomy were compared. The survival curves of the isolated and combined resection groups were generated by the Kaplan-Meier method and compared by a log-rank test. Sixteen (44.4%) of 36 patients underwent isolated total or partial caudate lobectomy whereas 20 (55.6%) received a total or partial caudate lobectomy combined with an additional partial hepatectomy. The median diameter of the tumor was 6.7 cm (range, 2.1-15.8 cm). Patients who underwent an isolated caudate lobectomy had significantly longer operative time (240 min vs 170 min), longer length of hospital stay (18 d vs 13 d) and more blood loss (780 mL vs 270 mL) than patients who underwent a combined caudate lobectomy (P<0.05). There were no perioperative deaths in both groups of patients. The complication rate was higher in the patients who underwent an isolated caudate lobectomy than in those who underwent combined caudate lobectomy (31.3% vs 10.0%, P<0.05). The 1-, 3- and 5-year disease-free survival rates for the isolated caudate lobectomy and the combined caudate lobectomy groups were 54.5%, 6.5% and 0% and 85.8%, 37.6% and 0%, respectively (P<0.05). The corresponding overall survival rates were 73.8%, 18.5% and 0% and 93.1%, 43.6% and 6.7% (P<0.05).
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Question: Choice of approach for hepatectomy for hepatocellular carcinoma located in the caudate lobe: isolated or combined lobectomy?
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The caudate lobectomy combined with an additional partial hepatectomy is preferred because this approach is technically less demanding and offers an adequate surgical margin.
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Answer the question based on the following context: The nucleolar organizer regions (NORs) are localized at the secondary constriction of the five pairs of acrocentric chromosomes (13, 14, 15, 21 and 22) in human. To evaluate whether increasing AgNOR protein synthesis effects or not the development of babies/children, 25 Down syndrome patients were included in this study. Firstly, the Ankara Development Screening Inventory (AGTE) test was performed. Then the buccal epithelial cells of patients were taken via a sterile toothpick on clean glass slides and spreaded and AgNOR staining technique was applied to the slides of each individual. Mean NOR area/Total nucleus area (NORa/TNa) were evaluated for each nucleus using a special computer program. The mean NORa/TNa was found to be 3.8+/-1.16. According to these data, a significant correlation was not evident between the NORa/TNa and developmental stages (p>0.05).
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Question: Does higher NORs expression affect the developmental stages of Down syndrome infants?
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There is no correlation between extra energy spending for NOR protein synthesis and developmental deficiency.
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Answer the question based on the following context: To investigate the attitudes, knowledge and practices of general dental practitioners (GDPs), specialists and consultants in paediatric dentistry in London, towards child protection. Additionally, to determine if children attending paediatric dental casualty at the Eastman Dental Hospital (EDH) and those who need treatment of caries under general anaesthesia (GA) are on the child protection register (CPR). The survey was conducted by postal questionnaires with 14 closed questions. A total of 228 dentists were invited to participate in the study. Children who attended EDH and required treatment under GA or at paediatric dental casualty were checked against the CPR. The respond rate was 46% (105/228). Overall 15% (16/105) of dentists had seen at least one patient with suspected child abuse in the last six months, but only 7% (7/105) referred or reported cases to child protection services. Reasons for dentists not referring included: fear of impact on practice (10%; 11/105); fear of violence to child (66%; 69/105); fear of litigation (28%; 29/105); fear of family violence against them (26%; 27/105); fear of consequences to the child (56%; 59/105); lack of knowledge regarding the procedures for referral (68%; 71/105); and lack of certainty about the diagnosis (86%; 90/105). Of the 220 children attending for dental GA and casualty from October 2004 to March 2005, one child was found to be on the CPR.
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Question: A survey of attitudes, knowledge and practice of dentists in London towards child protection. Are children receiving dental treatment at the Eastman Dental Hospital likely to be on the child protection register?
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More information and training is required to raise awareness of the potential importance of the role of dentists in child protection. Improved communication between dental and medical departments is important for safeguarding children.
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Answer the question based on the following context: Heart transplantation remains the last treatment option for patients with end-stage cardiac disease. Such diseases include ischemic cardiomyopathy, nonischemic cardiomyopathy and other conditions such as arrhythmogenic right ventricular dysplasia, cardiac sarcoidosis and cardiac amyloidosis. To review the changes that have occurred over time in the etiology of heart disease in patients requiring heart transplantation, and to compare the clinical and histological diagnoses of explanted hearts from patients with progressive cardiac disease. The pathological findings of 296 surgically excised hearts over a 20-year period (January 1987 to July 2006) at one institution were examined. Patients were separated into groups based on year of heart transplantation. The tissue was examined to determine the underlying cardiac pathology leading to congestive heart failure. Patient records were reviewed for preoperative clinical diagnoses and other relevant data, including pretransplant endomyocardial biopsy (EMB) results, information regarding left ventricular assist devices and, finally, evidence of disease recurrence in the grafted heart. A shift in the underlying etiology was found in patients who underwent heart transplantation from 1992 to 1996, and 1997 to 2001. Between 1987 and 1997, the majority of transplant cases consisted of ischemic cardiomyopathies. From 1997 to 2001, the majority of patients had nonischemic cardiomyopathies, and this trend continued to 2006. A majority of patients with ischemic and hypertrophic cardiomyopathy were diagnosed correctly (96.5% and 82%, respectively) before transplantation. Most patients diagnosed post-transplant with lymphocytic (viral, 15%), hypersensitive/ eosinophilic (25%) and giant cell (100%) myocarditis, arrhythmogenic right ventricle dysplasia (100%), cardiac sarcoidosis (83%) and iron overload toxicity- associated cardiomyopathy (100%) had been misdiagnosed in pretransplantation investigations. Investigations before transplantation did not include an EMB. Of all 296 patients, 51 patients (17%) were misdiagnosed. Excluding the patients with ischemic cardiomyopathy, 46 of 152 patients (30%) were misdiagnosed before transplantation.
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Question: Do clinical diagnoses correlate with pathological diagnoses in cardiac transplant patients?
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Although cardiac transplantation is a viable treatment option for patients with a variety of cardiac diseases, accurate diagnosis of patients before transplantation remains a priority. Accurate diagnosis of particular diseases (sarcoidosis, myocarditis, iron toxicity-associated cardiomyopathy and others) allows for proper treatment before transplantation, which may slow down disease progression and improve patient outcomes. Furthermore, it is important to accurately diagnose patients with diseases such as sarcoidosis, amyloidosis and particular types of myocarditis because these can readily recur in the grafted heart. The risk for recurrence must be known to practitioners and, most importantly, to the patient. We strongly recommend the use of EMB if a nonischemic cardiomyopathy is suspected, because the results may alter the diagnosis and modify the treatment strategy.
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Answer the question based on the following context: To examine whether low serum 25-hydroxyvitamin D (25OHD) concentration were associated with low muscle strength while taking into account the effects of potential confounders among a cohort of community-dwelling women aged 75 years and older. Cross-sectional study corresponding to the baseline assessment of the EPIDOS study. Five French cities including Amiens, Lyon, Montpellier, Paris and Toulouse. Randomized sample of 440 women included in the EPIDOS study. Maximal isometric voluntary contraction strength of the lower limb and hand with computerized dynamometers, serum 25OHD and parathyroid hormone concentration. Age at baseline evaluation, number of chronic diseases, body mass index (BMI), use of calcium drug, practice of a regular physical activity, serum calcium concentration and clearance of creatinine were used as covariables. Subjects were separated into 3 groups based on serum 25 OHD levels with the following cut-off values:<15 ng/ml, 15-30 ng/ml and>30 ng/ml. More than 90% of women had a serum 25OHD insufficiency (i.e.<30 ng/ml) and 40.2% had a related secondary hyperparathyroidism. The mean value of muscle strength was not different among the 3 groups of women (174.9 +/- 53.2 for serum 25OHD<15 ng/ml versus 175.9 +/- 52.6 for serum 25OHD 15-30 ng/ml versus 173.4 +/- 53.1 for serum 25OHD>30 ng/ml with P=0.946 for quadriceps, and 56.1 +/- 13.2 for serum 25OHD<15 ng/ml versus 57.1 +/- 13.5 for serum 25OHD 15-30 ng/ml versus 61.1 +/- 12.7 for serum 25OHD>30 ng/ml with P= 0.064 for handgrip). There was no significant association between serum 25OHD concentration and quadriceps strength (crude beta = 0.03 with P = 0.891 and adjusted beta = -0.04 with P = 0.837). Univariate linear regression showed a significant association between serum 25OHD concentration and handgrip strength (crude beta = 0.16 with P = 0.049) but not while using an adjusted model (adjusted beta = 0.13 with P = 0.106).
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Question: Is there an association between serum 25-hydroxyvitamin D concentration and muscle strength among older women?
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The findings of this study do not support the hypothesis of a relationship between low serum 25OHD concentration and low muscle strength. Further research is needed to corroborate and explain this finding.
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Answer the question based on the following context: Development or retention of abnormal gait patterns after total knee arthroplasty may be related to the predictable pattern of further deterioration of other lower extremity joints. The purpose of this study was to determine whether gait mechanics are abnormal after total knee arthroplasty by conducting a systematic review of the literature. Articles were identified by searching the following electronic databases: PubMed, Cinahl, Web of Science: 221 references were retrieved. The titles and abstracts were reviewed to identify studies that potentially met the inclusion criteria. These articles were retrieved for further assessment. Ten articles met the inclusion criteria and were included in the review. There was a lack of common variables across the studies. Studies indicated smaller peak knee flexion during weight acceptance and less knee flexion excursion in total knee arthroplasty subjects compared to controls. Knee angle at foot strike was generally similar in arthroplasty groups compared to controls. Maximum external knee flexion moment was generally lower in arthroplasty groups compared to controls. Conflicting results were found for other knee moments. Several other stance phase variables were reported by individual studies only.
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Question: Is gait normal after total knee arthroplasty?
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Peak knee flexion and knee flexion excursion during weight acceptance are smaller in the operated knee following total knee arthroplasty compared to healthy controls. There may also be a smaller peak knee flexion moment after arthroplasty compared to controls. Knee mechanics in the operated knee are not normal after total knee arthroplasty. Abnormal gait mechanics may predispose the individual to further joint degeneration, particularly in the nonoperated knee. Further research should focus on the effects of unilateral total knee arthroplasty on the nonoperated knee.
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Answer the question based on the following context: Differences in age, site, and histopathologic subtype exist in basal cell carcinoma (BCC). To compare the distribution of BCCs in patients younger than 40 with that of those aged 90 and older according to sex, site, and subtype.METHODS & One hundred seventy-five BCCs were examined. The site was classified as head and neck, trunk, or limbs and the subtype as nodular, superficial, or morpheic-infiltrative. Younger exhibited a lower prevalence of BCCs on the head and neck (36.0% vs 57.3%, p<.01) and a higher prevalence on the trunk (59.3% vs 31.5%, p<.01) and of superficial BCCs (43.0% vs 31.5%, p<.05) than older patients. Site was associated with subtype in younger (p<.001) and older (p=.004) patients. Superficial BCCs were mostly on the trunk (p<.001), with a higher prevalence in younger patients (86.5% vs 62.5%, p<.05). Morpheic BCCs were mostly on the head and neck (p<.001), and prevalence did not differ between age groups. Nodular BCCs were mostly on the head and neck in older patients (p=.011). Subtype was independently associated with site (p=.005) but not with age or sex.
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Question: Anatomic location and histopathologic subtype of basal cell carcinomas in adults younger than 40 or 90 and older: any difference?
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A different distribution of site and subtype occurs in younger and older patients. Subtype is associated with site independent of age and sex. These findings suggest that, at least in some patients, the anatomic location of BCC may favor the development of a particular subtype.
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Answer the question based on the following context: Hepatitis A virus (HAV) superinfection is associated with a high risk of liver failure and death in patients with hepatitis C virus (HCV) infection. The aim of this study was to investigate the presence of serological and molecular HAV markers in a population of HCV-infected patients in order to determine a cost-effective strategy to vaccinate against HAV. The presence of total and immunoglobulin (Ig)M anti-HAV antibodies was investigated in 399 patients (median age, 50 years; range, 4-81) referred to the Public Health Central Laboratory of Pernambuco State who tested positive for anti-HCV antibodies and HCV RNA. HAV RNA was investigated by reverse transcription-nested polymerase chain reaction in these patients. Three hundred and eighty-four (96%) patients were positive for anti-HAV total and negative for IgM anti-HAV antibodies (immune patients). Three patients had IgM (and total) anti-HAV antibodies, showing an acute infection, and two of them had HAV RNA detected in serum samples. HAV RNA was also found in another patient in the absence of detectable anti-HAV antibodies. By nucleotide sequencing, it was demonstrated that the HAV isolates infecting these patients belonged to subgenotype 1B.
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Question: Should Brazilian patients with chronic hepatitis C virus infection be vaccinated against hepatitis A virus?
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This study provides valuable new data on anti-HAV prevalence among HCV carriers in Brazil. In the present study, we found a high proportion of patients with anti-HAV positivity, indicating that anti-HAV testing of HCV-infected patients is a cost-effective strategy and should be carried out before vaccination against HAV in these patients, particularly in regions such as our geographical area with high total anti-HAV prevalence.
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Answer the question based on the following context: The debate about the timing of diagnostic laparoscopy in unexplained infertile women has been investigated in this prospective study. A total of 328 infertile women who underwent diagnostic laparoscopy for investigation of infertility at any stage of their infertility management from April 2001 to April 2003 were investigated. When the study group was resized according to the inclusion criteria 191 unexplained infertile patients were included. Preoperative and postoperative treatment strategies were compared. The correlation between hysterosalpingography and laparoscopy findings was identified. The results were evaluated using SPSS version 10.0 for Windows. A total of 106 patients were primary and 85 were secondary infertile. The mean ages of primary and secondary infertile patients were 27 +/- 5 and 29 +/- 5, respectively. Sixty percent of primary and 69% of secondary infertile patients had pelvic pathologies. Treatment strategies of 29 (43%) primary infertile and 27 (49%) secondary infertile patients with infertility-related risk factors changed after diagnostic laparoscopy.
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Question: Should diagnostic laparoscopy be performed initially or not, during infertility management of primary and secondary infertile women?
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Diagnostic laparoscopy in preparation for operative procedures (especially for secondary infertile women) should be performed initially in all unexplained infertile patients with or without risk factors related to pelvic pathologies.
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Answer the question based on the following context: Some men with premature ejaculation (PE) and normal erectile function record contradictory response/s to The Sexual Health Inventory for Men (SHIM) and may be incorrectly categorized as suffering from erectile dysfunction (ED). The aim of this study was to evaluate the frequency of false positive SHIM diagnosis of ED in men with lifelong PE. SHIM, stopwatch intravaginal ejaculation latency time (IELT). A prospective observational study of men with normal erectile function and lifelong PE, diagnosed using the ISSM definition of lifelong PE, was conducted. The SHIM was self-administered at Visit 1. Mean per subject stopwatch IELT was determined from four subsequent intercourse attempts. Seventy-eight subjects with a mean age of 33.2 +/- 8.3 years and a geometric mean IELT of 15.9 +/- 2.3 seconds were enrolled. The mean SHIM score for all subjects was 20.4 +/- 6.0. Fifty-two subjects (66.7%) have SHIM scores of>21 (mean 24.3 +/- 1.1), consistent with normal erectile function, and a geometric mean IELT of 18.3 +/- 2.2 seconds. Twenty-six subjects (33.3%) had SHIM scores<22 (mean 12.7 +/- 3.7), consistent with a false positive diagnosis of ED, and a geometric mean IELT of 10.5 +/- 2.3 seconds. The incidence of false positive SHIM diagnosis of ED (SHIM<22) was inversely related to the IELT. Although the geometric mean IELT for subjects with SHIM scores<22 was significantly less than that of all subjects and subjects with SHIM scores>21, there were no significant differences between the geometric mean IELT or the IELT distribution of all subjects vs. the normal erectile function IELT (SHIM>21) cohort.
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Question: Screening for erectile dysfunction in men with lifelong premature ejaculation--Is the Sexual Health Inventory for Men (SHIM) reliable?
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This study demonstrates a 33.3% false positive SHIM diagnosis of ED in men with PE. This is likely to limit subject recruitment in clinical trials by exclusion of subjects with low-range IELTs but is unlikely to result in significantly different baseline IELTs or IELT distributions.
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Answer the question based on the following context: Cavernous hemangiomas associated with epilepsy present an interesting surgical dilemma in terms of whether one should perform a pure lesionectomy or tailored resection, especially in the temporal lobe given the potential for cognitive damage. This decision is often guided by electrocorticography (ECoG), despite the lack of data regarding its value in cavernoma surgery. The purpose of the present study was several-fold: first, to determine the epilepsy outcome following resection of cavernomas in all brain regions; second, to evaluate the usefulness of ECoG in guiding surgical decision making; and third, to determine the optimum surgical approach for temporal lobe cavernomas. The authors identified from their surgical database 173 patients who had undergone resection of cavernomas. One hundred two of these patients presented with epilepsy, and 61 harbored temporal lobe cavernomas. Preoperatively, all patients were initially evaluated by an epileptologist. The mean follow-up was 37 months. Regardless of the cavernoma location, surgery resulted in an excellent seizure control rate: Engel Class I outcome in 88% of patients at 2 years postoperatively. Of 61 patients with temporal lobe cavernomas, the mesial structures were involved in 35. Among the patients with temporal lobe cavernomas, those who underwent ECoG typically had a more extensive parenchymal resection rather than a lesionectomy (p<0.0001). The use of ECoG in cases of temporal lobe cavernomas resulted in a superior seizure-free outcome: 79% (29 patients) versus 91% (23 patients) of patients at 6 months postresection, 77% (22 patients) versus 90% (20 patients) at 1 year, and 79% (14 patients) versus 83% (18 patients) at 2 years without ECoG versus with ECoG, respectively.
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Question: Electrocorticography-guided resection of temporal cavernoma: is electrocorticography warranted and does it alter the surgical approach?
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The surgical removal of cavernomas most often leads to an excellent epilepsy outcome. In cases of temporal lobe cavernomas, the more extensive the ECoG-guided resection, the better the seizure outcome. In addition to upholding the concept of kindling, the data in this study support the use of ECoG in temporal lobe cavernoma surgery in patients presenting with epilepsy.
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Answer the question based on the following context: The purpose of this hypothesis-generating study was to determine whether personality domains and specific personality traits are uniquely associated with sleep duration using data obtained from the National Comorbidity Survey (NCS). Using trained interviewers, we administered to the 5877 noninstitutionalized adults living in the United States the Composite International Diagnostic Interview (World Health Organization. Composite International Diagnostic Interview. Geneva, Switzerland: WHO, 1990) to assess for any DSM-III-R psychiatric diagnoses, and they completed self-report measures of personality and sleep. This was a secondary data analysis using information from a large existing public use data set (NCS-part II). The NCS-part II was an epidemiologic survey based on a stratified multistage area probability method with a response rate of 82.4%. Using a multivariate logistic regression technique, we found significant and positive associations between short sleep (defined as<or=6 hours of sleep per 24-hour period) and self-criticism (odds ratio [OR] = 1.36), the presence of a medical condition (OR = 1.35), neuroticism (OR = 1.30), and the use of sedating medication in the past 12 months (OR = 1.26). Significant and positive associations were found for long sleep (defined as>or=9 hours per 24 hour period) and a diagnosis of dysthymia (OR = 1.52), the use of a sedating medication in the past 12 months (OR = 1.52), emotional reliance on another person (OR = 1.37), employment status (OR = 1.31), and marital status (OR = 1.20).
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Question: Are personality dimensions associated with sleep length in a large nationally representative sample?
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Findings suggest that personality, even after controlling for psychiatric and medical conditions, is associated with sleep length and may be an additional factor to consider when assessing any individual patient.
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Answer the question based on the following context: Carotid endarterectomy (CEA) is the standard treatment of carotid stenosis for symptomatic and asymptomatic patients. Carotid angioplasty and stenting (CAS), however, has been proposed as alternative therapy for patients deemed at high-risk for CEA. This study examined 30-day adjudicated outcomes in a contemporary series of CEAs and assessed the validity of criteria used to define a potential high-risk patient population for CEA. Patients undergoing isolated CEA in private sector hospitals between Jan 1, 2005, and Dec 31, 2006, were identified using the prospectively gathered National Surgical Quality Improvement Program database. The primary study end points were 30-day stroke and death rates. Demographic, preoperative, and intraoperative variables were examined using multivariate models to identify variables associated with the study end points. Variables used to define systemic "high-risk" patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study (active cardiac disease, severe chronic obstructive pulmonary disease, and octogenarian status) were examined individually and in composite fashion for association with study endpoints. Of the 3949 CEAs performed, 59% were in men, 30% were "high-risk" (19% age>80), and 43% had a previous neurologic event. The 30-day stroke rate was 1.6%, the death rate was 0.7%, and combined stroke/death rate was 2.2%. Multivariate analysis showed that intraoperative transfusion (odds ratio [OR], 5.95; 95% confidence interval [CI], 1.71-20.66; P = .005), prior major stroke (OR, 5.34; 95% CI, 2.96-9.64; P<.0001), shorter height (surrogate for small artery size; OR, 1.09; 95% CI, 1.02-1.16; P = .010), and increased anesthesia time (OR, 1.02; 95% CI, 1.00-1.03; P = .008) were predictive of stroke. Critical limb ischemia (OR, 12.72; 95% CI, 3.49-46.40; P<.0001) and poor functional status (OR, 7.05; 95% CI, 2.95-16.82; P<.0001) were independent correlates of death. Systemic high-risk variables, either combined or individually, did not increase risk of stroke or death on multivariate analysis.
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Question: Outcomes after carotid endarterectomy: is there a high-risk population?
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CEA is associated with favorable 30-day outcomes across a spectrum of patient comorbidity features including octogenarian status. Anatomic and technical features are the important predictors of perioperative stroke, whereas critical limb ischemia and poor functional status are important predictors of death for patients undergoing CEA. These data refute the concept that CAS is preferred for patients deemed high-risk by virtue of systemic comorbidities.
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Answer the question based on the following context: To determine whether the metabolic syndrome is a discrete diagnostic category or the end of a continuum. The study sample consisted of 3959 individuals from the National Health and Nutrition Examination Survey 1999-2004. The taxometric methods of mean above minus mean below a cut (MAMBAC) and maximum covariance (MAXCOV) were used. The primary numerical outcome was the comparative curve fit index (CCFI). For men, the CCFI from MAMBAC and MAXCOV analyses were 0.290 and 0.260, respectively. Likewise, for women, the CCFI from MAMBAC and MAXCOV analyses were 0.317 and 0.311, respectively.
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Question: Is the metabolic syndrome a discrete diagnostic category or the end of a continuum?
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The results indicate that the metabolic syndrome is continuously distributed in nature, rather than a discrete diagnostic category.
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Answer the question based on the following context: A large prostate volume has historically been a relative contraindication to prostate brachytherapy (PB) because of concerns of toxicity and potential pubic arch interference. Common practice has been to downsize large prostates with androgen deprivation therapy (ADT) before proceeding with brachytherapy. The present study compares postimplant dosimetry in patients with prostate volumes>50 cc with those with prostate volumes</=50 cc. A review of all patients who underwent PB at our institution from 2001 to 2006 was performed. Postimplant dosimetry was obtained approximately 4 weeks after brachytherapy. One-hundred forty-five out of a total of 148 patients had available dosimetry. In the 113 patients with prostate volumes</=50 cc (mean, 35.4 cc, range, 14.2-49.7 cc); the mean D(90) (dose which covers 90% of the prostate), V(100) (volume of prostate receiving 100% of the prescribed dose), V(150) (volume of prostate receiving 150% of the prescribed dose), and V(200) (volume of prostate receiving 200% of the prescribed dose) was 128.9%, 95.6%, 73.9%, and 51.2%, respectively. In the 32 patients with prostate volumes>50 cc (mean 58.1 cc, range 50.2-86.0 cc); the mean D(90), V(100), V(150), and V(200) was 125.1%, 95.2%, 68.2%, and 41.7%, respectively. The rectal V(100) was 1.0 cc for both cohorts. There was no statistically significant difference between the cohorts with respect to postimplant dosimetry for D(90), V(100), and V(150). The V(200) for prostate volumes>50 cc was significantly lower (p<0.05).
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Question: Dosimetric outcomes in prostate brachytherapy: is downsizing the prostate with androgen deprivation necessary?
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In the present study, patients with prostate volumes>50 cc have postimplant dosimetry parameters similar to patients with prostate volumes</=50 cc for D(90), V(100), and V(150); and significantly lower values for V(200). These results suggest that patients with large prostate volumes may not need to be routinely placed on hormonal therapy; sparing patients the side effects of hormonal therapy, and sparing the health care system the costs of luteinizing hormone-releasing hormone agonist injections.
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Answer the question based on the following context: The study was carried out to determine the learning curve patterns for basic laparoscopic technical skills. Thirty-seven surgical residents with limited laparoscopic experience performed 10 repetitions of 6 tasks on a virtual-reality trainer (MIST-VR) with standardized distribution of practice. Assessment was based on time, errors, and economy of motion as measured by MIST-VR. Proficiency levels were established by testing experienced laparoscopic surgeons. Four learning curve patterns were determined. Surgeons in group 1 (5.4%) demonstrated proficiency from the beginning; group 2 (70.3%) achieved predefined expert criteria between 2 and 9 repetitions; group 3 (16.2%) demonstrated improvement but was unable to achieve proficiency within 10 repetitions. Group 4 (8.1%) underperformed and showed no tendency of skills improvement, reflecting a group of subjects who probably are unable to learn laparoscopic technique.
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Question: Can everyone achieve proficiency with the laparoscopic technique?
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The results indicated that a group of subjects could not reach proficiency in the psychomotor skills relevant for laparoscopy. We believe that this is an important issue that should be addressed in future research.
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Answer the question based on the following context: Although several tools have been designed to assess quality of life (QoL) among middle-aged women their capacity to specifically assess sexual dysfunction (SD) remains uncertain. Moreover, if SD impairs QoL within this population, then sexual assessment becomes a key issue. To evaluate the accuracy of the Menopause Rating Scale (MRS) in diagnosing SD among climacteric women. In this cross-sectional study 370 women aged 40-59 years filled out the MRS and the Female Sexual Functioning Index (FSFI) simultaneously. SD among surveyed women was defined as those obtaining a total FSFI score of<or=26.55. A receiver-operator curve (ROC) was used to plot and measure the diagnostic accuracy of one MRS item (item 8, assessing sexual problems) using the FSFI total score as a gold standard. Mean age of surveyed women was 49.3+/-5.8 years. A 56.5% of them were married, 44.3% were postmenopausal, 66.8% were sexually active and 57% had SD (FSFI total score<or=26.55). ROC curve determined a score>or=1 in the MRS item 8 as a cut-off value for discriminating women with SD (78% sensitivity and 62% specificity with an area below the curve of 0.70 Swett).
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Question: Is the Menopause Rating Scale accurate for diagnosing sexual dysfunction among climacteric women?
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The MRS was moderately accurate for diagnosing SD among climacteric women. More research is warranted in this regard.
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Answer the question based on the following context: We investigated whether hemodialysis (HD) patients prefer standard or renal-specific oral nutritional supplements (ONS). Standard ONS Fortisip (Nutricia Clinical Care, Wiltshire, Trowbridge, UK) and renal ONS Renilon (Nutricia Clinical Care) and Nepro (Abbott Laboratories, Ltd., Maidenhead, Berkshire, UK) were compared using single-blind taste tests and face-to-face, interviewer-administered questionnaires. This study took place in our HD unit in September 2007. There were 40 patients, including 24 males, 14 smokers, and 26 Caucasians, aged<30 years (n = 6), 31 to 50 years (n = 13), 51 to 70 years (n = 12), and>70 years (n = 9). Patients ranked ONS taste on a Likert scale (1 to 5), and compared flavor options, phosphate-binder requirements, and fluid contribution. Which factors influenced a patient's choice of ONS? Gender, smoking status, ethnicity, and age influenced patients' choices. The taste of Fortisip and Nepro was liked by 58% (n = 23), versus 28% liking Renilon (n = 11). Renilon was disliked by 35% (n = 14), Nepro was disliked by 30% (n = 12), and Fortisip was disliked by 25% (n = 10). The favorite taste was Fortisip, in 52% (n = 21). However, 21% (n = 4) who preferred the taste of renal ONS would not choose them long-term because of their limited flavor ranges. The lack of phosphate binders with Renilon was a deciding factor in 27% (n = 19/33). The low fluid contribution of renal ONS influenced the choice of 43% (n = 12/28). All factors considered, standard ONS remained most popular for patients aged>70 years. However, in all other subgroups, and particularly males and non-Caucasians, renal ONS became more popular. Many patients (23%; n = 9) would sacrifice taste for the benefits of renal ONS.
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Question: Do hemodialysis patients prefer renal-specific or standard oral nutritional supplements?
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Renal ONS are more popular in HD patients because of their low fluid contribution and phosphate-binder requirements, which can influence preference over taste. Patients need information to make informed choices.
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Answer the question based on the following context: To perform a meta-analysis examining the effects of foot orthoses on self-reported pain and function in patients with plantar fasciitis. MEDLINE, SPORTDiscus, and CINAHL were searched from their inception until December 2007 using the terms "foot", "plantar fascia", "arch", "orthotic", "orthoses" and "plantar fasciitis". Original research studies which met these criteria were included: (1) randomised controlled trials or prospective cohort designs, (2) the patients had to be suffering from plantar fasciitis at the time of recruitment, (3) evaluated the efficacy of foot orthoses with self-reported pain and/or function, (4) means, standard deviations, and sample size of each group had to be reported. We utilised the Roos, Engstrom, and Soderberg (Roos, E., Engstrom, M.,&Soderberg, B. (2006). Foot orthoses for the treatment of plantar fasciitis. Foot and Ankle International, 8, 606-611) night splint condition to compare our pooled orthoses results. The meta-analysis results showed significant reductions in pain after orthotic intervention. The Roos et al.' (Roos, E., Engstrom, M.,&Soderberg, B. (2006). Foot orthoses for the treatment of plantar fasciitis. Foot and Ankle International, 8, 606-611) study also showed significant reduction in pain after night splint treatment. The meta-analysis results also showed significant increases in function after orthotic use. In contrast, the Roos et al.' (Roos, E., Engstrom, M.,&Soderberg, B. (2006). Foot orthoses for the treatment of plantar fasciitis. Foot and Ankle International, 8, 606-611) study did not show a significant increase in function after night splinting for 12 weeks.
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Question: Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis?
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The use of foot orthoses in patients with plantar fasciitis appears to be associated with reduced pain and increased function.
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Answer the question based on the following context: To determine if there is evidence of abnormal hip joint range of motion (ROM) in youth and senior team professional footballers compared with matched controls. A case control study design was used. 40 professional footballers (20 youth and 20 senior team) and 40 matched control subjects. Bilateral measurements of passive hip internal rotation (IR), external rotation (ER), flexion, abduction and extension were made together with Faber's test and the hip quadrant. Youth and senior footballers had significantly less IR and Faber's range and significantly higher abduction than their respective controls (p<0.001). Senior footballers also had significantly reduced IR (p<0.05) and Faber's (p<0.001) than the youth team. A higher proportion of senior footballers had positive hip quadrants (45% of all hips) compared to all other groups. No significant difference in hip ROM was found between dominant and non-dominant legs.
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Question: Comparison of hip joint range of motion in professional youth and senior team footballers with age-matched controls: an indication of early degenerative change?
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A specific pattern of hip ROM was found in professional footballers which appeared to be different from controls. These changes may demonstrate the early stages of hip degeneration to which it has been shown ex-professional players are prone to. Hip joint ROM exercises may be necessary in these players to restore normal movement and prevent the onset of hip osteoarthritis (OA).
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Answer the question based on the following context: The use of self-rated health (SRH) for measuring health inequalities could present some limits. The impact of the same disease on SRH could be different according to health expectations people have which are associated with social characteristics. The aim of this study was to analyse the link between physical health status and SRH, according to level of education. Data from the National Health and Nutrition Examination Survey for the years 2001-4 were used. Multivariate logistic regression analyses were performed for assessing the relation between health status and SRH according to educational level. The sample consisted of 4661 men and 4593 women. Reporting functional limitation was associated more strongly with poor SRH in higher educated women than in lower educated women (OR, 8.73, 95% CI 5.87 to 12.98 vs OR, 3.97, 95% CI 2.93 to 5.38 respectively), as was reporting respiratory disease (OR, 5.17, 95% CI 3.67 to 7.30 vs OR, 2.60, 95% CI 1.72 to 3.95 respectively), cardiovascular disease (OR, 9.79, 95% CI 6.22 to 15.40 vs OR, 3.34, 95% CI 2.29 to 4.87 respectively) and dental problems (OR, 4.37, 95% CI 3.22 to 5.92 vs OR, 2.58, 95% CI 1.97 to 3.39 respectively). Reporting functional limitation was associated more strongly with poor SRH in higher educated men than in lower educated men (OR, 7.71, 95% CI 5.04 to 11.79 vs OR, 4.87, 95% CI 3.30 to 7.18 respectively), as reporting oral problems (OR, 2.62, 95% CI 1.84 to 3.74 vs OR, 3.63, 95% CI 2.81 to 4.68 respectively).
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Question: Using self-rated health for analysing social inequalities in health: a risk for underestimating the gap between socioeconomic groups?
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The impact of health problems on SRH is stronger among better educated individuals. This phenomenon could lead to an underestimate of the health inequalities across socioeconomic groups.
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Answer the question based on the following context: Brain volume of boys is larger than that of girls by approximately 10%. Prenatal exposure to testosterone has been suggested in the masculinization of the brain. For example, in litter-bearing mammals intrauterine position increases prenatal testosterone exposure through adjacent male fetuses, resulting in masculinization of brain morphology. The influence of intrauterine presence of a male co-twin on masculinization of human brain volume was studied in 9-year old twins. Magnetic resonance imaging brain scans, current testosterone, and estradiol levels were acquired from four groups of dizygotic (DZ) twins: boys from same-sex twin-pairs (SSM), boys from opposite-sex twin-pairs (OSM), girls from opposite-sex twin-pairs (OSF), and girls from same-sex twin-pairs (SSF; n=119 individuals). Data on total brain, cerebellum, gray and white matter volumes were examined. Irrespective of their own sex, children with a male co-twin as compared to children with a female co-twin had larger total brain (+2.5%) and cerebellum (+5.5%) volumes. SSM, purportedly exposed to the highest prenatal testosterone levels, were found to have the largest volumes, followed by OSM, OSF and SSF children. Birth weight partly explained the effect on brain volumes. Current testosterone and estradiol levels did not account for the volumetric brain differences. However, the effects observed in children did not replicate in adult twins.
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Question: Does having a twin brother make for a bigger brain?
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Our study indicates that sharing the uterus with a DZ twin brother increases total brain volume in 9-year olds. The effect may be transient and limited to a critical period in childhood.
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Answer the question based on the following context: Carotid artery plaque with a disrupted fibrous cap is characterized by a higher tendency to rupture, resulting in a higher rate of transitory ischemic attack and stroke. The purpose of our study was to evaluate whether there is a statistically significant correlation between the presence of fissured fibrous cap (FFC) (assessed by using multi-detector-row CT angiography (MDCTA)) and ipsilateral symptomaticity. 147 patients (105 males, 42 females; mean age 63 years, range 37-84) with a stenosis of at least 50% or a plaque alteration at sonography were retrospectively studied, yielding a total of 294 carotid arteries, by using a multi-detector-row CT (MDCT) scanner. A search for detection of FFC and a correlation with previously registered data about patients' symptomaticity by using statistical assessment were performed. Each examination was assessed independently by two readers and interobserver agreement was calculated. Among the 147 patients included in the study group, 15 were excluded because of inadequate quality images. In the 132 remaining patients, for a total of 264 carotids assessed, 30 FFCs were detected by using MDCTA and overall there were 36 symptomatic patients (12 ipsilateral symptomatic patients with FFC). A statistical correlation between the presence of FFC and symptomaticity (p = 0.0032) was found. The kappa value between readers was 0.781.
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Question: Fissured fibrous cap of vulnerable carotid plaques and symptomaticity: are they correlated?
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MDCT may depict FFC and the results of our study suggest that FFC may be used as an indicator for prediction of potential cerebrovascular pathology. The interobserver agreement obtained was good.
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Answer the question based on the following context: To maximize the hemodynamic benefit of cardiac resynchronization therapy (CRT), echocardiographic AV interval optimization is routinely performed, complemented by VV interval optimization especially in non-responders. Programming of the basic pacing rate, however, is largely empirical in these patients. Therefore, the present study aimed to systematically evaluate the impact of basic pacing rate on hemodynamic parameters in CRT patients with sinus bradycardia. We included 70 consecutive patients with moderate to severe heart failure, LV ejection fraction<or=35%, left bundle branch block or a QRS duration>120 ms combined with echocardiographic evidence of ventricular dyssynchrony. All patients were on optimal heart failure medication, with CRT-ICD devices implanted at least 6 months before inclusion into the study. All patients were in sinus rhythm with a spontaneous heart rate<40 bpm. In all patients, cardiac output (CO) and stroke volume (SV) were determined using electrical velocimetry (EV) (Aesculon, Osypka Medical, Berlin, Germany). EV provides a new algorithm to calculate CO based on variations in thoracic electrical bioimpedance, which has been recently validated. Hemodynamic measurements were performed at four different pacing rates ranging from 40 to 70 bpm. A stepwise increase in CO was encountered with increasing heart rates, reaching statistical significance when comparing 70 with 40 bpm. SV remained unchanged throughout all pacing rates.
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Question: The basic pacing rate in CRT patients: the higher the better?
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In the range between 40 and 70 bpm, an increase in basic pacing rate enhances CO without reducing SV. According to this pilot study, a basic pacing rate between 60 and 70 bpm would appear reasonable.
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Answer the question based on the following context: The cheek-to-cheek diameter (CCD) has been shown to be an indicator of subcutaneous tissue mass in the fetus. However, the correlation between CCD and the abdominal circumference (AC) has not been investigated yet. The objective of the present study was to demonstrate whether a correlation exists between fetal CCD, AC, estimated fetal weight (EFW), and the 1 h, 50 g, glucose challenge test (GCT) levels in patients with and without gestational diabetes mellitus. A prospective, institutional review board approved study was performed. The CCD was obtained as part of the ultrasound for obstetric interval growth scans and biophysical profiles. Exams were performed during the third trimester. The CCD was obtained on a coronal view of the fetal face, at the level of the nostrils and lips. Patients were enrolled between November 2005 and May 2006. Pearson correlation coefficient and linear regression modeling were used as appropriate. Eighty-three patients were enrolled, 29 (33%) of them were diabetic. The mean gestational age is 34.8 +/- 3 weeks and the mean maternal age is 29.9 +/- 5.1. A significant linear association was found between CCD and EFW (Pearson coefficient of correlation being 0.51, P = 0.01). The Pearson correlation coefficient of the relationship between the CCD and AC was 0.47 (P = 0.01). Using a linear regression model, controlling for gestational age at performance of the ultrasound, the association between CCD and EFW remained significant (P = 0.021). There were no significant differences between diabetic and non-diabetic patients regarding the CCD (6.2 +/- 0.9 vs. 6.3 +/- 0.9 respectively, P = 0.669) or the EFW (2,527.9 +/- 705 vs. 2,645 +/- 760 g). While AC was significantly correlated with the GCT levels (Pearson coefficient of correlation = 0.46, P = 0.024), no such correlation was demonstrated for CCD (Pearson correlation coefficient = 0.23, P = 0.160).
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Question: The fetal cheek-to-cheek diameter and abdominal circumference: are they correlated?
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The cheek-to-cheek diameter is significantly correlated to the abdominal circumference and the estimated fetal weight. However, the abdominal circumference has a tighter correlation with the glucose challenge test.
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Answer the question based on the following context: There is evidence of an allergy protective effect in children raised on farm. It has been assumed that microbial exposure may confer this protection. However in farm, little attention has been given to the pollen level and to concomitant microbiological exposure, and indoor pollen concentrations have never been precisely quantified. The kinetics of pollen in dairy farms have been studied in a pilot study (n = 9), and exposure in a sub-sample of the ongoing European birth cohort PASTURE (n = 106). Measurements of viable microorganisms and pollen were performed in air samples. To identify factors that modulate the pollen concentration multivariate regression analyses were run. Indoor pollen (95% of Poaceae fragments and grains) were significantly higher in winter than in summer (P = 0.001) and ranged between 858 to 11 265 counts/m(3) during feeding in winter, thus exceeding typical outdoor levels during the pollen season. Geometric mean in French farms was significantly higher than in German and Swiss farms (7 534, 992 and 1 079 count/m(3), respectively). The presence of a ventilation system and loose housing systems significantly reduced indoor pollen levels. This pollen concentration rise after feeding was accompanied by an increase in fungal and actinomycetal levels, whereas the concentration of bacteria was not associated with feeding.
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Question: High levels of grass pollen inside European dairy farms: a role for the allergy-protective effects of environment?
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Farmers and their children who attend cowsheds during the feeding sessions are exposed perennially to high pollen concentrations. It might be speculated that the combined permanent exposure to microbes from livestock and grass pollen may initiate tolerance in children living on a farm.
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Answer the question based on the following context: The aim of this study was to determine whether pre-existing diabetes mellitus increases the risk of rejection, infection and/or death in cystic fibrosis patients undergoing bilateral sequential single-lung transplantation. A retrospective audit of 25 consecutive patients with cystic fibrosis who underwent bilateral sequential single-lung transplantation between 1 January 2003 and 31 December 2005 at a tertiary referral hospital was carried out. Although 32% patients had diabetes diagnosed before lung transplantation, 92% had random blood glucose levels>or =11.1 mmol/L requiring insulin during admission. Patients with pre-existing diabetes had increased infection-related (3.9 vs 1.2, P= 0.01) and putative rejection-related (1.4 vs 0.5, P= 0.04) hospital admissions post-transplantation compared with those without diabetes pre-transplant. During the period of observation, four of eight patients with a prior diagnosis of diabetes died compared with none of 17 patients without prior diabetes (P= 0.0055).
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Question: Prior diabetes mellitus is associated with increased morbidity in cystic fibrosis patients undergoing bilateral lung transplantation: an 'orphan' area?
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Almost all cystic fibrosis patients develop hyperglycaemia after lung transplantation, but patients with prior diabetes have more complication-related admissions to hospital and a higher mortality rate.
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Answer the question based on the following context: The Gold Standards Framework was developed in primary care to improve the care provided for people at the end-of-life. Following its successful introduction to this setting it was adapted and implemented in care homes. A case study approach was appropriate for this study of a care programme into a 'real life' setting. Fourteen managers participated in an initial telephone interview. Ten of these homes participated in the case study phase and 61 staff participated in individual or group interviews. Seven residents and three relatives participated in face to face interviews. Qualitative data were analysed in line with the template approach. Survey data were also analysed and a validated Teamworking Questionnaire was used. It was found that teamwork is central to the successful introduction of the Gold Standards Framework in Care Homes. Good staffing levels and management support were also perceived to be key factors in homes where the Framework became established.
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Question: Delivering 'Gold Standards' in end-of-life care in care homes: a question of teamwork?
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Effective teamwork was necessary for changes in end-of-life care to be achieved in the care homes. If end-of-life care and other improvements in practice are to continue, teamwork will need to be supported and developed.
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Answer the question based on the following context: An earlier combined proactive and reactive telephone follow-up intervention for acute myocardial infarction patients after discharge from hospital showed positive effects after six months. The aim of the present study was to assess whether the intervention has long-term effects up to 18 months after discharge. A prospective randomised controlled trial with 18 months follow-up. The trial was conducted with 288 patients allocated to a telephone follow-up intervention group (n = 156) or control group (n = 132). The primary endpoint was health-related quality of life using the SF-36. Secondary endpoints included smoking and exercise habits, return to work and rehospitalisation due to chest pain. There were significant improvements over time on most dimensions of health-related quality of life in both the intervention and control group to US norm population levels on most SF-36 dimensions and summary scores. The intervention group showed no overall significant improvement beyond six months in the physical or mental summary scores, but there was a significant effect for those aged 70 or above. Although there was a promising effect for rehospitalisation due to chest pain, no significant differences were found between the groups on the secondary endpoints after six months.
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Question: Does a telephone follow-up intervention for patients discharged with acute myocardial infarction have long-term effects on health-related quality of life?
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This study demonstrated that despite positive short-term effects at six months, the telephone follow-up intervention had no long-term effects on health-related quality of life or secondary endpoints. However, the potential for improvement beyond six months was less than anticipated reflecting a reduced morbidity among acute myocardial infarction patients.
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Answer the question based on the following context: The aim and objective of this study was to determine whether the occurrence of pressure ulcers following cardiothoracic surgery increases the length of hospitalisation. Literature suggests that a pressure ulcer extends the length of hospital stay. The impact of pressure ulcers on length of hospital stay after cardiothoracic surgery is yet undetermined. Prospective follow-up study. Two hundred and four patients admitted for elective cardiothoracic surgery and with an intensive care unit stay of>48 hours were included in a prospective cohort study. The course of the skin condition in relation to pressure ulcers was monitored during their stay in a teaching hospital. Length of hospital stay was compared between the group with and without pressure ulcers. Hospital stay for cardiothoracic patients with and without pressure ulcers did not differ significantly (p = 0.23). Patients that developed pressure ulcers had a median hospital stay of 13 days (interquartile range: 9-19) vs. 12 days (interquartile range: 7-15) for patients without pressure ulcers. However, we observed that length of stay in the intensive care unit was significantly (p = 0.005) longer for patients with pressure ulcers. This was not associated with the occurrence of complications. However, the occurrence of pressure ulcers was significantly correlated with length of intensive care support in postoperative care.
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Question: Do pressure ulcers influence length of hospital stay in surgical cardiothoracic patients?
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Non-complicated pressure ulcers in postsurgery patients do not significantly increase the length of total hospital stay.
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Answer the question based on the following context: There is growing concern about alcohol-related harm, particularly within Scotland which has some of the highest rates of alcohol-related death in western Europe. There are large gender differences in alcohol-related mortality rates in Scotland and in other countries, but the reasons for these differences are not clearly understood. In this paper, we aimed to address calls in the literature for further research on gender differences in the causes, contexts and consequences of alcohol-related harm. Our primary research question was whether the kind of social environment which tends to produce higher or lower rates of alcohol-related mortality is the same for both men and women across Scotland. Cross-sectional, ecological design. A comparison was made between spatial variation in men's and women's age-standardised alcohol-related mortality rates in Scotland using maps, Moran's Index, linear regression and spatial analyses of residuals. Directly standardised mortality rates were derived from individual level records of death registration, 2000-2005 (n = 8685). As expected, men's alcohol-related mortality rate substantially exceeded women's and there was substantial spatial variation in these rates for both men and women within Scotland. However, there was little spatial variation in the relationship between men's and women's alcohol-mortality rates (r2 = 0.73); areas with relatively high rates of alcohol-related mortality for men tended also to have relatively high rates for women. In a small number of areas (8 out of 144) the relationship between men's and women's alcohol-related mortality rates was significantly different.
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Question: Are there gender differences in the geography of alcohol-related mortality in Scotland?
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In as far as geographic location captures exposure to social and economic environment, our results suggest that the relationship between social and economic environment and alcohol-related harm is very similar for men and women. The existence of a small number of areas in which men's and women's alcohol-related mortality had an different relationship suggests that some places may have unusual drinking cultures. These might prove useful for further investigations into the factors which influence drinking behaviour in men and women.
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Answer the question based on the following context: Smokers attribute respiratory symptoms, even when severe, to everyday causes and not as indicative of ill-health warranting medical attention. The aim of this pilot study was to conduct a structured vignette survey of people attending general practice to determine when they would advise a person with respiratory symptoms to consult a medical practitioner. Particular reference was made to smoking status and lung cancer. Participants were recruited from two general practices in Western Australia. Respondents were invited to complete self-administered questionnaires containing nine vignettes chosen at random from a pool of sixty four vignettes, based on six clinical variables. Twenty eight vignettes described cases with at least 5% risk of cancer. For analysis these were dubbed 'cancer vignettes'. Respondents were asked if they would advise a significant other to consult a doctor with their respiratory symptoms. Logistic regression and non-parametric tests were used to analyse the data. Three hundred questionnaires were distributed and one hundred and forty completed responses were collected over six weeks. The majority (70.3%) of respondents were female aged forty and older. A history of six weeks' of symptoms, weight loss, cough and breathlessness independently increased the odds of recommending a consultation with a medical practitioner by a factor of 11.8, 2.11, 1.40 and 4.77 respectively. A history of smoking independently increased the odds of the person being thought 'likely' or 'very likely' to have cancer by a factor of 2.46. However only 32% of cancer vignettes with a history of cigarette smoking were recognised as presentations of possible cancer.
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Question: Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms?
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Even though a history of cigarette smoking was more likely to lead to the suggestion that a symptomatic person may have cancer we did not confirm that smokers would be more likely to be advised to consult a doctor, even when presenting with common symptoms of lung cancer.
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Answer the question based on the following context: Delay in surgery for fractured neck of femur is associated with increased mortality; it is recommended that patients with fractured neck of femur are operated within 48 h. North West hospitals provide dedicated trauma lists, as recommended by the British Orthopaedic Association, to allow rapid access to surgery. We investigated trauma list provision by each trust and its effects on the time taken to get neck of femur patients to surgery and patient survival. The number of trauma lists provided by 13 acute trusts was determined by telephone interview with the theatre manager. Data on operating delays, reasons for delay and 30-day mortality were obtained from the Greater Manchester and Wirral fractured neck of femur audit. A total of 883 patients were included in the audit (35-126 per hospital). Overall, 5-15 trauma lists were provided each week, and 80% of lists were consultant-led. Of patients, 31.8% were operated on within 24 h and 36.9% were delayed more than 48 h; 37.7% of delays were for non-medical reasons. The 30-day mortality rates varied between 5-19% (mean, 11.8%). There were no significant relationships between the number of trauma lists and these variables. When divided into hospitals with>10 lists per week (n = 6) and those with<10 lists per week (n = 7) there were no significant differences in 48-h delay, non-medical delay or mortality. However, 24-h delay showed a trend to be lower in those with>10 lists (34.6% of patients versus 28.9%; P = 0.09).
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Question: Does the number of trauma lists provided affect care and outcome of patients with fractured neck of femur?
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Most trusts provided at least one dedicated daily list. This study shows that extra lists may enable trusts to cope better with fractured neck of femur but do not change mortality.
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Answer the question based on the following context: Patients with deep infiltrating endometriosis (DIE) of the rectum often benefit from surgical treatment, including disc or segmental bowel resection, in terms of pain relief and treatment of infertility. The aim of the present study was to evaluate the diagnostic accuracy of transvaginal sonography (TVS) for preoperative detection of rectal DIE. Furthermore, we aimed to investigate whether TVS can predict infiltration depth based on the distortion of characteristic sonomorphologic features of the rectal wall. Two-hundred patients with symptoms of endometriosis were prospectively assessed by TVS for the presence of rectal DIE before undergoing laparoscopic radical resection of endometriosis including segmental resection of the bowel in affected cases. Sensitivities, specificities, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LHR) and test accuracies were then calculated for the presence of infiltration of the serosal/smooth muscle (S/M) layer and submucosal/mucosal (MUC) layer as demonstrated by TVS and confirmed by histopathological analysis. Rectal endometriosis was confirmed in 43 out of 195 (22%) cases. The sensitivity, specificity, PPV, NPV, test accuracy and positive and negative LHR of TVS on S/M infiltration were 98%, 99%, 98%, 99%, 99%,150.24 and 0.02, respectively, whereas respective data on MUC involvement were 62%, 96%, 53%, 97%, 93.8%, 16 and 0.4.
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Question: Can transvaginal sonography predict infiltration depth in patients with deep infiltrating endometriosis of the rectum?
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TVS is a highly valuable tool in detecting rectal endometriosis preoperatively. Within this, S/M endometriotic infiltration can be accurately predicted, whereas TVS is less valuable for detection of MUC involvement.
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Answer the question based on the following context: Accurate assessment of exposure is a key factor in occupational epidemiology but can be problematic, particularly where exposures of interest may be many decades removed from relevant health outcomes. Studies have traditionally relied on crude surrogates of exposure based on job title only, for instance farm-related job title as a surrogate for pesticide exposure. This analysis was based on data collected in Western Australia in 2000-2001. Using a multivariate regression model, we compared expert-assessed likelihood of pesticide exposure based on detailed, individual-specific questionnaire and job specific module interview information with reported farm-related job titles as a surrogate for pesticide exposure. Most (68.8%) jobs with likely pesticide exposure were farm jobs, but 78.3% of farm jobs were assessed as having no likelihood of pesticide exposure. Likely pesticide exposure was more frequent among jobs on crop farms than on livestock farms. Likely pesticide exposure was also more frequent among jobs commenced in more recent decades and jobs of longer duration. Our results suggest that very little misclassification would have resulted from the inverse assumption that all non-farming jobs are not pesticide exposed since only a very small fraction of non-agricultural jobs were likely to have had pesticide exposure.
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Question: Is farm-related job title an adequate surrogate for pesticide exposure in occupational cancer epidemiology?
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Classification of all farm jobs as pesticide exposed is likely to substantially over-estimate the number of individuals exposed. Our results also suggest that researchers should pay special attention to farm type, length of service and historical period of employment when assessing the likelihood of pesticide exposure in farming jobs.
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Answer the question based on the following context: Qualitative analysis of US media coverage of four female celebrities (Michelle Rodriguez, Paris Hilton, Nicole Richie and Lindsay Lohan) was conducted over the year following their DUI arrest (December 2005 through June 2008). The media sample included five television and three print sources and resulted in 150 print and 16 television stories. Stories were brief, episodic and focused around glamorous celebrity images. They included routine discussion of the consequences of the DUI for the individual celebrities without much evidence of a consideration of the public health dimensions of drinking and driving or possible prevention measures.
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Question: Media coverage of celebrity DUIs: teachable moments or problematic social modeling?
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Our analysis found little material in the media coverage that dealt with preventing injury or promoting individual and collective responsibility for ensuring such protection. Media attention to such newsworthy events is a missed opportunity that can and should be addressed through media advocacy efforts.
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Answer the question based on the following context: Laryngeal dysfunction after thyroidectomy is a common complication. However, few data are available to differentiate whether these complications result from injury to the recurrent nerve or to the vocal folds from intubation. University medical center. Seven hundred sixty-one patients who underwent surgery to the thyroid gland from 1990 to 2002. Of these patients, 8.4% underwent a revision thyroidectomy. Preoperative and postoperative laryngostroboscopic examination. Laryngostroboscopic evaluation of laryngeal complications. The overall rate of laryngeal complications was 42.0% (320 patients). Complications from an injury to the vocal folds occurred in 31.3% of patients. Weakness or paresis of the recurrent nerve was initially present in 6.6% and was related to the nerves at risk. This rate was higher in revision thyroidectomies than in primary surgical interventions (6.2% vs 11.6%; P = .04). The rate of laryngeal injuries was higher in patients older than 65 years (39.8% vs 30.8%; P = .03).
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Question: Laryngeal complications after thyroidectomy: is it always the surgeon?
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These data suggest that laryngeal complications after thyroidectomies are primarily caused by injury to the vocal folds from intubation and to a lesser extent by injury to the laryngeal nerve. We recommend documentation of informed consent, especially for patients who use their voice professionally, such as singers, actors, or teachers.
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Answer the question based on the following context: To ascertain the prevalence of premedication before intubation and the choice of drugs used in UK neonatal units in 2007 and assess changes in practice since 1998. A structured telephone survey of 221 eligible units was performed. 214 of the units surveyed completed the telephone questionnaire. The units were subdivided into those that routinely intubated and ventilated neonates (routine group) and those that intubated neonates prior to transfer to a regional unit (transfer group). A similar study was performed by one of the authors in 1998. The same telephone methodology was used in both studies. Premedication for newborn intubations was provided by 93% (198/214) of all UK units and 76% (162/214) had a written policy or guideline concerning premedication prior to elective intubation. Of those 198 units which premedicate, morphine was the most widely used sedative for newborn intubations with 80% (158/198) using either morphine alone or in combination with other drugs. The most widely used combination was morphine and suxamethonium+/-atropine, which was used by 21% (41/198) of all units. 78% (154/198) of all units administered a paralytic agent.
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Question: Premedication before intubation in UK neonatal units: a decade of change?
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There has been substantial growth over the last decade in the number of UK neonatal units that provide some premedication for non-emergent newborn intubation, increasing from 37% in 1998 to 93% in 2007. This includes a concomitant increase in the use of paralytic drugs from 22% to 78%. However, the variety of drugs used merits further research.
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Answer the question based on the following context: To assess whether the removal of aids/devices and/or help from another person in the Childhood Health Assessment Questionnaire (C-HAQ) leads to a significant change in the disability index (DI) score and responsiveness in juvenile idiopathic arthritis (JIA). Changes in the C-HAQ DI score in a cross-sectional sample of 2663 children with JIA and in 530 active patients with JIA in a trial of methotrexate (MTX) were compared. Patients in the MTX trial had higher disease activity and disability than the cross-sectional sample. The frequency of aids/devices (range 1.2-10.2%) was similar between the two samples, while help (range 5.3-38.1%) was more frequently used in the MTX group. Correlation between disease severity variables and the two different C-HAQ DI scoring methods did not change substantially. There was a decrease in the C-HAQ DI score for both the cross-sectional (mean score from 0.64 with the original method to 0.54 without aids/devices and help, p<0.0001) and the MTX sample (mean score from 1.23 to 1.07, p<0.0001). A linear regression analysis of the original C-HAQ DI score versus the score without aids/devices and help demonstrated the substantial overlap of the different scoring methods. Responsiveness in the responders to MTX treatment did not change with the different C-HAQ DI scoring methods (range 0.86-0.82).
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Question: Does removal of aids/devices and help make a difference in the Childhood Health Assessment Questionnaire disability index?
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The removal of aids/devices and help from the C-HAQ does not alter the interpretation of disability at a group level. The simplified C-HAQ is a more feasible and valid alternative for the evaluation of disability in patients with JIA.
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Answer the question based on the following context: Hydrocephalus is a common pediatric problem. Ventriculoperitoneal shunts (VPS) are the most frequent operative procedures used to treat hydrocephalic children. The peritoneal end is usually placed in the general peritoneal cavity. We present an alternative site of peritoneal end placement in the suprahepatic space in an attempt to reduce the abdominal complications. All patients with a diagnosis of congenital hydrocephalus were included in the study. In group 1, the lower end of the VPS was placed in the suprahepatic space. Patients were evaluated for abdominal complications like pseudocyst formation, intestinal obstruction and blockage of the lower end of the VPS. The data were compared with those patients in whom the peritoneal end was placed in the general peritoneal cavity (group 2). The total number of patients in groups 1 and 2 was 133 and 175, respectively. Complications in group 1 were dislodgement of the shunt in the general peritoneal cavity in 28 (21.05%), suprahepatic pseudocyst formation in 2 (1.5%) and blocked lower end in 2 patients (1.5%). In group 2, complications noted were pseudocyst formation in 5 (2.8%), blocked lower end in 25 (14.2%), intestinal obstruction in 9 (5.1%), inguinoscrotal migration in 10 (5.7%) and perforation of viscera in 6 patients (3.4%). The overall follow-up period ranged from 1 to 7 years.
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Question: Placement of the peritoneal end of a ventriculoperitoneal shunt in the suprahepatic space: does it improve prognosis?
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Placement of the lower end of the shunt in the suprahepatic space can be advantageous to placing it in the general peritoneal cavity. The procedure is simple and results can be rewarding.
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Answer the question based on the following context: This study evaluates the agreement in prolapse staging between clinical examination, dynamic magnetic resonance (MR), imaging and perineal ultrasonography. Anatomical landmarks in the anterior, central, and posterior compartment were assessed in relation to three reference lines on dynamic MR imaging and one reference line on dynamic ultrasonography. These measurements were compared to the according POP-Q measurements. Agreement between the three methods was analyzed with Spearman's rank correlation coefficient (r(s)) and Bland and Altman plots. Correlations were good to moderate in the anterior compartment (r(s) range = 0.49; 0.70) and moderate to poor (r(s) range = -0.03; 0.49) in the central and posterior compartment. This finding was independent of the staging method and reference lines used.
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Question: POP-Q, dynamic MR imaging, and perineal ultrasonography: do they agree in the quantification of female pelvic organ prolapse?
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Pelvic organ prolapse staging with the use of POP-Q, dynamic MR imaging, and perineal ultrasonography only correlates in the anterior compartment.
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Answer the question based on the following context: The purpose of the study was to investigate the prevalence of the use of a transitional object (TO) in adolescence and its connection with depressive symptoms and mental distress in youth by gender. The study group consisted of 1,054 adolescents (465 boys, 589 girls) from normal comprehensive schools in Turku, a Finnish town with approximately 175,000 inhabitants. The mean age of both gender groups was 14.5 years (SD 0.5); respondents came from all social classes. Background and TO information was collected with questionnaires. Depressive symptoms and mental distress were explored by the children's depression inventory (CDI) and its subscales: low self-confidence, anhedonia and sadness. Of all respondents, 29% (n = 285) had a TO: 37% of girls and 18% of boys. The difference between genders was statistically significant. There was also a statistically significant gender difference in the character of the TO reported: 72 % of girls with a TO had a soft toy, whereas 49% of boys with a TO used hard objects, such as pens, hard toys or books. TO-users showed more depressive symptoms than non-users, but the difference was not statistically significant (P = 0.053). Significant differences were found in the CDI subscales: TO-users had more sadness than non-users and girls using a TO showed more sadness than non-using girls. TO-using boys did not differ from non-using boys with regard to sadness or the other CDI-subscales.
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Question: The prevalence of transitional object use in adolescence: is there a connection between the existence of a transitional object and depressive symptoms?
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The use of a TO seems to be common in adolescence. Adolescents with more depressive symptoms more often used a TO. The sadness of girls using TOs requires attention.
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Answer the question based on the following context: Suicidal behaviour is often considered in the context of depression. Taking an empirical, dimensional and population-based approach, this investigation examines two issues: first, whether it is justifiable to regard suicidality as a symptom of depression or an independent construct. Second, although suicidal behaviour has been shown to decline with increasing age and differ across gender, little is known about the stability of the underlying construct across the lifespan and between genders. Data were derived from a community-based sample consisting of 7485 people aged 20-24, 40-44 or 60-64 years. Confirmatory factor analysis was used to assess the adequacy of model fit and measurement invariance across gender and then age groups. The data fitted a two-factor model of depression and suicidality better than a single-factor model. Multi-group analysis indicated strict measurement invariance for both gender and age groups, indicating no significant differences between groups in measurement model fit.
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Question: Is suicidality distinguishable from depression?
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These analyses establish that suicidality is distinguishable from depression, although the factors are substantially correlated. Results suggest that the underlying factorial relationship between suicidality and depression appears not to vary considerably between genders or across cohorts aged 20-24, 40-44 and 60-64 years. Finally, the analyses also highlight the necessity of inventories with scales identifying symptoms of suicidality independent of depression symptoms.
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Answer the question based on the following context: Parasitic Orobanchaceae germinate only after receiving a chemical stimulus from roots of potential host plants. A preparatory phase of several days that follows seed imbibition, termed conditioning, is known to be required; thereafter the seeds can respond to germination stimulants. The aim of this study was to examine whether conditioning is essential for stimulant receptivity. Non-conditioned seeds of both Orobanche cumana Wallr. and O. aegyptiaca Pers. [syn. Phelipanche aegyptiaca (Pers.) Pomel] were able to germinate in response to chemical stimulation by GR24 even without prior conditioning. Stimulated seeds reached maximal germination rates about 2 weeks after the onset of imbibition, no matter whether the seeds had or had not been conditioned before stimulation. Whereas the lag time between stimulation and germination response of non-conditioned seeds was longer than for conditioned seeds, the total time between imbibition and germination was shorter for the non-conditioned seeds. Unlike the above two species, O. crenata Forsk. was found to require conditioning prior to stimulation.
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Question: Is seed conditioning essential for Orobanche germination?
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Seeds of O. cumana and O. aegyptiaca are already receptive before conditioning. Thus, conditioning is not involved in stimulant receptivity. A hypothesis is put forward, suggesting that conditioning includes (a) a parasite-specific early phase that allows the imbibed seeds to overcome the stress caused by failing to receive an immediate germination stimulus, and (b) a non-specific later phase that is identical to the pregermination phase between seed imbibition and actual germination that is typical for all higher plants.
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Answer the question based on the following context: We aimed to evaluate whether addition of myocardial contrast echocardiography (MCE) perfusion data improves the sensitivity of stress echocardiography for detection of single-vessel coronary artery disease (svCAD) and to compare the diagnostic value of MCE and single-photon emission computed tomography (SPECT) for detection of svCAD. One hundred and three patients with suspected or known stable CAD underwent dipyridamole (0.84 mg kg(-1) intravenously over 4 min)-atropine (up to 1 mg intravenously) stress echocardiography combined with MCE. Wall motion abnormalities (WMA) and perfusion defects were assessed visually. Presence of CAD was detected by coronary angiography. Single-vessel coronary artery disease defined as>or=70% stenosis was detected in 30% of patients, whereas 26% of patients had svCAD defined as>or=50% stenosis. Presence of inducible WMA had 35% and 26% sensitivity for detection of svCAD defined as>or=70% and>or=50% stenosis, respectively. Concomitant evaluation of MCE increased the sensitivity to 74% (P = 0.005) and 56% (P = 0.053), respectively, using any inducible abnormality (WMA or perfusion defects) as a criterion. Presence of any (inducible or fixed) WMA had 77% and 59% sensitivity for detection of svCAD defined as>or=70% and>or=50% stenosis, respectively. In case of such criterion for stress test positivity, the improvement in sensitivity provided by addition of MCE (to 94% and 78%, respectively) did not reach statistical significance.
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Question: Detection of single-vessel coronary artery disease by dipyridamole stress echocardiography: no longer a problem?
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Addition of MCE perfusion analysis during stress echocardiographical examination based on evaluation of inducible abnormalities improves the test sensitivity for detection of svCAD. This benefit is less apparent when fixed WMA and perfusion defects are incorporated into the stress test positivity criterion.
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Answer the question based on the following context: Focus groups as a research method are popular in nursing. Similarly, phenomenology is a dominant methodology for nurse researchers globally. A number of nurse researchers have combined focus groups and phenomenology, but there are others who argue that they are incompatible. The argument against using focus groups in phenomenological research is that phenomenology seeks essential characteristics or 'essences' of phenomena in a manner that requires an individual to describe their experiences in an 'uncontaminated' way. We recognize that traditionally most phenomenological interviews are conducted with only one interviewer and one respondent, but we question whether this needs to continue. We suggest means by which individual lived experience can be preserved within a group context. We draw on our own experience and the phenomenological literature to argue that focus groups are congruent with phenomenological research and extend this argument further by proposing that group interviews in phenomenology are actually beneficial because they stimulate discussion and open up new perspectives. Our observation is that some researchers who combine focus groups and phenomenology appear to do so uncritically and we argue that this is unacceptable.
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Question: The phenomenological focus group: an oxymoron?
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It is important for nurse researchers to develop critical awareness of the research methodologies and methods they employ. We argue that the phenomenological focus group is not an oxymoron. Rather, the use of focus groups can provide a greater understanding of the phenomenon under study.
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Answer the question based on the following context: To evaluate the psychometric properties of two commonly used low back pain (LBP) disability questionnaires in a sample solely comprising community-dwelling older adults. Single-group repeated measures design. Four continuing care retirement communities in Maryland and in Virginia. Participants. Convenience sample of 107 community-dwelling men and women (71.9%) aged 62 years or older with current LBP. Outcome Measures. All participants completed modified Oswestry Disability (mOSW) and Quebec Back Pain Disability (QUE) questionnaires, as well as the Medical Outcomes Survey Short-Form 36 questionnaire at baseline. At follow-up, 56 participants completed the mOSW and the QUE for reliability assessment. Test-retest reliability of the mOSW and QUE were excellent with intraclass correlation coefficients of 0.92 (95% confidence interval [CI]: 0.86, 0.95) and 0.94 (95% CI: 0.90, 0.97), respectively. Participants with high pain severity and high levels of functional limitation had higher scores on the mOSW (P<0.0001) and QUE (P<0.001) scales than other participants, which represents good construct validity for both scales. The threshold for minimum detectable change is 10.66 points for the mOSW and 11.04 points for the QUE. Both questionnaires had sufficient scale width to accurately measure changes in patient status.
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Question: Psychometric properties of commonly used low back disability questionnaires: are they useful for older adults with low back pain?
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It appears that both questionnaires have excellent test-retest reliability and good construct validity when used to evaluate LBP-related disability for older adults with varying degrees of LBP. Neither questionnaire appears to have superior psychometric properties; therefore, both the Oswestry and Quebec can be recommended for use among geriatric patients with LBP.
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Answer the question based on the following context: Nonoperative treatment of blunt renal trauma in children is progressively gaining acceptance; grade 5 renal trauma is associated with a significant rate of complications. To assess the feasibility and outcome of initial nonoperative management of grade 5 blunt renal trauma in children. This retrospective study included 18 children (12 boys and 6 girls; mean age: 8.4+/-3.4 yr) who presented to the authors' institutes with grade 5 blunt renal trauma between 1990 and 2007. An intravenous contrast-enhanced computed tomography (CT) scan demonstrated grade 5 renal trauma in all patients. Associated major vascular injuries were suspected in four patients. All were initially managed conservatively. Indications for intervention included hemodynamic instability, progressive urinoma, or persistent bleeding. Dimercaptosuccinic acid (DMSA) scans were performed at a mean time of 3.1 yr (range: 1-17) following the injury in nine patients. Four patients (22%) with suspected major vascular injuries required nephrectomy 1-21 d following the trauma. Two patients with continuing hemorrhage required selective lower-pole arterial embolization (11%). Three patients (17%) had their progressive urinoma drained percutaneously, and two of them required delayed reparative surgery for ureteropelvic junction (UPJ) avulsion. Nine patients (50%) were successfully managed nonoperatively. Kidneys were salvaged in 78% of patients. DMSA scanning showed a split function>40% in 44% of evaluated kidneys. Two patients (22%) had split function<30%. At last follow-up, none of the children were hypertensive or had any abnormality on urine analysis.
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Question: Nonoperative management of grade 5 renal injury in children: does it have a place?
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Nonoperative management of grade 5 renal trauma is feasible. Prompt surgical intervention is required for those with major vascular injuries. Superselective arterial embolization can be an excellent option in patients with continuing hemorrhage and who have pseudoaneurysms. Patients with UPJ disruption can be salvaged by initial drainage of the urinoma followed by deferred correction.
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Answer the question based on the following context: Angiotensin-converting enzyme inhibitors (ACE-Is) prevent the rise in myocardial angiotensin II that occurs after left ventricular assist device (LVAD) implantation, but do not fully normalize cardiac function. Here, we determined the effect of LVAD implantation, with or without ACE-Is, on cardiac renin, aldosterone, and norepinephrine, since these hormones, like angiotensin II, are likely determinants of myocardial recovery during LVAD support. Biochemical measurements were made in paired LV myocardial samples obtained from 20 patients before and after LVAD support in patients with and without ACE-I therapy. Pre-LVAD renin levels were 100x normal and resulted in almost complete cardiac angiotensinogen depletion. In non-ACE-I users, LVAD support, by normalizing blood pressure, reversed this situation. Cardiac aldosterone decreased in parallel with cardiac renin, in agreement with the concept that cardiac aldosterone is blood-derived. Cardiac norepinephrine increased seven-fold, possibly due to the rise in angiotensin II. Angiotensin-converting enzyme inhibitor therapy prevented these changes: renin and aldosterone remained high, and no increase in norepinephrine occurred.
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Question: The impact of left ventricular assist device-induced left ventricular unloading on the myocardial renin-angiotensin-aldosterone system: therapeutic consequences?
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Although LV unloading lowers renin and aldosterone, it allows cardiac angiotensin generation to increase and thus to activate the sympathetic nervous system. Angiotensin-converting enzyme inhibitors prevent the latter, but do not affect aldosterone. Thus, mineralocorticoid receptor antagonist therapy during LVAD support may play a role in further promoting recovery.
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Answer the question based on the following context: In most northern European countries adolescent smoking is most prevalent in lower social classes but there is little information about time trends in social inequality. This paper describes trends in social inequality in daily smoking among adolescents from 1991 to 2006 by both absolute social inequality (prevalence difference between low and high social class) and relative social inequality (prevalence ratio). We analysed 15-year-olds from the Health Behaviour in School-aged Children (HBSC) study in Denmark in 1991, 1994, 1998, 2002 and 2006, total n = 6703. The surveys were comparable because of similar procedures for sampling, data collection, and measurements of smoking and parents' occupational social class. From 1991 to 2006 the prevalence of daily smoking decreased from 15.9% to 10.9% among boys and from 20.1% to 10.6% among girls. The social inequality fluctuated over time and was different for boys and for girls. The prevalence difference between boys from low and high social class was 5.2% in 1991 and 9.3% in 2006, corresponding figures for girls were 4.8% and 7.0%. The prevalence ratio among boys was 1.38 (in 1991) and 2.19 (in 2006), among girls 1.28 and 1.95.
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Question: Social inequality in adolescent daily smoking: has it changed over time?
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Daily smoking was most prevalent among students from lower social classes and the level of inequality fluctuated over time. Conclusions on social inequality in adolescent smoking may appear differently when described by absolute and relative measures. The absolute and relative social inequality in adolescent smoking was higher in 2006 than in 1991.
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Answer the question based on the following context: We reviewed our institution's experience with carotid artery pseudo-occlusion (CAPO), to investigate whether internal carotid artery (ICA) end-diastolic velocity (EDV) as measured by duplex ultrasonography, was a predictor of need for further intervention. From February 2003 to January 2008, 7478 patients underwent duplex ultrasonographic evaluation of their carotid arteries. Diagnosis of CAPO included the appearance of a narrow flow jet (string sign) on power doppler images, low velocities in the ICA and additional criteria listed below. Ten patients (0.13%) were identified as having a CAPO. All patients were asymptomatic and had an EDV<78 cm/s. Occlusion or functional occlusion was identified in nine patients on contrast imaging studies. Eight of these patients were treated medically without neurologic complication on follow-up. Two patients were treated with interventions and were asymptomatic at follow up. The mean follow up for the entire group was 12 months.
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Question: Carotid artery pseudo-occlusion: does end-diastolic velocity suggest need for treatment?
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Although this is a low volume study, there is evidence to suggest that asymptomatic patients with low EDV in the setting of carotid artery pseudo-occlusion found of duplex, may be safely managed medically.
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Answer the question based on the following context: Minimally invasive surgery was born out of recent advances in neuroimaging and stereotaxy, and the scale of future neurosurgical procedures will soon be so small that it will not be possible for the unassisted surgeons. Hence, neurosurgical robotics is a natural evolution in this field. The aim of this study was to evaluate the performance of a new robotic system in a wide range of neurosurgical applications. Patients undergoing image-guided surgical procedures were recruited to participate in this prospective ethically approved study from 2005. The PathFinder (Prosurgics, UK) is a neurosurgical robotic system with 6 degrees of freedom. It uses a fiducial system that is automatically detectable by the planning software and a camera system embedded in the robot's head. The registration procedure was performed automatically by photographing the fiducials from different angles. The robot then aligns its end-effector and tool holder along the specified path for the surgeon to pass the probe to the target. We recruited 37 consecutive patients to test the application accuracy and consistency of the system using three different fiducial fixation mechanisms: a double adhesive fixed to the skin, an ECG lead dot fixed to the skin, and a registration plate fixed to the skull. Out of 37 consecutive patients, 17 were males and 20 were females, with a mean age of 46.6 years. The procedures were: transsphenoidal in 8, malignant tumour biopsies in 3 and resections in 5, benign tumour excisions in 6 and functional procedures in 15 [6 bilateral deep-brain stimulations (DBSs) of the subthalamic nucleus for Parkinson's disease, 3 bilateral anterior cingulotomies for depression, 3 bilateral DBSs of the ventral intermediate nucleus of the thalamus for tremor and 3 depth electrodes during epilepsy surgery]. We tested a total of 140 targets with an average of 3-4 targets per patient. The mean application accuracy was less than 1 mm and the application accuracy was consistent in all targets in the same patient.
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Question: Robotic neurological surgery applications: accuracy and consistency or pure fantasy?
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This robotic system was very accurate and consistent in practice as long as the robot had achieved acceptable registration.
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Answer the question based on the following context: Social conformity is a cornerstone of human culture because it accelerates and maintains the spread of behaviour within a group. Few empirical studies have investigated the role of social conformity in the maintenance of traditions despite an increasing body of literature on the formation of behavioural patterns in non-human animals. The current report presents a field experiment with free-ranging marmosets (Callithrix jacchus) which investigated whether social conformity is necessary for the maintenance of behavioural patterns within groups or whether individual effects such as habit formation would suffice. Using a two-action apparatus, we established alternative behavioural patterns in six family groups composed of 36 individuals. These groups experienced only one technique during a training phase and were thereafter tested with two techniques available. The monkeys reliably maintained the trained method over a period of three weeks, despite discovering the alternative technique. Three additional groups were given the same number of sessions, but those 21 individuals could freely choose the method to obtain a reward. In these control groups, an overall bias towards one of the two methods was observed, but animals with a different preference did not adjust towards the group norm. Thirteen of the fifteen animals that discovered both techniques remained with the action with which they were initially successful, independent of the group preference and the type of action (Binomial test: exp. proportion: 0.5, p<0.01).
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Question: The maintenance of traditions in marmosets: individual habit, not social conformity?
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The results indicate that the maintenance of behavioural patterns within groups 1) could be explained by the first rewarded manipulation and subsequent habit formation and 2) do not require social conformity as a mechanism. After an initial spread of a behaviour throughout a group, this mechanism may lead to a superficial appearance of conformity without the involvement of such a socially and cognitively complex mechanism. This is the first time that such an experiment has been conducted with free-ranging primates.
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Answer the question based on the following context: Cortical atrophy is correlated with the progression of neuropathological lesions within the medial temporal lobes (MTL) in Alzheimer's disease (AD). Our aim was to determine which local and remote functional changes result from MTL volume loss at the predementia stage. We studied the relationship between entorhinal and hippocampal MR volumes and whole-brain SPECT perfusion via a voxel-based correlative analysis in 19 patients with amnestic mild cognitive impairment with a memory profile suggestive of early AD. Right MTL volumes were positively correlated with remote posterior perfusion of the posterior cingulate cortex, and negatively correlated with remote anterior perfusion of the right medial and dorsolateral prefrontal cortex. There was no local correlation between volumes and perfusion within the MTL.
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Question: Effects of medial temporal lobe degeneration on brain perfusion in amnestic MCI of AD type: deafferentation and functional compensation?
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These findings provide further insight into functional changes that result from MTL volume loss during the predementia stage of AD. The positive correlation between MTL volumes and posterior cingulate perfusion may reflect the deafferentation of a temporocingulate network due to mediotemporal degeneration. The paradoxical negative correlation between MTL volumes and prefrontal perfusion may result from recruitment of an alternative anterior temporofrontal network. It remains to be investigated how the "net sum" of this perfusion modulation affects memory and other cognitive domains through a possible compensatory perspective.
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Answer the question based on the following context: In advanced gastric cancer (AGC) with duodenum invasion, the posterior pancreatic lymph nodes are susceptible to metastasis because of their proximity to the duodenum. The therapeutic value of lymph node dissection in this area for AGC with macroscopic duodenum invasion remains unclear. Patients who had undergone curative gastrectomy for lower-third AGC from 1970 to 2004 at the Cancer Institute Hospital were recruited for this study. Clinicopathological data were collected retrospectively, and compared between cases of AGC with duodenum invasion (AGC-DI group) and AGC without duodenum invasion (AGC-nDI group). In the AGC-DI group, the therapeutic value of lymph node dissection was evaluated using a therapeutic index (multiplication of the frequency of metastasis to the station by the 5-year survival rate of patients with metastasis to that station). The AGC-DI group generally had tumors of higher pathological stage, which might account for the poorer 5-year survival rate compared with that of the AGC-nDI group (50.1% versus 68.5%; P = 0.0002). The incidence of lymph node metastasis was higher in the AGC-DI group than that in the AGC-nDI group, including nodes in the posterior pancreatic head (23.9% versus 7.0%, P<0.0001). In the AGC-DI group, posterior pancreatic head lymph node dissection was of therapeutic value (4.19) equivalent to dissection of second-tier lymph nodes.
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Question: Therapeutic value of lymph node dissection in advanced gastric cancer with macroscopic duodenum invasion: is the posterior pancreatic head lymph node dissection beneficial?
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The dissection of posterior pancreatic head lymph nodes might be effective in AGC with macroscopic duodenum invasion since this has therapeutic value equivalent to that of second-tier lymph node dissection and might improve patients' long-term outcomes.
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Answer the question based on the following context: To report two successful antagonist IVF cycles; one ending up with pregnancy despite premature luteinization (case 1, aged 35 years), and the other with the retrieval of high quality oocytes despite premature ovulation (case 2, aged 39 years). Serum LH was 36 and 47 IU/L on cycle day 7 before antagonist administration, which was then brought to 6.94 and 3.92 IU/L by antagonist administration, and kept below these levels throughout the remaining stimulation in case 1 and 2 respectively. Serum progesterone was 1.42 and 5.5 ng/mL on the day of hCG respectively. Ten metaphase II (MII) oocytes were harvested wherein 3 grade A embryos were transferred in case 1, and seven good quality MII oocytes were retrieved wherein six embryos were cryopreserved in case 2.
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Question: Does premature luteinization or early surge of LH impair cycle outcome?
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More precise cut thresholds for both LH and progesterone are necessary for accurate prediction of the cycle outcomes.
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Answer the question based on the following context: Acromegaly is characterized not only by disabling symptoms, but also by relevant co-morbidities. Insulin resistance, leading to glucose intolerance is one of the most important contributory factors to the cardiovascular mortality in acromegaly. We analysed the records of 220 naïve patients with acromegaly diagnosed at our Department in the years 1995-2007. Diagnosis of active acromegaly was established on the basis of widely recognized criteria. In each patient glucose and insulin concentrations were assessed when fasting and during the 75 g OGTT. Normoglycaemia existed in 46% of acromegalic patients. Among glucose tolerance abnormalities we found impaired fasting glucose in 19%, impaired glucose tolerance in 15% and overt diabetes mellitus in 20%. There was no statistically significant differences in gender, duration of the disease, basal plasma GH, IGF-1 or fasting insulin concentrations between normoglycaemic patients and those with impairments in glucose tolerance. The groups showed statistically significant differences with respect to age at diagnosis (p<0.01). There was no significant correlation between GH, IGF-1 concentrations and fasting plasma glucose. There was no correlation between the duration of the disease and fasting plasma glucose. We found a statistically significant correlation between plasma GH, IGF-1 concentrations and HOMA, QUICKI and insulinAUC.
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Question: Abnormalities in glucose homeostasis in acromegaly. Does the prevalence of glucose intolerance depend on the level of activity of the disease and the duration of the symptoms?
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The prevalence of diabetes mellitus among acromegalics is much higher than in the general population. The occurrence of glucose tolerance impairments does not depend on the duration of the disease. In patients with acromegaly insulin resistance and hyperinsulinemia are positively correlated with the level of activity of the disease.
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Answer the question based on the following context: Primary graft dysfunction (PGD) is a predominant cause of early morbidity and mortality after lung transplantation. Although substantial work has been done to understand risk factors for PGD in terms of donor, recipient, and surgical factors, little is understood regarding the potential role of anaesthetic management variables in its development. We conducted a retrospective exploratory analysis of 107 consecutive lung transplants to determine if anaesthesia factors were associated with early graft function quantified by Pa(O(2))/Fi(O(2)). Multivariate regression techniques were used to explore the association between anaesthetic management variables and Pa(O(2))/Fi(O(2)) ratio 12 h after operation. The relationship between these variables and both time to tracheal extubation and intensive care unit (ICU) length of stay was further examined using the Cox proportional hazards. On multivariate analysis, increasing volume of intraoperative colloid, comprising predominantly Gelofusine (succinylated gelatin), was independently associated with a lower Pa(O(2))/Fi(O(2)) 12 h post-transplantation [beta coefficient -42 mm Hg, 95% confidence interval (CI) -7 to -77 mm Hg, P=0.02] and reduced rate of extubation [hazard ratio (HR) 0.65, 95% CI 0.49-0.84, P=0.001]. There was a trend for intraoperative colloid to be associated with a reduced rate of ICU discharge (HR 0.79, 95% CI 0.31-1.02, P=0.07).
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Question: Does anaesthetic management affect early outcomes after lung transplant?
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We observed an inverse relationship between volume of intraoperative colloid and early lung allograft function. The association persists, despite detailed sensitivity analyses and adjustment for potential confounding variables. Further studies are required to confirm these findings and explore potential mechanisms through which these associations may act.
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Answer the question based on the following context: Left ventricular (LV) function in the healthy aging heart is modified by biochemical changes with advancing age. We employed for the first time Tissue Doppler Imaging (TDI), to identify which phase of the cardiac cycle is involved. TDI was performed in 175 aging subjects, free of cardiovascular and/or respiratory disease (group II), and in 182 healthy adults enrolled as the control group (group I), to calculate the Myocardial Performance Index (MPI). The index derives from the values of Isovolumetric Contraction Time (ICT), Isovolumetric Relaxation Time (IRT) and Left Ventricular Ejection Time (LVET) measured in ms, according to the formula: (ICT+IRT)/LVET. An increase in MPI in group II was shown, with significant lengthening of IRT in comparison with the same value obtained in the control group (group I), ICT and LVET were unchanged.
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Question: Is the aging heart similar to the diabetic heart?
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The rise in IRT in the aging healthy heart is dependent on diastolic LV dysfunction consequent upon the formation of Advanced Glycosilation End-product (AGE) crosslinks with connectival proteins of interstitial myocardial tissue. Agerelated increase in oxidative stress also modifies some interstitial compounds, favoring hardening of ventricular walls. These changes are similar to those happening in the diabetic heart, and TDI seems to be able to define non-invasively which phase of the cardiac cycle is impaired.
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Answer the question based on the following context: Complex interactions between visual, vestibular and somatosensory information and the cerebellar system are involved in the maintenance of upright posture. Previous studies have shown that normal aging and pathologies may lead to deterioration of the control of upright standing posture. In order to investigate postural control during quiet standing in the elderly, the center of pressure (CoP) was analysed on two force platforms in three different groups. The first group was composed of 13 healthy older adults (O), the second consisted of 9 older adults with plantar sole deficit (OD), and the third (control) group was composed of 8 young healthy subjects (Y). All subjects were tested with eyes closed, before and after tactile plantar stimulation lasting ten minutes. Center of pressure displacements were analyzed in terms of sway area, mean velocity, and mean root mean square (RMS) along both mediolateral and antero-posterior axes. Results showed that, before tactile plantar stimulation, the sway area and mean RMS were greater in O and OD subjects compared with Y ones. After tactile plantar stimulation, a decrease in the mean RMS was observed in OD subjects, this effect being significant only for the medio-lateral axis.
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Question: Can tactile plantar stimulation improve postural control of persons with superficial plantar sensory deficit?
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These results suggest that application of tactile plantar stimulation may compensate a loss of superficial plantar sensitivity.
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Answer the question based on the following context: Does the greater auricular nerve (GAN) have an appropriate number of myelinated axons for use as an interposition graft for the facial nerve? Previous studies have suggested that the GAN has a suitable cross-sectional and fascicular area for use as an interposition graft for the facial nerve. In this study, counts of myelinated axons in the GAN have been undertaken to assess, at a microscopic level, its suitability as such a graft. Six GANs were examined, and the total myelinated axonal counts and axonal density per square millimeter of fascicular area were calculated. These counts were compared with previous studies on the facial nerve. Axonal density per square millimeter was comparable between greater auricular and facial nerves. However, there were significantly lower numbers of myelinated axons in the GAN compared with the published facial nerve data.
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Question: Axonal numbers in the greater auricular nerve: is there enough to go round?
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The findings support the concept of "doubling over" the GAN to act as an appropriate interpositional facial nerve graft when there is a size mismatch between the two.
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Answer the question based on the following context: The aim of this prospective study was to establish the degree to which parents report post-traumatic growth after the intensive care treatment of their child. Prospective cross-sectional cohort study. Paediatric Intensive Care Unit (PICU). A total of 50 parents of children, admitted to PICU for>12 h. Parents provided stress ratings as their child was discharged from PICU and, 4 months later, completed postal questionnaires rating their anxiety, depression, post-traumatic stress and post-traumatic growth. As much as 44 parents (88%) indicated on the Posttraumatic Growth Inventory (PTGI) [1] that they had experienced a positive change to a great degree as a result of their experiences in PICU. Parents of children who were ventilated (P = 0.024) reported statistically higher post-traumatic growth as did parents of older children (P = 0.032). PTGI scores were positively correlated with post-traumatic stress scores at 4 months (P = 0.021), but on closer inspection this relationship was found to be curvilinear.
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Question: Post-traumatic growth in parents after a child's admission to intensive care: maybe Nietzsche was right?
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Post-traumatic growth emerged as a salient concept for this population. It was more strongly associated with moderate levels of post-traumatic stress, than high or low levels.
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Answer the question based on the following context: It is unclear whether the rate of stimulation for somatosensory evoked potentials (SEPs) can influence the presence or absence of cortical responses to median nerve stimulation in comatose patients. If so, this could affect how SEPs are performed and interpreted for prognostication in coma. Our objective was to determine how frequently our comatose patients had absent median nerve SEP responses at 3 Hz stimulation, but present responses at 1 Hz stimulation, and to report outcomes of these patients. We reviewed SEP recordings in 639 comatose patients over a 9-year period. All had stimulation at 3 Hz and 1 Hz. This is a retrospective review. There were seven patients who had absent median nerve SEP responses at 3 Hz stimulation bilaterally, but had present responses at 1 Hz on one or both sides. Six of the seven died. One 16-year-old patient with traumatic brain injury awoke, but had moderate disability.
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Question: Does stimulus rate matter when performing somatosensory evoked potentials for coma patients?
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Stimulation rate is an important determinant of presence or absence of cortical responses in about 1% of comatose patients. It is unclear whether such patients have a different outcome that those with absent responses at both rates of stimulation.
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Answer the question based on the following context: Electroconvulsive therapy (ECT) is generally recommended for treating catatonic schizophrenia. Non-catatonic schizophrenia patients also receive ECT. We compared the speed of response to ECT among patients with catatonic and other subtypes of schizophrenia. Consecutive schizophrenia patients referred for ECT within 3 months of starting antipsychotic treatment were studied (19 with catatonic and 34 with non-catatonic schizophrenia). Nurse's Observation Scale for Inpatient Evaluation (NOSIE-30) and Clinical Global Impression (CGI) were used to rate improvement. Referring psychiatrists stopped ECTs based on clinical impression of improvement. Total number of ECTs was taken as an indirect measure of speed of response. NOSIE-30 scores were compared using repeated measures analysis of variance. Catatonic schizophrenia patients required significantly fewer ECTs to achieve clinically significant improvement. There was a significant group x occasion effect in NOSIE scores, suggesting faster response to ECT in the catatonia group (F=41.6; P<0.001). Survival analysis suggested that patients with catatonic schizophrenia required significantly fewer ECTs (one less session on an average) to achieve clinical improvement (Log-rank statistic =5.31; P=0.02).
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Question: Does catatonic schizophrenia improve faster with electroconvulsive therapy than other subtypes of schizophrenia?
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Catatonic schizophrenia responds faster to ECT than non-catatonic schizophrenia. However, the magnitude of the difference is modest.
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Answer the question based on the following context: A temporary loop ileostomy is often created to minimize the impact of peritoneal sepsis if anastomotic dehiscence occurs following low colorectal anastomosis. Although it has been suggested that a loop ileostomy should be reversed within 12 weeks of formation, this is often not the case. We set out to analyse the use of loop ileostomy following elective anterior resection in England and to identify factors associated with non and delayed reversal. Hospital episode statistics for the years 2001-2006 were obtained from the Department of Health. Patients undergoing elective anterior resection with a loop ileostomy for a primary diagnosis of rectal or recto-sigmoid cancer between April 2001 and March 2003 were identified as the study cohort. This cohort was followed until March 2006 to identify patients undergoing reversal of an ileostomy in an English NHS Hospital. A total of 6582 patients had an elective anterior resection between April 2001 and March 2003, of which 964 (14.6%) also had an ileostomy. Seven hundred and two (75.1%) patients were reversed before March 2006. Advancing age and comorbidity were statistically related to nonreversal. Median time to reversal was 207 days (Interquartile range 119-321.5 days). Postoperative chemotherapy and comorbidity significantly delayed reversal.
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Question: Loop ileostomy following anterior resection: is it really temporary?
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One in four loop ileostomies performed to defunction an elective anterior resection is not reversed, and in the presence of significant comorbidity one in three is not reversed. Only 12% is reversed within 12 weeks.
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Answer the question based on the following context: Long-term lamivudine therapy is required for patients with chronic hepatitis B, because hepatitis reappears frequently after it has withdrawn. However, hepatitis B virus (HBV) mutants resistant to lamivudine emerge frequently accompanied by breakthrough hepatitis. Effects of entecavir were evaluated in 19 patients who had developed breakthrough hepatitis during lamivudine therapy for longer than 5 years. This study is a subgroup analysis of a previously reported study. Entecavir, in either 0.5 or 1.0 mg/day doses, was given to 10 and nine patients for 52 weeks, respectively, and then all received 1.0 mg/day entecavir for an additional 68-92 weeks. There were no differences in biochemical and virological responses in the two groups of patients with respect to the two different initial doses of entecavir. Serum levels of alanine aminotransferase were normalized in 17 (90%) patients, and hepatitis B e antigen (HBeAg) disappeared from the serum in two (14%) of the 14 patients who were HBeAg-positive before. Furthermore, a decrease in histological activity index score greater than 2 points was achieved in nine of the 11 (82%) patients in whom annual liver biopsies were performed during 3 years while they received entecavir. HBV mutants resistant to entecavir emerged in five of the 19 (26%) patients, and hepatitis flare occurred in two of them (40%).
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Question: Efficacy of entecavir treatment for lamivudine-resistant hepatitis B over 3 years: histological improvement or entecavir resistance?
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Entecavir in the long term would be useful for histological improvement of breakthrough hepatitis induced by lamivudine-resistant HBV mutants in patients with chronic hepatitis B. However, the relatively high rate of entecavir resistance is a concern, and other strategies need to be considered when available.
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Answer the question based on the following context: To assess the percentage of first-trimester pregnancies with bleeding that demonstrate a visible sac but lack an identifiable embryo and have a mean sac diameter (MSD) in the controversial range of 16-20 mm. Retrospective study of all first-trimester sonograms among women with vaginal bleeding during a 4-year interval. The study cohort consisted of 546 first- trimester sonograms. An embryo was not seen in 132 cases (24%). Of these, the MSD in 69 cases (52%) was<16 mm, between 16 and 19 mm in 20 cases (15%), or>or=20 mm in 39 cases (30%). The percentage of women who were threatening to abort who demonstrated a visible sac but lacked an identifiable embryo and had a MSD in the controversial range of 16-20 mm was 3.7% (20/546).
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Question: "Empty" sac in pregnant women with bleeding: are measurements answering the right question?
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We found that of 546 sonograms undertaken in pregnant women with vaginal bleeding in the first trimester, only 20 patients (3.7%) fell in the MSD range of 16-20 mm. Therefore, even among those diagnosticians who adopt the most stringent criterion (MSD = 20 mm), an additional examination would be requested in fewer than 1 in 25 patients.
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Answer the question based on the following context: Recent studies still show parental smoke as the number one environmental exposure agent causing asthma in pediatric population. The purpose of this study is to determine the knowledge of parents about the adverse effects of passive smoking and the prevalence of passive smoking in children. Cross sectional study, participants were caregivers of students from first to sixth grade (three private and two public schools) who answered a self-administered survey. Data was analyzed using SPSS. Surveys were collected by availability. Total of caregivers was 594, (47% from private and 53% from public school). The total of estimated children in the survey was 1318, and 48.3% in general had recurrent respiratory illness. Among caregivers, 12.1% (72) reported to be smokers. There were 127 participants who revealed at least 1-3 smokers in their home; these smokers are affecting 167 children who are exposed to secondhand smoke. Among smokers, 16.9% smoked inside the house, 15.5% in their cars and 12.3% smoked in the presence of their children. Participants with higher education had a higher average score on knowledge about adverse effects of smoking (p<.001). Over half of the participants (52%) reported seen anti-smoking promotion on T.V. during previous days. Non-smokers revealed they have seen such promotion recently (p=0.00), but 31% of all participants reported not seen any anti-smoking promotion at all.
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Question: Do parents know about the adverse effects of passive smoking and the relationship with respiratory illness on their children?
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The prevalence of smokers in our study was 12.1%. We estimated there was more than one smoker in those households where smoking was allowed. There was a higher prevalence of smokers among parents from public schools. There was no significant difference between passive smoker households and non-smoker households for respiratory illness in their children. Pediatricians are giving information to caregivers about active and passive smoking but still, 34% of smokers reported not receiving any information. We need to reinforce the counseling given to caregivers about the adverse effects of smoking has on environmental pollution, and as a cause of other cancers besides lung cancer, recurrent infections and SIDS.
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Answer the question based on the following context: We investigated clinical and subgingival microbiologic changes during pregnancy in 20 consecutive pregnant women>or =18 years not receiving dental care. Bacterial samples from weeks 12, 28, and 36 of pregnancy and at 4 to 6 weeks postpartum were processed for 37 species by checkerboard DNA-DNA hybridization. Clinical periodontal data were collected at week 12 and at 4 to 6 weeks postpartum, and bleeding on probing (BOP) was recorded at sites sampled at the four time points. The mean BOP at week 12 and postpartum was 40.1% +/- 18.2% and 27.4% +/- 12.5%, respectively. The corresponding mean BOP at microbiologic test sites was 15% (week 12) and 21% (postpartum; not statistically significant). Total bacterial counts decreased between week 12 and postpartum (P<0.01). Increased bacterial counts over time were found for Neisseria mucosa (P<0.001). Lower counts (P<0.001) were found for Capnocytophaga ochracea, Capnocytophaga sputigena, Eubacterium saburreum, Fusobacterium nucleatum naviforme, Fusobacterium nucleatum polymorphum, Leptotrichia buccalis, Parvimonas micra (previously Peptostreptococcus micros or Micromonas micros), Prevotella intermedia, Prevotella melaninogenica, Staphylococcus aureus, Streptococcus anginosus, Streptococcus intermedius, Streptococcus mutans, Streptococcus oralis, Streptococcus sanguinis, Selenomonas noxia, and Veillonella parvula. No changes occurred between weeks 12 and 28 of pregnancy. Counts of Aggregatibacter actinomycetemcomitans (previously Actinobacillus actinomycetemcomitans), Porphyromonas gingivalis, Tannerella forsythia (previously T. forsythensis), and Treponema denticola did not change. Counts of P. gingivalis and T. forsythia at week 12 were associated with gingivitis (P<0.001).
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Question: Does pregnancy have an impact on the subgingival microbiota?
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Subgingival levels of bacteria associated with periodontitis did not change. P. gingivalis and T. forsythia counts were associated with BOP at week 12. A decrease was found in 17 of 37 species from week 12 to postpartum. Only counts of N. mucosa increased.
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Answer the question based on the following context: Periodontitis develops in a time-dependent manner. Cross-sectional studies document one moment in time but fail to capture the progressive nature of disease. Radiographic measures of bone loss are relatively insensitive but are reliable markers of irreversible disease. Longitudinal studies are needed to identify biomarkers that can precede radiographic evidence of bone loss and, thus, mark the period prior to clinical evidence of irreversible disease. A longitudinal study of students susceptible to localized aggressive periodontitis (LAgP) was conducted to evaluate chemokines/cytokines found in saliva derived from periodontally healthy children who subsequently developed alveolar bone loss. Students were screened, sampled for Aggregatibacter actinomycetemcomitans (previously Actinobacillus actinomycetemcomitans [Aa]), and divided into a cohort of Aa+ and Aa- students. Ninety-six periodontally healthy Aa+ and Aa- students were recalled every 6 to 9 months following screening. Examinations, saliva collections, and radiographs were performed. After seven students developed bone loss, the levels of 21 cytokines were assessed and matched to saliva from seven Aa+ and seven Aa- students who remained healthy for>or =1 year. Subsequently, saliva from an additional 27 students who remained healthy was analyzed. Nineteen cytokines were not detected or were detected at low levels. Macrophage inflammatory protein (MIP)-1alpha was elevated 50-fold in seven Aa+ students who developed disease 6 to 9 months prior to radiographic detection of bone loss compared to levels in 21 Aa+ and 20 Aa- students who remained healthy (P<0.001). Interleukin (IL)-1beta was also elevated (P = 0.01). MIP-1alpha had a specificity of 96.8% and a sensitivity of 100%, whereas IL-1beta showed 90.3% specificity and 85.7% sensitivity relative to bone loss. MIP-1alpha levels were also related to increasing probing depth and the number of pockets>6 mm.
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Question: Macrophage inflammatory protein-1alpha: a salivary biomarker of bone loss in a longitudinal cohort study of children at risk for aggressive periodontal disease?
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The superior sensitivity and specificity of MIP-1alpha, which correlated well with probing depths and the onset of bone loss, suggested that it could be used as an early biomarker for LAgP.
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Answer the question based on the following context: Recent years have brought important developments in preoperative imaging and use of laparoscopic staging of patients with pancreatic adenocarcinoma (PAC). There are few data about the optimal combination of preoperative studies to accurately identify resectable patients. We conducted a statewide review of all patients with surgically managed PAC from 1996 to 2003 using data from the Oregon State Cancer Registry, augmented with clinical information from primary medical record review. We documented the use of all staging modalities, including CT, endoscopic ultrasonography, and laparoscopy. Primary outcomes included resection with curative intent. The association between staging modalities, clinical features, and resection was measured using a multivariate logistic regression model. There were 298 patients from 24 hospitals who met the eligibility criteria. Patients were staged using a combination of CT (98%), laparoscopy (29%), and endoscopic ultrasonography (32%). The overall proportion of patients who went to surgical exploration and were resected was 87%. Of patients undergoing diagnostic laparoscopy, metastatic disease that precluded resection was discovered in 24 (27.6%). For patients who underwent diagnostic laparoscopy and were not resected, vascular invasion was the most common determinant of unresectability (56.6%). In multivariate analysis, preoperative weight loss and surgeon decision to use laparoscopy predicted unresectability at laparotomy.
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Question: Evolving preoperative evaluation of patients with pancreatic cancer: does laparoscopy have a role in the current era?
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This population-based study demonstrates that surgeons appear to use laparoscopy in a subset of patients at high risk for metastatic disease. The combination of current staging techniques is associated with a high proportion of resectability for patients taken to surgical exploration. With current imaging modalities, selective application of laparoscopy with a dual-phase CT scan as the cornerstone of staging is a sound clinical approach to evaluate pancreatic cancer patients for potential resectability.
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Answer the question based on the following context: Recent findings suggest that patients with behavioural variant frontotemporal dementia (bv-FTD) differ in their disease progression (progressive vs non-progressive patients). The current study investigates whether the two groups can be discriminated by their clinical features at first presentation. Archival clinical data of the Early Onset Dementia Clinic, Cambridge, UK, were analysed for 71 patients with bv-FTD: 45 progressive and 26 non-progressive cases with more than 3 years of follow-up. The subgroups were largely indistinguishable on the basis of the presenting clinical features but could be distinguished on general cognitive (Addenbrooke's Cognitive Examination-revised) and selected supportive diagnostic features (distractibility, stereotypic speech, impaired activities of daily living (ADLs) and current depression).
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Question: Can progressive and non-progressive behavioural variant frontotemporal dementia be distinguished at presentation?
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Progressive and non-progressive patients are difficult to differentiate on the basis of current clinical diagnostic criteria for FTD but a combination of general cognitive, executive dysfunction and impaired ADL measures appear to be the most promising discriminators.
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Answer the question based on the following context: Several models have been proposed to explain the association between ethnicity and health. It was investigated whether the association between Roma ethnicity and health is fully mediated by socioeconomic status in Hungary. Comparative health interview surveys were performed in 2003-04 on representative samples of the Hungarian population and inhabitants of Roma settlements. Logistic regression models were applied to study whether the relationship between Roma ethnicity and health is fully mediated by socioeconomic status, and whether Roma ethnicity modifies the association between socioeconomic status and health. The health status of people living in Roma settlements was poorer than that of the general population (odds ratio of severe functional limitation after adjustment for age and gender 1.8 (95% confidence interval 1.4 to 2.3)). The difference in self-reported health and in functionality was fully explained by the socioeconomic status. The less healthy behaviours of people living in Roma settlements was also related very strongly to their socioeconomic status, but remained significantly different from the general population when differences in the socioeconomic status were taken into account, (eg odds ratio of daily smoking 1.6 (95% confidence interval 1.3 to 2.0) after adjustment for age, gender, education, income and employment).
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Question: Does socioeconomic status fully mediate the effect of ethnicity on the health of Roma people in Hungary?
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Socioeconomic status is a strong determinant of health of people living in Roma settlements in Hungary. It fully explains their worse health status but only partially determines their less healthy behaviours. Efforts to improve the health of Roma people should include a focus on socioeconomic status, but it is important to note that cultural differences must be taken into account in developing public health interventions.
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Answer the question based on the following context: In family practice, chronic obstructive pulmonary disease (COPD) is usually not diagnosed until clinically apparent and of moderately advanced severity. To analyse the diagnostic process from early development onwards and to assess the current state of underpresentation and underdiagnosis of COPD and asthma in primary care in the Netherlands. The population-based study sample consisted of formerly undiagnosed subjects (n = 532) from family practice. Family physicians' (FPs) chronic respiratory disease diagnoses (as recorded over 10 years in their patient records) were compared to a cross-sectional but extensive diagnostic assessment by a chest physician. Logistic regression modelling was used for a retrospective analysis on the relation between respiratory symptoms, practice visit rate and FPs' diagnosis of COPD. After 10 years, the chest physician diagnosed 26% of subjects as COPD and 16% as (late-onset) asthma. Underpresentation of these patients in family practice was 46%, whereas underdiagnosis occurred in 37% of patients. A chest physician diagnosis of COPD was associated with the presence of chronic cough [odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.1-4.6], a FP diagnosis of COPD with chronic phlegm (OR = 10.6, 95% CI 1.3-83.6). Repeated practice visits (OR = 1.8) and presence of wheeze and breathlessness (OR = 5.5) appeared to trigger the diagnostic process in family practice.
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Question: Do family physicians' records fit guideline diagnosed COPD?
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There is still considerable underpresentation and underdiagnosis of COPD in family practice. As FPs focus on presented symptoms and as detection increases with the frequency of practice visits, diagnostic guidelines should stress the importance of persistent cough and phlegm to support timely diagnosis of COPD in family practice.
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Answer the question based on the following context: To analyze intraoperative data and possible differences in clinical evolution during postoperative hospital phase for aortic valve replacement surgery using different types of prosthesis. Analysis of 60 patients divided into three groups. Valve replacement with bioprosthesis (20), mechanical prosthesis (20) and homologous valve (20). The mean age was 51.1, 60% were male and 40% female patients; 86.7 % were in NYHA II or III; 63.3% presented arterial hypertension and 18.3% had diabetes. Aetiology of valve disease was degenerative for 39%, rheumatic for 36% and endocarditis for 15%. The hospital mortality was 5%; there were no differences in the incidence of septic or cardiogenic shock, acute renal failure, rhythms disorders during surgery or intensive care, neither for total time in intensive care and mechanical ventilation. However, there was statistical differences as regards the cardiopulmonary bypass total time (P=0.02) and the aortic clamping time (P<0.0001) unfavorable to homograft valve group. The ward admission time was greater for mechanical valve group (P=0.05) as well as for total admission time, but without statistical significance. It was observed that patients with preoperative hematocrit smaller than 38.1% used 2.73 units of blood components, and with postoperative hematocrit smaller than 32% used 1,79 units of blood components. Echocardiography control showed minimal evolutional differences.
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Question: Aortic valve replacement with different types of prosthesis: are there differences in the outcomes during hospital phase?
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The use of different types of prosthesis for this study does not cause differences in the results of postoperative hospital phase. The use of homograft valve is a feasible option with good clinical applicability.
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Answer the question based on the following context: Early detection of biliary atresia (BA) has a vital role in prevention of liver cirrhosis in these patients. There are some evidences that triangular cord (TC) sign, i.e., triangular structure located cranial to the portal vein bifurcation on ultrasonographic examination, is suggestive of BA in suspected cases. The aim of this study is to evaluate and compare the sensitivity, specificity, and accuracy of TC sign with other methods of diagnosis such as hepatobiliary scan. Fifty-eight infants referred to pediatric gastroenterology ward with diagnosis of infantile cholestasis from March 2004 to March 2008 were evaluated to find the cause of cholestasis. Diagnosis was made by means of history, clinical examination, hepatobiliary scan, and liver biopsy. Ultrasonographic examination was focused on presence of TC sign in patients. If the diagnosis was in favor of BA, patient was sent for direct cholangiography as a gold-standard test for confirmation of the diagnosis. The sensitivity, specificity, and accuracy of the tests were compared with golden standard. Among 58 infants with infantile cholestasis, BA was diagnosed and confirmed in 10 infants (17.2%). Hepatobiliary scintigraphy had 80% sensitivity, 72.9% specificity, and 74.1% accuracy. TC sign had 70% sensitivity, 95.8% specificity, and 91.3% accuracy.
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Question: Triangular cord sign in detection of biliary atresia: is it a valuable sign?
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TC sign is more accurate than hepatobiliary scan and has acceptable sensitivity and specificity for diagnosis of BA.
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Answer the question based on the following context: Cardiac computed tomography (CT) has gained increasing acceptance for diagnosing obstructive coronary artery disease (CAD). Several guidelines have been published on required education for proficiency in the interpretation of these examinations. To describe the learning-curve effect of the interpretation of 100 consecutive cardiac CT examinations aimed at diagnosing CAD. The diagnostic accuracy of radiologists and radiographers was also compared. Two radiologists and two radiographers, all with no prior experience in evaluation of cardiac CT, independently underwent a dedicated training program of 100 examinations randomized into 10 blocks (sessions), with 10 cases in each. They independently evaluated the coronary arteries regarding significant obstructive CAD. After every session, individual feedback on diagnostic accuracy and comparison with the corresponding invasive coronary angiography (currently regarded as the gold standard to detect coronary lesions) was given. The time required for interpretation was recorded. The mean review time decreased (P<0.0001) successively during the 10 sessions for all the observers together. The first session had a mean review time of 32 min, and the last session 16 min. No significant improvement in sensitivity, specificity, or negative predictive value (NPV) was observed. For positive predictive value (PPV), there was an improvement for the radiologists (P<0.05), but not for the radiographers. The radiographers had a higher total specificity compared to the radiologists (P<0.01).
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Question: Is training essential for interpreting cardiac computed tomography?
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The review time for novices in cardiac CT was approximately halved during the first 100 cases, with maintained accuracy. There was a learning-curve effect in PPV for the radiologists. The diagnostic accuracy of dedicated radiographers indicates that they might be considered to be included as part of the evaluation team.
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Answer the question based on the following context: To report the histopathologic findings of explanted Medpor lower eyelid spacers (LES) in complicated cases. Four cases of lower eyelid retraction due to thyroid orbitopathy (n = 2), facial nerve palsy (n = 1), and post-enucleation socket syndrome (n = 1) were treated with Medpor LES. All implants were removed between 6 months to 2 years following their original insertion due to exposure, poor stability, or contour. Histopathology of the implants showed fibrosis and vascularization although clinically, at the time of removal, did not appear vascularized. In addition, immunohistochemistry was positive for Factor VIII related antigen and CD34, thus highlighting the presence of vessels in the pores and around the implant.
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Question: Medpor lower eyelid spacer: does it biointegrate?
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To our knowledge, we are the first to report histopathologic findings of explanted high-density porous polyethylene implants from the lower eyelid in humans. Although this study shows that Medpor LES does biointegrate, we advocate using it sparingly due to associated complications such as exposure, poor stability, and contour.
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Answer the question based on the following context: To investigate the organizational perspectives on the effectiveness of their attendance management policies for chronically ill employees. A mixed-method approach was employed involving questionnaire survey with employees and in-depth interviews with key stakeholders of the organizational policies. Participants reported that attendance management polices and the point at which systems were triggered, posed problems for employees managing chronic illness. These systems presented risk to health: employees were more likely to turn up for work despite feeling unwell (presenteeism) to avoid a disciplinary situation but absence-related support was only provided once illness progressed to long-term sick leave. Attendance management polices also raised ethical concerns for 'forced' illness disclosure and immense pressures on line managers to manage attendance.
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Question: Sickness absence management: encouraging attendance or 'risk-taking' presenteeism in employees with chronic illness?
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Participants felt their current attendance management polices were unfavourable toward those managing a chronic illness. The policies heavily focused on attendance despite illness and on providing return to work support following long-term sick leave. Drawing on the results, the authors conclude that attendance management should promote job retention rather than merely prevent absence per se. They outline areas of improvement in the attendance management of employees with chronic illness.
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Answer the question based on the following context: to assess knowledge of pediatric residents attending adolescents, including ethical issues on contraceptive advice. A prospective study was conducted involving 75 residents in order to assess their knowledge, along with ethical issues involved, in clinical attendance of adolescents. The SPSS 13 software package was used for data analysis. 100% of interviewees stated that adolescents have the right to privacy during medical appointments. Yet, when asked from what age this privacy should be granted, 62% reported at any age. When questioned on whether an adolescent could be examined alone, without another person with them in the room, 50% of physicians answered yes and 50% no. 91.7% of interviewees felt that adolescents had the right to confidentiality and medical secrecy, but only 84.8% knew the contents of the Code of Medical Ethics regarding medical secrecy. A further 79.2% felt prepared to give advice on contraception to adolescents.
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Question: Contraception, adolescence, and ethics in Brazil: are we prepared?
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The attitudes held by pediatric residents on privacy, confidentiality and medical secrecy are highly ambiguous. The doctors interviewed were ill-prepared to deal with the issues of contraception in adolescence on both practical and legal levels.
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