Do mitochondria play a role in remodelling lace plant leaves during programmed cell death?

Abstract:
BACKGROUND Programmed cell death (PCD) is the regulated death of cells within an organism. The lace plant (Aponogeton madagascariensis) produces perforations in its leaves through PCD. The leaves of the plant consist of a latticework of longitudinal and transverse veins enclosing areoles. PCD occurs in the cells at the center of these areoles and progresses outwards, stopping approximately five cells from the vasculature. The role of mitochondria during PCD has been recognized in animals; however, it has been less studied during PCD in plants.
RESULTS The following paper elucidates the role of mitochondrial dynamics during developmentally regulated PCD in vivo in A. madagascariensis. A single areole within a window stage leaf (PCD is occurring) was divided into three areas based on the progression of PCD; cells that will not undergo PCD (NPCD), cells in early stages of PCD (EPCD), and cells in late stages of PCD (LPCD). Window stage leaves were stained with the mitochondrial dye MitoTracker Red CMXRos and examined. Mitochondrial dynamics were delineated into four categories (M1-M4) based on characteristics including distribution, motility, and membrane potential (ΔΨm). A TUNEL assay showed fragmented nDNA in a gradient over these mitochondrial stages. Chloroplasts and transvacuolar strands were also examined using live cell imaging. The possible importance of mitochondrial permeability transition pore (PTP) formation during PCD was indirectly examined via in vivo cyclosporine A (CsA) treatment. This treatment resulted in lace plant leaves with a significantly lower number of perforations compared to controls, and that displayed mitochondrial dynamics similar to that of non-PCD cells.
CONCLUSION Results depicted mitochondrial dynamics in vivo as PCD progresses within the lace plant, and highlight the correlation of this organelle with other organelles during developmental PCD. To the best of our knowledge, this is the first report of mitochondria and chloroplasts moving on transvacuolar strands to form a ring structure surrounding the nucleus during developmental PCD. Also, for the first time, we have shown the feasibility for the use of CsA in a whole plant system. Overall, our findings implicate the mitochondria as playing a critical and early role in developmentally regulated PCD in the lace plant.


Landolt C and snellen e acuity: differences in strabismus amblyopia?

Abstract:
BACKGROUND Assessment of visual acuity depends on the optotypes used for measurement. The ability to recognize different optotypes differs even if their critical details appear under the same visual angle. Since optotypes are evaluated on individuals with good visual acuity and without eye disorders, differences in the lower visual acuity range cannot be excluded. In this study, visual acuity measured with the Snellen E was compared to the Landolt C acuity.
PATIENTS AND METHODS 100 patients (age 8 - 90 years, median 60.5 years) with various eye disorders, among them 39 with amblyopia due to strabismus, and 13 healthy volunteers were tested. Charts with the Snellen E and the Landolt C (Precision Vision) which mimic the ETDRS charts were used to assess visual acuity. Three out of 5 optotypes per line had to be correctly identified, while wrong answers were monitored. In the group of patients, the eyes with the lower visual acuity, and the right eyes of the healthy subjects, were evaluated.
RESULTS Differences between Landolt C acuity (LR) and Snellen E acuity (SE) were small. The mean decimal values for LR and SE were 0.25 and 0.29 in the entire group and 0.14 and 0.16 for the eyes with strabismus amblyopia. The mean difference between LR and SE was 0.55 lines in the entire group and 0.55 lines for the eyes with strabismus amblyopia, with higher values of SE in both groups. The results of the other groups were similar with only small differences between LR and SE.
CONCLUSION Using the charts described, there was only a slight overestimation of visual acuity by the Snellen E compared to the Landolt C, even in strabismus amblyopia. Small differences in the lower visual acuity range have to be considered.


Syncope during bathing in infants, a pediatric form of water-induced urticaria?

Abstract:
BACKGROUND Apparent life-threatening events in infants are a difficult and frequent problem in pediatric practice. The prognosis is uncertain because of risk of sudden infant death syndrome.
CASE REPORTS Eight infants aged 2 to 15 months were admitted during a period of 6 years; they suffered from similar maladies in the bath: on immersion, they became pale, hypotonic, still and unreactive; recovery took a few seconds after withdrawal from the bath and stimulation. Two diagnoses were initially considered: seizure or gastroesophageal reflux but this was doubtful. The hypothesis of an equivalent of aquagenic urticaria was then considered; as for patients with this disease, each infant's family contained members suffering from dermographism, maladies or eruption after exposure to water or sun. All six infants had dermographism. We found an increase in blood histamine levels after a trial bath in the two infants tested. The evolution of these "aquagenic maladies" was favourable after a few weeks without baths. After a 2-7 year follow-up, three out of seven infants continue to suffer from troubles associated with sun or water.
CONCLUSION "Aquagenic maladies" could be a pediatric form of the aquagenic urticaria.


Double balloon enteroscopy: is it efficacious and safe in a community setting?

Abstract:
METHODS From March 2007 to January 2011, 88 DBE procedures were performed on 66 patients. Indications included evaluation anemia/gastrointestinal bleed, small bowel IBD and dilation of strictures. Video-capsule endoscopy (VCE) was used prior to DBE in 43 of the 66 patients prior to DBE evaluation.
RESULTS The mean age was 62 years. Thirty-two patients were female, 15 were African-American; 44 antegrade and 44 retrograde DBEs were performed. The mean time per antegrade DBE was 107.4±30.0 minutes with a distance of 318.4±152.9 cm reached past the pylorus. The mean time per lower DBE was 100.7±27.3 minutes with 168.9±109.1 cm meters past the ileocecal valve reached. Endoscopic therapy in the form of electrocautery to ablate bleeding sources was performed in 20 patients (30.3%), biopsy in 17 patients (25.8%) and dilation of Crohn's-related small bowel strictures in 4 (6.1%). 43 VCEs with pathology noted were performed prior to DBE, with findings endoscopically confirmed in 32 cases (74.4%). In 3 cases the DBE showed findings not noted on VCE.
CONCLUSION DBE appears to be equally safe and effective when performed in the community setting as compared to a tertiary referral center with a comparable yield, efficacy, and complication rate.


Do mutations causing low HDL-C promote increased carotid intima-media thickness?

Abstract:
BACKGROUND Although observational data support an inverse relationship between high-density lipoprotein (HDL) cholesterol and coronary heart disease (CHD), genetic HDL deficiency states often do not correlate with premature CHD.
METHODS Carotid intima-media thickness (cIMT) measurements were obtained in cases comprising 10 different mutations in LCAT, ABCA1 and APOA1 to further evaluate the relationship between low HDL resulting from genetic variation and early atherosclerosis.
RESULTS In a 1:2 case-control study of sex and age-related (+/-5 y) subjects (n=114), cIMT was nearly identical between cases (0.66+/-0.17 cm) and controls (0.65+/-0.18 cm) despite significantly lower HDL cholesterol (0.67 vs. 1.58 mmol/l) and apolipoprotein A-I levels (96.7 vs. 151.4 mg/dl) (P<0.05)
CONCLUSION Genetic variants identified in the present study may be insufficient to promote early carotid atherosclerosis.


A short stay or 23-hour ward in a general and academic children's hospital: are they effective?

Abstract:
OBJECTIVE We evaluated the usefulness of a short stay or 23-hour ward in a pediatric unit of a large teaching hospital, Westmead Hospital, and an academic Children's hospital, The New Children's Hospital, to determine if they are a useful addition to the emergency service.
METHODS This is a descriptive comparison of prospectively collected data on all children admitted to the short stay ward at Westmead Hospital (WH) during 1994 and the short stay ward at the New Children's Hospital (NCH) during 1997-98. These hospitals service an identical demographic area with the latter (NCH) a tertiary referral center. The following outcome measures were used: length of stay, appropriateness of stay, rate of admission to an in-hospital bed, and rate of unscheduled visits within 72 hours of discharge. Adverse events were reported and patient follow-up was attempted at 48 hours after discharge in all cases.
RESULTS The short stay ward accounted for 10.3% (Westmead Hospital) and 14.7% (New Children's Hospital) of admissions, with 56% medical in nature, 30% surgical, and the remainder procedural or psychological. Admission patterns were similar, with asthma, gastroenteritis, convulsion, pneumonia, and simple surgical conditions accounting for most short stay ward admissions. The short stay ward increased hospital efficiency with an average length of stay of 17.5 hours (Westmead Hospital) compared to 20.5 hours (New Children's Hospital). The users of the short stay ward were children of young age less than 2 years, with stay greater than 23 hours reported in only 1% of all admissions to the short stay ward. The rate of patient admission to an in-hospital bed was low, (4% [Westmead Hospital] compared to 6% [New Children's Hospital]), with the number of unscheduled visits within 72 hours of short stay ward discharge less than 1%. There were no adverse events reported at either short stay ward, with parental satisfaction high. The short stay ward was developed through reallocation of resources from within the hospital to the short stay ward. This resulted in estimated savings of $1/2 million (Westmead Hospital) to $2.3 million (New Children's Hospital) to the hospital, due to more efficient bed usage.
CONCLUSION This data demonstrates the robust nature of the short stay ward. At these two very different institutions we have shown improved bed efficient and patient care in a cost-effective way. We have also reported on greater parental satisfaction and early return of the child with their family to the community.


Did Chile's traffic law reform push police enforcement?

Abstract:
BACKGROUND The objective of the current study is to determine to what extent the reduction of Chile's traffic fatalities and injuries during 2000-2012 was related to the police traffic enforcement increment registered after the introduction of its 2005 traffic law reform.
METHODS A unique dataset with assembled information from public institutions and analyses based on ordinary least square and robust random effects models was carried out. Dependent variables were traffic fatality and severe injury rates per population and vehicle fleet. Independent variables were: (1) presence of new national traffic law; (2) police officers per population; (3) number of traffic tickets per police officer; and (4) interaction effect of number of traffic tickets per police officer with traffic law reform. Oil prices, alcohol consumption, proportion of male population 15-24 years old, unemployment, road infrastructure investment, years' effects and regions' effects represented control variables.
RESULTS Empirical estimates from instrumental variables suggest that the enactment of the traffic law reform in interaction with number of traffic tickets per police officer is significantly associated with a decrease of 8% in traffic fatalities and 7% in severe injuries. Piecewise regression model results for the 2007-2012 period suggest that police traffic enforcement reduced traffic fatalities by 59% and severe injuries by 37%.
CONCLUSION Findings suggest that traffic law reforms in order to have an effect on both traffic fatality and injury rates reduction require changes in police enforcement practices. Last, this case also illustrates how the diffusion of successful road safety practices globally promoted by WHO and World Bank can be an important influence for enhancing national road safety practices.


Therapeutic anticoagulation in the trauma patient: is it safe?

Abstract:
PURPOSE Trauma patients who require therapeutic anticoagulation pose a difficult treatment problem. The purpose of this study was to determine: (1) the incidence of complications using therapeutic anticoagulation in trauma patients, and (2) if any patient factors are associated with these complications.
METHODS An 18-month retrospective review was performed on trauma patients>or= 15 years old who received therapeutic anticoagulation using unfractionated heparin (UH) and/or fractionated heparin (FH). Forty different pre-treatment and treatment patient characteristics were recorded. Complications of anticoagulation were documented and defined as any unanticipated discontinuation of the anticoagulant for bleeding or other adverse events.
RESULTS One-hundred-fourteen trauma patients were initiated on therapeutic anticoagulation. The most common indication for anticoagulation was deep venous thrombosis (46%). Twenty-four patients (21%) had at least 1 anticoagulation complication. The most common complication was a sudden drop in hemoglobin concentration requiring blood transfusion (11 patients). Five patients died (4%), 3 of whom had significant hemorrhage attributed to anticoagulation. Bivariate followed by logistic regression analysis identified chronic obstructive pulmonary disease (OR = 9.2, 95%CI = 1.5-54.7), UH use (OR = 3.8, 95%CI = 1.1-13.0), and lower initial platelet count (OR = 1.004, 95%CI = 1.000-1.008) as being associated with complications. Patients receiving UH vs. FH differed in several characteristics including laboratory values and anticoagulation indications.
CONCLUSION Trauma patients have a significant complication rate related to anticoagulation therapy, and predicting which patients will develop a complication remains unclear. Prospective studies are needed to determine which treatment regimen, if any, is appropriate to safely anticoagulate this high risk population.


Prompting Primary Care Providers about Increased Patient Risk As a Result of Family History: Does It Work?

Abstract:
BACKGROUND Electronic health records have the potential to facilitate family history use by primary care physicians (PCPs) to provide personalized care. The objective of this study was to determine whether automated, at-the-visit tailored prompts about family history risk change PCP behavior.
METHODS Automated, tailored prompts highlighting familial risk for heart disease, stroke, diabetes, and breast, colorectal, or ovarian cancer were implemented during 2011 to 2012. Medical records of a cohort of community-based primary care patients, aged 35 to 65 years, who previously participated in our Family Healthware study and had a moderate or strong familial risk for any of the 6 diseases were subsequently reviewed. The main outcome measures were PCP response to the prompts, adding family history risk to problem summary lists, and patient screening status for each disease.
RESULTS The 492 eligible patients had 847 visits during the study period; 152 visits had no documentation of response to a family history prompt. Of the remaining 695 visits, physician responses were reviewed family history (n = 372, 53.5%), discussed family history (n = 159, 22.9%), not addressed (n = 155, 22.3%), and reviewed family history and ordered tests/referrals (n = 5, 0.7%). There was no significant change in problem summary list documentation of risk status or screening interventions for any of the 6 diseases.
CONCLUSION No change occurred upon instituting simple, at-the-visit family history prompts geared to improve PCPs' ability to identify patients at high risk for 6 common conditions. The results are both surprising and disappointing. Further studies should examine physicians' perception of the utility of prompts for family history risk.


Do emergency ultrasound fellowship programs impact emergency medicine residents' ultrasound education?

Abstract:
OBJECTIVES Recent years have seen a rapid proliferation of emergency ultrasound (EUS) programs in the United States. To date, there is no evidence supporting that EUS fellowships enhance residents' ultrasound (US) educational experiences. The purpose of this study was to determine the impact of EUS fellowships on emergency medicine (EM) residents' US education.
METHODS We conducted a cross-sectional study at 9 academic medical centers. A questionnaire on US education and bedside US use was pilot tested and given to EM residents. The primary outcomes included the number of US examinations performed, scope of bedside US applications, barriers to residents' US education, and US use in the emergency department. The secondary outcomes were factors that would impact residents' US education. The outcomes were compared between residency programs with and without EUS fellowships.
RESULTS A total of 244 EM residents participated in this study. Thirty percent (95% confidence interval, 24%-35%) reported they had performed more than 150 scans. Residents in programs with EUS fellowships reported performing more scans than those in programs without fellowships (P = .04). Significant differences were noted in most applications of bedside US between residency programs with and without fellowships (P<.05). There were also significant differences in the barriers to US education between residency programs with and without fellowships (P<.05).
CONCLUSION Emergency US fellowship programs had a positive impact on residents' US educational experiences. Emergency medicine residents performed more scans overall and also used bedside US for more advanced applications in programs with EUS fellowships.


Patient-Controlled Therapy of Breathlessness in Palliative Care: A New Therapeutic Concept for Opioid Administration?

Abstract:
CONTEXT Breathlessness is one of the most distressing symptoms experienced by patients with advanced cancer and noncancer diagnoses alike. Often, severity of breathlessness increases quickly, calling for rapid symptom control. Oral, buccal, and parenteral routes of provider-controlled drug administration have been described. It is unclear whether patient-controlled therapy (PCT) systems would be an additional treatment option.
OBJECTIVES To investigate whether intravenous opioid PCT can be an effective therapeutic method to reduce breathlessness in patients with advanced disease. Secondary aims were to study the feasibility and acceptance of opioid PCT in patients with refractory breathlessness.
METHODS This was a pilot observational study with 18 inpatients with advanced disease and refractory breathlessness receiving opioid PCT. Breathlessness was measured on a self-reported numeric rating scale. Richmond Agitation Sedation Scale scores, Palliative Performance Scale scores, vital signs, and a self-developed patient satisfaction questionnaire were used for measuring secondary outcomes. Descriptive and interference analyses (Friedman test) and post hoc analyses (Wilcoxon tests and Bonferroni corrections) were performed.
RESULTS Eighteen of 815 patients (advanced cancer; median age = 57.5 years [range 36-81]; 77.8% female) received breathlessness symptom control with opioid PCT; daily morphine equivalent dose at Day 1 was median = 20.3 mg (5.0-49.6 mg); Day 2: 13.0 mg (1.0-78.5 mg); Day 3: 16.0 mg (8.3-47.0 mg). Numeric rating scale of current breathlessness decreased (baseline: median = 5 [range 1-10]; Day 1: median = 4 [range 0-8], P < 0.01; Day 2: median = 4 [range 0-5], P < 0.01). Physiological parameters were stable over time. On Day 3, 12/12 patients confirmed that this mode of application provided relief of breathlessness.
CONCLUSION Opioid PCT is a feasible and acceptable therapeutic method to reduce refractory breathlessness in palliative care patients.


Is there still a need for living-related liver transplantation in children?

Abstract:
OBJECTIVE To assess and compare the value of split-liver transplantation (SLT) and living-related liver transplantation (LRT).
SUMMARY BACKGROUND DATA The concept of SLT results from the development of reduced-size transplantation. A further development of SLT, the in situ split technique, is derived from LRT, which itself marks the optimized outcome in terms of postoperative graft function and survival. The combination of SLT and LRT has abolished deaths on the waiting list, thus raising the question whether living donor liver transplantation is still necessary.
METHODS Outcomes and postoperative liver function of 43 primary LRT patients were compared with those of 49 primary SLT patients (14 ex situ, 35 in situ) with known graft weight performed between April 1996 and December 2000. Survival rates were analyzed using the Kaplan-Meier method.
RESULTS After a median follow-up of 35 months, actual patient survival rates were 82% in the SLT group and 88% in the LRT group. Actual graft survival rates were 76% and 81%, respectively. The incidence of primary nonfunction was 12% in the SLT group and 2.3% in the LRT group. Liver function parameters (prothrombin time, factor V, bilirubin clearance) and surgical complication rates did not differ significantly. In the SLT group, mean cold ischemic time was longer than in the LRT group. Serum values of alanine aminotransferase during the first postoperative week were significantly higher in the SLT group. In the LRT group, there were more grafts with signs of fatty degeneration than in the SLT group.
CONCLUSION The short- and long-term outcomes after LRT and SLT did not differ significantly. To avoid the risk for the donor in LRT, SLT represents the first-line therapy in pediatric liver transplantation in countries where cadaveric organs are available. LRT provides a solution for urgent cases in which a cadaveric graft cannot be found in time or if the choice of the optimal time point for transplantation is vital.


Do patterns of knowledge and attitudes exist among unvaccinated seniors?

Abstract:
OBJECTIVE To examine patterns of knowledge and attitudes among adults aged>65 years unvaccinated for influenza.
METHODS Surveyed Medicare beneficiaries in 5 areas; clustered unvaccinated seniors by their immunization related knowledge and attitudes.
RESULTS Identified 4 clusters: Potentials (45%) would receive influenza vaccine to prevent disease; Fearful Uninformeds (9%) were unsure if influenza vaccine causes illness; Doubters (27%) were unsure if vaccine is efficacious; Misinformeds (19%) believed influenza vaccine causes illness. More Potentials (75%) and Misinformeds (70%) ever received influenza vaccine than did Fearful Uninformeds (18%) and Doubters (29%).
CONCLUSION Findings suggest that cluster analyses may be useful in identifying groups for targeted health messages.


Is there a model to teach and practice retroperitoneoscopic nephrectomy?

Abstract:
INTRODUCTION Although the retroperitoneal approach has been the preferred choice for open urological procedures, retroperitoneoscopy is not the preferred approach for laparoscopy. This study aims to develop a training model for retroperitoneoscopy and to establish an experimental learning curve.
MATERIAL AND METHODS Fifteen piglets were operated on to develop a standard retroperitoneoscopic nephrectomy (RPN) training model. All procedures were performed with three ports. Intraoperative data (side, operative time, blood loss, peritoneal opening) were recorded. Animals were divided into groups A, the first eight, and B, the last seven cases. Data were statistically analyzed.
RESULTS We performed fifteen RPNs. The operative time varied from 15 to 50 minutes (median 30 minutes). Blood loss varied from 5 to 100 mL (median 20 mL). We experienced five peritoneal openings; we had two surgical vascular complications managed laparoscopically. There was statistical difference between groups A and B for peritoneal opening (p = 0.025), operative time (p = 0.0037), and blood loss (p = 0.026).
DISCUSSION RPN in a porcine model could simulate the whole procedure, from creating the space to nephrectomy completion. Experimental learning curve was eight cases, after statistical data analysis.
CONCLUSION RPN in a porcine model is feasible and could be very useful for teaching and practicing retroperitoneoscopy.


Cardiovascular risk in a rural adult West African population: is resting heart rate also relevant?

Abstract:
INTRODUCTION Elevated resting heart rate (RHR) is a neglected marker in cardiovascular risk factor studies of sub-Saharan African populations. This study aimed to determine the prevalence of elevated RHR and other risk factors for cardiovascular disease (CVD) and to investigate any associations between RHR and these risk factors in a rural population in Ghana.
DESIGN Cross-sectional analysis.
METHODS A total of 574 adults aged between 18-65 years were randomly sampled from a population register. Data collected included those on sociodemographic variables and anthropometric, blood pressure (BP), and RHR measurements. Within-person variability in RHR was calculated using data from repeat measurements taken 2 weeks apart.
RESULTS Of study participants, 36% were male. Prevalence of casual high BP was 19%. In the population, 10% were current cigarette smokers and habitual alcohol use was high at 56%. As measured by body mass index, 2% were obese and 14% had abdominal obesity. RHR was elevated (>90 bpm) in 19%. Overall, 79% of study participants were found to have at least one CVD risk factor. RHR was significantly associated with age, waist circumference, and BP. Individuals with an elevated RHR had a higher risk (OR 1.94, 95% CI 1.15-3.26%, p = 0.013) of casual high BP compared with participants with normal RHR independently of several established CVD risk factors. The regression dilution ratio of RHR was 0.75 (95% CI 0.62-0.89).
CONCLUSION Significant associations were observed between RHR and several established cardiovascular risk factors. Prospective studies are needed in sub-Saharan African populations to establish the potential value of RHR in cardiovascular risk assessment.


Israeli hospital preparedness for terrorism-related multiple casualty incidents: can the surge capacity and injury severity distribution be better predicted?

Abstract:
BACKGROUND The incidence of large-scale urban attacks on civilian populations has significantly increased across the globe over the past decade. These incidents often result in Hospital Multiple Casualty Incidents (HMCI), which are very challenging to hospital teams. 15 years ago the Emergency and Disaster Medicine Division in the Israeli Ministry of Health defined a key of 20 percent of each hospital's bed capacity as its readiness for multiple casualties. Half of those casualties are expected to require immediate medical treatment. This study was performed to evaluate the efficacy of the current readiness guidelines based on the epidemiology of encountered HMCIs.
METHODS A retrospective study of HMCIs was recorded in the Israeli Defense Force (IDF) home front command and the Israeli National Trauma Registry (ITR) between November 2000 and June 2003. An HMCI is defined by the Emergency and Disaster Medicine Division in the Israeli Ministry of Health as>or=10 casualties or>or=4 suffering from injuries with an ISS>or=16 arriving to a single hospital.
RESULTS The study includes a total of 32 attacks, resulting in 62 HMCIs and 1292 casualties. The mean number of arriving casualties to a single hospital was 20.8+/-13.3 (range 4-56, median 16.5). In 95% of the HMCIs the casualty load was<or=52. Based on severity scores and ED discharges 1022 (79.2%) casualties did not necessitate immediate medical treatment.
CONCLUSION Hospital preparedness can be better defined by a fixed number of casualties rather than a percentile of its bed capacity. Only 20% of the arriving casualties will require immediate medical treatment. Implementation of this concept may improve the utilisation of national emergency health resources both in the preparation phase and on real time.


Acute respiratory distress syndrome in children with malignancy--can we predict outcome?

Abstract:
PURPOSE The purpose of this study was to delineate early respiratory predictors of mortality in children with hemato-oncology malignancy who developed acute respiratory distress syndrome (ARDS).
MATERIALS AND METHODS We conducted a retrospective chart review of children with malignant and ARDS who needed mechanical ventilation and were admitted to a pediatric intensive care unit from January 1987 to January 1997.
RESULTS Seventeen children with ARDS and malignancy aged 10.5 +/- 5.1 years were identified. Six of the 17 children (35.3%) survived. Sepsis syndrome was present in 70.6% of all the children. Peak inspiratory pressure, positive end-expiratory pressure (PEEP), and ventilation index values could distinguish outcome by day 3. A significant relationship between respiratory data and outcome related to efficiency of oxygenation, as determined by PaO(2)/FIO(2) and P(A-a)O(2), was present from day 8 after onset of mechanical ventilation.
CONCLUSION Peak inspiratory pressure, PEEP, and ventilation index values could distinguish survivors from nonsurvivors by day 3. This may assist in early application of supportive nonconventional therapies in children with malignancy and ARDS.


Secondhand smoke risk in infants discharged from an NICU: potential for significant health disparities?

Abstract:
INTRODUCTION Secondhand smoke exposure (SHSe) threatens fragile infants discharged from a neonatal intensive care unit (NICU). Smoking practices were examined in families with a high respiratory risk infant (born at very low birth weight; ventilated>12 hr) in a Houston, Texas, NICU. Socioeconomic status, race, and mental health status were hypothesized to be related to SHSe and household smoking bans.
METHODS Data were collected as part of The Baby's Breath Project, a hospital-based SHSe intervention trial targeting parents with a high-risk infant in the NICU who reported a smoker in the household (N = 99). Measures of sociodemographics, smoking, home and car smoking bans, and depression were collected.
RESULTS Overall, 26% of all families with a high-risk infant in the NICU reported a household smoker. Almost half of the families with a smoker reported an annual income of less than $25,000. 46.2% of families reported having a total smoking ban in place in both their homes and cars. Only 27.8% families earning less than $25,000 reported having a total smoking ban in place relative to almost 60% of families earning more (p<.01). African American and Caucasian families were less likely to have a smoking ban compared with Hispanics (p<.05). Mothers who reported no smoking ban were more depressed than those who had a household smoking ban (p<.02).
CONCLUSION The most disadvantaged families were least likely to have protective health behaviors in place to reduce SHSe and, consequently, are most at-risk for tobacco exposure and subsequent tobacco-related health disparities. Innovative SHSe interventions for this vulnerable population are sorely needed.


Do nomograms designed to predict biochemical recurrence (BCR) do a better job of predicting more clinically relevant prostate cancer outcomes than BCR?

Abstract:
OBJECTIVE To examine the ability of various postoperative nomograms to predict prostate cancer-specific mortality (PCSM) and to validate that they could predict aggressive biochemical recurrence (BCR). Prostate-specific antigen (PSA), grade, and stage are the classic triad used to predict BCR after radical prostatectomy (RP). Multiple nomograms use these to predict risk of BCR. A previous study showed that several nomograms could predict aggressive BCR (prostate-specific antigen doubling time [PSADT] <9 months) more accurately than BCR. However, it remains unknown if they can predict more definitive endpoints, such as PCSM.
METHODS We performed Cox analyses to examine the ability of 4 postoperative nomograms, the Duke Prostate Center (DPC) nomogram, the Kattan postoperative nomogram, the Johns Hopkins Hospital (JHH) nomogram, and the joint Center for Prostate Disease Research(CPDR)/Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) nomogram to predict BCR and PCSM among 1778 men in the Shared Equal Access Regional Cancer Hospital (SEARCH) database who underwent RP between 1990 and 2009. We also compared their ability to predict BCR and aggressive BCR in a subset of men. We calculated the c-index for each nomogram to determine its predictive accuracy for estimating actual outcomes.
RESULTS We found that each nomogram could predict aggressive BCR and PCSM in a statistically significant manner and that they all predicted PCSM more accurately than they predicted BCR (ie, with higher c-index values).
CONCLUSION Currently available nomograms used to predict BCR accurately predict PCSM and other more clinically relevant endpoints. Moreover, not only do they significantly predict PCSM, but do so with generally greater accuracy than BCR.


Amblyopia: is visual loss permanent?

Abstract:
METHODS The records of 465 patients with an established diagnosis of age related macular degeneration who had attended a specialist macular clinic between 1990 and 1998 were scrutinised. A full clinical examination and standardised refraction had been carried out in 189 of these cases on a minimum of two occasions. Cases were looked for where an improvement of one or more lines of either distance or near acuity was recorded in the eye unaffected by macular disease. In each one of these cases the improvement in visual acuity could not be attributed to treatment of other existing pathology.
RESULTS 12 such cases were detected. In nine of these the eye showing improvement of acuity had a history of amblyopia. The mean improvement in distance and near acuity in amblyopic eyes by 12 months was 3.3 and 1.9 lines logMAR respectively. The improvement in acuity generally occurred between 1 and 12 months from baseline and remained stable over the period of follow up.
CONCLUSION Older people with a history of amblyopia who develop visual loss in the previously normal eye can experience recovery of visual function in the amblyopic eye over a period of time. This recovery in visual function occurs in the wake of visual loss in the fellow eye and the improvement appears to be sustained.


Implementation of epidural analgesia for labor: is the standard of effective analgesia reachable in all women?

Abstract:
BACKGROUND Social and cultural factors combined with little information may prevent the diffusion of epidural analgesia for pain relief during childbirth. The present study was launched contemporarily to the implementation of analgesia for labor in our Department in order to perform a 2 years audit on its use. The goal is to evaluate the epidural acceptance and penetration into hospital practice by women and care givers and safety and efficacy during childbirth.
PATIENTS AND METHODS This audit cycle measured epidural analgesia performance against 4 standards: (1) Implementation of epidural analgesia for labor to all patients; (2) Acceptance and good satisfaction level reported by patients and caregivers. (3) Effectiveness of labor analgesia; (4) No maternal or fetal side effects.
RESULTS During the audit period epidural analgesia increased from 15.5% of all labors in the first trimester of the study to 51% in the last trimester (p<0.005). Satisfaction levels reported by patients and care givers were good. A hierarchical clustering analysis identified two clusters based on VAS (Visual Analogue Scale) time course: in 226 patients (cluster 1) VAS decreased from 8.5±1.4 before to 4.1±1.3 after epidural analgesia; in 1002 patients (cluster 2) VAS decreased from 8.12±1.7 before (NS vs cluster 1), to 0.76±0.79 after (p<0.001 vs before and vs cluster 2 after). No other differences between clusters were observed.
CONCLUSION Present audit shows that the process of implementation of labor analgesia was quick, successful and safe, notwithstanding the identification of one cluster of women with suboptimal response to epidural analgesia that need to be further studies, overall pregnant womens'adhesion to labor analgesia was satisfactory.


Is halofantrine ototoxic?

Abstract:
INTRODUCTION Halofantrine is a newly developed antimalarial drug used for the treatment of Plasmodium falciparum malaria. The introduction of this drug has been delayed because of its possible side effects, and due to insufficient studies on adverse reactions in humans. There have been no studies investigating its effect on hearing.
METHODS Thirty guinea pigs were divided into three groups: a control group, a halofantrine therapeutic dose group and a halofantrine double therapeutic dose group. One cochlea specimen from each animal was stained with haematoxylin and eosin and the other with toluidine blue.
RESULTS No changes were detected in the control group. The halofantrine therapeutic dose group showed loss and distortion of inner hair cells and inner phalangeal cells, and loss of spiral ganglia cells. In the halofantrine double therapeutic dose group, the inner and outer hair cells were distorted and there was loss of spiral ganglia cells.
CONCLUSION Halofantrine has mild to moderate pathological effects on cochlea histology, and can be considered an ototoxic drug.


Visceral adipose tissue area measurement at a single level: can it represent visceral adipose tissue volume?

Abstract:
OBJECTIVE Measurement of visceral adipose tissue (VAT) needs to be accurate and sensitive to change for risk monitoring. The purpose of this study is to determine the CT slice location where VAT area can best reflect changes in VAT volume and body weight.
METHODS 60 plain abdominal CT images from 30 males [mean age (range) 51 (41-68) years, mean body weight (range) 71.1 (101.9-50.9) kg] who underwent workplace screenings twice within a 1-year interval were evaluated. Automatically calculated and manually corrected areas of the VAT of various scan levels using "freeform curve" region of interest on CT were recorded and compared with body weight changes.
RESULTS The strongest correlations of VAT area with VAT volume and body weight changes were shown in a slice 3 cm above the lower margin of L3 with r values of 0.853 and 0.902, respectively.
CONCLUSION VAT area measurement at a single level 3 cm above the lower margin of the L3 vertebra is feasible and can reflect changes in VAT volume and body weight. Advances in knowledge: As VAT area at a CT slice 3cm above the lower margin of L3 can best reflect interval changes in VAT volume and body weight, VAT area measurement should be selected at this location.


Necrotizing fasciitis: an indication for hyperbaric oxygenation therapy?

Abstract:
BACKGROUND The accepted treatment protocol for necrotizing fasciitis (NF) consists of extensive surgery and wide spectrum antibiotics. Hyperbaric oxygenation (HBO) has been recommended as adjuvant therapy for NF, improving patient mortality and outcome. However, the beneficial effect of HBO for NF remains controversial.
METHODS A retrospective evaluation of treatment outcome in 37 patients treated for NF between 1984 and 1993 was carried out. The mortality rate, morbidity criteria, and risk factors for grave prognosis were compared between a group of 25 patients who received HBO as part of their treatment protocol and a group of the remaining 12 patients treated by surgical excision and antibiotics alone.
RESULTS The two groups were found to be similar with regard to age, gender, the incidence of individual risk factors for ominous prognosis, and the Acute Physiology and Chronic Health Evaluation (APACHE) II score for disease's severity on presentation. The mortality rate among the HBO-treated patients was 36%, as opposed to 25% in the non-HBO group. The mean number of surgical débridements required per patient was significantly higher in the HBO group: 3.3 compared with 1.5 in the non-HBO-treated patients. Although the average length of hospitalization for survivors was shorter for the HBO group, the difference between the groups did not reach statistical significance.
CONCLUSION The results of this study cast doubt on the suggested advantage of HBO in reducing patient mortality and morbidity when used as adjuvant therapy for NF.


Is a mandatory general surgery rotation necessary in the surgical clerkship?

Abstract:
BACKGROUND Changes in the spectrum of general surgery and the delivery of surgical care have placed the requirement for a mandatory general surgery rotation in the surgical clerkship in question.
METHODS We tested the hypothesis that equal mastery of surgical clerkship objectives can be obtained in a clerkship with and without general surgery. Students chose any two surgical rotations and were assessed by written examination, objective structured clinical examination (OSCE), ward evaluations, self-assessment objectives questionnaire, and satisfaction survey.
RESULTS Data for 54 students showed no differences in scores between groups on any parameter. No specific concerns related to the absence of general surgery were identified.
CONCLUSION Effective undergraduate surgical education can be offered in many specialty settings. Removal of the requirement for general surgery in clerkship may lead to a more effective use of all educational opportunities. A careful analysis of local programs and facilities is necessary before suggesting this change to other institutions.


Is Acupuncture Efficacious for Treating Phonotraumatic Vocal Pathologies?

Abstract:
OBJECTIVES To investigate the effectiveness of acupuncture in treating phonotraumatic vocal fold lesions.STUDY DESIGN/
METHODS A total of 123 dysphonic individuals with benign vocal pathologies were recruited. They were given either genuine acupuncture (n = 40), sham acupuncture (n = 44), or no treatment (n = 39) for 6 weeks (two 30-minute sessions/wk). The genuine acupuncture group received needles puncturing nine voice-related acupoints for 30 minutes, two times a week for 6 weeks, whereas the sham acupuncture group received blunted needles stimulating the skin surface of the nine acupoints for the same frequency and duration. The no-treatment group did not receive any intervention but attended just the assessment sessions. One-hundred seventeen subjects completed the study (genuine acupuncture = 40; sham acupuncture = 43; and no treatment = 34), but only 84 of them had a complete set of vocal functions and quality of life measures (genuine acupuncture = 29; sham acupuncture = 33; and no-treatment = 22) and 42 of them with a complete set of endoscopic data (genuine acupuncture = 16; sham acupuncture = 15; and no treatment = 11).
RESULTS Significant improvement in vocal function, as indicated by the maximum fundamental frequency produced, and also perceived quality of life, were found in both the genuine and sham acupuncture groups, but not in the no-treatment group. Structural (morphological) improvements were, however, only noticed in the genuine acupuncture group, which demonstrated a significant reduction in the size of the vocal fold lesions.
CONCLUSION The findings showed that acupuncture of voice-related acupoints could bring about improvement in vocal function and healing of vocal fold lesions.


Is aneurysm repair justified for the patients aged 80 or older after aneurysmal subarachnoid hemorrhage?

Abstract:
BACKGROUND With the advancement of an aging society in the world, an increasing number of elderly patients have been hospitalized due to aneurysmal subarachnoid hemorrhage (aSAH). There is no study that compares the elderly cases of aSAH who receive the definitive treatment with those who treated conservatively. The aim of this study was to investigate the feasibility of the definitive surgery for the acute subarachnoid cases aged 80 or older.
METHODS We reviewed 500 consecutive cases with acute aSAH with surgical indication for aneurysm repair. Inoperable cases such as dead-on-arrival and the cases with both pupils dilated were excluded. We compared the cases aged 80 or older that received clipping or coil embolization with the controls that the family selected conservative treatment.
RESULTS 69 cases were included in this study (ranged 80-98, male:female=9:60). 56 cases (81.2%) had an aneurysm in the anterior circulation. 23 cases received clipping, 20 cases coil embolization and 26 cases treated conservatively. The cases with aneurysm repair showed significantly better clinical outcome than the controls, while World Federation of Neurological Surgeons (WFNS) grade on admission and premorbid modified Rankin Scale showed no difference between them.
CONCLUSION Better prognosis was obtained when ruptured aneurysm was repaired in the elderly than it was treated conservatively. From the results of this study, we should not hesitate to offer the definitive surgery for the elderly with aSAH.


Do general practice characteristics influence uptake of an information technology (IT) innovation in primary care?

Abstract:
INTRODUCTION Recent evaluations of IT innovations in primary care have highlighted variations between centres and practices in uptake and use. We evaluated whether structural characteristics of a general practice were associated with variations in use of a web-based clinical information system underpinning a Managed Clinical Network in diabetes, between the years 2001 and 2003.
METHODS Using a computerised audit trail, we calculated the numbers of web-based operations that occurred in each practice, stratified by staff type and year, and adjusted for the numbers of registered diabetic patients. In regression analyses, we determined whether total use was associated with structural characteristics of the practice (total list size, training status, numbers of GPs (general practitioners), mean age of the GPs, numbers of female GPs, level of deprivation of the population and whether staff had received advanced training in diabetes care).
RESULTS Initially there were a few practices which made very frequent use of the information system, with relatively high numbers of practices using the facility infrequently. However, overall use gradually became more evenly spread. This effect was particularly evident among nurse users. Frequent use by GPs was evident in only a small number of practices, with mean GP use decreasing over the three years. In linear regression analyses, none of the general practice variables were associated with online use, either overall or stratified by staff type, except for the numbers of diabetes-educated staff. This was consistently associated with increased use by nurses and GPs.
CONCLUSION The analyses show that structural characteristics of a practice are not associated with uptake of a new IT facility, but that its use may be influenced by post-graduate education in the relevant clinical condition. For this diabetes system at least, practice nurse use was critical in spreading uptake beyond initial GP enthusiasts and for sustained and rising use in subsequent years.


Biomolecular identification of allergenic pollen: a new perspective for aerobiological monitoring?

Abstract:
BACKGROUND Accurate and updated information on airborne pollen in specific areas can help allergic patients. Current monitoring systems are based on a morphologic identification approach, a time-consuming method that may represent a limiting factor for sampling network enhancement.
OBJECTIVE To verify the feasibility of developing a real-time polymerase chain reaction (PCR) approach, an alternative to optical analysis, as a rapid, accurate, and automated tool for the detection and quantification of airborne allergenic pollen taxa.
METHODS The traditional cetyl trimethyl ammonium bromide-based method was modified for DNA isolation from pollen. Taxon-specific DNA sequences were identified via bioinformatics or literature searches and were PCR amplified from the matching allergenic taxa; based on the sequences of PCR products, complementary or degenerate TaqMan probes were developed. The accuracy of the quantitative real-time PCR assay was tested on 3 plant species.
RESULTS The setup of a modified DNA extraction protocol allowed us to achieve good-quality pollen DNA. Taxon-specific nuclear gene fragments were identified and sequenced. Designed primer pairs and probes identified selected pollen taxa, mostly at the required classification level. Pollen was properly identified even when collected on routine aerobiological tape. Preliminary quantification assays on pollen grains were successfully performed on test species and in mixes.
CONCLUSION The real-time PCR approach revealed promising results in pollen identification and quantification, even when analyzing pollen mixes. Future perspectives could concern the development of multiplex real-time PCR for the simultaneous detection of different taxa in the same reaction tube and the application of high-throughput molecular methods.


Does diabetes mellitus influence the efficacy of FDG-PET in the diagnosis of cervical cancer?

Abstract:
PURPOSE Compared with computed tomography (CT) and magnetic resonance imaging (MRI), positron emission tomography (PET) may have additional value in the assessment of primary and recurrent cervical cancer. However, the degree of tumour uptake of (18)F-2-fluoro-2-deoxy-D: -glucose (FDG) uptake is sometimes influenced by diabetes mellitus (DM). Therefore, we conducted this prospective study to compare the diagnostic ability of FDG-PET in patients with cervical cancer complicated by DM and those without DM.
METHODS Patients with untreated locally advanced primary or clinically curable recurrent cervical carcinoma were enrolled. Both FDG-PET and MRI/CT scans were performed within 2 weeks. Patients were categorised into the following groups: hyperglycaemic DM (fasting blood sugar>126 mg/dl), euglycaemic DM and non-DM. The lesions were confirmed histologically or by clinical follow-up. The receiver operating characteristic curve method, with calculation of the area under the curve (AUC), was used to evaluate the discriminative power.
RESULTS From February 2001 to January 2003, 219 patients (75 with primary and 144 with recurrent cervical cancer) were eligible for analysis. Sixteen had hyperglycaemic DM, 12 had euglycaemic DM and 191 were in the non-DM group. The diagnostic power of PET in the hyperglycaemic DM, euglycaemic DM and non-DM groups did not differ significantly with regard to the identification of either metastatic lesions (AUC, 0.967/0.947/0.925, P>0.05) or primary tumours/local recurrence (AUC, 0.950/0.938/0.979, P>0.05). Considering all DM patients, PET showed a significantly higher detection power than MRI/CT scans in respect of metastatic lesions (AUC=0.956 vs 0.824, P=0.012).
CONCLUSION In comparison with its accuracy in non-DM patients, the accuracy of PET in cervical cancer patients with mild to moderate DM was not significantly reduced.


Does radiotherapy of the primary rectal cancer affect prognosis after pelvic exenteration for recurrent rectal cancer?

Abstract:
BACKGROUND Radiotherapy reduces local recurrence rates but is also capable of short- and long-term toxicity. It may also render treatment of local recurrence more challenging if it develops despite previous radiotherapy.
OBJECTIVE This study examined the impact of radiotherapy for the primary rectal cancer on outcomes after pelvic exenteration for local recurrence.
DESIGN We conducted a retrospective review of exenteration databases.
SETTING The study took place at a quaternary referral center that specializes in pelvic exenteration.
PATIENTS Patients referred for pelvic exenteration from October 1994 to November 2012 were reviewed. Patients who did and did not receive radiotherapy as part of their primary rectal cancer treatment were compared.
MAIN OUTCOME MEASURES The main outcomes of interest were resection margins, overall survival, disease-free survival, and surgical morbidities.
RESULTS There were 108 patients, of which 87 were eligible for analysis. Patients who received radiotherapy for their primary rectal cancer (n = 41) required more radical exenterations (68% vs 44%; p = 0.020), had lower rates of clear resection margins (63% vs 87%; p = 0.010), had increased rates of surgical complications per patient (p = 0.014), and had a lower disease-free survival (p = 0.022). Overall survival and disease-free survival in patients with clear margins were also lower in the primary irradiated patients (p = 0.049 and p<0.0001). This difference in survival persisted in multivariate analysis that corrected for T and N stages of the primary tumor.
LIMITATIONS This study is limited by its retrospective nature and heterogeneous radiotherapy regimes among radiotherapy patients.
CONCLUSION Patients who previously received radiotherapy for primary rectal cancer treatment have worse oncologic outcomes than those who had not received radiotherapy after pelvic exenteration for locally recurrent rectal cancer.


Colorectal cancer with synchronous liver metastases: does global management at the same centre improve results?

Abstract:
BACKGROUND Synchronous liver metastases (SLM) occur in 20% of colorectal cancers (CRC). Resection of SLM and CLC can be undertaken at different centres (separate management, SM) or at the same centre (global management, GM).
METHODS Retrospective study of SLM and CRC resections carried out during 01/2000 - 12/2006 by SM or GM, using a combined or delayed strategy.
RESULTS Morphologic characteristics and type of CRC and SLM resection were similar for the GM (n = 45) or SM (n = 66) groups. In patients with delayed liver resection (62 SM, 17 GM), chemotherapy prior to liver surgery was used in 92% and 38% of SM and GM patients (P<0.0001) and the median delay between procedures was 212 and 182 days, respectively (P = 0.04). First step of liver resection was more often performed during colorectal surgery in the GM group (62 vs. 6% for SM, P<0.0001) and the mean number of procedures (CRC+SLM) was lower (1.6 vs. 2.3, P = 0.003). Three-month mortality was 3% for GM and 0% for SM (n.s.). Overall survival rates were 67% and 51% for SM and GM at 3 years (n.s.), and 35 and 31% at 5 years (n.s.). Disease-free survival to 5 years was higher in SM patients (14% vs. 11%, P = 0.009).
CONCLUSION GM of CRC and SLM was associated with fewer procedures but did not influence overall survival. SM was associated with a longer delay and increased use of chemotherapy between procedures, suggesting that more rigorous selection of SM patients for surgery may explain the higher disease-free survival after SLM resection.


Is motion perception deficit in schizophrenia a consequence of eye-tracking abnormality?

Abstract:
BACKGROUND Studies have shown that schizophrenia patients have motion perception deficit, which was thought to cause eye-tracking abnormality in schizophrenia. However, eye movement closely interacts with motion perception. The known eye-tracking difficulties in schizophrenia patients may interact with their motion perception.
METHODS Two speed discrimination experiments were conducted in a within-subject design. In experiment 1, the stimulus duration was 150 msec to minimize the chance of eye-tracking occurrence. In experiment 2, the duration was increased to 300 msec, increasing the possibility of eye movement intrusion. Regular eye-tracking performance was evaluated in a third experiment.
RESULTS At 150 msec, speed discrimination thresholds did not differ between schizophrenia patients (n = 38) and control subjects (n = 33). At 300 msec, patients had significantly higher thresholds than control subjects (p = .03). Furthermore, frequencies of eye tracking during the 300 msec stimulus were significantly correlated with speed discrimination in control subjects (p = .01) but not in patients, suggesting that eye-tracking initiation may benefit control subjects but not patients. The frequency of eye tracking during speed discrimination was not significantly related to regular eye-tracking performance.
CONCLUSION Speed discrimination, per se, is not impaired in schizophrenia patients. The observed abnormality appears to be a consequence of impairment in generating or integrating the feedback information from eye movements. This study introduces a novel approach to motion perception studies and highlights the importance of concurrently measuring eye movements to understand interactions between these two systems; the results argue for a conceptual revision regarding motion perception abnormality in schizophrenia.


Transgastric endoscopic splenectomy: is it possible?

Abstract:
BACKGROUND We have previously reported the feasibility of diagnostic and therapeutic peritoneoscopy including liver biopsy, gastrojejunostomy, and tubal ligation by an oral transgastric approach. We present results of per-oral transgastric splenectomy in a porcine model. The goal of this study was to determine the technical feasibility of per-oral transgastric splenectomy using a flexible endoscope.
METHODS We performed acute experiments on 50-kg pigs. All animals were fed liquids for 3 days prior to procedure. The procedures were performed under general anesthesia with endotracheal intubation. The flexible endoscope was passed per orally into the stomach and puncture of the gastric wall was performed with a needle knife. The puncture was extended to create a 1.5-cm incision using a pull-type sphincterotome, and a double-channel endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated with air through the endoscope. The spleen was visualized. The splenic vessels were ligated with endoscopic loops and clips, and then mesentery was dissected using electrocautery.
RESULTS Endoscopic splenectomy was performed on six pigs. There were no complications during gastric incision and entrance into the peritoneal cavity. Visualization of the spleen and other intraperitoneal organs was very good. Ligation of the splenic vessels and mobilization of the spleen were achieved using commercially available devices and endoscopic accessories.
CONCLUSION Transgastric endoscopic splenectomy in a porcine model appears technically feasible. Additional long-term survival experiments are planned.


It's Fournier's gangrene still dangerous?

Abstract:
BACKGROUND Fournier's gangrene is known to have an impact in the morbidity and despite antibiotics and aggressive debridement, the mortality rate remains high.
OBJECTIVES To assess the morbidity and mortality in the treatment of Fournier's gangrene in our experience.
METHODS The medical records of 14 patients with Fournier's gangrene who presented at the University Hospital Center "Mother Teresa" from January 1997 to December 2006 were reviewed retrospectively to analyze the outcome and identify the risk factor and prognostic indicators of mortality.
RESULTS Of the 14 patients, 5 died and 9 survived. Mean age was 54 years (range from 41-61): it was 53 years in the group of survivors and 62 years in deceased group. There was a significant difference in leukocyte count between patients who survived (range 4900-17000/mm) and those died (range 20.300-31000/mm3). Mean hospital stay was about 19 days (range 2-57 days).
CONCLUSION The interval from the onset of clinical symptoms to the initial surgical intervention seems to be the most important prognostic factor with a significant impact on outcome. Despite extensive therapeutic efforts, Fournier's gangrene remains a surgical emergency and early recognition with prompt radical debridement is the mainstays of management.


Is it appropriate to implant kidneys from elderly donors in young recipients?

Abstract:
BACKGROUND Kidneys from elderly donors tend to be implanted in recipients who are also elderly. We present the results obtained after 10 years of evolution on transplanting elderly kidneys into young recipients.
METHODS Ninety-one consecutive transplants are studied, carried out in our center with kidneys from cadaver donors older than 60 years implanted in recipients younger than 60 years. The control group is made up of 91 transplants, matched with those from the study group, whose donor and recipient were younger than 60 years.
RESULTS There were no differences between groups with regard to recipient age, sex, cause of death and renal function of the donor, hepatitis C and cytomegalovirus serologies, cold ischemia time, tubular necrosis, immediate diuresis, need for dialysis, human leukocyte antigen incompatibilities, hypersensitized patients, acute rejection, waiting time on dialysis, and days of admission. Survival in both groups at 1, 5, and 10 years was 97.6%, 87.2%, and 76.6% vs. 98.8%, 87.5%, and 69.5% for the patient (P=0.642), 92.9%, 81.3%, and 64.2% vs. 93.9%, 76.4%, and 69.5% for the graft (P=0.980), and 94.4%, 92.6%, and 77.4% vs. 94.3%, 86.7%, and 84.4% for the graft with death censured (P=0.747), respectively. Creatininaemias at 1, 5, and 10 years were 172, 175, and 210 vs. 139, 134, and 155 (P<0.05).
CONCLUSION We conclude that patient and graft survival on transplanting kidneys from elderly donors to young recipients is superimposable on that obtained with young donors. However, renal function is better in the group of young donors.


Do provider service networks result in lower expenditures compared with HMOs or primary care case management in Florida's Medicaid program?

Abstract:
OBJECTIVE To determine the impact of Florida's Medicaid Demonstration 4 years post-implementation on per member per month (PMPM) Medicaid expenditures and whether receiving care through HMOs versus provider service networks (PSNs) in the Demonstration was associated with PMPM expenditures.DATA: Florida Medicaid claims from two fiscal years prior to implementation of the Demonstration (FY0405, FY0506) and the first four fiscal years after implementation (FY0607-FY0910) from two urban Demonstration counties and two urban non-Demonstration counties.
STUDY DESIGN A difference-in-difference approach was used to compare changes in enrollee expenditures before and after implementation of the Demonstration overall and specifically for HMOs and PSNs.
DATA EXTRACTION Claims data were extracted for enrollees in the Demonstration and non-Demonstration counties and collapsed into monthly amounts (N = 26,819,987 person-months).
PRINCIPAL FINDINGS Among SSI enrollees, the Demonstration resulted in lower increases in PMPM expenditures over time ($40) compared with the non-Demonstration counties ($186), with Demonstration PSNs lowering PMPM expenditures by $7 more than HMOs. Savings were also seen among TANF enrollees but to a lesser extent.
CONCLUSION The Medicaid Demonstration in Florida appears to result in lower PMPM expenditures. Demonstration PSNs generated slightly greater reductions in expenditures compared to Demonstration HMOs. PSNs appear to be a promising model for delivering care to Medicaid enrollees.


Processing fluency effects: can the content and presentation of participant information sheets influence recruitment and participation for an antenatal intervention?

Abstract:
OBJECTIVE To assess the extent to which the title and font of participant information sheets (PISs) can influence pregnant women's and trainee midwives' perceptions of an antenatal intervention.
METHODS Pregnant women (n=35) and trainee midwives (n=36) were randomly presented with one of four PISs where the title and font of the PIS had been manipulated to create four experimental conditions (i.e., Double Fluent; Double Awkward; Fluent Title-Awkward Font; Awkward Title-Fluent Font). After reading the PIS, participants rated their perceptions of the intervention (i.e., Attractiveness, Complexity, Expected Risk, Required Effort) using five-point Likert scales.
RESULTS A 4×2 factorial multivariate analysis of variance revealed that pregnant women rated the Double Awkward condition as significantly more complex than the Double Fluent (p=.024) and Awkward Title-Fluent Font (p=.021) conditions.
CONCLUSION Font influenced pregnant women's ratings of intervention complexity.


Sternal fracture in growing children : A rare and often overlooked fracture?

Abstract:
BACKGROUND Sternal fractures in childhood are rare. The aim of the study was to investigate the accident mechanism, the detection of radiological and sonographical criteria and consideration of associated injuries.
METHOD In the period from January 2010 to December 2012 all inpatients and outpatients with sternal fractures were recorded according to the documentation.
RESULTS A total of 4 children aged 5-14 years with a sternal fracture were treated in 2 years, 2 children were hospitalized for pain management and 2 remained in outpatient care.
CONCLUSION Isolated sternal fractures in childhood are often due to typical age-related traumatic incidents. Ultrasonography is a useful diagnostic tool for fracture detection and radiography is the method of choice for visualization of the extent of the dislocation.


Is there a correlation between androgens and sexual desire in women?

Abstract:
INTRODUCTION For women, the correlation between circulating androgens and sexual desire is inconclusive. Substitution with androgens at physiological levels improves sexual function in women who experience decreased sexual desire and androgen deficiency from surgical menopause, pituitary disease, and age-related decline in androgen production in the ovaries. Measuring bioactive testosterone is difficult and new methods have been proposed, including measuring the primary androgen metabolite androsterone glucuronide (ADT-G).AIM: The aim of this study was to investigate a possible correlation between serum levels of androgens and sexual desire in women and whether the level of ADT-G is better correlated than the level of circulating androgens with sexual desire.
METHODS This was a cross-sectional study including 560 healthy women aged 19-65 years divided into three age groups. Correlations were considered to be statistically significant at P<0.05.
MAIN OUTCOME MEASURE Sexual desire was determined as the total score of the sexual desire domain of the Female Sexual Function Index. Total testosterone (TT), calculated free testosterone (FT), androstenedione, dehydroepiandrosterone sulfate (DHEAS), and ADT-G were analyzed using mass spectrometry.
RESULTS Sexual desire correlated overall with FT and androstenedione in the total cohort of women. In a subgroup of women aged 25-44 years with no use of systemic hormonal contraception, sexual desire correlated with TT, FT, androstenedione, and DHEAS. In women aged 45-65 years, androstenedione correlated with sexual desire. No correlations between ADT-G and sexual desire were identified.
CONCLUSION In the present study, FT and androstenedione were statistically significantly correlated with sexual desire in the total cohort of women. ADT-G did not correlate more strongly than circulating androgens with sexual desire and is therefore not superior to measuring circulating androgens by mass spectrometry.


Does immediate breast reconstruction compromise the delivery of adjuvant chemotherapy?

Abstract:
BACKGROUND Immediate breast reconstruction (IBR) provides psychological benefit to many early breast cancer patients however concerns persist regarding its potential impact on chemotherapy delivery. We investigated the association between IBR, complications and adjuvant chemotherapy delivery.
METHOD Retrospective analysis of patients in an academic breast service, who underwent mastectomy, with or without reconstruction, and received adjuvant chemotherapy.
RESULTS Comparisons were made between 107 patients who received IBR and 113 who received mastectomy alone. Those receiving IBR were on average younger, with lower body mass index (BMI) and better prognoses. Overall complication rates were comparable (mastectomy alone: 45.1% versus IBR: 35.5%, p = 0.2). There was more return to surgery in the IBR group with 11.5% of tissue expanders requiring removal, whilst more seromas occurred in the mastectomy group. There was no significant difference in the median time to chemotherapy.
CONCLUSION We found no evidence that IBR compromised the delivery of adjuvant chemotherapy, although there was a significant incidence of implant infection.


Can PRISM predict length of PICU stay?

Abstract:
UNLABELLED PRISM is claimed to score disease severity which has attributed an impact on length of PICU stay (LOS).
PRIMARY OBJECTIVE To determine the impact of PRISM on LOS, and evaluate an Artificial Neural Network's (ANN) performance to estimate LOS from PRISM item patterns.
RESEARCH DESIGN AND METHODS Retrospectively we performed correlation and regression analyses on routinely scored PRISM data of all consecutive admissions to our level-III PICU from 1994 to 1999 (n>2000) with individual LOS. In addition, an ANN was trained on the chronologically first 75% of those data (inputs, PRISM items + age + sex; output, LOS). The ANN's performance was tested on the remaining most recent 25% of the data sets.
MAIN RESULTS The Spearman and Pearson coefficients of correlation between PRISM and LOS were 0.2 (p<0.001) and 0.08 (p = 0.0003), the latter being slightly higher when LOS was logarithmically transformed. Pearson's coefficient of correlation between ANN derived LOS estimate and actual LOS was 0.21 (p<0.001) (LOS logarithmically transformed: 0.34; p<0.001) in the independent validation sample.
CONCLUSION The ANN with its intrinsic ability to detect non-linear correlation, and to relate specific item patterns to LOS, outperformed linear statistics but was still disappointing in estimating individual LOS. It might be speculated that therapeutic intervention modulates the natural course of the disease thus counteracting both disease severity as initially scored by PRISM, and LOS. This being true, the inverse of the correlation between PRISM (or PRISM based LOS estimate) and LOS might be a candidate indicator of quality of care.


Can predilatation in transcatheter aortic valve implantation be omitted?

Abstract:
BACKGROUND The use of a balloon expandable stent valve includes balloon predilatation of the aortic stenosis before valve deployment. The aim of the study was to see whether or not balloon predilatation is necessary in transcatheter aortic valve replacement (TAVI).
METHODS Sixty consecutive TAVI patients were randomized to the standard procedure or to a protocol where balloon predilatation was omitted.
RESULTS There were no significant differences between the groups regarding early hemodynamic results or complication rates.
CONCLUSION TAVI can be performed safely without balloon predilatation and with the same early results as achieved with the standard procedure including balloon predilatation. The reduction in the number of pacing periods required may be beneficial for the patient.


Does a 4 diagram manual enable laypersons to operate the Laryngeal Mask Supreme®?

Abstract:
BACKGROUND Bystander resuscitation plays an important role in lifesaving cardiopulmonary resuscitation (CPR). A significant reduction in the "no-flow-time", quantitatively better chest compressions and an improved quality of ventilation can be demonstrated during CPR using supraglottic airway devices (SADs). Previous studies have demonstrated the ability of inexperienced persons to operate SADs after brief instruction. The aim of this pilot study was to determine whether an instruction manual consisting of four diagrams enables laypersons to operate a Laryngeal Mask Supreme® (LMAS) in the manikin.
METHODS An instruction manual of four illustrations with speech bubbles displaying the correct use of the LMAS was designed. Laypersons were handed a bag containing a LMAS, a bag mask valve device (BMV), a syringe prefilled with air and the instruction sheet, and were asked to perform and ventilate the manikin as displayed. Time to ventilation was recorded and degree of success evaluated.
RESULTS A total of 150 laypersons took part. Overall 145 participants (96.7%) inserted the LMAS in the manikin in the right direction. The device was inserted inverted or twisted in 13 (8.7%) attempts. Eight (5.3%) individuals recognized this and corrected the position. Within the first 2 minutes 119 (79.3%) applicants were able to insert the LMAS and provide tidal volumes greater than 150 ml (estimated dead space). Time to insertion and first ventilation was 83.2 ± 29 s. No significant difference related to previous BLS training (P = 0.85), technical education (P = 0.07) or gender could be demonstrated (P = 0.25).
CONCLUSION In manikin laypersons could insert LMAS in the correct direction after onsite instruction by a simple manual with a high success rate. This indicates some basic procedural understanding and intellectual transfer in principle. Operating errors (n = 91) were frequently not recognized and corrected (n = 77). Improvements in labeling and the quality of instructional photographs may reduce individual error and may optimize understanding.


Should circumcision be performed in childhood?

Abstract:
OBJECTIVE To evaluate prepuce development and retractibility in a group of boys. To point out the value of circumcision and prepucial forced dilation during childhood.
METHODS Prepuce development and retractibility were evaluated in 400 boys ages between 0-16 year old.
RESULTS In boys under 1 year prepuce retractibility (assessed only in children who did not undergo forced dilation previously) was type I (non retractile) in 71.5% whereas type V (completely retractile) was only 5.5%. In adolescent boys type I prepuce was observed in 1 boy only, 1.6%, whereas type V was observed in 82.3%. Furthermore, it was observed that at the time of examination for the study 106 boys who had undergone forced dilation at an earlier age had balano-prepucial adhesions again, which demonstrates that prepuce adheres again to glans penis in many boys after a forced dilation is performed. Only 11 boys were considered in need for circumcision, three of them for prepucial orifice stenosis, which prevented normal micturition, causing a prepucial sac, one case due to a constrictive ring below the prepucial edge that would have prevented ulterior retractability, two cases with repetitive balanopostitis, and five cases secondary to xerosol balanitis, accounting for 2.7% of all examined boys.
CONCLUSION Incomplete separation between prepuce and glans penis is normal and common among new-borns, progressing until adolescence to spontaneous separation, at which time it is complete in the majority of boys. Accordingly to the criteria we have sustained for years and present study's findings, circumcision has few indications during childhood, as well as forced prepucial dilation.


Does a colonoscopy after acute diverticulitis affect its management?

Abstract:
METHODS Medical records of 220 patients hospitalized for acute diverticulitis between June 1, 2002 and September 1, 2009 were reviewed. Acute diverticulitis was diagnosed by clinical criteria and characteristic CT findings. Fifteen patients were excluded either because of questionable CT or hematochezia. Mean age was 61.8±14.3 years (61% females). Clinical parameters, laboratory results, imaging, endoscopic and histopathological reports, and long-term patients' outcome were analyzed.
RESULTS One hundred patients (aged 61.8±13.3 y, 54.1% females), underwent an early (4 to 6 wk) colonoscopy after hospital discharge. There were no significant differences in patients' characteristics or survival between those with or without colonoscopy (4±1.9 vs. 4.2±2.1 y, P=0.62). No colonic malignancy was detected. However, in 32 patients (32%) at least 1 polyp was found. Only 1 was determined as an advanced adenoma. No new or different diagnosis was made after colonoscopy.
CONCLUSION Our results suggest that colonoscopy does not affect the management of patients with acute diverticulitis nor alter the outcome. The current practice of a routine colonoscopy after acute diverticulitis, diagnosed by typical clinical symptoms and CT needs to be reevaluated.


Do instrumental activities of daily living predict dementia at 1- and 2-year follow-up?

Abstract:
OBJECTIVES To investigate whether problems in instrumental activities of daily living (IADL) can add to conventionally used clinical measurements in helping to predict a diagnosis of dementia at 1- and 2-year follow-up.
DESIGN Multicenter prospective cohort study.
SETTING Memory clinics in Europe.
PARTICIPANTS Individuals aged 55 and older without dementia.
MEASUREMENTS IADLs were measured using pooled activities from five informant-based questionnaires. Structural equation modeling (SEM) was used to investigate the relation between IADLs and dementia. Age, sex, education, depression, and cognitive measures (Mini-Mental State Examination and verbal memory) were included in the model.
RESULTS Five hundred thirty-one participants had baseline and 1-year follow-up assessments; 69 (13.0%) of these had developed dementia at 1-year follow-up. At 2-year follow-up, 481 participants were seen, of whom 100 (20.8%) had developed dementia. Participants with IADL disabilities at baseline had a higher conversion rate (24.4%) than participants without IADL disabilities (16.7%) (chi-square = 4.28, degrees of freedom = 1, P = .04). SEM showed that IADL disability could help predict dementia in addition to the measured variables at 1-year follow-up (odds ratio (OR) = 2.20, 95% confidence interval (CI) = 1.51-3.13) and 2-year follow-up (OR = 2.11, 95% CI = 1.33-3.33).
CONCLUSION IADL disability is a useful addition to the diagnostic process in a memory clinic setting, indicating who is at higher risk of developing dementia at 1- and 2-year follow-up.


Body perception: do parents, their children, and their children's physicians perceive body image differently?

Abstract:
OBJECTIVES To compare children's, parents' and physicians' perceptions of children's body size.
PATIENTS AND METHODS We administered a structured questionnaire of body size perception using a descriptive Likert scale keyed to body image figures to children ages 12 to 18 years. The same scale was given to parents of children ages 5 to 18 years. The sample consisted of 91 children and their parents being seen in the Pediatric Gastroenterology Clinic for concerns unrelated to overweight. Weight and height of the children were measured, and body mass index (BMI) was calculated. The children's BMI percentiles were categorized as underweight (<15th), normal (15th-85th), overweight (85th-95th), and obese (95th and above). The attending physician independently completed the body image and description scale and indicated the figure that most accurately represented the patient without reference to BMI standards. Accuracy of the patients', parents', and doctors' estimates were statistically compared.
RESULTS The sample population consisted of 6.4% underweight, 70.5% normal weight, 7.7% overweight, and 15.4% obese. Forty-four percent of parents underestimated children's body size using word descriptions and 47% underestimated using figures. Forty percent of the children underestimated their own body size using descriptions and 43% underestimated using figures. The physicians in this study had a higher percentage of correct estimates; however, they underestimated 33% of the patients using both word descriptions and figures. Some obese children were not recognized, and several average children were perceived as underweight.
CONCLUSION Many children underestimated their degree of overweight. Their parents and even their attending physicians shared this misperception. This study demonstrates the need to further educate physicians to recognize obesity and overweight so that they can counsel children and their families.


Is a specialised training of phonological awareness indicated in every preschool child?

Abstract:
OBJECTIVE AND METHODS In a prospective study 218 preschool children were enrolled (stratified in 2 training programs, one specialized for phonologic awareness in order to prevent dyslexia, the other consisting in training of general perception) during the last year of kindergarten. After finishing the first grade 131 children were compared in their reading and writing abilities.
RESULTS In the whole group only a slight difference was found between both training modalities concerning their writing abilities. However, children with a history of hearing loss, actual hearing loss or pathologic middle ear findings profited most from the specialized training program compared to the control in their reading abilities.
CONCLUSION A specialized training program to improve phonologic awareness as a basis for reading and writing in every kindergarten and preschool child seems to be unnecessary. However, children with temporary hearing deficits benefit from such a program. For all other children general perception training may be sufficient.


Is the combination with 2-methoxyestradiol able to reduce the dosages of chemotherapeutices in the treatment of human ovarian cancer?

Abstract:
PURPOSE OF INVESTIGATION The endogenous estradiol metabolite, 2-methoxyestradiol (2ME), has been shown to be a potent inhibitor of cell growth and a strong anti-angiogenic substance. We investigated for the first time whether in vitro combinations of 2ME with various chemotherapeutic compounds may result in an additive inhibitory effect on the proliferation of human ovary cancer cells.
METHOD As a model two different human ovary cancer cell lines were used. All cell lines were incubated with equimolar concentrations of 2ME (0.8-25 microM) and the chemotherapeutics epirubicine, doxorubicine, paclitaxel, docetaxel, carboplatin, vinorelbine, 5-fluorouracil and mafosfamide. Proliferation was measured after four days using the ATP-chemosensitivity test.
RESULTS For both ovary cancer cell lines a significant additive effect of 2ME with epirubicine and carboplatin was observed at the lower concentration range of these chemotherapeutic substances.
CONCLUSION 2ME is able to enhance the antiproliferative activity of certain chemotherapeutics at pharmacological relevant concentrations. This estradiol metabolite is currently in a phase II trial in patients with refractary metastatic breast cancer and the tolerability has been shown to be very good. The combination of 2ME with chemotherapeutics may therefore offer a new clinically relevant treatment regimen for hormone-dependent cancer.


Assessing joint line positions by means of the contralateral knee: a new approach for planning knee revision surgery?

Abstract:
PURPOSE Reconstructing the natural joint line in knee revision surgery improves clinical and functional outcome but may be challenging when both cartilage and bone were removed during previous operations. Assessing joint lines (JLs) by means of bony landmarks is inadvisable because of large variations in human anatomy. Because of the inherent symmetry of the human body, we hypothesised that JLs may be directly assessed by measuring the distances from the bony landmarks to the JL of the contralateral knee by means of radiographic images.
METHODS Using scaled weight-bearing radiographs in anteroposterior view of both knees, two independent observers measured the distances from the fibular head, the medial and lateral epicondyle, and the adductor tubercle to the JL. A two-sided p value of ≤0.05 was considered statistically significant.
RESULTS Two hundred knees of 100 patients (50 men and 50 women) were examined. For the fibular head, the mean difference between the treated and the control knee was 0.0 mm with narrow confidence limits ranging from -1.1 to 1.1.
CONCLUSION As a new assessment method, we have suggested to assess the JL by means of radiographs of the contralateral knee. The most precise parameter was found to be the distance between the fibular head and the JL. The level of arthritis, age, gender, visibility of the landmarks, and misalignment did not influence measurement accuracy. This parameter is the first tibia-related landmark for assessing the JL, which advantageously corresponds to the tibia-first technique in revision surgery.


Does the type of tibial component affect mechanical alignment in unicompartmental knee replacement?

Abstract:
PURPOSE There are a number of factors responsible for the longevity of unicompartmental knee replacements (UKR). These include the magnitude of postoperative alignment and the type of material used. The effect of component design and material on postoperative alignment, however, has not been explored.
MATERIALS AND METHODS We retrospectively reviewed 89 patients who underwent UKR with robotic guidance. Patients were divided into two groups, according to whether they had received an all-polyethylene inlay component (Inlay group) or a metal-backed onlay component (Onlay group). We explored the magnitude of mechanical alignment correction obtained in both groups.
RESULTS Mean postoperative mechanical alignment was significantly closer to neutral in the Onlay group (mean=2.8°; 95% CI=2.4°, 3.2°) compared to the Inlay group (mean=3.9°; 95% CI=3.4°, 4.4°) (R2=0.65; P=0.003), adjusting for gender, BMI, age, side and preoperative mechanical alignment (Fig. 2). Further exploration revealed that the thickness of the tibial polyethyelene insert had a significant effect on postoperative alignment when added to the model (R2=0.68; P=0.01).
CONCLUSION Patients who received a metal-backed Onlay tibial component obtained better postoperative mechanical alignment compared to those who received all-polyethylene Inlay prostheses. The thicker overall construct of Onlay prostheses appears to be an important determinant of postoperative alignment. Considering their higher survivorship rates and improved postoperative mechanical alignment, Onlay prostheses should be the first option when performing medial UKR.


Is tumour expression of VEGF associated with venous invasion and survival in pT3 renal cell carcinoma?

Abstract:
STUDY OBJECTIVE To determine whether there is a relationship between VEGF expression and renal vein and vena cava invasion in stage pT3 renal cell carcinoma and to evaluate the impact of VEGF expression on survival in pT3 renal cell carcinoma.
MATERIAL AND METHODS 78 patients with a pT3a or pT3b tumour without vena cava invasion or pT3b tumour with vena cava invasion were compared for age, gender, Fuhrman grade and immunohistochemical expression of VEGF. All these variables were submitted to univariate and multivariate analysis to establish their impact on survival.
RESULTS Only tumour size appeared to be significantly different between the 3 groups. On univariate analysis, invasion of the perirenal fat, lymph node involvement, distant metastases and VEGF expression were significantly associated with survival (p<0.01). On multivariate analysis, lymph node involvement, distant metastases and VEGF expression (OR 6.07) were identified as independent predictive factors of survival.
CONCLUSION Progression of a pT3 tumour into the renal vein and vena cava is not associated with increased tumour expression of VEGF. However, VEGF is an independent prognostic factor in this group of poor prognosis renal tumours.


Injury and poisoning mortality among young men--are there any common factors amenable to prevention?

Abstract:
BACKGROUND Deaths from injury and poisoning (suicide, accidents, undetermined deaths, and homicide) are the major cause of death among young men aged 15-39 years in England and Wales and have been increasing in recent years.AIM: To describe common characteristics among young men who die from injury and poisoning.
DESIGN We employed a retrospective survey methodology to investigate factors associated with deaths by injury and poisoning among young men aged 15-39 years (n = 268) in Merseyside and Cheshire during 1995. Data were collected from Coroner's inquest notes and General Practitioner records.
MAIN RESULTS The most common cause of death was poisoning by alcohol and drugs (29.1%, n = 78). A high proportion of cases were unemployed (39.4%, n = 106). Cases were also more likely to be single compared to the general population (74.2% vs 55.5%). Self-destructive behaviour was evident in 77% of deaths (n = 206).
CONCLUSION Alcohol and drug use are important contributory factors to injury and poisoning deaths. More research is needed into the effects of unemployment and being single on the health of young men, and to investigate the motivations behind risk taking and self-destructive behaviour.


Does the clinical presentation of a prior preterm birth predict risk in a subsequent pregnancy?

Abstract:
OBJECTIVE The objective of the study was to determine whether risk of recurrent preterm birth differs based on the clinical presentation of a prior spontaneous preterm birth (SPTB): advanced cervical dilatation (ACD), preterm premature rupture of membranes (PPROM), or preterm labor (PTL).
STUDY DESIGN This retrospective cohort study included singleton pregnancies from 2009 to 2014 complicated by a history of prior SPTB. Women were categorized based on the clinical presentation of their prior preterm delivery as having ACD, PPROM, or PTL. Risks for sonographic short cervical length and recurrent SPTB were compared between women based on the clinical presentation of their prior preterm birth. Log-linear regression was used to control for confounders.
RESULTS Of 522 patients included in this study, 96 (18.4%) had prior ACD, 246 (47.1%) had prior PPROM, and 180 (34.5%) had prior PTL. Recurrent PTB occurred in 55.2% of patients with a history of ACD compared with 27.2% of those with PPROM and 32.2% with PTL (P = .001). The mean gestational age at delivery was significantly lower for those with a history of ACD (34.0 weeks) compared with women with prior PPROM (37.2 weeks) or PTL (37.0 weeks) (P = .001). The lowest mean cervical length prior to 24 weeks was significantly shorter in patients with a history of advanced cervical dilation when compared with the other clinical presentations.
CONCLUSION Patients with a history of ACD are at an increased risk of having recurrent preterm birth and cervical shortening in a subsequent pregnancy compared with women with prior preterm birth associated PPROM or PTL.


Is the Distance Worth It?

Abstract:
BACKGROUND It is unclear whether traveling long distances to high-volume centers would compensate for travel burden among patients undergoing rectal cancer resection.
OBJECTIVE The purpose of this study was to determine whether operative volume outweighs the advantages of being treated locally by comparing the outcomes of patients with rectal cancer treated at local, low-volume centers versus far, high-volume centers.
DESIGN This was a population-based study.
SETTINGS The National Cancer Database was queried for patients with rectal cancer.
PATIENTS Patients with stage II or III rectal cancer who underwent surgical resection between 2006 and 2012 were included.
MAIN OUTCOME MEASURES The outcomes of interest were margins, lymph node yield, receipt of neoadjuvant chemoradiation, adjuvant chemotherapy, readmission within 30 days, 30-day and 90-day mortality, and 5-year overall survival.
RESULTS A total of 18,605 patients met inclusion criteria; 2067 patients were in the long-distance/high-volume group and 1362 in the short-distance/low-volume group. The median travel distance was 62.6 miles for the long-distance/high-volume group and 2.3 miles for the short-distance/low-volume group. Patients who were younger, white, privately insured, and stage III were more likely to have traveled to a high-volume center. When controlled for patient factors, stage, and hospital factors, patients in the short-distance/low-volume group had lower odds of a lymph node yield ≥12 (OR = 0.51) and neoadjuvant chemoradiation (OR = 0.67) and higher 30-day (OR = 3.38) and 90-day mortality (OR = 2.07) compared with those in the long-distance/high-volume group. The short-distance/low-volume group had a 34% high risk of overall mortality at 5 years compared with the long-distance/high-volume group.
LIMITATIONS We lacked data regarding patient and physician decision making and surgeon-specific factors.
CONCLUSION Our results indicate that when controlled for patient, tumor, and hospital factors, patients who traveled a long distance to a high-volume center had improved lymph node yield, neoadjuvant chemoradiation receipt, and 30- and 90-day mortality compared with those who traveled a short distance to a low-volume center. They also had improved 5-year survival. See Video Abstract at http://links.lww.com/DCR/A446.


Aripiprazole: a new risk factor for pathological gambling?

Abstract:
OBJECTIVE It is commonly accepted that pathological gambling results from the interaction of multiple risk factors. Among these, dopamine replacement therapy (DRT) prescribed for Parkinson disease can be cited. Another dopamine agonist, aripiprazole, could be a new risk factor. We decided to explore this potential adverse drug reaction (ADR).
METHOD Based on a cohort of 166 pathological gamblers starting treatment in our department, data of each of the 8 patients treated by aripiprazole at inclusion were analyzed.
RESULTS The patients involved were schizophrenic or bipolar, mostly young men with a history of addictive disorders and regular gambling prior to the prescription of aripiprazole. For each one of them, the causality of aripiprazole was considered, using an algorithm. The probability that pathological gambling is actually due to aripiprazole is "possible" in 7 cases out of 8, and "doubtful" in one.
CONCLUSION Adverse drug reactions were confronted with other already published case reports. Dopamine partial agonist mechanism of aripiprazole could explain the occurrence of pathological gambling.


Immune suppression by lysosomotropic amines and cyclosporine on T-cell responses to minor and major histocompatibility antigens: does synergy exist?

Abstract:
BACKGROUND Using murine models, we have shown that the lysosomotropic amine, chloroquine, is effective in the prevention of graft-versus-host disease (GVHD) mediated by donor T cells reactive with recipient minor histocompatibility antigens (MiHCs). Because lysosomotropic amines can suppress major histocompatibility complex (MHC) class II antigen presentation, their mechanism of action is potentially different from current immune suppressant drugs used to control GVHD such as cyclosporine.
METHODS We investigated the use of cyclosporine and the lysosomotropic amines chloroquine and hydroxychloroquine in combination for additive or synergistic immunosuppression on T-cell responses in vitro to MiHC and MHC in mice.
RESULTS We found that similar concentrations of chloroquine and hydroxychloroquine suppress the T-cell response to MiHC in mice (C57BL/6 anti-BALB.B) and that lysosomotropic amines in combination with cyclosporine result in synergistic suppression of a proliferative response to MiHC. Similar suppression and synergy appear to be present in an alloreactive response (C57BL/6 anti-BALB/c). Direct inhibition by chloroquine of T-cell proliferative responses induced by anti-CD3epsilon in the absence of antigen-presenting cells is present at higher concentrations than that required to suppress responses to MiHC or MHC. Chloroquine appears to induce decreased T-cell viability at high concentrations. This effect does not appear to be due to decreased T-cell production of interleukin-2 or interferon-gamma. At lower concentrations (<25 microg/ml), chloroquine can also decrease the ability of antigen-presenting cells to stimulate an a C57BL/6 anti-BALB/c T-cell response and can inhibit MHC class II expression after activation with lipopolysaccharide.
CONCLUSION Lysosomotropic amines in combination with cyclosporine appear to be synergistic in the suppression of T-cell proliferation to MiHC and MHC. Use of chloroquine in combination with cyclosporine may result in improved control of GVHD.


Does induction chemotherapy have a role in the management of nasopharyngeal carcinoma?

Abstract:
PURPOSE To assess the outcomes of patients with nasopharyngeal carcinoma (NPC) whose treatment was determined by computerized tomography (CT) and/or magnetic resonance imaging staging and to analyze the impact of induction chemotherapy and accelerated fractionated radiotherapy.
METHODS AND MATERIALS The analysis is based on 122 of 143 previously untreated patients with NPC treated with radiation therapy at The University of Texas M. D. Anderson Cancer Center between 1983 and 1992. Excluded were 4 patients treated with palliative intent, 4 children, 12 patients not staged with CT, and 1 patient who died of a cerebrovascular accident prior to completion of treatment. The stage distribution was as follows: AJCC Stage I-2, Stage II-7, Stage III-12, Stage IV-101; Tl-15, T2-33, T3-22, T4-52; N0-32, N1-10, N2-47, N3-32, Nx-1. Fifty-nine (48%) patients had squamous cell carcinoma; 63 (52%) had lymphoepitheliomas, undifferentiated NPC or poorly differentiated carcinoma, NOS (UNPC). Sixty-seven patients (65 with Stage IV disease) received induction chemotherapy. Fifty-eight patients (24 of whom had induction chemotherapy) were treated with the concomitant boost fractionation schedule. The median follow-up for surviving patients was 57 months.
RESULTS The overall actuarial 2- and 5-year survival rates were 78 and 68%, respectively. Forty-nine patients (40%) had disease recurrence. Thirty-three (27%) had local regional failures; 19 at the primary site only, 8 in the neck and 6 in both. Local failure occurred in 31% of patients staged T4 compared to 13% of T1-T3 (p = 0.007). Sixteen patients failed at distant sites alone. Among Stage IV patients the 5-year actuarial rates for patients who did and did not receive induction chemotherapy were as follows: overall survival: 68 vs. 56% (p = 0.02), freedom from relapse: 64 vs. 37% (p = 0.01), and local control: 86 vs. 56% (p = 0.009). The actuarial 5-year distant failure rate in patients with UNPC who were treated with induction chemotherapy and controlled in the primary and neck was 13%. In patients who did not receive chemotherapy, the actuarial 5-year local control rates for patients treated with concomitant boost or conventional fractionation were 66 and 67%, respectively.
CONCLUSION While not providing conclusive evidence, this single institution experience suggests that neoadjuvant chemotherapy for Stage IV NPC patients improves both survival and disease control. Recurrence within the irradiated volume was the most prevalent mode of failure and future studies will evaluate regimens to enhance local regional control.