Bony defects in chronic anterior posttraumatic dislocation of the shoulder: Is there a correlation between humeral and glenoidal lesions?

Abstract:
BACKGROUND The prevalence of combined humeral and glenoid defects varies between 79 and 84 % in case of chronic posttraumatic anterior shoulder instability. The main goal of this study was to evaluate the relationship between humeral and glenoid defects based on quantitative radiological criteria.
METHODS A retrospective study was performed between 2000 and 2011 including patients who underwent primary surgical shoulder stabilization for chronic posttraumatic anterior shoulder instability, with bone defects in both the glenoid and humerus and a healthy contralateral shoulder. The following measurements were taken: D/R ratio (Hill-Sachs lesion depth/humeral head radius) on an AP X-ray in internal rotation and the D1/D2 ratio [diameter of the involved glenoid articular surfaces (D1)/the healthy one (D2)] on a comparative Bernageau glenoid profile view. Measurements were taken by two observers. Correlations were determined by the Spearman correlation coefficients (r), Bland and Altman diagrams, and intra-class correlation coefficients (ICC). A sample size calculation was done.
RESULTS Thirty patients were included, 25 men/5 women, mean age 29.8 ± 11.2 years. The mean D/R was 23 ± 12 % for observer 1 and 23 ± 10 % for observer 2. The mean D1/D2 was 95 ± 4 % for observer 1 and 94 ± 6 % for observer 2. No significant correlation was found between humeral and glenoid bone defects by observer 1 (r = 0.23, p = 0.22) or observer 2 (r = 0.05, p = 0.78). Agreement of the observers for the D/R ratio was excellent (ICC = 0.89 ± 0.04, p < 0.00001) and good for the D1/D2 ratio (ICC = 0.54 ± 0.14, p = 0.006).
CONCLUSION Humeral and glenoid bone defects were not correlated. Inter-observer reliability was excellent for the D/R ratio and good for the D1/D2 ratio.


Does ambulatory process of care predict health-related quality of life outcomes for patients with chronic disease?

Abstract:
OBJECTIVE The validity of quality of care measurement has important implications for practicing clinicians, their patients, and all involved with health care delivery. We used empirical data from managed care patients enrolled in west coast physician organizations to test the hypothesis that observed changes in health-related quality of life across a 2.5-year window reflecting process of care.DATA SOURCES/
STUDY SETTING Patient self-report data as well as clinically detailed medical record review regarding 963 patients with chronic disease associated with managed care from three west coast states.
STUDY DESIGN Prospective cohort study of change in health-related quality of life scores across 30 months as measured by change in SF-12 physical component scores.DATA COLLECTION/
EXTRACTION METHODS Patient self-report and medical record abstraction.
PRINCIPAL FINDINGS We found a positive relationship between better process scores and higher burden of illness (p<.05). After adjustment for burden of illness, using an instrumental variables approach revealed better process is associated with smaller declines in SF-12 scores across a 30-month observation window (p=.014). The application of the best quartile of process of care to patients currently receiving poor process is associated with a 4.24 increment in delta SF-12-physical component summary scores.
CONCLUSION The use of instrumental variables allowed us to demonstrate a significant relationship between better ambulatory process of care and better health-related quality of life. This finding underscores the importance of efforts to improve the process of care.


Is there a connection between sublingual varices and hypertension?

Abstract:
BACKGROUND Sublingual varices have earlier been related to ageing, smoking and cardiovascular disease. The aim of this study was to investigate whether sublingual varices are related to presence of hypertension.
METHODS In an observational clinical study among 431 dental patients tongue status and blood pressure were documented. Digital photographs of the lateral borders of the tongue for grading of sublingual varices were taken, and blood pressure was measured. Those patients without previous diagnosis of hypertension and with a noted blood pressure ≥ 140 mmHg and/or ≥ 90 mmHg at the dental clinic performed complementary home blood pressure during one week. Those with an average home blood pressure ≥ 135 mmHg and/or ≥ 85 mmHg were referred to the primary health care centre, where three office blood pressure measurements were taken with one week intervals. Two independent blinded observers studied the photographs of the tongues. Each photograph was graded as none/few (grade 0) or medium/severe (grade 1) presence of sublingual varices. Pearson's Chi-square test, Student's t-test, and multiple regression analysis were applied. Power calculation stipulated a study population of 323 patients.
RESULTS An association between sublingual varices and hypertension was found (OR = 2.25, p<0.002). Mean systolic blood pressure was 123 and 132 mmHg in patients with grade 0 and grade 1 sublingual varices, respectively (p<0.0001, CI 95 %). Mean diastolic blood pressure was 80 and 83 mmHg in patients with grade 0 and grade 1 sublingual varices, respectively (p<0.005, CI 95 %). Sublingual varices indicate hypertension with a positive predictive value of 0.5 and a negative predictive value of 0.80.
CONCLUSION An association was found between sublingual varices and hypertension. Examining the lateral borders of the tongue is easily done, causes no harm and could be a valuable method for the dental profession to take active part in preventive healthcare.


MR arthrography of the shoulder: do we need local anesthesia?

Abstract:
PURPOSE To assess pain intensity with and without subcutaneous local anesthesia prior to intraarticular administration of contrast medium for magnetic resonance arthrography (MRa) of the shoulder.
MATERIALS AND METHODS This single-center study was conducted after an IRB waiver of authorization, between January 2010 and December 2012. All patients provided written, informed consent for the procedure. Our prospectively populated institutional database was searched, based on our inclusion criteria. There were 249 outpatients (178 men and 71 women; mean age, 44.4 years ± 14.6; range, 15-79) who underwent MRa and were enrolled in this study. Patients were excluded if they had received surgery of the shoulder before MRa, had undergone repeated MRa of the same shoulder, and/or had undergone MRa of both shoulders on the same day. Patients were randomly assigned into one of three groups. Patients in group A (n=61) received skin infiltration with local anesthesia. Patients in control group B (n=92) and group C (n=96) did not receive local anesthesia. Pain levels were immediately assessed after the injection for MRa using a horizontal visual analog scale (VAS) that ranged from 0 to 10. To compare the pain scores of the three groups for male and female patients, a two-way analysis of variance was used. A p-value equal to or less than 0.05 was considered to indicate a significant result.
RESULTS Patients who received local anesthesia (group A) showed a mean pain level on the VAS of 2.6 ± 2.3. In patients who did not receive local anesthetics (groups B and C), a mean pain level on the VAS of 2.6 ± 2.2 and 2.7 ± 2.4 were detected, respectively. Between the three groups, no statistically significant difference in pain intensity was detected (p=.960). There were significant differences in subjective pain perception between men and women (p=.009). Moreover, the sex difference in all three groups was equal (p=.934).
CONCLUSION Local anesthesia is not required to lower a patient's pain intensity when applying intra-articular contrast media for MR arthrography of the shoulder. This could result in reduced costs and a reduced risk of adverse reactions, without an impact on patient comfort.


Does cognitive function predict frequency compressed speech recognition in listeners with normal hearing and normal cognition?

Abstract:
OBJECTIVE The aim was to investigate the relationship between cognitive ability and frequency compressed speech recognition in listeners with normal hearing and normal cognition.
DESIGN Speech-in-noise recognition was measured using Institute of Electrical and Electronic Engineers sentences presented over earphones at 65 dB SPL and a range of signal-to-noise ratios. There were three conditions: unprocessed, and at frequency compression ratios of 2:1 and 3:1 (cut-off frequency, 1.6 kHz). Working memory and cognitive ability were measured using the reading span test and the trail making test, respectively.
STUDY SAMPLE Participants were 15 young normally-hearing adults with normal cognition.
RESULTS There was a statistically significant reduction in mean speech recognition from around 80% when unprocessed to 40% for 2:1 compression and 30% for 3:1 compression. There was a statistically significant relationship between speech recognition and cognition for the unprocessed condition but not for the frequency-compressed conditions.
CONCLUSION The relationship between cognitive functioning and recognition of frequency compressed speech-in-noise was not statistically significant. The findings may have been different if the participants had been provided with training and/or time to 'acclimatize' to the frequency-compressed conditions.


Should cavitation in proximal surfaces be reported in cone beam computed tomography examination?

Abstract:
MATERIALS AND METHODS 79 adjacent proximal surfaces without restorations in permanent teeth were examined. Patients suspected to have carious lesions after a visual clinical and a bitewing examination participated in a CBCT examination (Kodak 9000 3D, 5 × 3.7 cm field of view, voxel size 0.07 mm). Ethical approval and informed consent were obtained according to the Helsinki Declaration. Radiographic assessment recording lesions with or without cavitation was performed by two observers in bitewings and CBCT sections. Orthodontic separators were placed interdentally between two lesion-suspected surfaces. The separator was removed after 3 days and the surfaces recorded as cavitated (yes/no), i.e. validated clinically. Differences between the two radiographic modalities (sensitivity, specificity and overall accuracy) were estimated by analyzing the binary data in a generalized linear model.
RESULTS For both observers, sensitivity was significantly higher for CBCT than for bitewings (average difference 33%, p<0.001) while specificity was not significantly different between the methods (p = 0.19). The overall accuracy was also significantly higher for CBCT (p<0.001).
CONCLUSION CBCT was more accurate in detecting cavitation in proximal surfaces than bitewing radiographs; therefore a CBCT examination performed for other clinical applications should also be assessed for proximal surface cavities in teeth without restorations, and when detected, this pathology must be part of the dentist's report.


Do supervised colorectal trainees differ from consultants in terms of quality of TME surgery?

Abstract:
OBJECTIVE The quality of surgical excision is held to be a major determinant of outcome following surgery for rectal cancer. Macroscopic examination of the excised mesorectum allows for reproducible assessment of the quality of surgery. We aimed to determine whether quality of excision undertaken by colorectal trainees under supervision was comparable with that performed by consultants, as measured using mesorectal grades.
METHOD A total of 130 consecutive patients undergoing potentially curative resection for primary adenocarcinoma of the rectum in our centre from 2001 to 2003 were included in the study. The pathologists graded the excised mesorectum according to staged classification proposed by Quirke. The outcome (quality of mesorectal excision and secondary outcomes including local recurrence and overall recurrence) of operations performed by consultants was compared with that of trainees. Statistical significance was tested using Pearson chi(2) test.
RESULTS Eighty-nine operations were performed by consultants and 41 by senior colorectal trainees with consultant supervision. Forty-four patients (49%) had good mesorectum when operated by consultants in comparison with 17 (41.5%) by the trainees. There was no statistically significant difference (P = 0.717) between the two groups in terms of quality of mesorectum excised after potentially curative resection. Furthermore, there were seven local recurrences in patients operated by consultants (7.8%) when compared with four in the trainee group (9.5%) and once again there was no statistical significance between the two groups (P = 0.719).
CONCLUSION We conclude that the quality of rectal cancer excision, as defined by mesorectal grades, achieved by supervised colorectal trainees is comparable with that achieved by consultants.


Affect-regulated exercise intensity: does training at an intensity that feels 'good' improve physical health?

Abstract:
OBJECTIVES Affect-regulated exercise to feel 'good' can be used to control exercise intensity amongst both active and sedentary individuals and should support exercise adherence. It is not known, however, whether affect-regulated exercise training can lead to physical health gains. The aim of this study was to examine if affect-regulated exercise to feel 'good' leads to improved fitness over the course of an 8-week training programme.
DESIGN A repeated measures design (pretest-posttest) with independent groups (training and control).
METHODS 20 sedentary females completed a submaximal graded exercise test and were then allocated to either a training group or control group. The training group completed two supervised sessions and one unsupervised session per week for 8 weeks. Exercise intensity was affect-regulated to feel 'good'. Following the 8 weeks of training, both groups completed a second submaximal graded exercise test.
RESULTS Repeated measures analyses of variance indicated a significant increase in the time to reach ventilatory threshold in the training group (318 ± 23.7s) compared to control (248 ± 16.9s). Overall compliance to training was high (>92%). Participants in the training group exercised at intensities that would be classified as being in the lower range of the recommended guidelines (≈ 50% V˙O(2) max) for cardiovascular health.
CONCLUSION Affect-regulated exercise to feel 'good' can be used in a training programme to regulate exercise intensity. This approach led to a 19% increase in time to reach ventilatory threshold, which is indicative of improved fitness.


Do socioeconomic differences in mortality persist after retirement?

Abstract:
OBJECTIVE To assess the risk of death associated with work based and non-work based measures of socioeconomic status before and after retirement age.
DESIGN Follow up study of mortality in relation to employment grade and car ownership over 25 years.
SETTING The first Whitehall study.
SUBJECTS 18,133 male civil servants aged 40-69 years who attended a screening examination between 1967 and 1970.
MAIN OUTCOME MEASURE Death.
RESULTS Grade of employment was a strong predictor of mortality before retirement. For men dying at ages 40-64 the lowest employment grade had 3.12 times the mortality of the highest grade (95% confidence interval 2.4 to 4.1). After retirement the ability of grade to predict mortality declined (rate ratio 1.86; 1.6 to 2.2). A non-work based measure of socioeconomic status (car ownership) predicted mortality less well than employment grade before retirement but its ability to predict mortality declined less after retirement. Using a relative index of inequality that was sensitive to the distribution among socioeconomic groups showed employment grade and car ownership to have independent associations with mortality that were of equal magnitude after retirement. The absolute difference in death rates between the lowest and highest employment grades increased with age from 12.9 per 1000 person years at ages 40-64 to 38.3 per 1000 at ages 70-89.
CONCLUSION Socioeconomic differences in mortality persist beyond retirement age and in magnitude increase with age. Social differentials in mortality based on an occupational status measure seem to decrease to a greater degree after retirement than those based on a non-work measure. This suggests that alongside other socioeconomic factors work itself may play an important part in generating social inequalities in health in men of working age.


Can emergency physicians accurately and reliably assess acute vertigo in the emergency department?

Abstract:
OBJECTIVE To validate a clinical diagnostic tool, used by emergency physicians (EPs), to diagnose the central cause of patients presenting with vertigo, and to determine interrater reliability of this tool.
METHODS A convenience sample of adult patients presenting to a single academic ED with isolated vertigo (i.e. vertigo without other neurological deficits) was prospectively evaluated with STANDING (SponTAneousNystagmus, Direction, head Impulse test, standiNG) by five trained EPs. The first step focused on the presence of spontaneous nystagmus, the second on the direction of nystagmus, the third on head impulse test and the fourth on gait. The local standard practice, senior audiologist evaluation corroborated by neuroimaging when deemed appropriate, was considered the reference standard. Sensitivity and specificity of STANDING were calculated. On the first 30 patients, inter-observer agreement among EPs was also assessed.
RESULTS Five EPs with limited experience in nystagmus assessment volunteered to participate in the present study enrolling 98 patients. Their average evaluation time was 9.9 ± 2.8 min (range 6-17). Central acute vertigo was suspected in 16 (16.3%) patients. There were 13 true positives, three false positives, 81 true negatives and one false negative, with a high sensitivity (92.9%, 95% CI 70-100%) and specificity (96.4%, 95% CI 93-38%) for central acute vertigo according to senior audiologist evaluation. The Cohen's kappas of the first, second, third and fourth steps of the STANDING were 0.86, 0.93, 0.73 and 0.78, respectively. The whole test showed a good inter-observer agreement (k = 0.76, 95% CI 0.45-1).
CONCLUSION In the hands of EPs, STANDING showed a good inter-observer agreement and accuracy validated against the local standard of care.


Orthostatic myoclonus: an underrecognized cause of unsteadiness?

Abstract:
BACKGROUND AND PURPOSE Recently, orthostatic myoclonus (OM) has been suggested as a cause of gait impairment and unsteadiness in neurodegenerative diseases. The aim of this study was to investigate the frequency of orthostatic myoclonus, its clinical characteristics and the underlying associated neurological disorders.
METHODS A retrospective analysis of clinical data and electromyogram surface recordings from subjects with unexplained unsteadiness/gait impairment was performed. Diagnosis of OM was made when a pattern of non-rhythmic bursts was observed (duration range 20-100 ms; bursts per second ≤16).
RESULTS Among 93 subjects studied, OM was the most frequent disorder (n = 16; 17.2%), followed by orthostatic tremor (13.9%) and low frequency tremors during orthostatism (12.9%). All patients with OM complained about unsteadiness during orthostatism and/or during gait. Leg jerking was only observed by visual inspection during orthostatism in four subjects and two also presented falls. Eleven out of 16 patients (68.7%) with OM had an associated neurodegenerative disease, such as multiple system atrophy (n = 3) Parkinson's disease (n = 2), Alzheimer's disease (n = 2), mild cognitive impairment (n = 2) and normal pressure hydrocephalus (n = 2). Although four subjects showed improvement of orthostatic myoclonus with antimyoclonic treatment, the follow-up was not systematic enough to evaluate their therapeutic effect on OM.
CONCLUSION Orthostatic myoclonus is often underdiagnosed and can be considered a possible cause of unsteadiness in subjects with neurodegenerative diseases. Electromyography surface recording is thereby an aid for investigating unsteadiness of unknown origin.


Contrast-enhanced MR imaging of hand and finger joints in patients with early rheumatoid arthritis: do we really need a full dose of gadobenate dimeglumine for assessing synovial enhancement at 3 T?

Abstract:
PURPOSE To investigate the diagnostic value of a half dose compared with a full dose of gadobenate dimeglumine in the assessment of synovitis or tenosynovitis in the wrist and finger joints in patients with early rheumatoid arthritis (RA) and a disease activity score greater than 3.2.
MATERIALS AND METHODS With institutional review board approval and informed consent, 57 patients with early RA underwent 3-T magnetic resonance (MR) imaging with two different doses of contrast media. The contrast enhancement was measured in inflamed synovial tissue at half dose (0.05 mmol per kilogram of body weight) and at full dose (0.1 mmol/kg) by using T1-weighted sequences with fat saturation. The differences and the correlation of signal intensities (SIs) at half- and full-dose sequences were compared by using the paired t test and Pearson correlations. Image quality, Rheumatoid Arthritis MRI Score (RAMRIS), and tenosynovitis score on half- and full-dose images were compared by two observers using the Wilcoxon test. Interrater agreement was assessed by using κ statistics.
RESULTS A significant difference in SI was found between half-dose and full-dose gadobenate dimeglumine-enhanced synovial tissue (mean: 914.35 ± 251.1 vs 1022 ± 244.5, P<.001). Because the SI showed high correlation between the ratio at half dose and full dose (r = 0.875), the formula, ratio of synovial enhancement to saline syringe at full dose = 0.337 + 1.070 × ratio of synovial enhancement to saline syringe at half dose, can be used to convert the normalized value of half dose to full dose. However, no difference in RAMRIS (score 0 in 490 of 1026 joints; score 1 in 344; score 2 in 158; and score 3 in 34) or tenosynovitis scores in grading synovitis or tenosynovitis in image quality and in assessment of synovial enhancement was detected between half-dose and full-dose images (P = 1).
CONCLUSION Postcontrast synovial SIs showed high correlation between half dose and full dose, and image quality was rated identically. Therefore, half-dose gadobenate dimeglumine at 3-T MR imaging may be sufficient for assessing synovitis or tenosynovitis in early RA.


Does case-mix based reimbursement stimulate the development of process-oriented care delivery?

Abstract:
OBJECTIVES Reimbursement based on the total care of a patient during an acute episode of illness is believed to stimulate management and clinicians to reduce quality problems like waiting times and poor coordination of care delivery. Although many studies already show that this kind of case-mix based reimbursement leads to more efficiency, it remains unclear whether care coordination improved as well. This study aims to explore whether case-mix based reimbursement stimulates development of care coordination by the use of care programmes, and a process-oriented way of working.
METHODS Data for this study were gathered during the winter of 2007/2008 in a survey involving all Dutch hospitals. Descriptive and structural equation modelling (SEM) analyses were conducted.
RESULTS SEM reveals that adoption of the case-mix reimbursement within hospitals' budgeting processes stimulates hospitals to establish care programmes by the use of process-oriented performance measures. However, the implementation of care programmes is not (yet) accompanied by a change in focus from function (the delivery of independent care activities) to process (the delivery of care activities as being connected to a chain of interdependent care activities).
CONCLUSION This study demonstrates that hospital management can stimulate the development of care programmes by the adoption of case-mix reimbursement within hospitals' budgeting processes. Future research is recommended to confirm this finding and to determine whether the establishment of care programmes will in time indeed lead to a more process-oriented view of professionals.


Risky sexual behavior among college students With ADHD: is the mother-child relationship protective?

Abstract:
OBJECTIVE This study examined the extent to which ADHD was associated with risky sexual behaviors (RSBs) in a sample of 92 undergraduates with (n = 44) and without (n = 48) ADHD. Mother-child relationship quality was examined as a potential moderator.
METHOD We conducted comprehensive assessments for ADHD and comorbid conditions and collected measures of RSB and mother-child relationship quality.
RESULTS Female students with ADHD were least likely to use condoms than males overall and females without ADHD. An interaction between ADHD and mother-child relationship quality accounted for significant variance in the number of past-year sexual partners, such that a high-quality relationship was protective only for students with ADHD. No other significant associations were found between ADHD and RSB.
CONCLUSION Results suggest that female college students with ADHD are at risk for unprotected sex. Moreover, a positive mother-child relationship may be protective for college students with ADHD in relation to RSB.


Rotator cuff tear--an occupational disease?

Abstract:
BACKGROUND In literature there are only few data which describe the influence of occupation on the development of rotator cuff disease.
METHODS In a retrospective study, 760 open rotator cuff repairs were analysed and related to the profession and occupational load. Exclusion criteria were traumatic tears and sports injuries. All male persons were statistically analysed and the data compared with occupational patterns of the region, obtained from the Federal Statistical State Office.
RESULTS Rotator cuff repairs were performed in 472 males who had no evidence for a traumatic origin. After statistical analysis (p<0.001) we found significantly more patients working in agriculture and forestry (6.38% versus 1.07% in Bavaria) and in the building industry (35.11% versus 13.40% in Bavaria).
CONCLUSION Our data suggest that working exposure increases the risk or leads to the clinical manifestation of rotator cuff tears. Although a detailed analysis of individual physical exposure is not available yet, the statistical results indicate that rotator cuff tears must be taken into consideration as a result of ergonomic exposure.


Is there a need for pelvic CT scan in cases of renal cell carcinoma?

Abstract:
OBJECTIVES To determine the necessity of pelvic computed tomography (CT) in patients of renal cell carcinoma (RCC).
MATERIALS AND METHODS We reviewed the records of 400 patients of RCC, who underwent treatment at our institution between January 1988 and February 2001. These patients were evaluated pre-operatively with ultrasonograms (USG) and contrast enhanced CT scan of the abdomen and pelvis. USG or CT scans of these cases were reviewed for presence of pathology in the pelvis, which were classified into 3 categories viz; benign and likely to be insignificant, benign and likely to be significant; and malignant.
RESULTS Of the 400 cases, 114 were stage I, 68 were stage II, 99 were stage III and 119 were stage IV. In all patients, tumour was identified in the kidney on preoperative CT scan. Fourteen patients (3.5%) had an abnormality on pelvic CT. Five (1.25%) had category 1, three (0.75%) had category 2 and six (1.5%) had category 3 abnormality on pelvic CT. However, all these abnormalities in pelvis were detected prior to CT by other investigations (USG or plain x-ray). Of the six cases with malignant findings, two had superficial bladder cancer, one had RCC in a pelvic kidney and three had bone metastases in the pelvis.
CONCLUSION Pelvic CT does not offer additional information in the vast majority of cases with RCC and should be performed selectively. Thus the cost of diagnostic imaging in RCC can be reduced.


Prognostic factors for cervical spondylotic amyotrophy: are signs of spinal cord involvement associated with the neurological prognosis?

Abstract:
OBJECTIVES The purpose of this study was to clarify the prognostic factors for cervical spondylotic amyotrophy (CSA).
METHODS The authors retrospectively reviewed the medical records of 47 consecutive patients with CSA in whom the presence/absence of the pyramidal tract sign was noted. We analyzed whether the age, sex, presence of diabetes mellitus, medication (vitamin B12), type of the most atrophic and impaired muscle, the muscle strength at the presentation, the presence of the pyramidal tract sign, magnetic resonance imaging (MRI) findings, including the presence and number of T2 high signal intensity areas (T2 HIA) in the spinal cord and the conversion to surgery were associated with the recovery of muscle strength in the patients. In addition, we also investigated whether the duration of symptoms before surgery and the type of surgery were associated with the recovery of muscle strength in patients who required conversion to surgical treatment.
RESULTS The presence of T2 HIA on MRI (P=0.002), the number of T2 HIA on MRI (P=0.002) and conversion to surgery (P=0.015) were found to be significantly associated with a poorer recovery at the observational final follow-up. Further, the presence of the pyramidal tract sign (P=0.043) was significantly associated with a poor recovery at the final follow-up after surgery.
CONCLUSION The presence of a high signal intensity change on T2-weighted MRI and the pyramidal tract sign can be used as prognostic factors for patients with CSA.


Ovarian torsion in children: is oophorectomy necessary?

Abstract:
BACKGROUND Most pediatric surgeons perform oophorectomy in girls presenting with ovarian torsion in which the ovary appears necrotic. However, the adult gynecology literature suggests that many ovaries can be treated by detorsion alone.
METHODS All children with ovarian torsion on the gynecology and general surgery services between 1988 and 2002 were reviewed.
RESULTS There were 36 torsions in 34 children. Seventeen underwent detorsion with or without ovarian cystectomy, and 19 had oophorectomy (mean age 10 years in both groups). Torsion was suspected preoperatively in 94% of the detorsion cases and in 47% of the oophorectomy patients. Median time from presentation to surgery was significantly lower in the detorsion than the oophorectomy group (median 14 v 27 hours; P =.04). Postoperative complications and length of stay were similar between the 2 groups. Despite the ovary being judged intraoperatively as moderately to severely ischemic in 53% of the detorsion cases, follow-up sonogram or ovarian biopsy available in 14 of the 17 cases showed normal ovary with follicular development in each case.
CONCLUSION Simple detorsion was not accompanied by an increase in morbidity, and all patients studied had functioning ovarian tissue on follow-up despite the surgeon's assessment of the degree of ovarian ischemia. Detorsion is the procedure of choice for most cases of ovarian torsion in children.


Does aerobic fitness influence microvascular function in healthy adults at risk of developing Type 2 diabetes?

Abstract:
METHODS Twenty-seven healthy normal glucose-tolerant humans with either a previous diagnosis of gestational diabetes or having two parents with Type 2 diabetes and 27 healthy adults who had no history of diabetes were recruited. Maximal oxygen uptake was assessed using an incremental exercise test to exhaustion. Skin microvascular function was assessed using laser Doppler techniques as the maximum skin hyperaemic response to a thermal stimulus (maximum hyperaemia) and the forearm skin blood flow response to the iontophoretic application of acetylcholine (ACh) and sodium nitroprusside.
RESULTS Maximal oxygen uptake was not significantly different in the 'at-risk' group compared with healthy controls. Maximum hyperaemia was reduced in those 'at risk' (1.29 +/- 0.30 vs. 1.46 +/- 0.33 V, P = 0.047); however, the peak response to acetylcholine or sodium nitroprusside did not differ in the two groups. A significant positive correlation was demonstrated between maximal oxygen uptake and maximum hyperaemia (r = 0.52, P = 0.006 l/min and r = 0.60, P = 0.001 ml/kg/min) and peak ACh response (r = 0.40, P = 0.04 l/min and r = 0.47, P = 0.013 ml/kg/min) in the 'at-risk' group when expressed in absolute (l/min) or body mass-related (ml/kg/min) terms. No significant correlations were found in the control group.
CONCLUSION In this 'at-risk' group with skin microvascular dysfunction maximal oxygen uptake was not reduced compared with healthy controls. However, in the 'at-risk' group alone, individuals with higher levels of aerobic fitness also had better microvascular and endothelial responsiveness.


Are high flow nasal cannulae noisier than bubble CPAP for preterm infants?

Abstract:
BACKGROUND Noise exposure in the neonatal intensive care unit is believed to be a risk factor for hearing loss in preterm neonates. Continuous positive airway pressure (CPAP) devices exceed recommended noise levels. High flow nasal cannulae (HFNC) are an increasingly popular alternative to CPAP for treating preterm infants, but there are no in vivo studies assessing noise production by HFNC.
OBJECTIVE To study whether HFNC are noisier than bubble CPAP (BCPAP) for preterm infants.
METHODS An observational study of preterm infants receiving HFNC or BCPAP. Noise levels within the external auditory meatus (EAM) were measured using a microphone probe tube connected to a calibrated digital dosimeter. Noise was measured across a range of frequencies and reported as decibels A-weighted (dBA).
RESULTS A total of 21 HFNC and 13 BCPAP noise measurements were performed in 21 infants. HFNC gas flows were 2-5 L/min, and BCPAP gas flows were 6-10 L/min with set pressures of 5-7 cm of water. There was no evidence of a difference in average noise levels measured at the EAM: mean difference (95% CI) of -1.6 (-4.0 to 0.9) dBA for HFNC compared to BCPAP. At low frequency (500 Hz), HFNC was mean (95% CI) 3.0 (0.3 to 5.7) dBA quieter than BCPAP. Noise increased with increasing BCPAP gas flow (p=0.007), but not with increasing set pressure. There was a trend to noise increasing with increasing HFNC gas flows.
CONCLUSION At the gas flows studied, HFNC are not noisier than BCPAP for preterm infants.


Standardizing care in medical oncology: are Web-based systems the answer?

Abstract:
BACKGROUND Medical oncology is embracing information technology to standardize care and improve patient outcomes, with a range of Web-based systems used internationally. The authors' aim was to determine the factors affecting the uptake and use of a Web-based protocol system for medical oncology in the Australian setting.
METHODS The authors conducted 50 interviews and observed medical oncology physicians, nurses, and pharmacists in their treatment setting at 6 hospitals in different geographic locations.
RESULTS The Web-based system plays a major role in guiding oncology treatment across participating sites. However, its use varies according to hospital location, clinician roles, and experience. A range of issues impact on clinicians' attitudes toward and use of the Web-based system. Important factors are clinician-specific (eg, their need for autonomy and perceptions of lack of time) or environmental (eg, hospital policy on protocol use, endorsement of the system, and the availability of appropriate infrastructure, such as sufficient computers). The level of education received regarding the system was also found to be integral to its ongoing use.
CONCLUSION Although the provision of high-quality evidence-based resources, electronic or otherwise, is essential for standardizing care and improving patient outcomes, the authors' findings demonstrate that this alone does not ensure uptake. It is important to understand end-users, the environment in which they operate, and the basic infrastructure required to implement such a system. Implementation must also be accompanied by continuing education and endorsement to ensure both long-term sustainability and use of the system to its full potential.


Antiretroviral therapy related adverse effects: Can sub-Saharan Africa cope with the new "test and treat" policy of the World Health Organization?

Abstract:
BACKGROUND Recent studies have shown that early antiretroviral therapy (ART) initiation results in significant HIV transmission reduction. This is the rationale behind the "test and treat" policy of the World Health Organization (WHO). Implementation of this policy will lead to an increased incidence of ART-related adverse effects, especially in sub-Saharan Africa (SSA). Is the region yet ready to cope with such a challenging issue?
MAIN BODY The introduction and widespread use of ART have drastically changed the natural history of HIV/AIDS, but exposure to ART leads to serious medication-related adverse effects mainly explained by mitochondrial toxicities, and the situation will get worse in the near future. Indeed, ART is associated with an increased risk of developing cardiovascular disease, lipodystrophy, prediabetes and overt diabetes, insulin resistance and hyperlactatemia/lactic acidosis. The prevalence of these disorders is already high in SSA, and the situation will be exacerbated by the implementation of the new WHO recommendations. Most SSA countries are characterized by (extreme) poverty, very weak health systems, inadequate and low quality of health services, inaccessibility to existing health facilities, lack of (qualified) health personnel, lack of adequate equipment, inaccessibility and unaffordability of medicines, and heavy workload in a context of a double burden of disease. Additionally, there is dearth of data on the incidence and predictive factors of ART-related adverse effects in SSA, to anticipate on strategies that should be put in place to prevent the occurrence of these conditions or properly estimate the upcoming burden and prepare an adequate response plan. These are required if we are to anticipate and effectively prevent this upcoming burden.
CONCLUSION While SSA would be the first region to experience the huge benefits of implementing the "test and treat" policy of the WHO, the region is not yet prepared to manage the consequential increased burden of ART-related toxic and metabolic complications. Urgent measures should be taken to fill the lacunae if SSA is not to become over-burdened by the consequences of the "test and treat" policy.


Preoperative staging of patients with liver metastases of colorectal carcinoma. Does PET/CT really add something to multidetector CT?

Abstract:
PURPOSE This study was designed to determine prospectively whether the systematic use of PET/CT associated with conventional techniques could improve the accuracy of staging in patients with liver metastases of colorectal carcinoma. We also assessed the impact on the therapeutic strategy.
METHODS Between 2006 and 2008, 97 patients who were evaluated for resection of LMCRC were prospectively enrolled. Preoperative workup included multidetector-CT (MDCT) and PET/CT. In 11 patients with liver steatosis or iodinated contrast allergy, MR also was performed. Sixty-eight patients underwent laparotomy. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values for hepatic and extrahepatic staging of MDCT and PET-CT were calculated.
RESULTS In a lesion-by-lesion analysis of the hepatic staging, the sensitivity of MDCT/RM was superior to PET/CT (89.2 vs. 55%, p < 0.001). On the extrahepatic staging, PET/CT was superior to MDCT/MR only for the detection of locoregional recurrence (p = 0.03) and recurrence in uncommon sites (p = 0.016). New findings in PET/CT resulted in a change in therapeutic strategy in 17 patients. However, additional information was correct only in eight cases and wrong in nine patients.
CONCLUSION PET/CT has a limited role in hepatic staging of LMCRC. Although PET-CT has higher sensitivity for the detection of extrahepatic disease in some anatomic locations, its results are hampered by its low PPV. PET/CT provided additional useful information in 8% of the cases but also incorrect and potentially harmful data in 9% of the staging. Our findings support a more selective use of PET/CT, basically in patients with high risk of local recurrence.


Can myometrial electrical activity identify patients in preterm labor?

Abstract:
OBJECTIVE The objective of the study was to determine whether myometrial electrical activity can differentiate false from true preterm labor.
STUDY DESIGN Electrical uterine myography (EUM) was measured prospectively on 87 women, gestational age less than 35 weeks. The period between contractions, power of contraction peaks and movement of center of electrical activity (RMS), was used to develop an index score (1-5) for prediction of preterm delivery (PTD) within 14 days of the test. The score was compared with fetal fibronectin (fFN) and cervical length (CL).
RESULTS Patients delivering within 14 days from testing showed a higher index and mean RMS (P = .000). No patients with EUM index scores of 1-2 delivered in this time frame. Combining EUM with CL or fFN increased predictability. Logistic regression revealed that history of PTD and EUM index had 4- to 5-fold increased risk for PTD. Gestational age at testing, body mass index, fFN, and CL were nonsignificant contributors to PTD risk.
CONCLUSION Measuring myometrial electrical activity may enhance identification of patients in true premature labor.


Schizophrenia patients with high intelligence: A clinically distinct sub-type of schizophrenia?

Abstract:
BACKGROUND Schizophrenia patients are typically found to have low IQ both pre- and post-onset, in comparison to the general population. However, a subgroup of patients displays above average IQ pre-onset. The nature of these patients' illness and its relationship to typical schizophrenia is not well understood. The current study sought to investigate the symptom profile of high-IQ schizophrenia patients.
METHODS We identified 29 schizophrenia patients of exceptionally high pre-morbid intelligence (mean estimated pre-morbid intelligence quotient (IQ) of 120), of whom around half also showed minimal decline (less than 10 IQ points) from their estimated pre-morbid IQ. We compared their symptom scores (SAPS, SANS, OPCRIT, MADRS, GAF, SAI-E) with a comparison group of schizophrenia patients of typical IQ using multinomial logistic regression.
RESULTS The patients with very high pre-morbid IQ had significantly lower scores on negative and disorganised symptoms than typical patients (RRR=0.019; 95% CI=0.001, 0.675, P=0.030), and showed better global functioning and insight (RRR=1.082; 95% CI=1.020, 1.148; P=0.009). Those with a minimal post-onset IQ decline also showed higher levels of manic symptoms (RRR=8.213; 95% CI=1.042, 64.750, P=0.046).
CONCLUSION These findings provide evidence for the existence of a high-IQ variant of schizophrenia that is associated with markedly fewer negative symptoms than typical schizophrenia, and lends support to the idea of a psychosis spectrum or continuum over boundaried diagnostic categories.


Is ankle/arm pressure predictive for cardiovascular mortality in older patients living in nursing homes?

Abstract:
DESIGN longitudinal descriptive study.
SETTING 2 large nursing homes in Turin, Italy.
SUBJECTS 418 dependent elderly (83 males, 335 females, mean age 83.7+/-8.5 y, range 55-102) living in the nursing homes.
MEASUREMENTS the prevalence of peripheral arterial disease (PAD) was evaluated using a Doppler Ultrasound measurement of AAI (Ankle/Arm blood pressure Index). Death causes according to ICD-9-CM were ascertained on patient's clinical records.
RESULTS Diagnosis of PAD was made in 122 subjects (29.2%) with AAI<0.90. After a 3 year follow-up 203 patients (48.6%) died. The presence of PAD was not related to total mortality or to mortality for ischemic heart disease (IHD), cerebrovascular disease or other causes. IHD mortality was significantly and independently related to low haemoglobin values, previous cerebrovascular disease, polypharmacy and poor mobility conditions.
CONCLUSION The prevalence of PAD is high in nursing home residents. AAI is not predictive for IHD mortality in this population. In very frail elderly traditional risk factors and PAD are less important predictors of death compared to poor functional status, nutritional factors and previous cardiovascular disease.


Is nasogastric decompression useful in prevention of leaks after laparoscopic sleeve gastrectomy?

Abstract:
INTRODUCTION Although its excellent results, laparoscopic sleeve gastrectomy (LSG) presents major complications ranging from 0% to 29%. Among them, the staple line leak presents an incidence varying from 0% to 7%. Many trials debated about different solutions in order to reduce leaks' incidence. No author has investigated the role of gastric decompression in the prevention of this complication. Aim of our work is to evaluate if this procedure can play a role in avoiding the occurrence of staple line leaks after LSG.
MATERIALS AND METHODS Between January 2008 and November 2012, 145 patients were prospectively and randomly included in the study. Seventy patients composed the group A, whose operations were completed with placement of nasogastric tube; the other 75 patients were included in the group B, in which no nasogastric tube was placed.
RESULTS No statistical differences were observed between group A and group B regarding gender distribution, age, weight, and BMI. No intraoperative complications and no conversion occurred in both groups. Intraoperative blood loss (50.1 ± 42.3 vs. 52.5 ± 37.6 ml, respectively) and operative time (65.4 ± 25.5 vs. 62.6 ± 27.8 min, respectively) were comparable between the two groups (p: NS). One staple line leak (1.4%) occurred on 6th postoperative day in group A patients. No leak was observed in group B patients. Postoperative hospital stay was significantly longer in group A vs. group B patients (7.6 ± 3.4 vs. 6.2 ± 3.1 days, respectively, p: 0.04).
CONCLUSION Routine placement of nasogastric tube in patients operated of LSG seems not useful in reducing leaks' incidence.


Does open access endoscopy close the door to an adequately informed patient?

Abstract:
BACKGROUND The use of open access endoscopy is increasing. Its effect on the adequacy of patient informed consent, procedure acceptance and the impact on subsequent communication/transfer of procedure results to the patient have not been evaluated. The aim of our study was to compare the extent of preknowledge of procedures and test explanation, patient medical complexity, information transfer and overall patient satisfaction between a patient group referred for outpatient open access endoscopy versus a patient group from a gastrointestinal (GI) subspecialty clinic.
METHODS Information was obtained from all patients presenting for outpatient upper and lower endoscopy by using a 1-page questionnaire. Patients from the two groups who had an outpatient upper/lower endoscopic procedure were contacted by phone after the procedure to obtain information with a standardized questionnaire.
RESULTS The open access patients reported receiving significantly less information to help them identify the procedure (p<0.01) and less explanation concerning the nature of the procedure than the group of patients referred from the subspecialty clinic (p<0.005). There was no difference between the two groups in satisfaction scores for examinations performed under conscious sedation. For flexible sigmoidoscopy without sedation, however, the GI clinic patient group were more satisfied with their procedure. The majority of patients, regardless of access, were more likely to receive endoscopic results from a gastroenterologist than the referring physician. Furthermore, the patients in the GI clinic group who underwent colonoscopy felt significantly better at follow-up.
CONCLUSION Patients undergoing open access procedures are less likely to be properly informed about their endoscopic procedure. Our results indicate that with open access endoscopy, a defined mechanism needs to be in place for communication of endoscopic results to the patient.


Is hypoalbuminemia an independent prognostic factor in patients with gastric cancer?

Abstract:
BACKGROUND Studies have indicated that hypoalbuminemia is associated with decreased survival of patients with gastric cancer. However, the prognostic value of albumin may be secondary to an ongoing systemic inflammatory response. The aim of the study was to assess the relation between hypoalbuminemia, the systemic inflammatory response, and survival in patients with gastric cancer.
METHODS Patients diagnosed with gastric carcinoma attending the upper gastrointestinal surgical unit in the Royal Infirmary, Glasgow between April 1997 and December 2005 and who had a pretreatment measurement of albumin and C-reactive protein (CRP) were studied.
RESULTS Most of the patients had stage III/IV disease and received palliative treatment. The minimum follow-up was 15 months. During follow-up, 157 (72%) patients died of their cancer. On univariate analysis, stage (p<0.001), treatment (p<0.001), albumin level (p<0.001), and CRP level (p<0.001) were significant predictors of survival. On multivariate analysis, stage (p<0.001), treatment (p<0.001), and CRP level (p<0.001) remained significant predictors of survival. Albumin was no longer an independent predictor of survival.
CONCLUSION Low albumin concentrations are associated with poorer survival in patients with gastric cancer. However, the strength of this relation with survival is dependent on the presence of a systemic inflammatory response, as evidenced by an elevated CRP level. Therefore, it appears that the relation between hypoalbuminemia and poor survival is secondary to that of the systemic inflammatory response.


Can the postoperative pain level be predicted preoperatively?

Abstract:
PURPOSE OF THE STUDY We searched for factors present preoperatively which could be used to predict the intensity of postoperative pain.
MATERIAL AND METHODS We undertook a prospective study among all patients aged over 18 years who underwent shoulder surgery from January to September 2004 in our unit. The study included 86 patients for which the following data were noted preoperatively: past history of pain, intensity and duration of prior pain, triggering factors, localization, psychological context. The intensity of the postoperative pain was measured on a visual analog scale (VAS); measurements were noted up to 24 hours postop then at one month. Data processing was performed with Statview5.5.
RESULTS Significant postoperative pain was correlated with a prior history of surgical pain, with duration of prior pain, with intensity of preoperative pain, and with depression.
DISCUSSION Significant sustained preoperative pain can favor memory of pain leading to postoperative sensitivization of nociception neurons. Intense postoperative pain can favor the development of refractory chronic pain.
CONCLUSION Significant postoperative pain can be expected in the following situations: pain after prior surgery, presence of chronic pain sustained for more than six months, intense preoperative pain, state of depression.


Proliferative index obtained by DNA image cytometry. Does it add prognostic information in Auer IV breast cancer?

Abstract:
OBJECTIVE To investigate whether the S + G2/M fraction (proliferative index) is a prognostic determinant in breast cancers classified as Auer IV.
STUDY DESIGN Prognostic evaluation of Auer IV DNA histograms with respect to the high versus low S + G2/M fraction, obtained by image cytometry on consecutive breast cancer imprint preparations.
RESULTS When studying recurrence-free survival (n = 136), the prognostic value of S + G2/M was found to vary with time: it was negligible before the median time to relapse (1.5 years) but thereafter statistically significant, in both univariate and multivariate analysis. The same pattern was found when overall survival was used as the end point; the effect was delayed to about the median time until death (three years). Tumors with a low S + G2/M fraction were smaller and more often estrogen receptor- and progesterone receptor-positive than those with a high S + G2/M fraction.
CONCLUSION According to ICM-DNA values corresponding to the S + G2/M region, patients with breast cancers classified as Auer IV can be divided into subgroups with different tumor characteristics and prognoses.


Does skin care frequency affect the severity of incontinence-associated dermatitis in critically ill patients?

Abstract:
BACKGROUND Incontinence-associated dermatitis (IAD) is a potentially serious skin injury that can lead to pressure ulcers (PUs). Multiple studies have indicated the need for evidence to find the most effective skin care protocol to reduce the incidence and severity of IAD in critically ill patients.
OBJECTIVE To compare the incidence and severity of IAD in two groups on a progressive care unit (PCU) using a defined skin care protocol: cleaning with a gentle cleanser and moisturizer, then applying a skin protectant/barrier. The control group received the skin care protocol every 12 hours and the interventional group received the protocol every 6 hours; both groups also received it as needed.
METHODS A 9-month randomized prospective study was conducted on 99 patients (N = 55 in the intervention group and N = 44 in the control group) who were incontinent of urine, stool, or both, or had a fecal diversion device or urinary catheter for more than 2 days.
RESULTS The dermatitis score in the intervention group on discharge was significantly less (7.1%; P ≤ 0.001) in the moderate IAD group than in the control group (10.9%). The dermatitis score means and P values of each group were compared using a paired t test.
CONCLUSION The researchers studied a defined skin care protocol using a cleanser with aloe vera and a cleansing lotion, followed by application of either a moisture barrier with silicone or skin protectant with zinc oxide and menthol, undertaken at two different frequencies. Data revealed the incidence of moderate IAD was decreased in the experimental group (receiving the skin protocol every 6 hours and p.r.n.).


Is primary angioplasty an acceptable alternative to thrombolysis?

Abstract:
OBJECTIVE The National Infarct Angioplasty Project assessed the feasibility of establishing a comprehensive primary angioplasty service. We aimed to compare satisfaction at intervention hospitals offering angioplasty-based care and control hospitals offering thrombolysis-based care.
DESIGN Mixed methods, with postal survey of patients and their carers, supported by semi-structured interviews.
SETTING AND PARTICIPANTS Survey of 682 patients and 486 carers, and interviews with 33 patients and carers, in eight English hospitals.
INTERVENTIONS Primary angioplasty or thrombolysis.
MAIN OUTCOME MEASURES Satisfaction with treatment.
RESULTS Responses were received from 595/682 patients (87%) and 418/486 carers (86%). Satisfaction with overall care was high at both intervention and control sites (78% vs. 71% patients rated their care as 'excellent', P = 0.074). Patient satisfaction was higher at intervention sites for some aspects of care such as speed of treatment (80% vs. 67%'excellent', P = 0.001). Convenience of visiting was rated lower at intervention sites by carers (12% vs. 1%'poor', P = 0.001). During interviews, carers reported that they accepted the added inconvenience of visiting primary angioplasty sites in the context of this life-saving treatment. Patient satisfaction with discharge and aftercare was lower in both treatment groups than for other aspects of care.
CONCLUSION Reorganization of care to offer a primary angioplasty service was acceptable to patients and their carers. Satisfaction levels were high regardless of the type of care received, with the exception of discharge and aftercare.


Does the aggressive use of polyvalent antivenin for rattlesnake bites result in serious acute side effects?

Abstract:
OBJECTIVE To determine the incidence and severity of acute side effects from the use of polyvalent antivenin in victims of rattlesnake bites.
DESIGN We retrospectively reviewed the records of all patients who presented with rattlesnake bites to a university teaching hospital during an 11-year period. From patient medical records, we extracted demographic data, clinical measurements, and outcomes during emergency department evaluation and subsequent hospitalization. Data regarding serum sickness were not collected.
OUTCOME MEASURES Primary outcome variables were the occurrence of immediate hypersensitivity reaction to antivenin, the type of reaction, permanent disability at hospital discharge, and mortality.
RESULTS We identified a total of 73 patients with rattlesnake bites during the study period. Bite envenomation was graded as nonenvenomated, 7 patients (10%); mild, 23 patients (32%); moderate, 32 patients (44%); and severe, 11 patients (15%). We identified 65 patients who received antivenin. Antivenin doses ranged from 1 to 30 vials per patient (mean, 12.0 +/- 6.0), for a total of 777 vials. In 43 patients (66%), 10 or more vials of antivenin were given. The mean number of vials of antivenin given to each snakebite grade were as follows: mild, 8.4 (+/-4.0); moderate, 11.8 (+/-5.7); and severe, 18.7 (+/-6.3). No deaths, amputations, or permanent disability from snakebite occurred in the patients receiving antivenin. Acute side effects of antivenin-occurring within the first 6 hours after administration-were seen in 12 patients (18%; 95% confidence interval, 10%-30%). Acute side effects consisted solely of urticaria in all but 1 patient (2%; 95% confidence interval, 0%-8%). This patient had a history of previous antivenin reaction and required a short course of intravenous epinephrine for blood pressure support. No other complications occurred.
CONCLUSION The administration of polyvalent Crotalidae antivenin is safe. Acute hypersensitivity, when it occurs, consists solely in most cases of urticaria. Serious side effects are uncommon.


Do resident's leadership skills relate to ratings of technical skill?

Abstract:
BACKGROUND This study sought to compare general surgery research residents' survey information regarding self-efficacy ratings to their observed performance during a simulated small bowel repair. Their observed performance ratings were based on their leadership skills in directing their assistant.
METHODS Participants were given 15 min to perform a bowel repair using bovine intestines with standardized injuries. Operative assistants were assigned to help assist with the repair. Before the procedure, participants were asked to rate their expected skills decay, task difficulty, and confidence in addressing the small bowel injury. Interactions were coded to identify the number of instructions given by the participants to the assistant during the repair. Statistical analyses assessed the relationship between the number of directional instructions and participants' perceptions self-efficacy measures. Directional instructions were defined as any dialog by the participant who guided the assistant to perform an action.
RESULTS Thirty-six residents (58.3% female) participated in the study. Participants who rated lower levels of decay in their intraoperative decision-making and small bowel repair skills were noted to use their assistant more by giving more instructions. Similarly, a higher number of instructions correlated with lower perceived difficulty in selecting the correct suture, suture pattern, and completing the entire surgical task.
CONCLUSION General surgery research residents' intraoperative leadership skills showed significant correlations to their perceptions of skill decay and task difficulty during a bowel repair. Evaluating resident's directional instructions may provide an additional individualized intraoperative assessment metric. Further evaluation relating to operative performance outcomes is warranted.


CYP2D6*4 allele and breast cancer risk: is there any association?

Abstract:
BACKGROUND CYP2D6 is an important cytochrome P450 enzyme. These enzymes catalyse the oxidative biotransformation of about 25% of clinically important drugs as well as the metabolism of numerous environmental chemical carcinogens. The most frequent null allele of CYP2D6 in European populations, CYP2D6*4, has been studied here in order to elucidate whether a relationship exists between this allele and the risk of developing breast cancer in a Spanish population.
MATERIALS AND METHODS Ninety-six breast cancer Spanish patients and one hundred healthy female volunteers were genotyped for the CYP2D6*4 allele using AmpliChip CYP450 Test technology.
RESULTS Homozygous CYP2D6*4 frequency was significant lower in breast cancer patients than in the control group (OR=0.22, p=0.04). The heterozygous CYP2D6*4 group also displayed lower values in patients than in controls but the difference was not significant (OR=0.698, p=0.28). Therefore, the presence of the CYP2D6*4 allele seems to decrease susceptibility to breast carcinoma in the selected population.
CONCLUSION A possible decreased transformation of procarcinogens by CYP2D6*4 poor metabolisers could result in a protective effect against carcinogens.


Does base deficit predict mortality in patients with severe traumatic brain injury?

Abstract:
OBJECTIVE Base Deficit (BD) is a marker of tissue hypoxia in polytrauma patients. It guides resuscitative measures, and predicts outcomes, complications and mortality. The aim of this study was to examine the presence of BD in patients with isolated severe traumatic brain injury (TBI), and to assess if it correlates with the outcomes in these patients.
METHOD This was a retrospective observational study. All patients over the age of 16 years presenting to Aga Khan University Hospital from 2009 to 2013 with isolated TBI, were included. Data was extracted from 2009 to 2013. Glasgow Outcome Scale (GOS) of 4 and 5 at last follow up was categorized as favorable outcome. Data was analyzed using SPSS version 19 and receiver operative curve (ROC) was generated for BD as a predictor of mortality and unfavorable outcome.
RESULTS One hundred and eight patients were analyzed. Ninety-eight (90.7%) were males. Mean age was 36.69 ± 17.65. Eighty-eight (81.5%) patients had BD, while 20 (18.5%) patients had base excess. 62 (58.5%) of the patients had unfavorable outcomes. BD on admission had a statistically significant negative correlation with Glasgow Coma Scale (GCS) on presentation (r = -0.239, p = 0.025) and Revised Trauma Score (RTS) (r = -0.214, p = 0.046). However, there was no statistically significant difference in means of BD between survivors and non survivors. Area under receiver operator curve (ROC) for BD as a predictor of mortality statistically non-significant.
CONCLUSION Although BD is correlated with GCS at presentation and RTS, it is not a reliable prognostic marker for outcome and mortality in patients with isolated TBI.


Does confined placental mosaicism account for adverse perinatal outcomes in IVF pregnancies?

Abstract:
BACKGROUND IVF singletons have poorer perinatal outcomes than singletons from spontaneous conceptions. This may be due to the influence of ovarian stimulation on the chromosomal constitution of the embryos which could be translated into localized chromosomal anomalies in the placenta. The aim of this study was to compare the incidence of confined placental mosaicism (CPM) in IVF/ICSI pregnancies and spontaneous conceptions.
METHODS We conducted a multi-centre retrospective analysis of karyotype results obtained by chorionic villus sampling (CVS), performed due to advanced maternal age (>or=36 years at 18 weeks of gestation), in the Netherlands between 1995 and 2005.
RESULTS From a total of 322 246 pregnancies, 20 885 CVS results were analysed: 235 in the IVF/ICSI group and 20 650 in the control group. The mean age of women in both groups was 38.4 years (mean difference -0.08, 95% CI -0.35 to 0.18). Data relating to the fetal karyotype were missing in 143 cases in the control group. When taking into account missing data, the incidence of CPM was lower in the IVF-ICSI group than in the control group, 1.3% versus 2.2% (odds ratio 0.59, 95% CI 0.19-1.85), whereas the incidence of fetal chromosomal anomalies was increased 4.3% versus 2.4% (odds ratio 1.81, 95% CI 0.95-3.42). Neither differences were statistically significant.
CONCLUSION The incidence of CPM is not increased in IVF/ICSI pregnancies compared with spontaneous conceptions. CPM probably does not account for the adverse perinatal outcomes following IVF/ICSI.


Utility of unenhanced fat-suppressed T1-weighted MRI in children with sickle cell disease -- can it differentiate bone infarcts from acute osteomyelitis?

Abstract:
BACKGROUND Children with sickle cell disease (SCD) are at risk of bone infarcts and acute osteomyelitis. The clinical differentiation between a bone infarct and acute osteomyelitis is a diagnostic challenge. Unenhanced T1-W fat-saturated MR images have been proposed as a potential tool to differentiate bone infarcts from osteomyelitis.
OBJECTIVE To evaluate the reliability of unenhanced T1-W fat-saturated MRI for differentiation between bone infarcts and acute osteomyelitis in children with SCD.
MATERIALS AND METHODS We retrospectively reviewed the records of 31 children (20 boys, 11 girls; mean age 10.6 years, range 1.1-17.9 years) with SCD and acute bone pain who underwent MR imaging including unenhanced T1-W fat-saturated images from 2005 to 2010. Complete clinical charts were reviewed by a pediatric hematologist with training in infectious diseases to determine a clinical standard to define the presence or absence of osteomyelitis. A pediatric radiologist reviewed all MR imaging and was blinded to clinical information. Based on the signal intensity in T1-W fat-saturated images, the children were further classified as positive for osteomyelitis (low bone marrow signal intensity) or positive for bone infarct (high bone marrow signal intensity).
RESULTS Based on the clinical standard, 5 children were classified as positive for osteomyelitis and 26 children as positive for bone infarct (negative for osteomyelitis). The bone marrow signal intensity on T1-W fat-saturated imaging was not significant for the differentiation between bone infarct and osteomyelitis (P = 0.56). None of the additional evaluated imaging parameters on unenhanced MRI proved reliable in differentiating these diagnoses.
CONCLUSION The bone marrow signal intensity on unenhanced T1-W fat-saturated MR images is not a reliable criterion to differentiate bone infarcts from osteomyelitis in children.


Cancer of the buccal mucosa: are margins and T-stage accurate predictors of local control?

Abstract:
UNLABELLED Cancer of the buccal mucosa is an uncommon and aggressive neoplasm of the oral cavity. Less than 2% of patients treated for cancer of the oral cavity at Roswell Park Cancer Institute (RPCI) from 1971 to 1997 had primary buccal cancers. Because the majority of these patients did not undergo any adjuvant treatment, this group provided us with the opportunity to assess the relationship between margin status and local recurrence for both small (T1-T2) and large (T3-T4) tumors treated with surgery alone.
MATERIALS AND METHODS The RPCI tumor registry database reported 104 patients who were treated for buccal carcinoma. A retrospective chart review identified 27 patients who met our criteria for a buccal mucosal primary tumor (epicenter of the mass in the buccal mucosa). There were 13 men and 14 women, ranging in age from 34 to 94 years (mean, 75). Data were collected regarding patient demographics, presenting symptoms, stage, treatment received, and outcome.
RESULTS All patients underwent surgical resection of their primary lesion; 21 (75%) had T1 or T2 tumors. The rate of local recurrence was 56% for the group as a whole. Patients with close or positive margins had a 66% local failure rate as compared with 52% when surgical margins were negative (greater than or equal to 5 mm from the resection margin after tissue fixation; P = ns). Among those in whom negative margins were achieved, patients with T1-T2 disease had a 40% local failure rate with surgical resection alone.
CONCLUSION Local excision of T1 and T2 buccal mucosa cancers with pathologically negative margins had a high rate of local recurrence in our series. Low T-stage and negative margins are not adequate predictors of local control. Even early buccal tumors may benefit from adjuvant therapy to enhance local control.


Can mass drug administration lead to the sustainable control of schistosomiasis?

Abstract:
BACKGROUND In the Philippines, the current national control strategy for schistosomiasis is annual mass drug administration (MDA) with 40 mg/kg of praziquantel in all schistosomiasis-endemic villages with a prevalence ≥10%.
METHODS A cross-sectional survey of schistosomiasis was conducted in 2012 on 18 221 individuals residing in 22 schistosomiasis-endemic villages in the province of Northern Samar. The prevalence of schistosomiasis, intensity of Schistosoma infection, and morbidity of disease were assessed.
RESULTS Despite an active schistosomiasis-control program in Northern Samar for>30 years, which included a MDA campaign in the last 5 years, the mean prevalence of schistosomiasis among 10 435 evaluated subjects was 27.1% (95% confidence interval [CI], 26.3%-28.0%), and the geometric mean intensity of infection among 2832 evaluated subjects was 17.2 eggs per gram of feces (95% CI, 16.4-18.1). Ultrasonography revealed high levels of schistosomiasis-induced morbidity in the schistosomiasis-endemic communities. Left lobe liver enlargement (≥70 mm) was evident in 89.3% of subjects. Twenty-five percent of the study population had grade II/III liver parenchyma fibrosis, and 13.3% had splenomegaly (≥100 mm).
CONCLUSION MDA on its own was insufficient to control the prevalence of schistosomiasis, intensity of Schistosoma infection, or morbidity of the disease. Alternative control measures will be needed to complement the existing national MDA program.


Can D-dimer become a new diagnostic parameter for acute appendicitis?

Abstract:
INTRODUCTION In this study, we investigated D-dimer serum level as a diagnostic parameter for acute appendicitis.
MATERIALS AND METHODS Forty-nine patients were enrolled in the study. Patients were classified according to age; sex; duration between the beginning of pain and referral to a hospital or clinic; Alvarado scores; and in physical examination, presence of muscular defense, the number of leukocytes, preoperative ultrasonography, and D-dimer levels of histopathologic study groups were analyzed.
RESULTS Of the patients enrolled in the study, 26.5% were females and 73.5% males. The average age was 21 years (range, 16-38 years) and 81.7% acute appendicitis (AA). According the duration of pain, 63.2% of the patients were referred to the hospital within the first 24 hours, 26.5% of the patients were referred to the hospital within 24 to 48 hours, and 10.3% were referred to the hospital within a period of more than 48 hours. No statistically significant difference was determined regarding D-dimer levels between the histopathologic study groups (P>.05). Alvarado scores lower than 7 were found in 36.7% and 7 or higher in 63.3% of the patients. There was no statistically significant difference related with D-dimer levels between histopathologic study groups (P>.05). The ratio of cases with a number of leukocytes below the upper limit were determined respectively as 32.7% and 67.3%, and no statistically significant difference was found regarding d-dimer levels between histopathologic study groups (P>.05).
CONCLUSION Increased D-dimer levels should not be considered as a diagnostic parameter in diagnosis of acute appendicitis.


Is there a relationship between rheumatoid arthritis and periodontal disease?

Abstract:
METHODS 1,412 individuals attending the University of Queensland's School of Dentistry were assessed for the prevalence of periodontal disease and rheumatoid arthritis. Analysis of data obtained from a self-reported health questionnaire and dental records was carried out and included: number of individuals referred for advanced periodontal care (test group); number of individuals attending for routine dentistry; determination of rheumatoid arthritis, cardiovascular disease and diabetes mellitus through self-reporting and assessment of prescription medications; assessment of periodontal disease through assessment of existing oral radiographs.
RESULTS In patients referred for periodontal treatment, the prevalence of self-reported rheumatoid arthritis was 3.95% which is significantly higher than that seen in patients not referred for periodontal treatment (0.66%) and also that reported in the general population (1%). Of those referred patients with rheumatoid arthritis, 62.5% had advanced forms of periodontal disease. These results were mirrored in the results of the self-reported prevalence of cardiovascular disease and diabetes mellitus which was consistent with the published higher prevalence in periodontal patients.
CONCLUSION Based on data derived from self-reported health conditions, and not withstanding the limitations of such a study, we conclude that there is good evidence to suggest that individuals with moderate to severe periodontal disease are at higher risk of suffering from rheumatoid arthritis and vice versa.


Do clinical variables predict pathologic radiographs in the first episode of wheezing?

Abstract:
OBJECTIVE To determine if clinical variables assessed in relation to Albuterol aerosol treatments accurately identify children with pathologic radiographs during their initial episode of bronchospasm.
METHODS A prospective convenience sample of children with a first episode of wheezing. Data collected included demographics, baseline and post-treatment clinical score and physical examination, number of aerosols, requirement for supplemental oxygen, and disposition. Chest radiographs were obtained and interpreted, and patients were divided into 2 groups based on a pathologic versus nonpathologic radiograph interpretation. Chi2 testing was performed for categoric variables, and the student t test was performed for continuous variables. A discriminant analysis was used to develop a model.
RESULTS Pathologic radiographs were identified in 61 patients (9%). Between groups, a significant difference was noted for pretreatment oxygen saturation only. Clinical score, respiratory rate, and presence of rales both pretreatment and posttreatment were not significantly different between groups. The discriminant analysis correctly predicted 90% of nonpathologic radiographs but only 15% of pathologic radiographs.
CONCLUSION Clinical variables, either isolated or as components of a model, could not identify all children with pathologic radiographs.


MiraLAX vs. Golytely: is there a significant difference in the adenoma detection rate?

Abstract:
BACKGROUND In recent clinical trials (RCT) of bowel preparation, Golytely was more efficacious than MiraLAX. We hypothesised that there is a difference in adenoma detection between Golytely and MiraLAX.
AIMS To compare the adenoma detection rate (ADR) between these bowel preparations, and to identify independent predictors of bowel preparation quality and adenoma detection.
METHODS This was a post hoc analysis of an RCT that assessed efficacy and patient tolerability of Golytely vs. MiraLAX/Gatorade in average risk screening colonoscopy patients. Bowel preparation quality was measured with the Boston Bowel Preparation Scale (BBPS). An excellent/good equivalent BBPS score was defined as ≥ 7. Polyp pathology review was performed. ADR was defined as the proportion of colonoscopies with an adenoma. Univariate and multivariate analyses were conducted.
RESULTS One hundred and ninety patients were prospectively enrolled (87 MiraLAX, 103 Golytely). Golytely had a higher rate of a BBPS score ≥ 7 (82.5% vs. MiraLAX 67.8%, P=0.02). The ADR in the Golytely cohort was 26.2% (27/103), and was 16.1% (14/87) for MiraLAX (P = 0.091). On multivariate analyses, Golytely was 2.13 × more likely to be associated with a BBPS ≥ 7 (95% CI 1.05-4.32, P = 0.04) and 2.28 × more likely to be associated with adenoma detection (95% CI 1.05-4.98, P = 0.04) than MiraLAX.
CONCLUSION Golytely was more efficacious than MiraLAX in bowel cleansing, and was independently associated with both bowel prep quality (BBPS ≥ 7) and higher adenoma detection. Golytely should be used as first line for bowel prep for colonoscopy. Studies with larger populations are needed to confirm these results.


Does telmisartan prevent hepatic fibrosis in rats with alloxan-induced diabetes?

Abstract:
AIMS This study evaluated the effect of telmisartan on the livers of diabetic rats and also aimed to determine the hepatic distribution and role of transforming growth factor beta (TGF-beta) in diabetes-related hepatic degeneration while taking into account the possible protective effects of telmisartan.
METHODS Fifteen adult male rats were used and divided into three groups: the non-diabetic healthy group, alloxan-induced diabetic control group, and the alloxan-induced diabetic telmisartan group. The non-diabetic healthy group and the diabetic control group were exposed to saline for 30 days, while the group treated with diabetic drugs was orally administered telmisartan for 30 days (10 mg/kg/day). At the end of the experiment, the rats were sacrificed and the livers were dissected and transferred into the fixation solution. The livers were then evaluated using stereological and histopathological methods.
RESULTS Our study of the numerical density of hepatocytes shows a significant difference between the diabetic control group and diabetic rats treated with telmisartan. Immunohistochemical staining for TGF-beta in liver sections of the diabetic rats treated with telmisartan showed no immunoreactivity. The diabetic control group was determined to be strongly immunoreactive to TGF-beta.
CONCLUSION Results suggest that telmisartan may reduce type-I diabetes mellitus-induced hepatic injury by suppressing activated hepatic stellate cells through concomitant TGF-beta1 down-regulation.


Two-year follow-up survey of patients with allergic contact dermatitis from an occupational cohort: is the prognosis dependent on the omnipresence of the allergen?

Abstract:
BACKGROUND Skin diseases are the most frequently recognized occupational diseases in Denmark. The prognosis for occupational contact dermatitis is often poor.
OBJECTIVES To investigate the prognosis, assessed by eczema, job status and skin-related quality of life, among patients allergic to rubber chemicals and latex (ubiquitous allergens) and epoxy (nonubiquitous allergen), 2 years after recognition of occupational allergic contact dermatitis.
METHODS From a cohort of all patients recognized as having occupational dermatitis by the Danish National Board of Industrial Injuries in 2010, 199 patients with relevant rubber allergy (contact allergy to rubber chemicals or contact urticaria from latex) or epoxy allergy were identified. Follow-up consisted of a questionnaire covering current severity of eczema, employment, exposure and quality of life.
RESULTS The response rate was 75%. Clearance of eczema was reported by 11% of patients and 67% reported improvement. Overall 22% of patients with allergy to a nonubiquitous allergen had total clearance of eczema compared with 10% of cases allergic to ubiquitous allergens and 0% of those with contact urticaria (P = 0·116). Improvement was significantly more frequent in those who had changed jobs compared with those who had not (P = 0·01).
CONCLUSION At follow-up, patients with contact urticaria had significantly poorer prognosis than those with contact allergy, and there was a trend towards a poorer prognosis for those with contact allergy to rubber chemicals than those with allergy to epoxy. A significant positive association between job change and improvement was found.


Can nurse-led preoperative education reduce anxiety and postoperative complications of patients undergoing cardiac surgery?

Abstract:
BACKGROUND The effect of preoperative education on anxiety and postoperative outcomes of cardiac surgery patients remains unclear.AIM: The aim of the study was to estimate the effectiveness of a nurse-led preoperative education on anxiety and postoperative outcomes.
METHODS A randomised controlled study was designed. All the patients who were admitted for elective cardiac surgery in a general hospital in Athens with knowledge of the Greek language were eligible to take part in the study. Patients in the intervention group received preoperative education by specially trained nurses. The control group received the standard information by the ward personnel. Measurements of anxiety were conducted on admission-A, before surgery-B and before discharge-C by the state-trait anxiety inventory.
RESULTS The sample consisted of 395 patients (intervention group: 205, control group: 190). The state anxiety on the day before surgery decreased only in the intervention group (34.0 (8.4) versus 36.9 (10.7); P=0.001). The mean decrease in state score during the follow-up period was greater in the intervention group (P=0.001). No significant difference was found in the length of stay or readmission. Lower proportions of chest infection were found in the intervention group (10 (5.3) versus 1 (0.5); P=0.004). Multivariate linear regression revealed that education and score in trait anxiety scale on admission are independent predictors of a reduction in state anxiety.
CONCLUSION Preoperative education delivered by nurses reduced anxiety and postoperative complications of patients undergoing cardiac surgery, but it was not effective in reducing readmissions or length of stay.


Is there a discrepancy between patient and physician quality of life assessment?

Abstract:
AIMS Quality of Life (QoL) assessment remains integral in the investigation of women with lower urinary tract dysfunction. Previous work suggests that physicians tend to underestimate patients' symptoms and the bother that they cause. The aim of this study was to assess the relationship between physician and patient assessed QoL using the Kings Health Questionnaire (KHQ).
METHODS Patients complaining of troublesome lower urinary tract symptoms (LUTS) were recruited from a tertiary referral urodynamic clinic. Prior to their clinic appointment they were sent a KHQ, which was completed before attending. After taking a detailed urogynecological history, a second KHQ was filled in by the physician, blinded to the patient responses, on the basis of their impression of the symptoms elicited during the interview. These data were analyzed by an independent statistician. Concordance between patient and physician assessment for individual questions was assessed using weighted kappa analysis. QoL scores were compared using Wilcoxons signed rank test.
RESULTS Seventy-five patients were recruited over a period of 5 months. Overall, the weighted kappa showed relatively poor concordance between the patient and physician responses; mean kappa: 0.33 (range 0.18-0.57). The physician underestimated QoL score in 4/9 domains by a mean of 5.5% and overestimated QoL score in 5/9 domains by a mean of 6.9%. In particular, physicians underestimated the impact of LUTS on social limitations and emotions (P<0.05).
CONCLUSION This study confirms that physicians often differ from patients in the assessment of QoL. This is most likely due to a difference in patient-physician perception of "significant" LUTS and clearly demonstrates the importance of patient evaluated QoL in routine clinical assessment.


Impact of MPH programs: contributing to health system strengthening in low- and middle-income countries?

Abstract:
BACKGROUND The "health workforce" crisis has led to an increased interest in health professional education, including MPH programs. Recently, it was questioned whether training of mid- to higher level cadres in public health prepared graduates with competencies to strengthen health systems in low- and middle-income countries. Measuring educational impact has been notoriously difficult; therefore, innovative methods for measuring the outcome and impact of MPH programs were sought. Impact was conceptualized as "impact on workplace" and "impact on society," which entailed studying how these competencies were enacted and to what effect within the context of the graduates' workplaces, as well as on societal health.
METHODS This is part of a larger six-country mixed method study; in this paper, the focus is on the qualitative findings of two English language programs, one a distance MPH program offered from South Africa, the other a residential program in the Netherlands. Both offer MPH training to students from a diversity of countries. In-depth interviews were conducted with 10 graduates (per program), working in low- and middle-income health systems, their peers, and their supervisors.
RESULTS Impact on the workplace was reported as considerable by graduates and peers as well as supervisors and included changes in management and leadership: promotion to a leadership position as well as expanded or revitalized management roles were reported by many participants. The development of leadership capacity was highly valued amongst many graduates, and this capacity was cited by a number of supervisors and peers. Wider impact in the workplace took the form of introducing workplace innovations such as setting up an AIDS and addiction research center and research involvement; teaching and training, advocacy, and community engagement were other ways in which graduates' influence reached a wider target grouping. Beyond the workplace, an intersectoral approach, national reach through policy advisory roles to Ministries of Health, policy development, and capacity building, was reported. Work conditions and context influenced conduciveness for innovation and the extent to which graduates were able to have effect. Self-selection of graduates and their role in selecting peers and supervisors may have resulted in some bias, some graduates could not be traced, and social acceptability bias may have influenced findings.
CONCLUSION There was considerable impact at many levels; graduates were perceived to be able to contribute significantly to their workplaces and often had influence at the national level. Much of the impact described was in line with public health educational aims. The qualitative method study revealed more in-depth understanding of graduates' impact as well as their career pathways.


Is diffusion-weighted imaging a significant indicator of the development of vascularization in hypovascular hepatocellular lesions?

Abstract:
OBJECTIVE The objective was to evaluate the efficacy of diffusion-weighted imaging (DWI) in predicting the development of vascularization in hypovascular hepatocellular lesions (HHLs).
MATERIALS AND METHODS Forty-two HHLs that were diagnosed by computed tomographic (CT) arteriography were evaluated retrospectively. The lesion on DWI was classified as isointense, hypointense, or hyperintense. Follow-up studies that included intravenous dynamic CT or magnetic resonance imaging were performed.
RESULTS The 730-day cumulative developments of vascularization in hypointense, isointense, and hyperintense lesions were 17%, 30%, and 40%, respectively. The differences among these developments were not statistically significant.
CONCLUSION The signal intensity on DWI showed no significant difference in the development of vascularization.


Are failures of anterior cruciate ligament reconstruction associated with steep posterior tibial slopes?

Abstract:
BACKGROUND Recently, increasing number of literature has identified the posterior tibial slope (PTS) as one of the risk factors of primary anterior cruciate ligament (ACL) injury. However, few studies concerning the association between failure of ACL reconstruction (ACLR) and PTS have been published. The objective of this study was to explore the association between the failure of ACLR and PTS at a minimum of two years follow-up.
METHODS Two hundred and thirty eight eligible patients from June 2009 to October 2010 were identified from our database. A total of 20 failure cases of ACLR and 20 randomly selected controls were included in this retrospective study. The demographic data and the results of manual maximum side-to-side difference with KT-1000 arthrometer at 30° of knee flexion and pivot-shift test before the ACLR and at the final follow-up were collected. The medial and lateral PTSs were measured using the magnetic resonance imaging (MRI) scan, based on Hudek's measurement. A comparison of PTS between the two groups was performed.
RESULTS The overall failure rate of the present study was 8.4%. Of the 40 participants, the mean medial PTS was 4.1° ± 3.2° and the mean lateral PTS was 4.6° ± 2.6°. The medial PTS of the ACLR failure group was significantly steeper than the control group (3.5° ± 2.5° vs. 6.1° ± 2.1°, P = 0.000). Similarly, the lateral PTS of the ACLR failure group was significantly steeper than the control group (2.9° ± 2.1° vs. 5.5° ± 3.0°, P = 0.006). For medial PTS ≥ 5°, the odds ratio of ACLR failure was 6.8 (P = 0.007); for lateral PTS ≥5°, the odds ratio of ACLR failure was 10.8 (P = 0.000).
CONCLUSION Both medial and lateral PTS were significantly steeper in failures of ACLR than the control group. Medial or lateral PTS ≥5° was a new risk factor of ACLR failure.


Does evidence-based practice improve patient outcomes?

Abstract:
RATIONALE, AIMS AND OBJECTIVES Evidence-based practice (EBP) is widely promoted, but does EBP produce better patient outcomes? We report a natural experiment when part of the internal medicine service in a hospital was reorganized in 2003 to form an EBP unit, the rest of the service remaining unchanged. The units attended similar patients until 2012 permitting comparisons of outcomes and activity.
METHODS We used routinely collected statistics (2004-11) to compare the two different methods of practice and test whether patients being seen by the EBP unit differed from standard practice (SP) patients. Data were available by doctor and year. To check for differences between the EBP and SP doctors prior to reorganization, we used statistics from 2000 to 2003. We looked for changes in patient outcomes or activity following reorganization and whether the EBP unit was achieving significantly different results from SP. Data across the periods were combined and tested using Mann-Whitney test.
RESULTS No statistically significant differences in outcomes were detected between the EBP and the SP doctors prior to reorganization. Following the unit's establishment, the mortality of patients being treated by EBP doctors compared with their previous performance dropped from 7.4% to 6.3% (P < 0.02) and length of stay from 9.15 to 6.01 days (P = 0.002). No statistically significant improvements were seen in SP physicians' performance. No differences in the proportion of patients admitted or their complexity between the services were detected. Despite this, EBP patients had a clinically significantly lower risk of death 6.27% versus 7.75% (P < 0.001) and a shorter length of stay 6.01 versus 8.46 days (P < 0.001) than SP patients. Readmission rates were similar: 14.4% (EBP); 14.5% (SP). EBP doctors attended twice as many patients/doctor as SP doctors.
CONCLUSION The EBP unit was associated with better patient outcomes and more efficient performance than achieved by the same physicians previously or by SP concurrently.


Multidisciplinary decisions in breast cancer: does the patient receive what the team has recommended?

Abstract:
BACKGROUND A multidisciplinary team (MDT) approach to breast cancer management is the gold standard. The aim is to evaluate MDT decision making in a modern breast unit.
METHODS All referrals to the breast MDT where breast cancer was diagnosed from 1 July 2009 to 30 June 2011 were included. Multidisciplinary team decisions were compared with subsequent patient management and classified as concordant or discordant.
RESULTS Over the study period, there were 3230 MDT decisions relating to 705 patients. Overall, 91.5% (2956 out of 3230) of decisions were concordant, 4.5% (146 out of 3230), were discordant and 4% (128 out of 3230) had no MDT decision. Of 146 discordant decisions, 26 (17.8%) were considered 'unjustifiable' as there was no additional information available after the MDT to account for the change in management. The remaining 120 discordant MDT decisions were considered 'justifiable', as management was altered due to patient choice (n=61), additional information available after MDT (n=54) or MDT error (n=5).
CONCLUSION The vast majority of MDT decisions are implemented. Management alteration was most often due to patient choice or additional information available after the MDT. A minority of management alterations were 'unjustifiable' and the authors recommend that any patient whose treatment is subsequently changed should have MDT rediscussion prior to treatment.


Does quilting suture prevent seroma in abdominoplasty?

Abstract:
BACKGROUND Seroma is the most frequent complication in abdominoplasty. Some patients are more prone to develop this complication. Ultrasound is a well-known method with which to diagnose seroma in the abdominal wall. The purpose of this study was to verify the efficacy of the use of quilting suture to prevent seroma.
METHODS Twenty-one female patients who presented with abdominal deformity type III/A according to the authors' classification of abdominal skin and myoaponeurotic deformity had undergone abdominoplasty. The selected patients should have had at least one of the following characteristics: body mass index greater than 25 kg/m; weight loss greater than 10 kg; previous incision in the supraumbilical region; or present thinning of the subcutaneous in the area above the umbilicus. Ultrasound was performed for every patient from 15 to 18 days after the operation to search for fluid collection in the abdominal wall.
RESULTS The average fluid collection found was 8.2 cc per patient. Only two patients underwent aspiration because ultrasound showed greater than 20 cc collected above the fascial layer. These patients did not present with recurrence of seroma after aspiration.
CONCLUSION The quilting suture seems to be an efficient technique with which to prevent seroma formation.


Does feeding tube insertion and its timing improve survival?

Abstract:
OBJECTIVES To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival.
DESIGN Prospective cohort study.
SETTING All U.S. nursing homes (NHs).
PARTICIPANTS Thirty-six thousand four hundred ninety-two NH residents with advanced cognitive impairment from dementia and new problems eating studied between 1999 and 2007.
MEASUREMENTS Survival after development of the need for eating assistance and feeding tube insertion.
RESULTS Of the 36,492 NH residents (88.4% white, mean age 84.9, 87.4% with one feeding tube risk factor), 1,957 (5.4%) had a feeding tube inserted within 1 year of developing eating problems. After multivariate analysis correcting for selection bias with propensity score weights, no difference was found in survival between the two groups (adjusted hazard ratio (AHR) = 1.03, 95% confidence interval (CI) = 0.94-1.13). In residents who were tube-fed, the timing of PEG tube insertion relative to the onset of eating problems was not associated with survival after feeding tube insertion (AHR = 1.01, 95% CI = 0.86-1.20, persons with a PEG tube inserted within 1 month of developing an eating problem versus later (4 months) insertion).
CONCLUSION Neither insertion of PEG tubes nor timing of insertion affect survival.


Does prostate morphology affect outcomes after holmium laser enucleation?

Abstract:
OBJECTIVE To determine whether prostate morphology or technique used has any effect on postoperative outcomes after holmium laser enucleation of the prostate.
MATERIALS AND METHODS A retrospective review of prospectively collected data was completed for all patients undergoing a holmium laser enucleation of the prostate at our institution. Prostate morphology was classified as either "bilobar" or "trilobar" according to the cystoscopic appearance. The baseline characteristics, complications, and postoperative outcomes were collected.
RESULTS A total of 304 patients with either "bilobar" (n = 142) or "trilobar" (n = 162) prostate morphology were included. The trilobar group was more likely to have longer operative times (112 vs 100 minutes, P = .04), although this difference was not significant on multivariate analysis. The postoperative outcomes were similar between the 2 groups for American Urological Association symptom score, change in American Urological Association symptom score, bother score, maximal flow rate, change in maximal flow rate, postvoid residual urine volume, and complication rate. However, the trilobar group had a significantly greater decrease in their PVR urine volume (296 vs 176 mL, P = .01), a difference that persisted on multivariate analysis. A subset analysis of the trilobar prostates revealed that performing a 2-lobe technique achieved shorter operative and enucleation times, although the difference was not significant.
CONCLUSION Those patients with trilobar prostate morphology are more likely to achieve a greater decrease in the PVR urine volume after holmium laser enucleation of the prostate. All other outcomes appeared to be similar between the 2 groups. In addition, a 2-lobe technique can be safely used for trilobar prostates when deemed feasible by the surgeon.