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8044198 | Effects of exercise training on absolute and relative measurements of regional adiposity. | The purpose of the present study was to determine whether absolute and relative measurements of regional adiposity differ in their responses to exercise intervention and which measures are most predictive of changes in plasma lipids, insulin sensitivity and adiposity. Thirteen middle-aged men (BMI 30.4 +/- 1.5 kg/m2, age 47.2 +/- 1.5 years, mean +/- s.e.) were examined before and after 14 weeks of endurance-oriented physical activity (3-4 days/week, 30-45 min/day). Significant (P < 0.05) decreases in the absolute measures of chest, waist and hip girths and sagittal diameter were evident. The waist-to-hip ratios (WHR) of umbilicus/maximal hip and minimal waist/maximal hip decreased significantly (P < 0.05). However, the WHRs of umbilicus/anterior superior iliac spine and umbilicus/greater trochanters did not change due to parallel decreases in waist and hip girths. Trunk and extremity skinfolds decreased significantly (P < 0.05); however, trunk/extremity skinfold ratios were virtually unaltered. The training programme significantly (P < 0.05) increased insulin sensitivity (60%) and HDL (8%), and reduced triglyceride (25%) and total cholesterol/HDL (8%). Changes in these variables were related to changes in sagittal diameter and waist girth. These data indicate different responses to physical activity between measurements of regional adiposity, and emphasize the need for considering absolute central girths such as waist circumference and sagittal diameter when assessing fat topography and cardiovascular risk. |
8044197 | Energy metabolism and metabolite patterns of rats after application of dexfenfluramine. | Serotoninergic neuronal networks are important for food intake and body weight regulation. However, the mechanisms by which some metabolic pathways are influenced are rather unclear. Dexfenfluramine (DF), a serotonin releaser and re-uptake inhibitor, was used to investigate changes in food intake, body weight development, energy expenditure, respiratory quotient and substrate oxidation rates for 12 days. Normal rats, receiving an energy-controlled mash diet and water ad libitum were intraperitoneally injected daily with either saline, 1, 2.5, 5 or 10 mg DF/kg. Compared to controls, food intake, body weight development and energy expenditure were decreased in a dose-dependent manner, especially during the first six days. Lipid oxidation was increased while oxidation of carbohydrates was decreased. Pair-feeding experiments over three days revealed that this was a clear pharmacological effect and not simply a result of diminished food intake. At the end of these experiments, plasma glucose and liver and muscle glycogen were unchanged after DF, but isoleucine, leucine and lysine were significantly decreased in plasma and liver. Therefore, the plasma tryptophan/large neutral amino acids ratio was slightly increased. Protein oxidation was unchanged after DF. It is concluded that a prompt decline in energy expenditure with increased fat oxidation rates could mediate the body weight reducing effect of DF. |
8044196 | A multicompartment body composition technique based on computerized tomography. | The objective of this study was to develop a body composition method based on computerized tomography (CT) which would make it possible to divide the body into multiple compartments at the tissue and organ level. Eight healthy males (21-42 years old) with BMIs ranging from 18.6 to 25.3 kg/m2 were used for the methodological development. Areas of tissues, organs and air/gas were measured in 28 cross-sectional scans having defined and identical positions in all examined subjects. The area determinations were performed with the following attenuation intervals (given in Hounsfield units, HU): air, gas and lungs: -1001 to -191 HU; adipose tissue (AT): -190 to -30 HU; all other soft tissues and organs: -29 to +151 HU; skeleton: 152 to 2500 HU. Various tissue and organ areas in the -29 to +151 HU interval were obtained by means of cursor circumscriptions, while area determinations in other intervals were based on the number of pixels fulfilling given attenuation criteria. Volumes of tissues, organs and gas were obtained from corresponding areas and the distances between the scans. The body was divided into 12 main volumes of tissues, organs and gas that could be further subdivided by region. The main volumes observed (in litres; mean +/- s.d.) were: skeleton (subdivisible into dense skeleton, red and yellow bone marrow): 8.7 +/- 0.9; skeletal muscle: 31.9 +/- 5.1; visceral AT (subdivisible into intra- and retroperitoneal, cardiac, other thoracic AT): 3.0 +/- 1.7; intra- and retroperitoneal organs other than AT: 4.6 +/- 0.8; gastrointestinal gas: 0.25 +/- 0.09; heart: 0.61 +/- 0.12; lungs and bronchial air: 5.1 +/- 1.1; other thoracic organs: 0.32 +/- 0.08; mammary glands: 0.001 +/- 0.004; CNS (subdivisible into brain and contents of spinal channel): 1.6 +/- 0.15; air in sinuses and trachea: 0.19 +/- 0.05; subcutaneous AT: 11.6 +/- 2.8; skin: 2.4 +/- 0.39. Precision errors as determined from double analyses of different tissue volumes ranged from 0.01 to 0.3 litres. For validation purposes, CT-estimated organ weights were obtained by multiplying organ volumes by their assumed densities. The sums of all organ weights were then compared with the measured body weights. The error calculated from the individual differences between these weights was 0.6 kg (0.85%). The multicompartmentation technique described has a high validity and reproducibility and is applicable over a wide range of medical fields which require body composition measurements at the tissue and organ level. |
8044195 | Concentrations of adipsin in blood and rates of adipsin secretion by adipose tissue in humans with normal, elevated and diminished adipose tissue mass. | Adipsin, which is identical to complement factor D, is synthesized by fat cells, circulates in the bloodstream and is profoundly deficient in mice with genetic and hypothalamic obesity. With the recent cloning of human adipsin, a quantitative human immunoassay has been developed. In the present study, we measured adipsin blood concentrations in humans with increased and decreased adipose stores as well as adipsin secretion by adipose tissue obtained from lean and obese individuals. The results demonstrate that adipsin is released by human adipose tissue fragments as has previously been shown in mice, and that, in contrast to obese mice, blood adipsin concentrations were not reduced in the obese humans tested in this study. We also observed that blood adipsin concentrations can vary as a function of feeding or adiposity, in that they tend to be mildly elevated in obese individuals or mildly reduced in individuals with total lipo-atrophy, cachexia related to AIDS and anorexia nervosa. Thus, the circulating concentration of adipsin tends to correlate positively with degree of adiposity. Clearly, no deficiency in blood adipsin concentrations or adipsin secretion by adipose tissue was observed in the obese individuals studied. |
8044194 | Sexual dimorphism of age-related changes in whole-body fat distribution in the obese. | We performed a cross-sectional study using whole-body computerized tomographic (CT) scans in order to clarify age-related changes in whole-body fat distribution in both genders. The subjects were 66 men and 96 women, whose body mass index (BMI) was over 25 kg/m2. CT scans were performed at seven levels (head, fore-arms, upper arms, chest, abdomen, thighs and calves), and the fat volumes of the segments were calculated from the cross-sectional areas of the fat tissues. After calibrating to the total fat volumes, the relationship between age and the relative segmental fat volumes was analysed. In both genders, the relative intra-abdominal visceral fat volume increased and that of the legs decreased with age. The relative abdominal subcutaneous fat volume decreased with age only in male subjects. The increase in the relative visceral fat volume with age was about 2.6 times larger in males than in pre-menopausal females, while post-menopausal females showed the same increase as male subjects. These data suggest that there is a definite gender difference in the age-related changes in whole-body fat distribution, especially in the abdominal fat tissues. In addition, the accumulation of visceral fat is markedly accelerated by menopause in women. |
8044193 | Dexfenfluramine reduces cardiovascular risk factors. | This study investigated the potential for dexfenfluramine to improve biochemical and clinical risk factors for cardiovascular disease, in obese dyslipidaemic individuals. Dexfenfluramine, the dextro isomer of fenfluramine, has been shown to aid weight reduction and lower blood lipids in normal subjects, and to improve glucose tolerance and insulin sensitivity in subjects with diabetes mellitus. Twenty-nine overweight (mean weight 83.3 +/- 11.3 kg), hyperlipidaemic (mean total cholesterol 7.3 +/- 1.2 mol/l) subjects participated in a 12-week randomized double-blind parallel study of dexfenfluramine versus placebo. After an eight-week dietary run-in phase, subjects were randomised to treatment with either dexfenfluramine or placebo for 12 weeks. During the run-in, energy intakes fell in both groups (5.5% for dexfenfluramine, 5% for placebo, no significant difference between groups). Dietary composition improved, fat as a percentage of energy decreased (14%, P < 0.001, for dexfenfluramine; 11.7%, P < 0.05, for placebo), and carbohydrate increased (8.5%, P < 0.05, for dexfenfluramine; 5.6%, not significant, for placebo). During the treatment period, energy intakes in the dexfenfluramine group were further reduced by 7.5%, whereas there was no change in the placebo group (P = 0.02 between dexfenfluramine and placebo groups); however, nutrient composition remained constant for both groups. Side-effects were formally reported by 40% of subjects during the initial four weeks' treatment with dexfenfluramine with three subjects withdrawing from the study. Side-effects were largely resolved by week 4. Both groups lost weight similarly during the run-in but there were no significant changes in any biochemical parameters.(ABSTRACT TRUNCATED AT 250 WORDS) |
8044192 | Ventricular mass in hypertensive and normotensive obese subjects. | Two-dimensional echocardiography was performed in 29 normotensive obese subjects and 21 hypertensive obese subjects representative of the Chilean population. The left ventricular mass (LVM) did not correlate with height or body surface area (BSA) in these patients, but positively correlated with body mass index (BMI), tricipital skinfold thickness and blood pressure (BP). The LVM/BSA ratio was significantly higher in the hypertensive subjects and was correlated with BP only. Left ventricular hypertrophy (LVM/BSA > 120 or 150 g/m2 in women or men, respectively) was found in 28% of normotensive and 58% of hypertensive subjects (P = 0.036). No statistical differences were found in relative wall thickness (RWT) between both groups. Posterior wall thickness was independently associated with BP while interventricular septum thickness was positively associated with the waist/hip ratio. Systolic function, evaluated through fractional shortening and end systolic diameters, was negatively and independently associated with body fat area. Left ventricular hypertrophy is a prevalent condition in these obese subjects. Hypertension seems to exert an additive effect, mainly increasing posterior wall thickness. Fat accumulation was negatively related to systolic function in this sample, irrespective of blood pressure. |
8044188 | [Retroperitoneal fibrosis due to barium]. | The authors report two cases of retroperitoneal fibrosis secondary to rectal perforation occurring during barium enema. In view of the variable interval between the radiological accident and the urological complications, a long patient follow-up is recommended. If ureteric obstruction occurs, ureteric catheterisation is a temporary alternative, but surgery is the treatment of choice. When ureterolysis cannot be performed, the authors propose ureteroileoplasty to restore continuity of the urinary tract. |
8044186 | [The treatment of sterility due to retrograde ejaculation, using implantation of a pericervical sphincter prosthesis. Apropos of a case]. | The authors report the case of a 26 year old man consulting for primary sterility due to retrograde ejaculation, which was associated with urinary incontinence secondary to repeated surgery to the bladder neck for neurogenic bladder in a patient with incomplete spina bifida. Pericervical implantation of an AMS 800 artificial sphincter restored perfect continence and normal ejaculation followed by a pregnancy for his wife. |
8044185 | [A simple alteration in a ureteral double J stent to improve its clinical acceptability]. | The authors describe a modification of the classical double J stent designed to improve its clinical acceptability. It consists of cutting the lower J so that the catheter, inserted in the ureter, does not protrude into the bladder. A loop of nonresorbable suture attached to the lower extremity of the stent is passed through the ureteric orifice, allowing its easy extraction. This procedure has been used in eight patients with no complications. |
8044182 | [Endoscopic treatment of vesico-ureteral reflux using teflon injections]. | We have reviewed 124 patients with vesicoureteral reflux who were treated by endoscopic injection of polytetrafluoroethylene (Teflon) in four institutions. Of these patients 71 had bilateral reflux and 53 had unilateral reflux. In all, 195 ureters were treated. Reflux was primary in 94 cases (143 ureters) and secondary in 30 cases (52 ureters). Only 118 ureters (60.5%) showed no more reflux after a single injection. Seventy-seven ureters needed a second or third Teflon injection to control their reflux. In this group, reflux was cured in 46 ureters (23.6%) for a total cure rate by Teflon injection of 84.1%. Thirty-one ureters (15.9%) needed reimplantation (follow-up ranged from 1-4 years). In this study we assessed results in relation to the grade and type of reflux, the injected dose of Teflon and the technique used. The possible causes of failure and the reported complications are discussed. |
8044184 | [The Medical Information System Program in urology: what should be considered?]. | Medical data processing, introduced in France in 1985 has been compulsory for public hospitals since 1989 and has been tested in private institutions since 1991. A trial is currently underway in the Languedoc-Roussillon region to determine whether medical data processing can be used to modulate the global budget for hospitals and to define a new fees scheme for private clinics. The objective of the first part of this paper is to explain the origins of medical data processing and to understand its mechanisms and limitations. The second part situates medical data processing in the more general context of medicalization of information systems and emphasises the importance of an individual discipline approach for urology. |
8044181 | [A new technic of continent urinary diversion: preliminary results]. | This paper presents the results of a series of 10 continent urinary valves performed in the urology department of Ibnou-Rochd hospital in Casablanca according to an original technique between 1991 and 1993. These 10 patients (6 men and 4 women) suffered from various diseases of the lower urinary tract: 4 bladder tumrous, 3 complex vesicovaginal fistulae, two of which were associated with a rectovaginal fistula, one bladder exstrophy, one neurogenic bladder and one extensive urethral stricture. The authors describe the surgical technique and the postoperative course. A detubularized ileal graft was used to create a monoblock valve-reservoir. An effective antireflux system protects the upper urinary tract and continence is ensured by a robust hydraulic valve whose flexibility and patency allow very easy self-catheterization. The physical and urodynamic characteristics of this new diversion make it a solid, perfectly continent solution providing undeniable comfort for the patient. Although based on a limited series, these results illustrate the advantages of this new continent detubularized ileal graft diversion. |
8044183 | [Antenatal diagnosis of obstructive uropathies: state of the art]. | The development of ultrasonography has allowed the antenatal diagnosis of various forms of obstructive uropathy. The diagnosis of urinary tract dilatation is now possible by the 15th week of pregnancy. More recently, the study of foetal urine biochemistry has defined the prognostic factors of the course of postnatal renal function. The authors define and limit the current indications for the various antenatal interventions on the basis of the combination of antenatal ultrasonography and foetal urine biochemistry. |
8044180 | [Treatment of kidney and retroperitoneal abscesses using percutaneous drainage. Apropos of 17 cases]. | For a long time, the treatment of retroperitoneal abscesses was exclusively surgical. Ultrasonography and computed tomography provide new therapeutic approaches to these lesions. The authors report a series of 17 renal and retroperitoneal abscesses treated by primary percutaneous drainage. This treatment generally ensures a favourable course, avoiding the need for surgery, which is still indicated in patients with associated uropathy or after failure of percutaneous drainage. |
8044179 | [Percutaneous drainage nephrostomy in patients over 70 years of age. Apropos of 98 nephrostomies in 74 patients]. | From 1985 to 1992, 98 ultrasound-guided percutaneous drainage nephrostomies were performed in 74 patients with a mean age of 77 years (range: 70-88 years). The diversion was indicated because of upper urinary tract obstruction (87% of cases), urinary fistula (4%) or secondary displacement of the first PCN (9%). The initial disease was benign in 29 patients (42.5%, including 48% of renal and ureteric stones), malignant in 39 cases (53%, including 79% of pelvic cancers) and not specified in 6 cases (4.5%). PCN was performed successfully in 93% of patients and allowed improvement in renal failure and/or treatment of the initial infectious syndrome in the majority of cases. The following complications were observed: secondary displacement of the drain (13 cases), infection (3 cases), renal subcapsular haematoma (1 case). The outcome of the patients was directly related to the initial disease: 28 of the 29 patients diverted for a benign disease were still alive and the PCN drain was able to be removed in 96% of cases after curative treatment; 95% of the patients diverted for cancer had died within 13 months after PCN. Patients with previously untreated prostatic cancer had the best prognosis, as androgen suppression allowed removal of the PCN without any additional procedure, in some cases. Drainage of the upper urinary tract by percutaneous nephrostomy under local anaesthesia has a limited morbidity and a low failure rate and therefore appears to be a technique of choice, particularly in elderly patients. |
8044178 | [Urethro-vesical stenosis after radical prostatectomy]. | Stricture of the urethrovesical anastomosis is an uncommon complication of radical prostatectomy, but it can affect the patient's quality of life. From January 1991 to December 1993, 50 patients underwent radical prostatectomy for clinically localised prostatic cancer (41 via a retropubic incision and 9 via a perineal incision). We retrospectively studied the influence of several factors on the incidence of anastomotic stricture: history of prostatic surgery, surgical incision, blood loss, pathological stage, presence of a contrast agent leak during follow-up urethrocystography, postoperative adjuvant treatment, oncological status at the time of the stricture. Seven patients developed clinically significant anastomotic stricture (14%). The time to onset was 1.5 to 10 months (median: 3 months). We were unable to demonstrate any pre-, intra- or postoperative or histological factors able to predict the development of anastomotic stricture. The transperineal approach appears to be associated with a lower incidence, but this finding must be confirmed in a larger series of patients. The seven patients with an anastomotic stricture were treated by endoscopic scalpel incision of the stricture, followed by insertion of a 22 F Foley catheter for 48 hours. No patient has developed a recurrent stricture with a mean follow-up of 8 months (0 to 13 months). Postoperative continence was normal in every case. |
8044176 | Cytochrome c oxidase subunit I from the cockroach Blattella germanica: cloning, developmental pattern and tissue expression. | The nucleotide sequence of a cDNA corresponding to the transcription product of the mitochondrial structural gene cytochrome c oxidase subunit I was determined. A polypeptide of 508 residues was deduced from the reading frame established by the nucleotide sequence. TGA codes tryptophan, as in most other mitochondrial systems. From the comparison of the amino acid sequence of the putative Blattella germanica cytochrome c oxidase with those of Drosophila, we conclude that ATA and AGA codons specify methionine and serine respectively, instead of isoleucine and arginine. The sequence proposed for cytochrome c oxidase subunit I of B. germanica is largely homologous to that of other species. From the alignment of cytochrome c oxidase subunit I protein sequences we have found that 125 residues (positional identity of 22.3%) have remained invariant in this enzyme for more than one billion years of divergence. There is a developmental pattern of gene expression affecting the embryo stages. Northern blot analysis of RNA samples from different adult female tissues shows high cytochrome c oxidase subunit I mRNA levels in gut and fat body, and lower levels in ovary and colleterial glands. |
8044175 | Cloning of cDNA for vitellogenin of Athalia rosae (Hymenoptera) and characterization of the vitellogenin gene expression. | Athalia rosae (Hymenoptera) was previously shown to have two vitellins (L-Vn and S-Vn) and the two corresponding vitellogenins (L-Vg and S-Vg). A cDNA expression library was constructed from poly(A)+ RNA prepared from adult female fat body cells, and was screened for the vitellogenins by using antisera against the L- and S-Vn, respectively. Examinations of cloned cDNAs show that the vitellogenin gene is transcribed as a single unit, with the 5'-terminal site coding for the S-Vg and the 3'-terminal site for the L-Vg. Nucleotide sequence at the 5'-end suggests the presence of a 16 amino acid-long signal peptide. Deduced amino acid sequence following the signal peptide shows a complete match with up to the 28 N-terminal amino acid sequence determined on S-Vn. The S-L Vg boundary with deduced amino acid sequence matching with 6 N-terminal amino acid sequence determined on L-Vn is also detected. Northern blot hybridization analysis shows that the vitellogenin gene is expressed in the female fat body as a single 6.5 kb mRNA but not in the ovary, and not in the male fat body. Western blot analysis detects a large precursor polypeptide, reacting with the anti-L-Vn and S-Vn antisera, in the adult female fat body. |
8044174 | Monoamine uptake in insect synaptosomal preparations. | Biochemical studies of mammalian synaptosomal nerve fractions indicate the existence of multiple transporter proteins important for the termination of synaptic transmission by each of several monoamines. In insects, however, data on monoamine uptake has been limited to the study of whole tissue preparations, making it unclear whether neuronal (as opposed to glial) uptake is a significant mechanism in the insect. The present experiments elucidate the difficulties that have limited the use of insect synaptosomal preparations for characterizing amine reuptake. Key procedural improvements, including the utilization of carrier protein for tracer separation and the use of receptor antagonists to decrease non-specific membrane binding are described. With these and other modifications, reproducible sodium-dependent and cocaine-inhibitable dopamine and octopamine uptake are described in synaptosomal-containing preparations from insect brain and ganglia. These studies therefore support the existence of specific Na(+)-dependent uptake mechanisms in insect neurons. |
8044173 | Biochemical and cytological characterization of DROP-1: a widely distributed proteoglycan in Drosophila. | Using Drosophila testis as a source of antigen, 12 monoclonal antibodies were isolated that all recognize a set of three high molecular weight molecules present on Drosophila sperm and also in the fertilized egg. Among these antibodies, one is highly specific for sperm, while the remaining 11 detect epitopes present not only on sperm, but also in yolk spheres or in a punctate distribution in the egg. Here we cytologically and biochemically characterize the (common) antigens to five of these antibodies. Several biochemical properties suggest that these antibodies recognize a family of glycosaminoglycan-containing proteoglycans: (1) three diffuse, poorly focused high molecular weight bands, all in excess of 200,000 Da were observed on Western blots of denaturing SDS gels; (2) all three bands have a pI in the range of 3.0-3.5; (3) the molecules are strongly resistant to proteolysis; (4) mild periodate oxidation renders the molecules reactive towards the derivatizing agent digoxygenin-hydrazide, indicating the likely presence of saccharide moieties; (5) trifluoromethyl sulfonic acid treatment, which removes saccharide moieties, shifts the pI to 7.0; (6) beta-elimination increases electrophoretic mobility of the antigens on SDS gels; (7) nitrous acid treatment, which cleaves N-sulfated glycosaminoglycans, also increases the electrophoretic mobility of the antigens on SDS gels. We conclude that the antigens recognized by these antibodies are likely to be heparan sulfate proteoglycans. These results indicate that DROP-1 may represent a family of proteoglycans present during embryogenesis and later stages of development in Drosophila. DROP-1 represents the third proteoglycan to be characterized in Drosophila. |
8044172 | Lipopolysaccharide-lipophorin complex formation in insect hemolymph: a common pathway of lipopolysaccharide detoxification both in insects and in mammals. | The formation of the lipophorin-lipopolysaccharide (LPS) complex in Bombyx mori hemolymph and its role in LPS detoxification were explored. LPS, an antibacterial protein inducer in insects, was injected into B. mori larvae. Analytical density gradient ultracentrifugation revealed that after injection the LPS peak shifts to a zone of lower density with time. The shifted peak was identified as the lipophorin-LPS complex. This complex formation was also achieved in an in vitro mixture of cell-free hemolymph and LPS at 25 degrees C but not at 1 degree C. The lipophorin-LPS complex had a significantly lower capacity to elicit the mRNA of cecropin B, an antibacterial protein. The biological activity of reextracted LPS from the complex was slightly reduced in the Limulus test and no structural modification was observed in sodium dodecylsulfate-polyacrylamide gel electrophoresis (SDS-PAGE). These results suggested that the formation of lipophorin-LPS strikingly reduces the cecropin inducibility of LPS without any structural change in LPS. Similar serum lipoprotein-LPS complex formation and reduction of biological activities of LPS were also observed in mammals. We, therefore, suggest that the formation of the serum lipoprotein-LPS complex is a common pathway to inactivate LPS both in insects and in mammals. |
8044171 | Conflict of interest in medical research and development. | The introduction of laparoscopic cholecystectomy via nontraditional methods opened Pandora's box regarding issues of cost effectiveness, diagnostic need, safety, and efficacy. This article discusses one of many ethical concerns related to new-procedure introduction, conflict of interest in medical research and development. Conflict of interest is defined and suggestions of how to implement conflict of interest rules are discussed. As new procedures and modalities continue to be introduced at a rapid rate, it will be important to manage them appropriately. |
8044170 | Endoscopy: a perspective from industry. | This article discusses industry's role in the field of minimally invasive surgery. The product development cycle is explained, from the selection of products for development to the establishment of quality control and measurement systems, and industry's place is sponsoring and facilitating professional education and research. |
8044169 | Reusable laparoscopic instruments: continuous quality improvement. | Proactive management of processing activities is cost effective, fulfills the requirements of the Joint Commission for the Accreditation of Healthcare Organizations, and meets professional recommended practices. Controlling the variables is the key to producing an acceptable product each and every time. It may not be possible to completely eliminate variations, but they can be reduced to an acceptable level with product testing; simple, illustrated procedures with measurable outcomes; employee education; and adequate inventory. A cost-effective system approach can be developed to provide a high level of assurance that rigid laparoscopic instruments are clean, functional, and sterile each time they are used. |
8044167 | What's new in gynecologic endoscopy: endometrial ablation. | From January 1987 to December 1993, 247 patients underwent endometrial ablation as an alternative to hysterectomy in our practice. All these patients had abnormal uterine bleeding, and were evaluated by diagnostic office hysteroscopy and endometrial biopsy and then treated in the hospital outpatient center. The success rates for the procedure were greater than 95% as measured by patient satisfaction, and had amenorrhea rates varying from 50% for those patients in their reproductive years to 85% for those patients who were postmenopausal. The complication rates for the procedure were 0.7% and included perforation of the uterus and fluid overload. The procedure of endometrial ablation is a safe, effective alternative to hysterectomy for the treatment of abnormal uterine bleeding. |
8044168 | Sinoscopy. | Endoscopic sinus surgery is relatively new to the United States, having been imported from Europe in 1985. It has brought about a new way of looking at and treating chronic bacterial infections of the paranasal sinuses. The advance in technology rests on the development of the computed tomography scan as well as on the more recent development of the sinus endoscopes. These two technologies allow one to make a diagnosis of much more subtle chronic bacterial sinus infections than was possible in the past. In addition, it allows for more directed treatment in a way that spares mucosa, allowing for faster and better healing. |
8044166 | Perioperative care management for the patient undergoing gynecologic laparoscopy. | Patients undergoing abdominal laparoscopy require a process that is systematic and thorough and that at the same time has the flexibility to adapt to each individual's needs. The use of standards of care will facilitate the delivery of care by all staff, providing important links to standardized perioperative documentation, orientation, and meeting of quality performance indicators. Two examples of standards of care are provided in this article. |
8044165 | Competency for the endoscopy team. | To ensure the delivery of quality patient care during endoscopic procedures, competency of all the team members must be ensured. The physician community deals with this differently than the other members of the perioperative team. Using questionnaires and skill checklists to conduct thorough assessments is essential. Developing programmed learning tools, levels of competency, and performance standards are some examples described in this article. The issue of competency must be managed on a regular basis to continually ensure that quality care is delivered. |
8044164 | Technology assessment and cost management. | Endoscopic, less-invasive surgery has reshaped health care. The skill of correctly assessing purchases and leases is critical to a surgical service's success. Video technology changes rapidly, and systems become obsolete in months, not years. Each update presents new learning curves, thus additional educational costs. Choosing reusable instrumentation may include hidden costs not fully appreciated, whereas disposables may create waste management and environmental problems. Assessing and managing the costs related to less-invasive surgery require in-depth analyses of an institution's specific needs and of available and future technology. |
8044163 | Establishing a minimally invasive surgery suite. | Establishing an exclusive minimally invasive surgery suite requires a commitment from management, administration, staff, and physicians. A specialized, dedicated staff becomes devoted to perfecting the procedures. There are many rewards associated with this obligation, the most rewarding being improvement in total quality patient care. |
8044161 | A brief history of endoscopy. | Endoscopy has revolutionized surgery. However, this recent revolution would not have been possible without the history of a series of technological breakthroughs in instrumentation, light sources, optics/photography, insufflation, and energy sources. |
8044160 | Opinion polling and decision making: a critical appraisal of quality of life assessment. | The relationship between quality of life (QOL) assessments and decision making, in relation to the delivery of health services, is subjected to critical appraisal. Three levels of decision making in the health care system are taken into account in the analysis. Criticisms of opinion polling provide the basis for the appraisal. Examples of criticisms considered are: Might the use of QOL information be manipulative? Could the interviews or questionnaires used to obtain QOL data influence personal opinions? Are the methods used sometimes defective and/or superficial? Will QOL information always be used in decision making in ways that are ascertainable and justifiable? It is concluded that the time has come for the main focus of critical appraisal in QOL research to shift, from an emphasis on evaluation of the quality of methods used for assessments of QOL, toward an emphasis on the practical usefulness of QOL data. |
8044162 | The future of surgical endoscopy. | The first great discoveries in endoscopy were made more than 100 years ago, but it is only recently that its potential has been appreciated by the majority of surgeons. Impelled by technical breakthroughs in optics, video, and instrumentation, endoscopic surgical procedures such as laparoscopic cholecystectomy have transformed the way surgeons and nurses perform their jobs in the operating room. As the dust settles after the initial frenzy of training courses, dizzying numbers of fresh procedures and ever-spiralling costs in high technology, conscientious appraisal of new methods ensuring their safety, efficacy, and cost-effectiveness must be accomplished. Perioperative nurses are singularly well placed to share in this process with surgeons. |
8044159 | Quality of life of cancer patients with different prognoses. | This study examines differences and similarities in the quality of life of 253 cancer patients with good, medium and poor prognoses. Our main hypothesis was that patients with a good prognosis will experience a higher quality of life than patients with a medium or poor prognosis. A multivariate analysis of covariance of eight quality of life scales was performed with prognosis as a factor and with age, sex, and the duration of the illness as covariates. Significant main effects of prognosis were found for the general QOL-scale and for physical aspects of quality of life. There were, however, only marginal and non-significant effects of prognosis groups on social and psychological functioning. A final multivariate analysis confirms earlier findings that performance status shows a weak but significant relationship with the psychological functioning. Thus, the physical condition of the patient at the time of measurement seems to have some influence on the psychological functioning, whereas the severity of the disease as indicated by the classification into prognosis groups does not. These results question the general attitude that seriously ill cancer patients have reduced social and psychological well-being. An alternative interpretation is that the scales used to measure psychological aspects of quality of life are inadequately sensitive. |
8044158 | Quality of life in adult survivors of lung, colon and prostate cancer. | In a cross-sectional study design, a disease free sample of 57 lung, 117 colon, and 104 prostate cancer survivors who represented short, intermediate and long-term survivors completed a detailed assessment of quality of life (QOL) and rehabilitation needs using the CAncer Rehabilitation Evaluation System (CARES). Demographic and medical data, social support, and a global QOL rating were also assessed. Lung cancer patients showed no differences in QOL with respect to their period of survival. QOL improved for survivors of colon cancer as they lived for longer periods, but declined with time for survivors of prostate cancer. The best predictor of QOL for all groups was KPS, although other variables such as type of hospital, gender, and work status were predictive for survivors of colon cancer. For survivors of prostate cancer comorbidity with other medical illnesses, time since diagnosis and comorbidity due to psychiatric difficulties were predictive of QOL. All groups had significant rehabilitation problems in the domains of physical, psychosocial, sexual, medical interaction, and marital relationships. Lung cancer survivors had more problems than the other cancer survivors. We conclude that patients who survive cancer do not return to a state of normal health. They demonstrate a variety of difficulties with which they must cope as they continue to survive. Greater efforts need to be made early in diagnosis and treatment to understand rehabilitation problems and target interventions in the hope of reducing later sequelae. |
8044157 | Quality of life among patients post-myocardial infarction at baseline in the Survival and Ventricular Enlargement (SAVE) trial. | A quality of life ancillary study was incorporated into the Survival and Ventricular Enlargement (SAVE) trial of captopril versus placebo among patients who survived an acute myocardial infarction with compromised ventricular functioning, but no overt heart failure. Assessments included patient symptoms, health perceptions, emotional, cognitive, social and sexual levels of functioning, as well as potential covariates, such as life events and social support. The purpose of this study was to evaluate the psychometric properties of the quality of life measures in the SAVE at baseline, and provide a pre-randomization profile of the SAVE patients. One hundred and eighty-four patients participated in this aspect of the trial. Reliability alpha coefficients were adequate or better for all questionnaires, except for life events and sexual activities. Consistent with prior studies, the quality of life parameters were uncorrelated with ventricular ejection fraction. Despite experiencing a recent myocardial infarction with compromised ventricular functioning, patients at baseline generally neither appeared depressed nor focused on symptoms. The baseline findings support the inclusion of the quality of life ancillary study in the overall SAVE trial because of the independent contribution likely to be achieved in terms of evaluating both disease progression and treatment efficacy. |
8044155 | [Method for predicting danger induced by longitudinal accelerations in the 'head-pelvis' direction]. | The paper deals with the results of the studies aimed to validate the criterion of prediction of human tolerance to longitudinal tailward accelerations on the basis of structural changes in cardiac rhythm recorded directly during exposure. The experiments have been done on centrifuge with recording the sequences of cardiac intervals at rest and each stage of exposure with successively increasing intensity. Representation of basic information as two-dimensional distributions of cardiointerval durations based on the autocorrelation rhythmography method has been used. In order to develop a criterion together with the traditional statistical parameters the factors of instability of the internal structure of cardiac rhythm have been considered. All parameters then have been intercompared in terms of a simple function permitting optimization even with small volume of experimental material. The proposed criterion made it possible to predict with high significance tolerance to exposure with minimal intensity while the clinico-physiologic and traditional statistical indices enable one to assess it under significantly greater loads. |
8044154 | Simulation of physical and biological aspects of GCR in ground-based experiments. | Many aspects of the interplanetary radiation environment can be simulated using high-energy charged-particle beams at ground based accelerator facilities. Some of the criteria and parameters used to define science requirements for such simulations are discussed. Some results from a ground-based radiation transport experiment are used to illustrate these considerations. |
8044153 | [Morphologic and histoenzymologic analysis of effect of electrical fields at 17 khz on testis and testis appendages in mice]. | Methods of quantitative morphological and histochemical assay were used to study effects of 9-month electrical exposure (f = 17 kHz, E = 100 kW/m2 for 1 or 4 hrs, 5 d/w) on testis and testis appendages in mice. Exposure in electromagnetic field gave rise to desquamation of spermatogenic epithelial layers in the seminiferous tubes, reduction of the number of testosterone-producing cells, microcirculatory changes, metabolic rearrangements, principally compensatory by nature and aimed to maintain spermatogenesis and steroidogenesis. Results of the experiment suggest accelerated reproductive ageing. |
8044152 | [Hypobaric atmosphere and decompression safety of outer space explorations on the first days of flight]. | 54 subjects aged 21-47 participated in 8 series of experiments (298 altitude investigations) aimed at selecting decompression-safe protocols for transition from hypobaric normoxic environment to reduced pressure. Experimental data is discussed and some protocols for safe transition to reduced pressure are recommended. The experiments allowed to display in diagram form the ratio of permissible magnitudes of residual pressure (the working pressure in the extravehicular suit) to the duration of a preliminary exposure in normoxic hypobaric conditions. |
8044151 | [Medical and biological aspects of artificial gravity: animal studies]. | In the review there analyzed the results of ground-based studies of rotation effects (at a gravity value near 1 g) on the animals, the experimental findings to determine a minimum effective value of artificial gravity as well as the data of biosatellite experiments. The major trends of animal studies in the artificial gravity area is presented. |
8044150 | [Changes of uric acid levels in rat tissues as a systemic reaction to hyperoxia]. | The levels of tissue antioxidant uric acid in relation to chromosomal aberrations and leaving erythrocytic chromatin were determined in the spleen, bone marrow and blood of rats exposed to toxic hyperoxia (0.7 MPa O2, convulsions). Considerable growth of the uric acid levels and the rate of chromosomal aberrations in all tissues was observed within the first hours after treatment. The article discusses mechanisms of uric acid formation, redistribution and disintegration in tissues under extreme conditions. Specificity of the uric acid metabolism in tissues was shown with the help of the correlation analysis of uric acid concentrations. Inverse relationship between uric levels and chromosomal impairments noted in some cases permits to make a supposition about genoprotective properties and adaptogenic role of uric acid during oxidative stress. |
8044149 | [Effect of hypothalamus and amygdala on the impulse activity of neurons of the medullary respiratory center in rats during hypoxia]. | Investigations into the role of the hypothalamus nuclei (dorsomedial and posthypothalamic) and amygdala (cortical and central) in regulation of impulse activity of medullary respiratory neurons and respiration as a whole revealed: a) phasic changes of there exponents in hypoxia; b) variety effect of excitation (activation, inhibition) due to stimulation of the structures. At the initial stage of hypoxia (the altitude of 4000-5000 m) hypoxic activation of the impulse discharge made moderating effect of stimulation more expressed as compared with the initial stage of hypoxia. At maximal altitudes (7500-8000 m) inhibition of respiratory neurons occurred and respiration grew slow and superficial. It is noteworthy that on this background stimulation of hypothalamus and amygdala caused more marked moderating effect when compared with the initial stage. This is apparently associated with disengaging of inhibitory effects of cortex on subcortical structures and increased influence of limbic structures on the bulbar respiratory center. |
8044148 | [Pulmonary hemodynamics and hemostasis in rabbits exposed to high altitude]. | Pulmonary hemodynamics, homeostasis and red blood parameters were studied in 77 rabbits in the mountains of the Tien Shan (3200 m above sea-level). Exposure of animals in alpine environment gave rise to pulmonary hypertension, polycythemia, alterations of homeostasis by the pattern of hyper- and hypocoagulation syndrome. On certain stages of adaptation products of paracoagulation were observed in blood as well as intravascular aggregation of formed elements, increased sensitivity of blood plates to platelet activation, increased fibrinolysis. Given existing hypothesis about involvement of changes in homeostasis and red blood in the pathogenesis of altitude pulmonary hypertension, the coefficients of paired linear correlation between indices of pulmonary hemodynamics and blood have been calculated. These coefficients are valid only for low values of the ratio. |
8044147 | [Effect of decompression on the compliment system]. | Decompression effects on the complement system were studied in healthy male volunteers who made 39 "ascents" to 7000-9000 m and 13 "descents" to 30 m. Hemolytic activity of the complement system components was determined in the blood serum taken from the cubital vein of the subjects immediately before and after decompression. The results of this study showed that in the absence symptoms of decompression sickness (DCS) and doppler-detected gas bubbles (GB) the subjects reduced activities of C1 and C4. In the event of altitude joint pains the activity of the complement system components was significantly unchanged. In subjects with circulating GB the complement status was more markedly altered following simulated descents rather than ascents pointing to an alternative activation of the system. Subject with the skin DCS had a two-fold reduction of the complement system activity by the alternative mechanism and a reduction of C5 activity whereas there were no changes in the activities of C1, C2, C3, C4, CH50. It is concluded that alternative activation of the complement system may be involved in the genesis of those DCS forms whose emergence relates to gaseous embolism of veins and pulmonary capillaries. |
8044146 | [Potassium transport from Infusoria Tetrahymena pyriformis GL, immobilized by accelerations of 80-260 g]. | The effects of direct influence of gravity on a cell have been studied. Potassium transport from infusoria. Tetrahymena pyriformis GL induced by the high gravitational levels which immobilize the cell (80, 140, 260 g) was examined. A minimum acceleration level at which the cells become motionless is 80 g. Kinetics of potassium output can be described as containing "fast" and "slow" component. The rate of potassium output relating to fast component does not depend on an acceleration level but is a function of the age and density of culture. The potassium output rate associated with slow component increases as acceleration is increased. It also rises in the course of time which points to a change of internal structure of the cells occurring the more rapidly the higher level of acceleration is. Direct effect of gravity on the cell is realized by two ways: 1) effect which results from difference of densities of cell and its environment; 2) effect on intracellular structures due to difference of their densities. It is supposed that the observed effects in main are being developed at the cost of a 2nd type of gravity effect. |
8044145 | [Gravity and animal development]. | Based on the literature data and the author's findings, a comparative-and-physiological analysis of the responses of the animals of a different evolutionary level to micro- and hypergravity has been attempted. The experimental data accumulated by this time show a good fit to N.N.Sirotinin's concept about an evolution of the resistance and the reactivity: the high tolerance to a changed gravity in the insects, the presence of reaction in fish and amphibians mainly in most early developmental stages or in reduced (having high sensitivity) lay, a wide range of the responses to a changed gravity in birds and mammals. The investigative prospects in the field of gravitational biology of the development are discussed. |
8044144 | [The role of vitamin-supplying greenhouse in the improvement of the functional performance of the Mars research crew]. | The paper deals with the problem of providing space crews with adequate diets in extended space flights (lasted for 2 yrs and longer). On the basis of analytic review of the literature data, the questions related to quality of frozen and canned diets after their long-term preservation and first of all the problem of safety of C and A group vitamins in these diets are discussed. There exists two opposing tendencies which counteract each other in providing the space crews with diets: an increased, as compared to adopted norms of consuming the vitamins by cosmonauts in the extreme spaceflight environments, on the one hand, and an expected inevitable decrease in the amount of some vitamins and the quality of some foods during their long-term preservation aboard spacecraft, on the other hand. It is concluded that the most probable solution of the problem under study would be the development of onboard greenhouse to supply the space crew in extended space flights with the required vitamins and other fresh food substances. It is proposed that using of space greenhouse as a part of food regeneration system must contribute to an increased stability and reliability of functioning of the major object of spacecraft, namely, the space crew. |
8044143 | Some aspects of zinc transport across eel (Anguilla anguilla) red blood cell membranes. | Zinc movement across eel and human red blood cell membranes was measured by atomic absorption spectrophotometry. It was observed that: 1) In human red blood cells zinc uptake is twice as rapid as in fish red blood cells over a temperature range of 10-40 degrees C. The low rate of zinc uptake in eel red blood cell may be simply the side effect of different surface area to volume ratios for the differences in cell size or, it may be due to the low permeability of bicarbonate through the red blood cell membranes. 2) Zinc uptake measured in eel and human red blood cells treated and untreated with external trypsin shows different features. The zinc uptake was reduced by about 40% in treated eel red blood cells with respect to the total uptake of untreated red blood cells. Human red blood cells treated and untreated with trypsin do not show any differences in the amount of zinc transported. 3) In fish red blood cells, zinc uptake in NaNO3 medium is markedly reduced, compared with that measured in NaCl medium. The [Zn2+i slightly increases in the presence of bicarbonate. In human red blood cells in NaNO3 medium the zinc uptake is strongly reduced and the presence of bicarbonate marginally increases the zinc influx. 4) In eel red blood cells there seem to be two independent pathways for zinc uptake: one DIDS-sensitive and the other DIDS-insensitive. DIDS 10 microM inhibits only 64% of the total zinc transported. Increasing the DIDS concentration did not give more inhibition. In human red blood cells only one DIDS-sensitive pathway for zinc transported seems to exist, because, 2, 5 microM DIDS inhibits 97% of zinc uptake. |
8044142 | Aphidicolin induces myogenic differentiation in the human rhabdomyosarcoma cell line KFR. | The effects of aphidicolin, a specific inhibitor of DNA polymerase alpha, on cell growth, DNA synthesis and myogenic differentiation in the human alveolar rhabdomyosarcoma cell line KFR were studied. The treatment with aphidicolin at 5 x 10(-6) M concentration, which completely inhibited DNA synthesis and cell growth, induced morphological differentiation of small mononuclear cells to elongated, multinucleated (myotube-like) structures. The morphological differentiation was accompanied by the expression of skeletal muscle myosin; about 30% myosin-positive cells were observed after 14 days of treatment, compared to 2.3% in untreated cultures. The results showed that aphidicolin induces differentiation of human rhabdomyosarcoma cells and that multinucleated myotube-like elements may develop simply by cell fusion without cell division and DNA synthesis. |
8044141 | Protective effects of Nocardia delipidated cell mitogen on the mucosa of the small intestine after irradiation of germ-free piglets. | The radioprotective effect of the bacterial immunomodulator Nocardia delipidated cell mitogen (NDCM) on intestinal mucosa and disaccharidase activities was studied in irradiated germ-free piglets. Three-week-old germ-free (GF) piglets were intragastrically pretreated with 1 mg NDCM per 1 kg body weight. The piglets were whole-body irradiated with 2.5 Gray five days after the NDCM pretreatment and sacrificed eight days after irradiation. In the non-irradiated group of GF piglets, NDCM application stimulated lactase activity and markedly increased sucrase activity. This stimulatory effect of NDCM disappeared after irradiation and the piglets exhibited a normal activity of lactase in the jejunal brush-border membrane vesicles, while the sucrase activity decreased to the level found in irradiated controls. NDCM-pretreated intestinal mucosa contained some infrequent lymphocytes which disappeared from the control irradiated tissue. It also exhibited less injury of the epithelium and stroma cells. |
8044140 | Extracts from mdx and normal mouse skeletal muscle contain similar levels of mitogenic activity for myoblasts. | The mdx mouse has been used as an animal model for human Duchenne muscular dystrophy (DMD). Unlike DMD, skeletal muscles of mdx mice undergo successful regeneration and do not show extensive fibrosis and functional impairment. Growth factors have been proposed to be involved in muscle growth and regeneration. We compared mitogenic activity for skeletal myoblasts released after injury in mdx and control mice, using crushed muscle extract (CME) as a model system. We found that CMEs from normal and mdx mice contained similar mitogenic activities per microgram protein, and produced similar maximal levels of mitogenic stimulation. Skeletal muscles from mdx mice, however, released higher amounts of CME protein per gram of muscle weight compared to controls, possibly as a result of histological or physiological alterations in mdx muscle tissue. Adequate mitogenic activity in CME from mdx muscles may be related to successful muscle regeneration in mdx mice. |
8044139 | Psychotherapy and integrated treatment of social phobia and comorbid conditions. | Various treatment interventions for social phobia and its comorbid conditions have been developed in the past decade, including psychodynamic, cognitive-behavioral, and psychopharmacological approaches. Because social phobia has only fairly recently been recognized, no one form of treatment has been identified as superior to another. The difficulty in recognizing social phobia and identifying its frequent comorbidity with other psychiatric disorders poses particular treatment challenges. In this light, the author suggests eight operating principles that should be implemented to facilitate an effective, integrated approach to the treatment of patients with social phobia and comorbid conditions. |
8044138 | The diagnosis and treatment of social phobia and alcohol abuse. | There seems to be a high rate of comorbidity between social phobia and alcohol abuse. Evidence suggests that patients with social phobia are more than twice as likely to have alcohol problems as are nonpatients, and persons with alcohol disorders are nine times as likely to have social phobia as the general population. After examining possible reasons for the relationship between social phobia and alcohol abuse, the author discusses approaches to diagnosis and treatment of these conditions, in both alcohol treatment and mental health settings. |
8044137 | Comorbidity in social phobia: implications for cognitive-behavioral treatment. | As our system of nosology evolves and continues to split into more tightly defined discrete disorders, the issue of comorbidity looms larger. The fact of extensive comorbidity has implications for conceptualizing the nature of psychopathology as well as its treatment. The author presents recent conceptualizations of the nature of anxiety and the relationship of social phobic features to more generalized anxiety. After discussing new data on the treatment of social phobia from a cognitive-behavioral perspective, he reviews new findings demonstrating patterns of extensive comorbidity that have emerged from research at the Center for Stress and Anxiety Disorders at the University at Albany, State University of New York. The implications of comorbidity for integrated treatment of social phobia are then discussed. |
8044136 | Uncharted waters: psychodynamic considerations in the diagnosis and treatment of social phobia. | Despite the prevalence and psychological toll of social phobia, it has only recently been systematically studied. Although major advances in pharmacotherapy and cognitive-behavioral therapies have added to treatment options available for these patients, social phobia still goes unrecognized and untreated. The author examines how particular countertransference reactions to patients may interfere with the recognition and subsequent treatment of social phobia. She notes that the psychodynamic literature has also neglected this topic, although aspects of social phobia are imbedded in previously described neurotic or characterologically disturbed patients. Two case examples are presented that explore psychodynamic issues related to shame, aggression, trauma, and unresolved grief in the etiology of social phobia. The author believes that treatments that more fully integrate psychodynamic principles with pharmacological treatment and cognitive-behavioral methods will be efficacious in treating this diverse group of patients. |
8044135 | Social phobia: anxiety disorder comorbidity. | Research findings indicate significant comorbidity rates among the anxiety disorders, both between the various anxiety conditions and with other psychiatric and medical disorders. Although some other anxiety disorders have been widely investigated, social phobia was relatively unstudied before 1985. The authors review relevant epidemiological and clinical studies on comorbidity among the anxiety disorders, as well as on the relationship of social phobia with other anxiety disorders. They suggest that social phobia is a distinct diagnostic category and conclude that until a common methodological framework is established for obtaining reliable data, controlled comorbidity studies will not be fully beneficial. |
8044133 | Agoraphobia: the interface between anxiety and personality disorder. | Although agoraphobia includes distinct symptoms of avoidant and dependent personality disorder, it is currently classified as a form of "anxiety disorder." Such categorization seems to imply that uncontrolled panic attacks sometimes generate subsequent avoidant and dependent traits, leading afflicted persons to virtually seclude themselves in the home. The authors propose an alternate view, suggesting that in many cases the etiology of the disorder can be attributed to a predisposing antecedent character structure. The initial panic attacks are triggered by a stressor, but patients can then use these symptoms to further intensify and justify avoidant and dependent behavior. This paper features the autobiographical account of an agoraphobic woman who seldom comes to the clinic for therapy, and never on her own. The "fear of fear" characteristic of agoraphobia is readily traced in her history to a family background in which she was conditioned to feel that she could not manage without the direct support of her father. |
8044132 | Enhancing treatment with psychotropic medicines. | Psychiatric treatment of persons with severe, recurring, or chronic disorders of mood, cognition, or behavior is increasingly provided in ambulatory settings where control of treatment shifts to the patient. Medicines are a fundamental component in the effective, comprehensive care of such severely ill patients, and often are required for prolonged periods. The author discusses ways to enhance the effectiveness and safety of medication usage, including objective evaluation of responses, awareness of predictable pharmacological factors, use of adequate but simplified regimens, recognition of the patient as a consumer of services, and appreciation of individual and interpersonal psychological factors. The author concludes that sound clinical judgement and common sense, as well as sensitivity to the needs, circumstances, and reactions of individual patients, can increase adherence to and success of any psychiatric treatment. |
8044131 | Innovative uses of psychodynamic group psychotherapy. | Psychodynamic group psychotherapy is gaining renewed attention as an effective form of treatment, due in part to increasing economic constraints that make other forms of treatment less accessible. The author highlights some innovative applications of both extended and time-limited groups. She also describes specific issues that can be addressed effectively in homogeneous time-limited group therapy. |
8044130 | Challenges in conceptualizing psychotic mood disorders. | Psychotic mood disorders represent a complex group of syndromes in which depression and/or mania are accompanied by delusions, hallucinations, or both. The presence of psychotic features has a profound influence on the course and treatment response of mood disorders, and psychotic disorders in turn are influenced by coexisting dysregulation of mood. Psychosis and mood, along with other features such as severity, a high rate of recurrence, psychomotor changes, dissociation, and mental states reflecting a history of trauma, appear to interact to alter each other's expression. The treatment of psychotic mood disorders, regardless of coexisting conditions, requires pharmacotherapy--usually a combination of an antipsychotic drug and a medication for mood--or electroconvulsive therapy. The results of treatment are usually positive. |
8044129 | Borderline disorders in children and adolescents: the concept, the diagnosis, and the controversies. | The concept of borderline disorders in children and adolescents remains controversial. After reviewing the development of the "borderline" diagnosis, the author discusses the concept of personality disorders in children and clinical features of borderline personality disorder. He also highlights current ideas on the etiology of the disorder, including psychodynamic, developmental, and biological theories, family factors such as the effects of early loss or separation from parents, and physical and sexual abuse. The author concludes by discussing the differences and similarities between posttraumatic stress disorder as a result of sexual abuse and borderline personality disorder in children and adolescents. |
8044127 | Prevalence of HIV and associated risk behaviour in attendees at a Dublin needle exchange. | The aim of this study was to measure the prevalence of HIV infection and assess the level of equipment-sharing and unsafe sexual activity among attendees at a Dublin needle exchange. Using an anonymous unlinked approach, attendees were asked to complete a brief questionnaire and provide a sample of saliva for HIV testing. Of the 144 attendees eligible for inclusion during the study period, 106 agreed to participate and complete a questionnaire, a response rate of 74%. Of the 81 respondents who submitted a usable saliva sample, 14.8% were HIV positive. Half of the respondents claimed that they had not shared equipment during the preceding 28 days, but a third had shared with multiple partners. Half of the respondents claimed that they had multiple sexual partners during the preceding year, but only a quarter said that they always used condoms. The prevalence of HIV infection is similar to that found in routine linked testing of drug users in Ireland. The high level of unsafe injecting and sexual activity makes clear the need for more effective health promotion among drug users in Dublin. |
8044126 | The alcohol content of self-report and 'standard' drinks. | A stubborn problem in alcohol epidemiology is that of standardization of unit of measurement. Consistent use of the 'standard drink' in research reports is hampered by difficulties in the assessment of the alcohol content of, particularly, self-reported drinks. Alcohol content of a drink depends on strength of the beverage and volume of the glass or container from which the beverage is taken. Both factors vary considerably between times, regions and individuals. Interview protocols and questionnaires rarely take into account the fact that people consume alcoholic beverages from a large variety of glasses and containers. In the present study the common presumption is tested of equality of alcohol content of standard and self-reported drinks. The test consisted of measuring the amount of wine, fortified wine and spirits people usually pour in the glass typical for the beverage type. The sample was drawn from the general Dutch population in 1985. The results show that on average self-reported drinks taken at home contained more than the presumed standard (10 g per drink). The deviation was highest for spirits (+26%), followed by fortified wines (+14%) and least for wine (+4%). There seemed to be a positive relationship between deviation from 'standard' and strength of the alcoholic beverage. This result is in line with data on the coverage of sales data: aggregate, survey-based spirits consumption shows the lowest coverage of sales. The effect of the difference between actual and presumed content of drinks on estimates of consumption is an overall increase of 7.5%, higher for women (+12%) than for men (+6%). Results are discussed with respect to the use of the concept of 'standard unit' in research protocols and health education campaigns. |
8044125 | Alcohol consumption and insomnia in a sample of Japanese alcoholics. | The amount of ethanol consumed by chronic alcoholics in a Japanese slum area with persistent insomnia (n = 40) and those without it (n = 40) was compared using a questionnaire. For both groups, the present habitual consumption (PHC) of ethanol per day was most frequently between 60 g and 150 g and no difference was observed between the two groups. In contrast, the maximum habitual consumption (MHC) of ethanol per day throughout the alcoholic history was found to be greater for the insomnia patients than the non-insomniacs (p < 0.001). No difference between the groups was found in the kind of alcoholic drink consumed, with sake (Japanese rice wine) being the most popular in both groups. The results suggest that persistent insomnia in alcoholics is related to excessive alcohol intake and persists even when drinking levels have fallen. |
8044124 | Negative affect, alcohol expectancies and alcohol-related problems. | Using data from the first epidemiological study of mainland Puerto Rican drinking, the authors explore the relationships between negative affect, alcohol expectancies and drinking problems. Results revealed that the co-occurrence of depressed mood and drinking problems was strongly moderated by alcohol expectancies. More specifically, the co-occurrence was strongest among those Puerto Ricans who most expected alcohol to elevate their mood. Findings are discussed in terms of their explication of the co-morbidity of depressive symptomatology and alcohol abuse. |
8044123 | Validity of the bi-axial dependence concept: a test in the US general population. | According to the "bi-axial" concept of alcohol dependence, the Alcohol Dependence Syndrome (ADS) constitutes an axis or dimension of alcohol difficulties, while other alcohol-related problems (social, legal, etc.) constitute one or more separate dimensions. The validity of the bi-axial distinction was investigated in a stratified probability sample of 3212 US current drinkers who were interviewed in their households. Indicators of the Alcohol Dependence Syndrome and potentially distinct alcohol-related problems were covered in a structured interview administered by carefully trained interviewers. This interview provided extensive coverage of drinking patterns and problems. Aspects of the ADS covered included narrowing, salience, tolerance, withdrawal, withdrawal relief/avoidance and compulsion/control. Other alcohol problems included difficulties with work, health, the law, general social difficulties and problems in marriage/home life. Confirmatory and exploratory factor analyses were used to determine whether a single factor (dimension) or two or more factors fit the data best. Using all methods, we found that one general factor explained the structure of the data better than a two-factor model or other models for males, females, blacks and whites. Thus, the utility of this approach to distinguishing between types of alcohol problems was challenged, raising some questions about abuse/dependence distinctions in various nomenclatures. |
8044122 | Development of the Leeds Dependence Questionnaire (LDQ): a questionnaire to measure alcohol and opiate dependence in the context of a treatment evaluation package. | The Leeds Dependence Questionnaire (LDQ) has been developed as part of a treatment evaluation package. The LDQ is a 10-item, self completion questionnaire designed to measure dependence upon a variety of substances; it has been shown to be understood by users of alcohol and opiates. The questionnaire was designed to be sensitive to change over time and to be sensitive through the range from mild to severe dependence; the follow-up data are insufficient to demonstrate change over time, but are encouraging. It is expected that both clinicians and researchers will find it useful to have a single measure relating to substance use, but not limited by specific substances. All items are scored 0-1-2-3; there are no normative data. The procedure for establishing content validity is described and estimates of concurrent, discriminant and convergent validities are reported; these validities are thought to be satisfactory. A principal components analysis produced a single factor accounting for 64% of the variance. Cronbach's alpha was 0.94. Test-retest reliability was found to be 0.95. |
8044121 | A test of the matching hypothesis: alcohol dependence, intensity of treatment, and 12-month outcome. | The "matching hypothesis"--the concept that treatment will be improved if matched to individual needs or characteristics--has, over recent years, attracted attention, and some research to test its validity has been conducted. These studies are briefly reviewed and an analysis then reported which focuses on exploration of the possible interaction between treatment intensity, patient characteristics with particular reference to degree of dependence on alcohol, and 12-month treatment outcome. The data derive from a controlled trial in which patients were randomized between "Treatment" and "Advice". No significant interactions of the kind postulated were identified and, at least for this data set, the matching hypothesis is not confirmed. Possible interpretations of these findings are discussed. |
8044119 | What if alcoholism had not been invented? The dynamics of American alcohol mythology. | This essay speculates on what might have been had alcoholism not been invented. The invention is viewed as a product of the ongoing myth-making process whereby society continuously defines and redefines alcohol, seeking to integrate it into the culture in ways that allow enjoyment of its pleasures with minimum pain. Had alcoholism not been invented, (a) the myth-making process might have yielded another simplistic explanation of drunkenness, but more likely alcohol would have remained the supposed cause; (b) the per capita alcohol consumption uptrend of some 50 years standing might not have reversed as it did in 1982; (c) chronic drunkards might still be denied life-saving hospitalization which gains them more time for the natural reform process to work for them; and (d) local communities nationwide might have taken common-sense actions to facilitate the natural rehabilitation process and provided more benefit to more alcoholics for less cost than treating alcoholism. It is expected that Americans will continue to drink and will continue to seek a more harmonious relationship with alcohol. The informal social controls will continue to largely constrain individual appetites for alcohol's pleasures, and most alcoholics will continue to gain control of their excessive drinking in the natural course of events with or without exposure to alcoholism treatment. |
8044118 | Needle Park: what can we learn from the Zürich experience? | Needle Park in Zürich existed as an open air drug scene from 1986 until February 1992. Within this six year period the City Government, City Parliament, governmental and non-governmental organizations implemented a wide range of permissive and restrictive drug policies, from extensive harm reduction to closing the park. Police statistics and several studies suggest that tolerating an open air drug scene can have unforeseen and unfortunate consequences. Low drug prices, lack of law enforcement and lack of social control seem to attract drug users towards the open drug scene and the increase in problems appears to have been more rapid than the increase in the population of addicts. |
8044100 | Medical ethics: four principles plus attention to scope. | The "four principles plus scope" approach provides a simple, accessible, and culturally neutral approach to thinking about ethical issues in health care. The approach, developed in the United States, is based on four common, basic prima facie moral commitments--respect for autonomy, beneficence, nonmaleficence, and justice--plus concern for their scope of application. It offers a common, basic moral analytical framework and a common, basic moral language. Although they do not provide ordered rules, these principles can help doctors and other health care workers to make decisions when reflecting on moral issues that arise at work. |
8044097 | Screening and self examination for breast cancer. | Breast cancer is the major form of cancer in women, with nearly 30,000 new cases and over 15,000 deaths in the United Kingdom each year. Breast screening by mammography has been shown in randomised trials to reduce mortality from breast cancer in women aged 50 and over. An NHS breast screening programme has been in operation in the United Kingdom since 1988. Its aim is to reduce mortality from breast cancer by 25% in the population of women invited to be screened. The uptake of mammography among the eligible population may be the single most important determinant if the programme is to be effective. Primary care teams have an important part to play in encouraging women to attend for screening and in providing information, advice, and reassurance at all stages of the screening process. To date, routine breast self examination has not been shown to be an effective method of screening for breast cancer and should not therefore be promoted as a primary screening procedure. There is, however, a case to be made for women to become more "breast aware." |
8044095 | Late deaths and survival after childhood cancer: implications for cure. | To investigate causes of death and survival in subjects who had survived at least five years after diagnosis of childhood cancer; to compare observed mortality with that expected in the general population; and to compare results with a corresponding cohort diagnosed earlier. Retrospective cohort study. Population based National Register of Childhood Tumours. 9080 five year survivors of childhood cancer diagnosed in Britain during 1971-85, of whom 793 had died. Comparison with corresponding cohort diagnosed during 1940-70. Cause of death established from all available sources of information (including hospital and general practitioner records and postmortem reports) and underlying cause of death coded on death certificate. Of the 781 deaths for which sufficient information was available, death was attributed to recurrent tumour in 578 (74%) cases, treatment related effect in 121 (15%), second primary tumour in 52 (7%), and other causes in 30 (4%). Comparison of observed mortality with that expected in the general population indicated a fourfold excess of deaths from non-neoplastic causes. The risk of dying of recurrent tumour in the next 10 years after surviving five years from diagnosis during 1940-70 and 1971-85 fell from 12% to 8%. The risk of dying from a treatment related effect increased slightly from 1% to 2%. Improvements in five year survival after childhood cancer have been accompanied by a reduction in risk of dying from recurrent tumour during the subsequent 10 years and by a slight increase in risk of dying from treatment related effects. The results provide information relevant to decisions concerning balance between effective treatments and their potentially harmful effects. |
8044094 | Significant increase in trisomy 21 in Berlin nine months after the Chernobyl reactor accident: temporal correlation or causal relation? | To assess whether the increased prevalence of trisomy 21 in West Berlin in January 1987 might have been causally related to exposure to ionising radiation as a result of the Chernobyl reactor accident or was merely a chance event. Analysis of monthly prevalence of trisomy 21 in West Berlin from January 1980 to December 1989. Confines of West Berlin. Owing to the former "island" situation of West Berlin and its well organised health services, ascertainment of trisomy 21 was thought to be almost complete. A cluster of 12 cases occurred in January 1987 as compared with two or three expected. After exclusion of factors that might have explained the increase, including maternal age distribution, only exposure to radiation as a result of the Chernobyl reactor accident remained. In six of seven cases that could be studied cytogenetically the extra chromosome was of maternal origin, confirming that nondisjunction had occurred at about the time of conception. On the basis of two assumptions--(a) that maternal meiosis is an error prone process susceptible to exogenous factors at the time of conception; (b) that owing to the high prevalence of iodine deficiency in Berlin a large amount of iodine-131 would have been accumulated over a short period--it is concluded that the increased prevalence of trisomy 21 in West Berlin in January 1987 was causally related to a short period of exposure to ionising radiation as a result of the Chernobyl reactor accident. |
8044093 | Risk of acute childhood leukaemia in Sweden after the Chernobyl reactor accident. Swedish Child Leukaemia Group. | To evaluate the risk of acute childhood leukaemia in areas of Sweden contaminated after the Chernobyl reactor accident in April 1986. Population based study of childhood leukaemia diagnosed during 1980-92. Coordinates for places of residence of all 1.6 million children aged 0-15 years; aerial mapped areas of Sweden heavily contaminated after the Chernobyl accident. 888 children aged 0-15 years with acute leukaemia diagnosed in Sweden during 1980-92, identified with place of birth and residence at diagnosis. Risk of leukaemia in areas contaminated after the Chernobyl accident compared with the rest of Sweden and in the same areas before the accident. During six and a half years of follow up after the accident the odds ratio for acute leukaemia was 0.9 (95% confidence interval 0.6 to 1.4) in highly contaminated areas (> or = 10 kBq/m2) compared with the same areas before the accident. For the subgroup acute lymphoblastic leukaemia in children aged under 5 years at diagnosis the odds ratio was 1.5 (0.8 to 2.6). For all cases diagnosed after May 1986 in highly contaminated areas compared with areas of low contamination the odds ratio was 0.9 (0.7 to 1.3). For acute lymphoblastic leukaemia in children aged under 5 years at diagnosis the odds ratio was 1.2 (0.8 to 1.9) in highly contaminated areas compared with areas of low contamination. Dose-response analysis showed no correlation between the degree of contamination and the incidence of childhood leukaemia. There has been no significant increase in the incidence of acute childhood leukaemia in areas of Sweden contaminated after the Chernobyl reactor accident. |
8044092 | Fallout from Chernobyl and incidence of childhood leukaemia in Finland, 1976-92. | To assess effects of fallout from Chernobyl on incidence of childhood leukaemia in Finland. Nationwide cohort study. External exposure measured for 455 Finnish municipalities with instruments driven 19,000 km throughout the country. Values specific to municipalities corrected for shielding due to houses and fallout from A bomb testing. Internal exposure estimated from whole body measurements on a random sample of 81 children. Mean effective dose for two years after incident calculated from these measurements. Data on childhood leukaemia obtained from Finnish cancer registry and verified through hospitals treating childhood cancers. Finland, one of the countries most heavily contaminated by the Chernobyl accident; the population was divided into fifths by exposure. Children aged 0-14 years in 1976-92. Standardised incidence ratio of childhood leukaemia and relative excess risk of childhood leukaemia per mSv. From incidence data of Finnish cancer registry for 1976-85, expected numbers specific to sex and age group (0-4, 5-9, and 10-14 years) were calculated for each municipality for three periods (1976-85, 1986-8, and 1989-92) and pooled as exposure fifths. Dose response was estimated as regression slope of standardised incidence ratios on mean doses for fifths for each period. Population weighted mean effective doses for first two years after the accident were 410 microSv for the whole country and 970 microSv for the population fifth with the highest dose. In all Finland the incidence of childhood leukaemia did not increase 1976-92. The relative excess risk 1989-92 was not significantly different from zero (7% per mSv; 95% confidence interval -27% to 41%). An important increase in childhood leukaemia can be excluded. Any effect is smaller than eight extra cases per million children per year in Finland. The results are consistent with the magnitude of effect expected. |
8044070 | Run an emergency helpline. | Telephone helplines are an effective way of dealing with health related incidents in which large numbers of people need personal counselling or information for reassurance or case finding. Helplines often have to be set up at short notice, which is labour intensive and makes recruitment of appropriate staff difficult. They should ideally be part of local emergency planning resources. Doctors need to be included in the team organising the helpline to ensure that staff are properly briefed, to determine what data need to be collected, and to deal with specialised queries. |
8044068 | Inventing a new diagnostic test for vaginal infection. | Bacterial vaginosis, which is underdiagnosed in clinical practice, has a characteristic fishy smell because of production of diamines. This smell is the basis of a visual rapid diagnostic test that is technically simple to perform. The test has been patented in Europe and America, and a licence agreement has been negotiated. This paper describes the process from idea to invention to patenting and licensing. The combined costs of research and patenting were met by a multinational company in return for rights to exploit the patent invention. The process has taken nine years and has needed clinical, scientific, legal, and commercial input to get the test to the marketplace. |
8044063 | Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. | To estimate the extent to which changes in the main coronary risk factors (serum cholesterol concentration, blood pressure, and smoking) explain the decline in mortality from ischaemic heart disease and to evaluate the relative importance of change in each of these risk factors. Predicted changes in ischaemic heart disease mortality were calculated by a logistic regression model using the risk factor levels assessed by cross sectional population surveys, in 1972, 1977, 1982, 1987, and 1992. These predicted changes were compared with observed changes in mortality statistics. North Karelia and Kuopio provinces, Finland. 14,257 men and 14,786 women aged 30-59 randomly selected from the national population register. Levels of the risk factors and predicted and observed changes in mortality from ischaemic heart disease. The observed changes in the risk factors in the population from 1972 to 1992 predicted a decline in mortality from ischaemic heart disease of 44% (95% confidence interval 37% to 50%) in men and 49% (37% to 59%) in women. The observed decline was 55% (51% to 58%) and 68% (61 to 74) respectively. An assessment of the data on the risk factors for ischaemic heart disease and mortality suggests that most of the decline in mortality from ischaemic heart disease can be explained by changes in the three main coronary risk factors. |
8044061 | Decline in sperm counts: an artefact of changed reference range of "normal"? | To investigate a reported fall in sperm counts during 1940-90 in relation to the reduced lower reference value of "normal" during the same period by assuming the null hypothesis that no change had occurred in the probability distribution of the sperm concentration. Analysis by using various mathematical models of the probability distribution of sperm concentration together with experimental data which supported a model employing a logarithmic distribution. 235 men presenting for stimulated in vitro fertilisation at Midland Fertility Services, Aldridge, in 1992 together with samples of 20 ejaculates from each of five men attending the same centre during 1992-3. The effect of the change in lower reference value for the "normal" sperm concentration (from 60 x 10(9) to 20 x 10(9)/l) depended on the probability distribution of the concentration in the population. If that distribution was normal or uniform, then very little of the reported decline was a consequence of the change in lower reference value. If it was heavily skewed, then most or all of the reported decline may have been a consequence of that change. The limited experimental data available indicate that the distribution was heavily skewed. Depending on the actual distribution of sperm concentration in the population, the reported decline in concentration may have been accounted for entirely or in part by the change in lower reference value. The original evidence does not support the hypothesis that the sperm count declined significantly between 1940 and 1990. |
8044060 | Multicentre criterion based audit of the management of induced abortion in Scotland. | To assess and improve the quality of care provided to women undergoing induced abortion. Two rounds of prospective, criterion based case note review audit. Ten NHS gynaecology units throughout Scotland. 2004 patient episodes of abortion care identified consecutively during two rounds of audit. The first round comprised 967 cases and the second round 1037. Dissemination of results from the first round of audit and recommendations for change in the form of a written report and at postgraduate meetings in participating hospitals. Improvements in quality of care as assessed against 16 previously agreed criteria, both overall across the 10 study hospitals and within individual hospitals. Overall, four significant improvements occurred: increased availability of early medical abortion, decreased utilisation of surgical abortion at very early gestation, increased use of mifepristone priming before second trimester medical abortion, and increased provision of follow up. At the individual hospital level 42 of 150 elements of care studied were "close to optimal" at the time of the first round of audit, rising to 54 at the second round (NS). A total of 31 significant improvements in individual elements of care occurred, but 11 significant deteriorations also occurred (at the P < 0.05 level). The prospective multicentre audit proved feasible and achieved the aims of any form of audit in terms of identifying deficiencies and variations in care. The audit results prompted objective review of local abortion services in participating hospitals. At least for some elements of care in some hospitals significant improvements were detectable. |
8044059 | Influence of total cholesterol, high density lipoprotein cholesterol, and triglycerides on risk of cerebrovascular disease: the Copenhagen City Heart Study. | To estimate the influence of plasma total cholesterol, high density lipoprotein cholesterol, and triglycerides on risk of cerebrovascular disease. The Copenhagen City Heart Study is a prospective observational survey with two cardiovascular examinations at five year intervals. Non-fasting plasma lipids were measured in participants once at each examination, along with other variables. The Cox regression model was used to establish the effect of the factors recorded on cerebrovascular events of mostly, but not exclusively, ischaemic origin. 19,698 women and men at least 20 years old, randomly selected after age stratification from an area of central Copenhagen. Initial cases of stroke and transient ischaemic attack recorded from hospital records and death certificates from 1976 through 1988. 660 non-haemorrhagic and 33 haemorrhagic events were recorded. Total cholesterol was positively associated with risk of non-haemorrhagic events, but only for levels > 8 mmol/l, corresponding to the upper 5% of the distribution in the study population. For lower plasma cholesterol values the relative risk remained nearly constant. Plasma triglyceride concentration was significantly, positively associated with risk of non-haemorrhagic events. The relative risk corresponding to an increase of 1 mmol/l was 1.12 (95% confidence interval 1.07 to 1.16). There was a negative, log linear association between high density lipoprotein cholesterol and risk of non-haemorrhagic events (0.53 (0.34 to 0.83)). There was no indication that the effects of plasma lipids were different in women and men. The pattern of the association between plasma cholesterol and risk of ischaemic cerebrovascular disease was not log linear, and the increased risk was confined to the upper 5% of the cholesterol distribution. Further studies should concentrate on the association between plasma cholesterol and verified haemorrhagic stroke. |
8044057 | Toward a general procedure for quality improvement: the double track process. | Quality improvement efforts are the focus of leaders in many fields. While we have emerging examples of successful efforts we have fewer presentations of the pathways to follow. This paper offers a general procedure based on a Double Track model. Two procedural processes are offered: (1) at the whole organization level, Track 1, as a strategic means to quality improvement; and (2) at the project level, Track 2, for an operational path to quality improvement work at the team level. It is suggested that successful efforts follow this Double Track effort already and that further identification and elaboration of the pathway will speed diffusion of quality improvement efforts. |
8044056 | Indicators of physician timeliness in the process of care. | Physician timeliness at the junctures that define an episode of inpatient care is an extremely important clinical process variable. Medical staff policies that describe acceptable performance with respect to timeliness could be used in peer review and continuous quality improvement activities. The authors' external peer review experiences suggest that physician timeliness may be of concern during the admission and discharge processes, the monitoring and follow-up of patient progress, the provision of verbal orders, the transfer of responsibility between physicians, and the use of consultants. A full discussion of the implications of physician timeliness could provide the vehicle for greater understanding of the value of continuous quality improvement in the hospital setting and lead to more complete participation in developing strategies to improve the processes of care. |
8044054 | Reliability of a utilization review instrument in a large field study. | One important question for a utilization management program is whether the utilization review instrument is consistent or stable when used on many occasions by the same abstractor (intrarater reliability) or by several abstractors (inter-rater reliability). As part of a nationwide study of inappropriate utilization of inpatient services by the Department of Veterans Affairs, we conducted a thorough investigation of the inter-rater reliability of a widely used utilization review instrument by 27 nurse abstractors. All abstractors were extensively trained, both by the developers of the instrument and by use of practice medical records. A standard protocol for resolving questions was implemented, with immediate communication of decisions to abstractors. The results of three reliability assessments, conducted immediately after formal training, after several weeks of reviewing practice records, and midway through review of the study records, demonstrated good to excellent reliability, both when comparing the nurse abstractors with a physician gold standard and among themselves. Therefore, with appropriate training and monitoring, utilization management programs in large hospitals, multihospital systems, and other health care organizations needing to examine inpatient utilization should feel confident that they can achieve reviews that would be in close agreement with physician and other nurse abstractors. Such confidence should increase the acceptability of utilization management programs. |
8044055 | A first step in total quality management of nursing facility care: development of an empirical causal model of structure, process and outcome dimensions. | While the structure, process, and outcome taxonomy has long been used in the field of health care quality measurement and evaluation, it has not been used in a true causal model which assesses facility level quality. Total quality management and continuous quality improvement call for routinely assessing facility and resident level quality in a causal framework. This paper presents a causal modeling methodology as a more appropriate method for assessing and understanding the inter-relatedness among each of the quality dimensions of Nursing Facility care, and presents how such a causal model directly relates to the notion of continuous quality improvement. The methodology consists of five steps: (1) sample definition and data collection, (2) data reduction through factor analysis, (3) development and testing of a causal model through path analysis, (4) identification of patterns of care through cluster analysis, and (5) integration of the model to both continuous quality improvement and to complex relationships involving quality and organizational variables. The methodology is fully illustrated by using a sample of 104 nursing facilities in Wisconsin in which quality dimensions have been captured through the Quality Assessment Index. The analysis demonstrates that nursing facilities may be substantially benefited by having access to causal linkages which materially affect outcome quality. Management would then have first-hand knowledge of the structural characteristics and the process activities that they may pursue in order to improve outcome quality. |
8044053 | Utilization review for Medicaid diagnosis-related group systems: practice, innovation, and lessons of experience. | Utilization review practices, innovations and trends for the 21 states using diagnosis-related groups for Medicaid during 1992 are described. According to this descriptive survey, Medicaid inpatient utilization review programs vary widely in authority, approach and focus, reflecting state payment system incentives, health and hospital system characteristics, and provider practice norms. More than half of the states with Medicaid diagnosis-related group systems contract with a Medicare Peer Review Organization. State programs are developing complementary clinical and data analytic approaches, advised by multidisciplinary utilization review committees, and are moving from random review to strategies that focus on specific types of admissions/procedures, and shift as provider practices and utilization patterns change. Utilization review strategies also support payment incentives and system features, e.g., by targeting outliers, readmissions and transfers, and short stays. Overall, programs are becoming more flexible, targeted, and interactive. Trends and suggestions for refining utilization review programs for diagnosis-related group systems are presented. |
8044052 | Utilization of pulmonary function tests by primary care internists in a community hospital. | A quality assurance effort to evaluate the use of pulmonary function tests by primary care physicians. Specifically, to examine the patient's understanding of the test, the types of tests physicians order, and the appropriateness of the ordered tests for answering questions posed by physicians. Concurrent chart review, clinical interviews, and patient interviews. Community teaching hospital. 101 consecutive inpatients and outpatients, referred to the Pulmonary Function Laboratory over a consecutive 5-month period. Interview of the patient by a pulmonary technician. Interview of the primary care physician by a pulmonary physician. Interview, where applicable, with the house staff. Final assessment by a pulmonary physician. 64% of the patients understood the purpose of the test and 49% of the patients felt there was some potential benefit to be derived from participating in the testing. Sixty-five percent of the physicians ordered specific tests on their patients. Seventy-two percent of physicians planned on using the data obtained from testing to formulate treatment decisions. Fifty percent of the interviewed physicians said they were using the results for decisions regarding further diagnostic evaluation and/or treatment. The reviewing pulmonary physician considered that 31% of the pulmonary function tests ordered were appropriate for the goals defined by the requesting physician. Sixty-eight percent of the ordered tests could have had some aspects of ordering improved, and 1% of the testing was unnecessary. 1) There is a need to increase patient understanding of the indications and potential benefits of participating in pulmonary function testing. 2) When physicians-in-training are involved in the process of requesting pulmonary function tests, greater staff-level supervision and involvement should be present. 3) There is a need to increase physician knowledge regarding the appropriate pulmonary function tests that should be requested for specific clinical questions and situations. 4) The requesting form for pulmonary function testing may serve to remind and educate the physician, while documenting the indications for the testing and the physician's efforts. 5) Quality assurance/utilization-review efforts can be combined with educational efforts that could result in a diminution of the deficiencies. |
8044051 | Risk adjustment methods can affect perceptions of outcomes. | When comparing outcomes of medical care, it is essential to adjust for patient risk, including severity of illness. A variety of severity measures exist, but perceptions of outcomes may differ depending on how severity is defined. We used two severity-adjustment approaches to demonstrate that comparisons of outcomes across subgroups of patients can vary dramatically depending on how severity is assessed. We studied two approaches: model 1 was the admission MedisGroups score; model 2 was computed from age and 12 chronic conditions defined by diagnosis codes. Although common summary measures of model performance (R-squared and C) both suggested that model 1 is a better predictor of in-hospital death than model 2, the weaker model consistently produced more accurate expectations by payer class and age group. Using model 1 for severity adjustment suggested that Medicare patients did substantially worse than expected and Medicaid patients substantially better. In contrast, use of model 2 found Medicare patients doing as expected, but Medicaid patients faring poorly. |
8044049 | Subcortical disease and neuropsychiatric illness. | The relationship between neuropsychiatric disorders and dysfunction of subcortical structures is the theme of the 1994 joint meeting of the British and American Neuropsychiatric Associations, to be held July 21-24, 1994, in Newport, Rhode Island. In this essay Dr. Salloway, chair of the Scientific Program Committee, and Dr. Cummings, director-elect of The American Neuropsychiatric Association, define the structures embraced in the "subcortical" concept and summarize the relationship between specific neuropsychiatric symptoms and regional subcortical dysfunction. These concepts and observations will be expanded, challenged, and refined at the meeting. (See the Preliminary Annual Meeting Program in this issue.) |
8044044 | Clinical correlates of body weight changes in schizophrenia. | Body weight was examined in chronic schizophrenic patients. Underweight medicated patients had normal ventricular brain ratios (VBRs) on CT. Overweight patients had both normal and abnormal VBRs. Weight decreased during neuroleptic withdrawal; caloric intake and weight increased when neuroleptics were reinstituted. Weight gain on neuroleptics correlated with symptom improvement independent of VBR or gender. Weight changes and psychosis in schizophrenia may be mediated by similar neurochemical systems. |
8044043 | Neurological soft signs in female trichotillomania patients, obsessive-compulsive disorder patients, and healthy control subjects. | Female trichotillomania patients, obsessive-compulsive disorder patients, and normal control subjects did not differ in total scores on a neurological soft signs battery. Further studies should determine whether the increased neurological soft signs present in obsessive-compulsive disorder and perhaps in obsessive-compulsive spectrum disorders are associated with male gender only. |
8044042 | Treatment of organic bipolar mood disorders in Parkinson's disease. | Two patients with long-standing idiopathic Parkinson's disease (PD), without individual or family histories of affective disorders, developed bipolar mood disorders. Both were treated with lithium and clozapine, and one responded favorably. These may be the first reported cases in which mania was treated with clozapine in PD patients. |
8044041 | Obsessive-compulsive disorders in Pick's disease. | The authors present a follow-up of a previously described patient with obsessive-compulsive disorder (OCD). Her condition continued to worsen, and she died 5 years after disease onset. Neuropathological findings were consistent with the diagnosis of Pick's disease. They revealed, in addition to the "knife-edge" frontotemporal atrophy, striking atrophy with extensive neuronal loss and gliosis involving the caudate nuclei and, to a lesser degree, the putamens and globus pallidus. Neuroimaging data had showed isolated atrophy of the caudate nuclei in the early stages of Pick's disease in this patient when OCD was the leading clinical manifestation. Relevant literature is reviewed, and the role of caudate nuclei atrophy in the development of OCD is discussed. |
8044040 | SPECT scan and cognitive findings in subclinical hepatic encephalopathy. | The authors studied 6 patients with end-stage cirrhosis and 6 age- and sex-matched normal control subjects by using SPECT brain scans to determine whether subclinical hepatic encephalopathy (HE) altered regional cerebral blood flow (rCBF). In addition, cirrhosis patients performed a battery of standardized neuropsychological tests known to be sensitive to effects of liver disease, and these were compared with published norms. Results of cognitive tests that showed impairment were correlated with ratios of rCBF values. In cirrhosis patients, rCBF was decreased in bilateral frontotemporal and right basal ganglia regions as compared with control subjects. These defects were compatible with the cirrhosis patients' visuopractic neuropsychological deficits, which were consistent with known subclinical HE cognitive patterns. |
8044039 | Parkinson's disease and depression: the relationship to disability and personality. | In a study of 104 patients with Parkinson's disease (PD) and 61 control subjects with equal disability scores, PD patients had higher depression scores (P < 0.001) than control subjects. Functional disability was correlated with depression in PD and, in a regression analysis, explained 9% of the variance in depression (P < 0.001). Depression was not correlated with novelty seeking, a personality trait related to dopaminergic pleasure and reward systems. Harm avoidance, a trait related to central serotonergic systems, was, however, correlated with depression (P < 0.001) and explained 31% of the variance in depression scores. Results support the hypotheses that both physiologic and psychologic factors contribute to depression seen in these patients and that serotonergic function plays a more critical role than dopaminergic function. |
8044038 | Duration of illness and neuropsychological performance in asymptomatic HIV infection. | The relationship between duration of illness and neuropsychological performance was examined in 25 asymptomatic HIV-infected men with an estimated date of seroconversion. Mean duration of illness was approximately 2 years. After controlling for CD4 level at the time of neuropsychological examination, duration of illness was correlated with measures of visual attention, mental flexibility, dexterity, auditory information processing, and response fluency, as well as an overall measure of neuropsychological performance. Although these patients performed within normal limits, these data suggest that duration of infection may be related to subtle alterations in neuropsychological performance. These results are discussed with regard to possible mechanisms that implicate gradual accumulation of neurotoxins. |
8044037 | ECT as a treatment for depression in Huntington's disease. | The authors review the records of 6 patients with Huntington's disease (HD) who received electroconvulsive therapy (ECT) for depression. Five patients met criteria for major depression and 1 for bipolar disorder, depressed. None of the patients had responded to pharmacologic intervention, and 5 improved after ECT treatment. The 2 patients who had prominent delusions showed the greatest improvement. Apathy, and to some extent irritability, responded less well. One patient developed delirium, and the movement disorder worsened in another patient. ECT should be a treatment option in the management of depression in Huntington's disease, particularly when depression is resistant to pharmacologic treatment. |