bluuebunny/crossref_metadata_2025 huggingface dataset:
Amplitude of the Electrocardiographic QRS Complexes during and after Severe Pulmonary Edema
Authors: Madias John E.
Published: April 2004

There is recent evidence that anasarca peripheral edema, irrespective of its etiology, attenuates ECG QRS potentials. Pulmonary edema (PE) also is thought to cause reduction in the amplitude of QRS complexes. The case reported herein is of a patient with severe PE, hypertension, left ventricular diastolic dysfunction, and no peripheral edema who did not show changes in the QRS complexes with the management of her pulmonary edema. Thus it appears that PE does not attenuate the amplitude of QRS complexes, and alleviation of this condition does not cause augmentation of QRS voltage. This is in contrast to alterations of peripheral edematous states in the setting of congestive heart failure, which result in changes in the QRS amplitude, as shown previously.
T Wave Alternans Does not Assess Arrhythmic Risk in Patients with Brugada Syndrome
Authors: Kirchhof Paulus , Eckardt Lars , Rolf Sascha , Esperer Hans‐D. , Paul Matthias , Wichter Thomas , Klein Helmut U. , Breithardt Günter , Böcker Dirk
Published: April 2004

Background: Brugada syndrome is associated with a risk for sudden death, but the arrhythmic risk in an individual Brugada syndrome patient is difficult to predict. Pathologic changes in the early repolarization phase of the ventricular action potential probably constitute part of the arrhythmogenic substrate in Brugada syndrome. Microvolt T wave alternans (TWA) assesses dynamic beat‐to‐beat changes in repolarization and has been suggested as a marker for repolarization‐related sudden death. We therefore tested whether TWA is an indicator for arrhythmias in Brugada syndrome with a focus on right precordial ECG leads.

Methods: We assessed TWA in nine symptomatic, inducible patients with established Brugada syndrome and in seven healthy controls. TWA was assessed at rest and during exercise using both standard methods and an algorithm that assesses TWA in the early ST segment and the right precordial leads.

Results: None of the Brugada patients developed TWA in this study irrespective of analysis at rest or during exercise, neither using standard methods nor when the early ST segment was included in the analysis. When the early ST segment was included in the analysis, nonsustained TWA was found in three out of seven, and sustained TWA in one control.

Conclusion: T wave alternans is not an appropriate test to detect arrhythmic risk in patients with Brugada syndrome.
Comparing Methods of Measurement for Detecting Drug‐Induced Changes in the QT Interval: Implications for Thoroughly Conducted ECG Studies
Authors: Azie Nkechi E. , Adams Gregory , Darpo Borje , Francom Steven F. , Polasek Emery C. , Wisser Joy M. , Fleishaker Joseph C.
Published: April 2004

Background: The aim of this study was to compare the reproducibility and sensitivity of four commonly used methods for QT interval assessment when applied to ECG data obtained after infusion of ibutilide.

Methods: Four methods were compared: (1) 12‐lead simultaneous ECG (12‐SIM), (2) lead II ECG (LEAD II), both measured on a digitizing board, (3) 3‐LEAD ECG using a manual tangential method, and (4) a computer‐based, proprietary algorithm, 12SL™ ECG Analysis software (AUT). QT intervals were measured in 10 healthy volunteers at multiple time points during 24 hours at baseline and after single intravenous doses of ibutilide 0.25 and 0.5 mg. Changes in QT interval from baseline were calculated and compared across ECG methods, using Bland–Altman plots. Variability was studied using a mixed linear model.

Results: Baseline QT values differed between methods (range 376–395 ms), mainly based on the number of leads incorporated into the measurement, with LEAD II and 3‐LEAD providing the shortest intervals. The 3‐LEAD generated the largest QT change from baseline, whereas LEAD II and 12‐SIM generated essentially identical result within narrow limits of agreement (0.4 ms mean difference, 95% confidence interval ± 20.5 ms). Variability with AUT (standard deviation 15.8 ms for within‐subject values) was clearly larger than with 3‐LEAD, LEAD II, and 12‐SIM (9.6, 10.0, and 11.3 ms).

Conclusion: This study demonstrated significant differences among four commonly used methods for QT interval measurement after pharmacological prolongation of cardiac repolarization. Observed large differences in variability of measurements will have a substantial impact on the sample size required to detect QT prolongation in the range that is currently advised in regulatory guidance.
Andersen Syndrome: The Newest Variant of the Hereditary‐Familial Long QT Syndrome
Authors: Ricardo Pérez Riera Andrés , Ferreira Celso , Dubner Sérgio J. , Schapachnik Edgardo
Published: April 2004

Andersen's Syndrome is a rare disease, hereditary with autosomal dominant transmission, of the ion channels of the sarcolemmal membranes of the cardiac and skeletal muscles (channelopathy), which affects chromosome 17 of the KCNJ2 gene, responsible for encoding the outward potassium delayed rectifier current KIR2.1, resulting in a loss or suppression of the function of this channel.
Association of gingival crevicular fluid and serum intracytoplasmic enzyme levels in periodontally healthy homozygous (major) β‐thalassemia patients
Authors: Tsalikis Lazaros E. , Kaklamanos Eleftherios G. , Kavadia‐Tsatala Smaragda , Chasapopoulou Eleni , Pidonia‐Manika Ifigenia
Published: April 2004

Objective: To assess tissue necrosis in β‐thalassemia major patients, as in other areas of medicine, lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) have been widely used. These markers of tissue degradation have also been studied in the gingival crevicular fluid (GCF) in relation to periodontal disease status. The purpose of this study was to investigate whether periodontal diagnostic tests based on these markers of tissue degradation are influenced from the enzymes' levels in serum and, therefore, could be used in the assessment of the patient's periodontal status.

Material and Methods: Forty‐four periodontally healthy, homozygous β‐thalassemia patients were enrolled in the study. GCF and serum samples were obtained and the levels of AST, ALT and LDH were determined; the measurements took place in an automated analyzer (Hitachi 777) using the kits of Roche Company.

Results: Lack of correlations between serum and GCF enzyme levels was demonstrated. Serum LDH and serum AST, serum AST and serum ALT are significantly positively correlated. Concerning the GCF, AST and ALT were proved to be significantly positively correlated.

Conclusions: Elevated values of LDH, ALT and AST in serum do not constitute a confounding factor in GCF measurements of the respective enzymes.
Histopathological observations of human periimplantitis lesions
Authors: Berglundh Tord , Gislason Örn , Lekholm Ulf , Sennerby Lars , Lindhe Jan
Published: April 2004

Objective: The aim of the present study was to analyze some characteristics of advanced and progressive periimplantitis lesions in man.

Material and methods: Soft tissue biopsies were obtained from 12 implants in six patients. The implants had been in function between 4 and 21 years and were, with one exception, located in the maxilla. The radiographic examination performed prior to biopsy revealed that all sites exhibited advanced bone loss. Further, clinical signs of severe inflammation, such as suppuration, swelling and/or fistula formation were detected in the majority of sites and seven of the 12 implants were found to be mobile at biopsy. Each biopsy was following fixation embedded in epoxy resin and sections were prepared for histometric and morphometric analysis.

Results and conclusion: It was demonstrated (i) that all soft tissue units harbored large inflammatory cell infiltrates (ICT) that extended to a position apical of a pocket epithelium and (ii) that about 60% of the lesions were occupied by inflammatory cells, among which plasma cells dominated. Numerous amounts of PMN cells occurred not only in the pocket epithelium and adjacent connective tissue areas, but were also present in peri‐vascular compartments in more central areas of the ICT.
Dentine hypersensitivity: development and evaluation ofamodel in situ to study tubulepatency
Authors: Banfield N. , Addy M.
Published: April 2004

Background and aims: Lesions of dentine hypersensitivity have numerous tubules open at the dentine surface as opposed to non‐sensitive dentine where tubules are mostly covered by a smear layer. The present two studies were designed to model both states in situ and evaluate the effects of agents on the model.

Method: Etched (sensitive) and smeared (non‐sensitive) dentine specimens prepared from human third molar teeth were retained in lower buccal acrylic appliances. The results of Study 1 led to the development of a method to ensure tubules were sectioned at right angles. Study 1 was a 5‐day period, seven treatment regimens randomised, part blind cross over design involving five subjects. Treatments were 2× day application of a desensitising (SA) or non‐desensitising toothpastes (F) or chlorhexidine (CHX) mouthwash with or without drinking orange juice (OJ)(1 l/day). A no treatment group (P) allowed plaque to accumulate. The evaluation of effects was observational by scanning electron microscopy (SEM). Study 2 involved 1 subject, 4 treatments applied once and studied after 0, 6, and 12 h by SEM with image analysis. The 12 h groups were studied with and without imbibing water or OJ. Treatments were two desensitising (SA & SC) and one non‐desensitising (F) toothpastes and an in office product (DS).

Results: Study 1: Treatment SA resulted in occlusion of tubules an outcome little changed by OJ. Treatment P produced a bio‐film, which covered the dentine surface. CHX produced some tubule occlusion in three of the five subjects. F±OJ and CHX+OJ had little effect and tubules remained open. For smeared specimens toothpastes and OJ removed the smear layer but SA±OJ blocked tubules. P and CHX had no effect on the smear layer. Study 2: At 0 h, tubule occlusion was in order of magnitude DSSA>SC>F. After 6 and 12 h with SA, SC and F some loss of occlusion occurred but not DS. Water and OJ by 12 h decreased occlusion for SA, SC and particularly F. Water and OJ removed virtually all of DS.

Conclusions: The aims of Study 1 were achieved and effect of treatments was not inconsistent with data in vitro. The need for more standardisation of specimens was appreciated and applied in Study 2 to allow image analysis to quantitatively record data. Further use of the model in randomised controlled clinical trials is envisaged.
Thermal imaging of ultrasonic scaler tips during tooth instrumentation
Authors: Lea Simon C. , Landini Gabriel , Walmsley A.Damien
Published: April 2004

Objectives: During ultrasonic scaling procedures, contact of the scaler tip with the tooth surface will produce frictional heating. The aim of this study was to assess this heat generation using an Agema 900 thermal imaging system.

Materials and Methods: Both the Cavitron sustained performance system (SPS) with TFI‐3 tip and the Mini Piezon with P‐tip were tested. Handpieces were fixed with their sides facing the thermal camera and thermal image sequences or “movies” created. Measurements were performed with tips under loads of 25, 50 and 100 g, at water flow rates of 10, 20 and 40 ml/min and low, medium and high generator power settings. A measurement point was superimposed on the resulting thermal images at the tip/tooth contact site and the temperature variation with time recorded.

Results: All combinations of instrumentation produced an increase in temperature. An increase in temperature was generally observed with increasing load (for given power/water), power setting (for given load/water) and a decrease in water flow rate (for given load/power).

Conclusion: Heat generation is minimised by using low/medium power settings and light contact. Care must be taken to ensure adequate water is present at the site of instrumentation to prevent patient discomfort due to excessive heating.
The association of gingivitis and periodontitis with ischemic stroke
Authors: Dörfer Christof E. , Becher Heiko , Ziegler Christoph M. , Kaiser Claudia , Lutz Rainer , Jörß Daniela , Lichy Christoph , Buggle Florian , Bültmann Stefan , Preusch Michael , Grau Armin J.
Published: April 2004

Objectives:The aim of this study was to assess the associations of different periodontal parameters with cerebral ischemia.

Methods:In a case–control study, 303 consecutive patients with ischemic stroke or transient ischemic attack, and 300 representative population controls received a complete clinical and radiographic dental examination. Patients were examined on average 3 days after ischemia. The individual mean clinical attachment loss measured at four sites per tooth was used as indicator variable for periodontitis.

Results:Patients had higher clinical attachment loss than population (p<0.001). After adjustment for age, gender, number of teeth, vascular risk factors and diseases, childhood and adult socioeconomic conditions and lifestyle factors, a mean clinical attachment loss >6 mm had a 7.4 times (95% confidence interval 1.55–15.3) a gingival index >1.2 a 18.3 times (5.84–57.26) and a radiographic bone loss a 3.6 times (1.58–8.28) higher risk of cerebral ischemia than subjects without periodontitis or gingivitis, respectively.

Conclusion:Periodontitis is an independent risk factor for cerebral ischemia and acute exacerbation of inflammatory processes in the periodontium might be a trigger for the event of cerebral ischemia.
Regulation of single NMDA receptor channel activity by alpha‐actinin and calmodulin in rat hippocampal granule cells
Authors: Rycroft Beth K. , Gibb Alasdair J.
Published: April 2004

The NMDA receptor is modulated by changes in the intracellular calcium concentration, through activation of various intracellular calcium‐dependent proteins. We have investigated regulation of single NMDA receptor channel activity by the calcium‐sensing proteins alpha‐actinin and calmodulin. Both of these proteins bind to the NMDA receptor NR1 subunit C‐terminus at the C0 region where they compete for occupation of the C0 site and contribute to calcium‐dependent inactivation of NMDA receptor‐mediated whole‐cell currents. Calmodulin has also been shown to bind to the neighbouring C1 region where it has been shown to reduce single channel open time. To investigate regulation of single NMDA channel activity by alpha‐actinin and calmodulin, we selected concentrations of these two proteins that would result in maximal binding to the C0 region and/or the C1 region in the case of calmodulin. Alpha‐actinin binding was found to predominantly decrease single channel shut time, resulting in an increased open probability (Popen), whereas calmodulin binding reduced single channel mean open time, resulting in an overall reduction in Popen. The physiological implications of these findings are discussed.
The role of the sympathetic nervous system in postasphyxial intestinal hypoperfusion in the pre‐term sheep fetus
Authors: Quaedackers Josine S. , Roelfsema Vincent , Heineman Erik , Gunn Alistair J. , Bennet Laura
Published: April 2004

Asphyxiain uteroin pre‐term fetuses is associated with evolving hypoperfusion of the gut after the insult. We examined the role of the sympathetic nervous system (SNS) in mediating this secondary hypoperfusion. Gut blood flow changes were also assessed during postasphyxial seizures. Preterm fetal sheep at 70% of gestation (103–104 days, term is 147 days) underwent sham asphyxia or asphyxia induced by 25 min of complete cord occlusion and fetuses were studied for 3 days afterwards. Phentolamine (10 mg bolus plus 10 mg h−1i.v.) or saline was infused for 8 h starting 15 min after the end of asphyxia or sham asphyxia. Phentolamine blocked the fall in superior mesenteric artery blood flow (SMABF) after asphyxia and there was a significant decrease in MAP for the first 3 h of infusion (33 ± 1.6 mmHgversusvehicle 36.7 ± 0.8 mmHg,P< 0.005). During seizures SMABF fell significantly (8.3 ± 2.3versus11.4 ± 2.7 ml min−1,P< 0.005), and SMABF was more than 10% below baseline for 13.0 ± 1.7 min per seizure (versusseizure duration of 78.1 ± 7.2 s). Phentolamine was associated with earlier onset of seizures (5.0 ± 0.4versus7.1 ± 0.7 h,P< 0.05), but no change in amplitude or duration, and prevented the fall in SMABF. In conclusion, the present study confirms the hypothesis that postasphyxial hypoperfusion of the gut is strongly mediated by the SNS. The data highlight the importance of sympathetic activity in the initial elevation of blood pressure after asphyxia and are consistent with a role for the mesenteric system as a key resistance bed that helps to maintain perfusion in other, more vulnerable systems.
Landau levels, molecular orbitals, and the Hofstadter butterfly in finite systems
Authors: Analytis James G. , Blundell Stephen J. , Ardavan Arzhang
Published: April 2004

The Hofstadter butterfly is the energy spectrum of an infinite square lattice, plotted as a function of the magnetic field. We illustrate a method of calculating similar spectra for finite lattices in a magnetic field, using methods that consider the appropriate molecular orbitals, and find that the spectra resemble the Hofstadter butterfly. We relate the bonding and antibonding orbitals used to describe small systems to the Landau levels of the infinite system. This approach provides an unusual, but instructive, method of introducing the physics of Landau levels from the basic quantum mechanics of small systems.
Sequential folding of a rigid wire into three-dimensional structures
Authors: Keller Sarah L.
Published: April 2004

Nitinol wire is used to encode a three-dimensional structure in a linear chain. The folding of the structure progresses sequentially along the rigid wire from one end using only short-range forces. Three different shapes are constructed, an overhand pseudoknot, a protein structure with α-helices, and a protein structure without α-helices. The overhand pseudoknot was designed to be noncommutative so that forward folding along the chain results in the correct structure whereas reverse folding does not. The manipulation of nitinol wire structures leads to simple empirical rules for folding for noncommutative pseudoknots. Suggestions for additional noncommutative pseudoknot structures that can be designed both from wire and from DNA or RNA are given. The folding also can be accomplished using ordinary stiff wire. The folding of the wire provides an intuitive way to visualize sequential folding freed from a lattice.
Speed of radio waves along a coaxial transmission line
Authors: Mak Se-yuen
Published: April 2004

We describe three independent methods for measuring the speed of radio waves along a homemade coaxial transmission line. These experiments confirm the predictions obtained from a general circuit equation subjected to simple boundary conditions. The sources of errors and relative merits of each method are discussed.
Random walk with shrinking steps
Authors: Krapivsky P. L. , Redner S.
Published: April 2004

We outline the properties of a symmetric random walk in one dimension in which the length of the nth step equals λn, with λ<1. As the number of steps N→∞, the probability that the end point is at x approaches a limiting distribution Pλ(x) that has many beautiful features. For λ<1/2, the support of Pλ(x) is a Cantor set. For 1/2⩽λ<1, there is a countably infinite set of λ values for which Pλ(x) is singular, while Pλ(x) is smooth for almost all other λ values. In the most interesting case of λ=g≡(5−1)/2, Pg(x) is riddled with singularities and is strikingly self-similar. This self-similarity is exploited to derive a simple form for the probability measure M(a,b)≡∫abPg(x) dx.
The nonrelativistic frequency-dependent electric polarizability of a bound particle
Authors: Maize M. A. , Williams Michael
Published: April 2004

We calculate the frequency-dependent electric polarizability of a particle that is bound by a one-dimensional delta function potential. A perturbation technique based on the work by Noziéres is employed. Comparison is made with previous work.
Center of percussion of hand-held implements
Authors: Cross Rod
Published: April 2004

The center of percussion is commonly regarded as a sweet spot when referring to a baseball bat or a tennis racquet because it is assumed that there will be no sudden motion of the handle with respect to the hand if the corresponding axis of rotation passes through the hand. A problem with this interpretation is that the hand extends over a finite length of the handle and exerts an opposing reaction force on the handle. The hand also changes the total mass and moment of inertia of the system, while the arm restricts free motion of the hand. Experimental results are presented showing that the axis of rotation passes through the hand or the wrist for all the usual impact points on a hand-held implement. As a result, the impact point that feels best is usually the node of the fundamental vibration mode, not the center of percussion.
Energy conservation in quantum mechanics
Authors: Prentis Jeffrey J. , Fedak William A.
Published: April 2004

In the classical mechanics of conservative systems, the position and momentum evolve deterministically such that the sum of the kinetic energy and potential energy remains constant in time. This canonical trademark of energy conservation is absent in the standard presentations of quantum mechanics based on the Schrödinger picture. We present a purely canonical proof of energy conservation that focuses exclusively on the time-dependent position x(t) and momentum p(t) operators. This treatment of energy conservation serves as an introduction to the Heisenberg picture and illuminates the classical-quantum connection. We derive a quantum-mechanical work-energy theorem and show explicitly how the time dependence of x and p and the noncommutivity of x and p conspire to bring about a perfect temporal balance between the evolving kinetic and potential parts of the total energy operator.
Hyperhelices: A classical analog for strings and hidden dimensions
Authors: Fletcher N. H.
Published: April 2004

A hyperhelix is a structure consisting of a rod coiled into a helix, coiled into a helix,…, through a finite or even infinite number of orders. An examination of the transverse vibrations of such a structure shows that the macroscopic behavior is accounted for by waves on the rod that are confined to an extremely small range of wave numbers centered about a value equal to the reciprocal of the smallest helical radius involved. All other dynamical aspects of the behavior and their associated physical dimensions are completely hidden at the level of the final helix. It is suggested that the study of the dynamics of such a structure might provide a fruitful analogy for understanding the string theory.
The PIDDosome, a Protein Complex Implicated in Activation of Caspase-2 in Response to Genotoxic Stress
Authors: Tinel Antoine , Tschopp Jürg
Published: April 2004

Apoptosis is triggered by activation of initiator caspases upon complex-mediated clustering of the inactive zymogen, as occurs in the caspase-9–activating apoptosome complex. Likewise, caspase-2, which is involved in stress-induced apoptosis, is recruited into a large protein complex, the molecular composition of which remains elusive. We show that activation of caspase-2 occurs in a complex that contains the death domain–containing protein PIDD, whose expression is induced by p53, and the adaptor protein RAIDD. Increased PIDD expression resulted in spontaneous activation of caspase-2 and sensitization to apoptosis by genotoxic stimuli. Because PIDD functions in p53-mediated apoptosis, the complex assembled by PIDD and caspase-2 is likely to regulate apoptosis induced by genotoxins.
Post-Perovskite Phase Transition in MgSiO
3
Authors: Murakami Motohiko , Hirose Kei , Kawamura Katsuyuki , Sata Nagayoshi , Ohishi Yasuo
Published: April 2004

In situ x-ray diffraction measurements of MgSiO
3
were performed at high pressure and temperature similar to the conditions at Earth's core-mantle boundary. Results demonstrate that MgSiO
3
perovskite transforms to a new high-pressure form with stacked SiO
6
-octahedral sheet structure above 125 gigapascals and 2500 kelvin (2700-kilometer depth near the base of the mantle) with an increase in density of 1.0 to 1.2%. The origin of the D″ seismic discontinuity may be attributed to this post-perovskite phase transition. The new phase may have large elastic anisotropy and develop preferred orientation with platy crystal shape in the shear flow that can cause strong seismic anisotropy below the D″ discontinuity.
Illuminating the Evolutionary History of Chlamydiae
Authors: Horn Matthias , Collingro Astrid , Schmitz-Esser Stephan , Beier Cora L. , Purkhold Ulrike , Fartmann Berthold , Brandt Petra , Nyakatura Gerald J. , Droege Marcus , Frishman Dmitrij , Rattei Thomas , Mewes Hans-Werner , Wagner Michael
Published: April 2004

Chlamydiae are the major cause of preventable blindness and sexually transmitted disease. Genome analysis of a chlamydia-related symbiont of free-living amoebae revealed that it is twice as large as any of the pathogenic chlamydiae and had few signs of recent lateral gene acquisition. We showed that about 700 million years ago the last common ancestor of pathogenic and symbiotic chlamydiae was already adapted to intracellular survival in early eukaryotes and contained many virulence factors found in modern pathogenic chlamydiae, including a type III secretion system. Ancient chlamydiae appear to be the originators of mechanisms for the exploitation of eukaryotic cells.
Childhood abuse and risk of smoking onset
Authors: Nichols H B , Harlow B L
Published: April 2004

Study objective:To determine the association between childhood abuse and becoming a smoker.

Design:Retrospective cohort study.

Setting:Boston, Massachusetts.

Participants:722 women aged 36–45 years who completed the baseline questionnaire for the Harvard study of moods and cycles and the survey of interpersonal relationships.

Main results:Women who experienced either physical or sexual abuse as a child were 40% more likely to begin smoking compared with women with no history of abuse (95% CI 1.0 to 2.0). Virtually all of this association was confined to sexual abuse (OR = 2.2, 95% CI 1.1 to 4.3) as compared with physical abuse (OR = 0.7, 95% CI 0.7 to 1.6). However, the joint effect of experiencing both physical and sexual abuse as a child led to a 3.5-fold increase in the likelihood of becoming a smoker (95% CI 1.3 to 9.4) compared with women who did not experience any childhood abuse after adjustment for religion, social class, and poverty.

Conclusions:Women who experience childhood abuse, even in the absence of depression, are at increased risk of becoming cigarette smokers.
A framework for modelling differences in regional mortality over time
Authors: Lix L M , Ekuma O , Brownell M , Roos L L
Published: April 2004

Study objective:To present a conceptual framework for testing differences in mortality for small geographical areas over time using the generalised linear model with generalised estimating equations. This framework can be used to test whether the magnitude of regional inequalities in health status has changed over time.

Design:A Poisson regression model for correlated data is used to investigate the relation of population health status to demographic, geographical, and temporal explanatory variables. Differences between regions at one or more points in time are tested with linear contrasts.

Setting and participants:A case example shows the application of the framework. All cause mortality and cause specific mortality were compared for three rural regions of Manitoba, Canada between 1985 and 1999. The data were obtained from Vital Statistics records and the provincial health registry.

Main results:Tests of linear contrasts on the regression coefficients for time and region show an increase in the magnitude of the difference in the risk of all cause mortality and heart disease mortality between northern and southern regions of the province for the 1985–1989 and 1995–1999 time periods. No significant differences are identified for cancer, injury, or respiratory disease mortality.

Conclusions:The proposed framework enables testing of a variety of hypotheses about differences between regions and time periods and can be applied to other measures of population health status.
Is perceived failure in school performance a trigger of physical injury? A case-crossover study of children in Stockholm County
Authors: Laflamme L , Engström K , Möller J , Hallqvist J
Published: April 2004

Objectives:To investigate whether perceived failure in school performance increases the potential for children to be physically injured.

Subjects:Children aged 10–15 years residing in the Stockholm County and hospitalised or called back for a medical check up because of a physical injury during the school years 2000–2001 and 2001–2002 (n = 592).

Methods:A case-crossover design was used and information on potential injury triggers was gathered by interview. Information about family socioeconomic circumstances was gathered by a questionnaire filled in by parents during the child interview (response rate 87%).

Results:Perceived failure in school performance has the potential to trigger injury within up to 10 hours subsequent to exposure (relative risk = 2.70; 95% confidence intervals = 1.2 to 5.8). The risk is significantly higher among pre-adolescents and among children from families at a higher education level.

Conclusions:Experiencing feelings of failure may affect children’s physical safety, in particular among pre-adolescents. Possible mechanisms are perceptual deficits and response changes occasioned by the stress experienced after exposure.
Avoidable mortality among child welfare recipients and intercountry adoptees: a national cohort study
Authors: Hjern A , Vinnerljung B , Lindblad F
Published: April 2004

Objective:To compare rates of avoidable mortality in adolescence in child welfare recipients and intercountry adoptees with the general population.

Design:A register study of the entire national cohort of 989 871 Swedish residents born 1973–82 in the national census of 1990. Multivariate Cox analyses of proportional hazards were used to analyse avoidable deaths between 13 to 27 years of age during 1991–2000.

Participants:12 240 intercountry adoptees, 6437 foster children, 15 868 subjected to other forms of child welfare interventions, and the remaining 955 326 children in the cohort.

Results:Intercountry adoptees had a high sex and age adjusted relative risk (RR) for suicide death only (RR 3.5; 95% CI 2.3 to 5.0) in comparison with the general population, while foster children and adolescents who had received other kinds of child welfare interventions had high sex and age adjusted RRs for suicide death; 4.3 (2.8 to 6.6) and 2.7 (1.9 to 3.9) respectively, as well as for other avoidable deaths; RRs 2.5 (1.6 to 3.7) and 2.8 (2.1 to 3.6). The RRs of avoidable deaths for foster children and other child welfare recipients decreased considerably when compared with youth brought up in homes with similar psychosocial characteristics as their original home.

Conclusion:Children in substitute care in early childhood were at particular risk for suicide death in adolescence and young adulthood. Child welfare interventions were insufficient to prevent excess deaths in children at risk.
The ethics of research related to health care in developing countries
Authors: McMillan J R , Conlon C
Published: April 2004

A report by the Nuffield Council on Bioethics, contrary to the Declaration of Helsinki, permits most important research initiatives in developing countries.

The Ethics of Research Related to Health Care in Developing Countries by the Nuffield Council on Bioethics makes a number of innovative recommendations that depart from codes such as the Declaration of Helsinki. It recommends that standards of care might be relativised to the standard of that nation. It recommends that very good reasons need to be given for not giving post-trial access to medications but recognises that there may be justifiable instances of this. It is the view of the authors that these and other recommendations of the report are sensible pieces of advice given the complexities of the developing world.
Ethical and professional conduct of medical students: review of current assessment measures and controversies
Authors: Boon K , Turner J
Published: April 2004

As medical education increasingly acknowledges the importance of the ethical and professional conduct of practitioners, and moves towards more formal assessment of these issues, it is important to consider the evidence base which exists in this area. This article discusses literature about the health needs and problems experienced by medical practitioners as a background to a review of the current efforts in medical education to promote ethical conduct and develop mechanisms for the detection and remediation of problems.
Should patients be allowed to veto their participation in clinical research?
Authors: Evans H M
Published: April 2004

Patients participating in the shared benefits of publicly funded health care enjoy the benefits of treatments tested on previous patients. Future patients similarly depend on treatments tested on present patients. Since properly designed research assumes that the treatments being studied are—so far as is known at the outset—equivalent in therapeutic value, no one is clinically disadvantaged merely by taking part in research, provided the research involves administering active treatments to all participants. This paper argues that, because no other practical or moral considerations count decisively against so doing, we could and should oblige patients to agree to receive indicated treatment within the terms of any concurrent research protocols. This ensures their treatment will benefit not only themselves but also future patients through contributing to new knowledge. By analogy with the paying of income tax, patients should not be allowed to “veto” their social responsibility to take part in clinical research.
Evidence based medicine guidelines: a solution to rationing or politics disguised as science?
Authors: Saarni S I , Gylling H A
Published: April 2004

“Evidence based medicine” (EBM) is often seen as a scientific tool for quality improvement, even though its application requires the combination of scientific facts with value judgments and the costing of different treatments. How this is done depends on whether we approach the problem from the perspective of individual patients, doctors, or public health administrators. Evidence based medicine exerts a fundamental influence on certain key aspects of medical professionalism. Since, when clinical practice guidelines are created, costs affect the content of EBM, EBM inevitably becomes a form of rationing and adopts a public health point of view. This challenges traditional professionalism in much the same way as managed care has done in the US. Here we chart some of these major philosophical issues and show why simple solutions cannot be found. The profession needs to pay more attention to different uses of EBM in order to preserve the good aspects of professionalism.
Ethics of evidence based medicine in the primary care setting
Authors: Slowther A , Ford S , Schofield T
Published: April 2004

Evidence based medicine has had an increasing impact on primary care over the last few years. In the UK it has influenced the development of guidelines and quality standards for clinical practice and the allocation of resources for drug treatments and other interventions. It has informed the thinking around patient involvement in decision making with the concept of evidence based patient choice. There are, however, concerns among primary care clinicians that evidence based medicine is not always relevant to primary care and that undue emphasis placed on it can lead to conflict with a clinician’s duty of care and respect for patient autonomy. In this paper we consider the impact of evidence based medicine on primary care, and the ethical implications of its increasing prominence for clinicians and managers in primary care.
Are patient information leaflets contributing to informed consent for cataract surgery?
Authors: Brown H , Ramchandani M , Gillow J T , Tsaloumas M D
Published: April 2004

Aim:To assess, against a checklist of specific areas of required information and using standard published criteria, to what extent leaflets given before cataract surgery provided patients with enough information to give adequately informed consent.

Method:Twelve ophthalmology departments in the West Midlands region were asked to submit the cataract information leaflets given to their patients at the preoperative assessment for analysis. Using criteria published by the General Medical Council, British Medical Association, and Medical Defence Union the leaflets were assessed for their contribution to informed consent for patients considering cataract surgery. Leaflets were scored according to the information they provided on: diagnosis, prognosis, treatment options, costs to the patient, details about the procedure, its purpose, likely benefits, how to prepare for it, what to expect during and after the operation, and the common as well as serious complications that may occur. The readability of the information was also assessed.

Results:All the units’ leaflets provided information on diagnosis, the lifestyle changes required postoperatively, and cost involved to the patient. Only five units had leaflets that mentioned the risks involved in cataract surgery. The other areas of information were covered by 50–75% of the leaflets. Fifty per cent of the leaflets included a diagram. The average SMOG readability score was high.

Conclusion:Although present cataract information leaflets make some contribution to the process of informed consent, most do not address important areas outlined by the General Medical Council. Many of the areas of information that are required for informed consent could easily be covered, and should be borne in mind when designing patient information leaflets. Resources are available on the internet including toolkits, guides, and means of assessment for the production of patient information leaflets.
Should research samples reflect the diversity of the population?
Authors: Allmark P
Published: April 2004

Recent research governance documents say that the body of research evidence must reflect population diversity. The response to this needs to be more sophisticated than simply ensuring minorities are present in samples.

For quantitative research looking primarily at treatment effects of drugs and devices four suggestions are made. First, identify where the representation of minorities in samples matters—for example, where ethnicity may cause different treatment effects. Second, where the representation of a particular group matters then subgroup analysis of the results will usually be necessary. Third, ensuring representation and subgroup analysis will have costs; deciding on whether such representation is worthwhile will involve cost benefit analysis. Fourth, the representation of minorities should not be seen as mainly a locality issue.

For qualitative research it is argued that the representation of diversity is often important. Given the small samples of many qualitative projects, however, the best way to ensure representation occurs is to allow a proliferation of such research, not to stipulate such representation in samples.
The standard of care debate: against the myth of an “international consensus opinion”
Authors: Schüklenk U
Published: April 2004

It is argued by Lieet alin the current issue of theJournal of Medical Ethicsthat an international consensus opinion has formed on the issue of standards of care in clinical trials undertaken in developing countries. This opinion, so they argue, rejects the Declaration of Helsinki’s traditional view on this matter. They propose furthermore that the Declaration of Helsinki has lost its moral authority in the controversy in research ethics. Although the latter conclusion is supported by this author, it will be demonstrated in this paper that there is not such a thing as an international consensus opinion, and that the authorities used by Lieet alas evidence in support of their claim should not be relied upon as authorities or final arbiters in this debate. Furthermore, it will be shown that arguments advanced substantively to show that lower standards of care are ethically acceptable in the developing world, conflate scientific with economic reasons, and ultimately fail to bolster the case they are designed to support.
Ethical problems arising in evidence based complementary and alternative medicine: Table 1
Authors: Ernst E , Cohen M H , Stone J
Published: April 2004

Complementary and alternative medicine has become an important section of healthcare. Its high level of acceptance among the general population represents a challenge to healthcare professionals of all disciplines and raises a host of ethical issues. This article is an attempt to explore some of the more obvious or practical ethical aspects of complementary and alternative medicine.
Coordinating the norms and values of medical research, medical practice and patient worlds—the ethics of evidence based medicine in orphaned fields of medicine
Authors: Vos R , Willems D , Houtepen R
Published: April 2004

Evidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other things being equal, ethically unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome.

It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients.
Ethics, EBM, and hospital management
Authors: Biller-Andorno N , Lenk C , Leititis J
Published: April 2004

Matters of hospital management do not figure prominently on the medical ethics agenda. However, management decisions that have to be taken in the area of hospital care are in fact riddled with ethical questions and do have significant impact on patients, staff members, and the community being served. In this decision making process evidence based medicine (EBM) plays an increasingly important role as a tool for rationalising as well as rationing health care resources. In this article, ethical issues of hospital management and the role of EBM will be explored, with particular reference to disease management programs, diagnosis related groups, and clinical pathways as recent developments in the German health care system.
Evidence-based medicine and ethics: a practical approach
Authors: Vineis P
Published: April 2004

The clinical decision is supposed to be based on evidence. In fact, what counts as evidence is far from being established. Some definition of “proof” is needed to distinguish between scientific medicine and charlatanism. My thesis is that unfortunately a clear-cut boundary between evidence and lack of evidence cannot be found, for several reasons that I summarise in the paper. Evidence in medicine very often has fuzzy boundaries, and dichotomising fuzziness and uncertainty can have serious consequences. Physicians and patients should accept the irreducible fuzziness of many of the concepts they use when dealing with health and disease.
The direction of mental health care for the elderly
Authors: Barker A
Published: April 2004

The way that mental health care for older people is developing in the UK is being shaped by a number of factors. These include demographic shifts, changes in the general population’s attitudes to health, alterations in professional practice, governmental policy, and medical and technological advances. This article summarises some key aspects of these changes and predicts the likely direction of growth of mental health services in response.
Use of diuretics in cardiovascular diseases: (1) heart failure
Authors: Shah S U , Anjum S , Littler W A
Published: April 2004

Diuretics are used extensively in hospitals and in community medical practice for the management of cardiovascular diseases. They are used frequently as the first line treatment for mild to moderate hypertension and are an integral part of the management of symptomatic heart failure. Although diuretics have been used for several decades, there is still some ambiguity and confusion regarding the optimal way of using these common drugs. In this paper, the classes and action of diuretics are reviewed, and the various indications, optimal doses, and recommendations on the effective use of these agents are discussed.
Effect of maternal antibiotics on breast feeding infants
Authors: Mathew J L
Published: April 2004

Antibiotic usage is fairly common among breastfeeding mothers and there is potential for transfer to infants through breast milk. While most medicines taken by lactating women cause no harm to their babies, at times it can result in serious consequences. This article reviews the principles governing tranfer of maternal antibiotics to breast milk, its clinical significance, and ways to minimise inadvertent infant exposure.
Can an information booklet on an ethnic minority increase the knowledge base of junior doctors?
Authors: Ward B , de Chazal P , Mayberry J F
Published: April 2004

Many doctors encounter people of different cultural backgrounds for the first time as patients. In Leicester a significant proportion of the area’s population comes from a Gujarati and Hindu background. In an attempt to better inform junior doctors about the views and beliefs of their patients, a group of clinicians and administrators developed an information booklet about the beliefs and practices of people from this community. The impact of this booklet on a group of 54 junior doctors’ knowledge was investigated over a period of one month. Such an information booklet was found to significantly increase awareness of the cultural background of patients from a minority community and this knowledge was maintained for at least one month after distribution. The study did not investigate impact on attitudes.