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<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Awakening after cardiac arrest and post resuscitation hypothermia: are we pulling the plug too early? Answer the question given the following information: Context: Time to awakening after out-of-hospital cardiac arrest (OHCA) and post-resuscitation therapeutic hypothermia (TH) varies widely. We examined the time interval from when comatose OHCA patients were rewarmed to 37°C to when they showed definitive signs of neurological recovery and tried to identify potential predictors of awakening. Context: With IRB approval, a retrospective case study was performed in OHCA patients who were comatose upon presentation to a community hospital during 2006-2010. They were treated with TH (target of 33°C) for 24h, rewarmed, and discharged alive. Comatose patients were generally treated medically after TH for at least 48h before any decision to withdraw supportive care was made. Pre-hospital TH was not used. Data are expressed as medians and interquartile range. Context: The 89 patients treated with TH in this analysis were divided into three groups based upon the time between rewarming to 37°C and regaining consciousness. The 69 patients that regained consciousness in ≤48h after rewarming were termed "early-awakeners". Ten patients regained consciousness 48-72h after rewarming and were termed "intermediate-awakeners". Ten patients remained comatose and apneic>72h after rewarming but eventually regained consciousness; they were termed "late-awakeners". The ages for the early, intermediate and late awakeners were 56 [49,65], 62 [48,74], and 58 [55,65] years, respectively. Nearly 67% were male. Following rewarming, the time required to regain consciousness for the early, intermediate and late awakeners was 9 [2,18](range 0-47), 60.5 [56,64.5] (range 49-71), and 126 [104,151]h (range 73-259), respectively. Within 90 days of hospital admission, favorable neurological function based on a Cerebral Performance Category (CPC) score of 1 or 2 was reported in 67/69 early, 10/10 intermediate, and 8/10 late awakeners. Think step by step to answer my question. [/INST] Following OHCA and TH, arbitrary withdrawal of life support<48h after rewarming may prematurely terminate life in many patients with the potential for full neurological recovery. Additional clinical markers that correlate with late awakening are needed to better determine when withdrawal of support is appropriate in OHCA patients who remain comatose>48h after rewarming.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do physicians have lower risk of severe sepsis and associated mortality? Answer the question given the following information: Context: Physicians generally have higher disease awareness and easier access to medical care, which may help them reduce risk of developing severe sepsis and associated mortality when they suffer from acute infection. However, the opposite situation may occur due to the presence of potential barriers to healthcare in physicians. We aim to examine the risk of severe sepsis and associated mortality in physicians. Context: A matched cohort study. Context: Registry of medical professionals and inpatient and outpatient claims data from Taiwan's National Health Insurance Research Database. Context: Physicians (n = 29,697) in Taiwan and a group of persons who were demographically and socioeconomically matched (1:1 ratio) and without any medical education and background. All subjects were followed from the index date (January 1, 2000) to the occurrence of endpoint, withdrawal, or December 31, 2008, whichever date came first. Context: None. Context: Primary outcome was development of severe sepsis. Secondary outcome was 90-day mortality following severe sepsis. The overall incidence density of severe sepsis was lower in physicians than in controls (3.25 vs 3.90 per 1,000 person-years, p<0.001). According to the Cox regression model, severe sepsis develops in physicians 24% less likely than controls after baseline covariates were adjusted (adjusted hazard ratio, 0.76; 95% CI, 0.68-0.85). The 90-day mortality rates were similar between physicians and controls with severe sepsis (46.5% vs 45.7%, p = 0.72). However, after controlling for the baseline and additional covariates, the risk of death was significantly lower in physicians than in controls (adjusted hazard ratio, 0.82; 95% CI, 0.71-0.95). Think step by step to answer my question. [/INST] These findings support the hypothesis that physicians are less likely than controls to develop or die of severe sepsis, implying that medical knowledge, higher disease awareness, and easier healthcare access in physicians may help reduce their risk of severe sepsis and associated mortality.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes? Answer the question given the following information: Context: Systematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26% to 36%, reoperation rates of 22% to 27%, and high rates of persistent opioid use 2 years after surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including postoperative functional restoration in this "at risk" population, has been suggested as a possible solution. Context: To compare objective socioeconomic and patient-reported outcomes for WC patients with different lumbar surgeries followed by functional restoration, relative to matched comparison patients without surgery.STUDY DESIGN/ Context: A prospective cohort study of chronic disabling occupational lumbar disorder (CDOLD) patients with WC claims treated in an interdisciplinary functional restoration program. Context: A consecutive cohort of 564 patients with prerehabilitation surgery completed a functional restoration and was divided into groups based on surgery type: lumbar fusion (F group, N=331) and nonfusion lumbar spine surgery (NF group, N=233). An unoperated comparison group was matched for length of disability (U group, N=349). Context: Validated patient-reported measures of pain, disability, and depression were administered pre- and postrehabilitation. Socioeconomic outcomes were collected via a structured 1-year "after" interview. Context: All patients completed an intensive, medically supervised functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. The writing of this article was supported in part by National Institutes of Health Grant 1K05-MH-71892; no conflicts of interest are noted among the authors. Context: The F group had a longer length of disability compared with the NF and U groups (M=31.6, 21.7, and 25.9 months, respectively, p<.001). There were relatively few statistically significant differences for any socioeconomically relevant outcome among groups, with virtually identical postrehabilitation return-to-work (F=81%, NF=84%, U=85%, p=.409). The groups differed significantly after surgery on diagnosis of major depressive disorder and opioid dependence disorder as well as patient-reported depressive symptoms and pain intensity prerehabilitation. However, no significant differences in patient-reported outcomes were found postrehabilitation. Prerehabilitation opioid dependence disorder significantly predicted lower rates of work return and work retention as well as higher rates of treatment-seeking behavior. Higher levels of prerehabilitation perceived disability and depressive symptoms were significant risk factors for poorer work return and retention outcomes. Think step by step to answer my question. [/INST] Lumbar surgery in the WC system (particularly lumbar fusion) have the potential achieve positive outcomes that are comparable to CDOLD patients treated nonoperatively. This study suggests that surgeons have the opportunity to improve lumbar surgery outcomes in the WC system, even for complex fusion CDOLD patients with multiple prior operations, if they control postoperative opioid dependence and prevent an excessive length of disability. Through early referral of patients (who fail to respond to usual postoperative care) to interdisciplinary rehabilitation, the surgeon determining this continuum of care may accelerate recovery and achieve socioeconomic outcomes of relevance to the patient and WC jurisdiction through the combination of surgery and postoperative rehabilitation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: A phenomenological study of day-to-day experiences of living with heart failure: do cultural differences matter? Answer the question given the following information: Context: Although there is a significant body of literature addressing heart failure (HF) epidemiology, physiology, and treatment, little is known about the experiences of Thai patients living with this chronic condition. The primary goal of this study was to gain a better understanding of how Thai patients with HF live with chronic and debilitating illness. Context: A phenomenological approach was chosen to investigate the experience of living with HF. Fifteen Thai men and women with HF in New York Heart Association classes I to III, aged between 47 and 75 years, were interviewed with open-ended questions. Data were analyzed using qualitative inductive content analysis. Context: Three themes emerged from the data analysis: identifying losses or changes in their lives, accepting the losses, and regaining some control. Unlike their western counterparts, the Thai patients with HF incorporated their karma, a Buddhist belief system, as a tool to rationalize the occurrence of their HF experience. The participants of this study used kreng jai as a cultural desire not to disrupt the happiness of others, even at the expense of efficiency, or to burden others, which might affect their own quality of life. Think step by step to answer my question. [/INST] The Thai patients with HF faced many limitations. The Thai patients with HF use religion and traditional culture to overcome their life situations. To support Thai patients with HF, healthcare providers must have an understanding of cultural differences.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Prophylactic level II neck dissection guided by frozen section for clinically node-negative papillary thyroid carcinoma: is it useful? Answer the question given the following information: Context: Prophylactic lateral neck dissection (PLND) is generally not performed for papillary thyroid carcinoma(PTC). When performed, occult metastases are found in upto 50 % of patients, although the incidence of occult level II nodes seems low. Our aim was to evaluate frozen section analysis-oriented elective level II PLND in patients with clinically node-negative (cN0) PTC. Context: This retrospective study included patients with cN0 PTC treated with total thyroidectomy and prophylactic bilateral central and lateral neck dissection of ipsilateral levels III and IV. Frozen section analysis of PLND III and IV was performed. If positive, the PLND was extended to level II. We measured the accuracy of frozen section analysis, the incidence of occult level II metastasis, and oncologic outcomes. Context: A total of 295 patients were included. For frozen section analysis, the sensitivity was 71.0 %, specificity 99.6 %, positive predictive value 97.8 %, negative predictive value 92.4 %, overall accuracy 93.2 %. Definitive analysis found lateral node metastases in 63 of the 295(21 %) patients. Extension to level II was performed in 27 of 46 cases (59 %). Level II contained metastatic nodes in 12 of 27 (44 %) patients. There was no difference in total doses of 131I administered to patients with or without level II disease. Even when extension of PLND to level II was not performed, no cases of recurrent or persistent disease in level II occurred. Think step by step to answer my question. [/INST] Frozen section analysis was highly accurate.The rate of occult metastases in level II was low. Detection of additional metastases in level II did not modify subsequent treatment or the rate of recurrence and is not useful for routine application.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Endovascular treatment of ruptured abdominal aortic aneurysms: is now EVAR the first choice of treatment? Answer the question given the following information: Context: This study was designed to evaluate the effectiveness of endovascular treatment (EVAR) for ruptured abdominal aortic aneurysms (rAAAs). Context: Between September 2005 and December 2012, 44 patients with rAAA suitable for endovascular repair underwent emergency EVAR. We did not consider hemodynamic instability to be a contraindication for EVAR. Context: Successful stent-graft deployment was achieved in 42 patients, whereas 2 required open surgical conversion. The overall 30-day mortality was 10 of 44 patients (5/34 in stable patients, 5/10 in unstable patients). Postoperative complications were observed in 7 of 44 patients (16 %): 5 patients developed abdominal compartment syndrome requiring decompressive laparotomy; 1 patient developed bowel ischemia; 1 patient had limb ischemia, and 1 had hemodynamic shock. Mean length of intensive care unit stay was 2.9 (range 2–8) days, and mean length of hospital stay was 8.6 (range 0–18) days. At a mean follow-up of 22.2 (range 1–84) months, the overall incidence of endoleak was 23.5 %: 1 type I and 7 type II endoleaks. Think step by step to answer my question. [/INST] Our study demonstrates that EVAR of rAAA is associated with acceptable mortality and morbidity rates in dedicated centers.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do audiologic characteristics predict outcomes in children with unilateral hearing loss? Answer the question given the following information: Context: To determine whether audiologic characteristics of unilateral hearing loss in children were associated with language, cognitive, or achievement scores. Context: Case-control study Context: Pediatric otolaryngology ambulatory practice Context: Cases (n = 109) were children aged 6 to 12 years with permanent unilateral hearing loss; controls (n = 95) were siblings with normal bilateral hearing. Context: Audiologic characteristics measured included side and severity of hearing loss and word recognition scores in quiet and in noise. Context: Cognitive abilities were measured using the Wechsler Abbreviated Scale of Intelligence; reading, math, and writing achievement was measured with the Wechsler Individual Achievement Test - Second Edition - Abbreviated; and oral language skills were measured with the Oral Written and Language Scales. Context: Children with unilateral hearing loss had worse verbal cognitive and oral language scores than children with normal hearing, but there were no differences in achievement scores. Children with profound unilateral hearing loss tended to have worse cognitive scores and had significantly lower oral language scores. Higher word recognition scores of the normal hearing ear in quiet were associated with higher cognitive, oral language, and reading achievement scores. Higher word recognition scores in noise were slightly correlated with higher oral language scores. Think step by step to answer my question. [/INST] As expected, children with unilateral hearing loss had worse language scores than their siblings with normal hearing, with trends toward worse cognitive scores. Children with profound unilateral hearing loss tended to have worse outcomes than children with normal hearing or less severe unilateral loss. However, there were no differences in outcomes between children with right or left unilateral hearing loss.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do 5-Year-Old Children Perform Dual-Task Coordination Better Than AD Patients? Answer the question given the following information: Context: A cross-sectional study was carried out to examine the pattern of changes in the capacity to coordinate attention between two simultaneously performed tasks in a group of 570 volunteers, from 5 to 17 years old. Context: The results revealed that the ability to coordinate attention increases with age, reaching adult values by age 15 years. Also, these results were compared with the performance in the same dual task of healthy elderly and Alzheimer disease (AD) patients found in a previous study. Context: The analysis indicated that AD patients showed a lower dual-tasking capacity than 5-year-old children, whereas the elderly presented a significantly higher ability than 5-year-old children and no significant differences with respect to young adults. Think step by step to answer my question. [/INST] These findings may suggest the presence of a working memory system's mechanism that enables the division of attention, which is strengthened by the maturation of prefrontal cortex, and impaired in AD.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are teachers' judgements of pupils' ability influenced by body shape? Answer the question given the following information: Context: Evidence indicates that teachers can judge pupils on the basis of their physical appearance, including their body shape. Teacher bias towards obese pupils has been suggested as a potential pathway through which obese children attain relatively lower academic levels. The aim of this study was to investigate whether teachers' judgements of pupils' ability are influenced by the body shape of the child. Context: The sample includes English, singleton children in state schools from the Millennium Cohort Study. The data were taken from the fourth wave of data collection, when the children were approximately 7 years old. In all, 5086/5072 children had teacher ability ratings of reading and maths. Logistic regression analyses were used to test whether teachers' perceptions of the child's reading and mathematics ability were influenced by the pupil's waist circumference, conditional upon cognitive test scores of reading and maths ability. Context: After adjustment for cognitive test scores, no significant overall relationship was found between the pupil's waist circumference and the teacher's judgements of ability. No statistically significant differences were observed in the probability of being judged as above average after further adjustments were made for potential confounders. Think step by step to answer my question. [/INST] There is little evidence that teachers' judgements of pupils' ability are influenced by obesity.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Diabetes: time to redefine goals? Answer the question given the following information: Context: The aim of this study was to assess if the A1c goals from the Brazilian Diabetes Society (SBD) were compatible with their goals for blood glucose. Context: An online simulation (AIDA) was used to simulate a hypothetical patient with blood glucose values similar to the SBD's goals. Average glucose was calculated from generated blood glucose values, and then converted to the corresponding A1c value, using the ADA online calculator. Other glycemic profiles, using different levels of blood glucose, were also simulated in order to assess which would be the A1c value associated with each profile. Context: Glycemic goals proposed by the SBD (fasting glucose<100 mg/dL, preprandial<110 mg/dL, and postprandial<140 mg/dL), were associated with an A1c of 5.9%, much lower than the goal of 7% recommended by the SBD. This demonstrates incompatibility among A1c and blood glucose goals proposed by the SBD. Such A1c levels are associated with increased mortality among high-risk patients. Think step by step to answer my question. [/INST] Besides recommending different A1c goals for different patients, the SBD should probably review its recommendations and adopt different blood glucose goals that are compatible with the proposed A1c goals, making therapeutic targets clearer.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Proximal fractures of the humerus in patients older than 75 years of age: should we consider operative treatment? Answer the question given the following information: Context: Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly. Context: In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations. Context: Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction). Think step by step to answer my question. [/INST] This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Highly visible street-based HIV rapid testing: is it an attractive option for a previously untested population? Answer the question given the following information: Context: Given the shortage of community-based HIV testing initiatives in resource-rich countries not targeting most-at-risk populations, we aimed to evaluate whether a highly visible mobile programme promoting and offering rapid HIV testing in the street can attract persons at risk for infection who have never been tested. Context: Between 2008 and 2011, the programme served 7552 persons in various Spanish cities who answered a brief questionnaire while awaiting their results. The factors associated with being tested for the first time were analysed using two logistic regression models, one for men who have sex with men (MSM) and the other for only heterosexual men (MSW) and women. Context: 3517 participants (47%) were first-time testers (24% of MSM, 56% of MSW and 60% of women). Among them, 22 undiagnosed HIV infections were detected with a global prevalence of 0.6% and 3.1% in MSM. Undergoing a first HIV test was independently associated with age<30, being from Spain or another developed country, lack of university education, having fewer partners, having had unprotected sex with casual partners and not having been diagnosed with a sexually transmitted infection. In heterosexuals, also with never injected drugs, and in MSM, with not being involved in the gay community. Among those tested for the first time, 22% had never thought of being tested and 62% decided to be tested when they passed by and noticed the programme, regardless of their previous intentions. Think step by step to answer my question. [/INST] This community programme attracted a substantial number of persons previously untested and particularly hard to reach, such as those with low education and MSM who were least involved in the gay community. Programme visibility was a decisive factor for almost two of every three persons who had never been tested.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: p53 antibody: is it an indicator of dedifferentiated thyroid cancer? Answer the question given the following information: Context: Patients who were diagnosed with thyroid cancer, treated with total or near total thyroidectomy and referred for I-131 therapy or low dose I-131 whole body scan were included in our study. Blood samples were taken before the administration of I-131 orally in the group of patients. Besides, 28 healthy subjects were included. We quantified the presence of p53 autoantibodies from serums. Context: In the present study were enrolled 171 patients with a mean age of 47.7±13.5 years (range 16–80 years) and 28 healthy subjects with an age range of 18–52 years (mean 36.0±9.8 years). One hundred and forty-eight patients had papillary (86.5%), 7 (4.1%) follicular, 10 (5.8%) thyroid tumors of uncertain malignant potential, 2 (1.2%) Hürthle cell carcinoma, 3 (1.8%) poor differentiated, and 1 (0.6%) undifferentiated thyroid carcinoma. The p53 antibodies were positive in 16 (9.4%) patients and negative in 155 (90.6%). The p53 antibodies were positive in 3 (10.7%) healthy subjects, and negative in 25 (89.3%) healthy subjects. In five patients with high Tg level and negative radioiodine scan, who were accepted as dedifferentiated, p53 antibodies were also negative. Think step by step to answer my question. [/INST] The results of the present study suggested that the level of serum p53 antibody seems to be of limited value in the demonstration of dedifferentiation in thyroid cancer patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is there a suburban sleeping sickness in Libreville? Answer the question given the following information: Context: The transmission of sleeping sickness occurs primarily in rural areas, and exposed populations are those living from rural activities such as agriculture, fishing, animal husbandry or hunting. However, urban and suburban foci are more and more reported in T. b. gambiense areas. In Libreville town, sleeping sickness cases are regularly diagnosed. In order to investigate about the establishment of a transmission cycle of that disease, we have carried out an entomological survey in two quarters in the vicinity of the town. Context: Vavoua traps were set out in all suitable biotopes for tsetse flies during four days and examined twice a day. Flies were collected, identified and dissected. Context: Two species of Glossina were caught: G. palpalis palpalis (90.58%) and G. caliginea (9.42%). A total infection rate of 9.37% was observed after dissection of all non-teneral flies captured. Think step by step to answer my question. [/INST] These results suggest the establishment of a trypanosomiasis transmission cycle in the area. No salivary gland was found infected. Given that infected persons are regularly detected, we can think about the existence of a suburban sleeping sickness focus in Libreville. More analysis is needed concerning the identification of human trypanosomes and the origin of Glossina blood meals that may confirm the existence of that focus.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is delayed pressure urticaria associated with increased systemic release of sCD40L? Answer the question given the following information: Context: Elevated levels of soluble CD40 Ligand (sCD40L) were found in serum but not in plasma of patients with chronic spontaneous urticaria (CU). What is important is that sCD40L has proinflammatory properties, and its elevated plasma level may indicate increased risk of cardiovascular events. These observations should stimulate further evaluation of sCD40L in different forms of urticaria.AIM: In the present study, sCD40L plasma level was investigated in delayed pressure urticaria (DPU). Context: As platelets are predominant and variable sources of sCD40L, we investigated sCD40L concentration in platelet-poor plasma (PPP), which seems the best way to minimize the potential contribution of these cells to the ligand level. Context: Plasma sCD40L concentration was significantly increased in the DPU group compared to the healthy controls. Think step by step to answer my question. [/INST] It seems that DPU is associated with increased systemic release of sCD40L, which is believed to derive predominantly from activated platelets. The present study as well as the earlier contributions suggest that distinct cells activity, including platelets, may be identified in different types of urticaria.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can structured clinical assessment using modified Duke's criteria improve appropriate use of echocardiography in patients with suspected infective endocarditis? Answer the question given the following information: Context: Although echocardiography has been incorporated into the diagnostic algorithm of patients with suspected infective endocarditis, systematic usage in clinical practice remains ill defined. Context: To test whether the rigid application of a predefined standardized clinical assessment using the Duke criteria by the research team would provide improved diagnostic accuracy of endocarditis when compared with usual clinical care provided by the attending team. Context: Between April 1, 2000 and March 31, 2001, 101 consecutive inpatients with suspected endocarditis were examined prospectively and independently by both teams. The clinical likelihood of endocarditis was graded as low, moderate or high. All patients underwent transthoracic echocardiography and appropriate transesophageal echocardiography if deemed necessary. All diagnostic and therapeutic outcomes were evaluated prospectively. Context: Of 101 consecutive inpatients (age 50+/-16 years; 62 males) enrolled, 22% subsequently were found to have endocarditis. The pre-echocardiographic likelihood categories as graded by the clinical and research teams were low in nine and 37 patients, respectively, moderate in 83 and 40 patients, respectively, and high in nine and 24 patients, respectively, with only a marginal agreement in classification (kappa=0.33). Of the 37 patients in the low likelihood group and 40 in the intermediate group, no endocarditis was diagnosed. In 22 of 24 patients classified in the high likelihood group, there was echocardiographic evidence of vegetations suggestive of endocarditis. Discriminating factors that increased the likelihood of endocarditis were a prior history of valvular disease, the presence of an indwelling catheter, positive blood cultures, and the presence of a new murmur and a vascular event. General internists, rheumatologists and intensive care physicians were more likely to order echocardiography in patients with low clinical probability of endocarditis, of which pneumonia was the most common alternative diagnosis. Think step by step to answer my question. [/INST] Although prediction of clinical likelihood varies between observers, endocarditis is generally found only in those individuals with a moderate to high pre-echocardiographic clinical likelihood. Strict adherence to indications for transthoracic echocardiography and transesophageal echocardiography may help to facilitate more accurate diagnosis within the moderate likelihood category. Patients with low likelihood do not derive additional diagnostic benefit with echocardiography although other factors such as physician reassurance may continue to drive diagnostic demand.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Placebo practice trials: the best predictor of adherence readiness for HAART among drug users? Answer the question given the following information: Context: This study assessed the utility of a placebo practice trial in determining adherence readiness among drug users. Context: Participants with histories of drug dependency completed a 2-week practice trial that mimicked HAART (Phase 1), followed by a 2-week observation of adherence to HAART (Phase 2) for those who began antiretroviral therapy during the study period. The primary measure of adherence was electronic monitoring. Context: There were 201 participants enrolled; 39% met criteria for current drug dependency. Mean adherence to the practice trial was 67%. Of the 184 Phase 1 completers, 83 (45%) initiated HAART prior to the end of the study. Mean adherence to HAART was 74%, including 33 patients (39%) with 90+% adherence. Adherence to the practice trial was correlated with antiretroviral adherence (r =.49, p<.001), and 90+% adherence to the practice trial was an accurate marker of the "adherence readiness" (ability to adhere 90+% on HAART) of 72% of the participants. In multivariate analyses, practice trial adherence was the best independent predictor of antiretroviral adherence, accounting for 19% of the explained variance; other predictors included adherence to recent clinic appointments, cognitive functioning, unstable housing, and adherence self-efficacy. Think step by step to answer my question. [/INST] These findings suggest that a brief placebo practice trial has the potential to provide clinicians and patients with an accurate screening tool for evaluating adherence readiness.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Grading of age-related maculopathy for epidemiological studies: is digital imaging as good as 35-mm film? Answer the question given the following information: Context: To compare stereo digital images with stereo 35-mm color transparencies as to the quality and reliability of grading age-related maculopathy (ARM) in the context of a multicenter European epidemiologic study (the EUREYE Study). Context: Instrument validation study. Context: Ninety-one subjects (137 eyes) with varying degrees of ARM, including no ARM. Context: From both eyes of the participants, 35-mm film and digital stereoscopic fundus images were obtained with two identical Topcon fundus cameras. Two experienced graders classified all signs of ARM according to the International Classification System. Agreement between imaging techniques and between graders was calculated using the weighted kappa statistic. Context: Signs of ARM (number, size, and morphologic characteristics of drusen; pigmentary changes; geographic atrophy; and neovascular macular degeneration) as well as an overall staging system of increasing ARM severity. Context: The weighted kappa value for between-technique agreement ranged from 0.41 for number of drusen<63 microm to 0.79 for drusen type and total area occupied by drusen. The kappa values for atrophic and neovascular end-stage ARM were 0.87 and 0.94, respectively. The between-technique agreement on stages of ARM was approximately 0.76. The agreement between graders was largely the same for both techniques of imaging. Think step by step to answer my question. [/INST] In the described setting, digital images were as good as 35-mm film for the grading of ARM. Considering the practical advantages of digital imaging, this technique may serve well in epidemiologic studies of ARM.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is neck ultrasound necessary for early stage oral tongue carcinoma with clinically N0 neck? Answer the question given the following information: Context: To define the necessity of neck ultrasound for investigation of T1 and T2 oral tongue carcinoma with N0 neck. Context: The medical records of all patients with early stage (T1-2 N0) oral tongue cancer treated surgically between January 1985 and December 2000 were reviewed. Patients with 30 neck dissections were identified for analysis. The result of neck ultrasound examination was correlated with the histological examination. Context: The sensitivity, specificity and overall accuracy of ultrasound examination were found to be 47%, 93% and 70%, respectively. The implication of ultrasound examination with respect to elective neck treatment was discussed in the management of the N0 neck. Think step by step to answer my question. [/INST] It is concluded that ultrasound alone is inadequate for making decisions regarding neck management of patients with T1 and T2 N0 carcinoma of the tongue and cannot replace a policy of elective neck dissection.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the Canadian childhood obesity epidemic related to physical inactivity? Answer the question given the following information: Context: This study examined the relation among children's physical activity, sedentary behaviours, and body mass index (BMI), while controlling for sex, family structure, and socioeconomic status. Context: Epidemiological study examining the relations among physical activity participation, sedentary behaviour (video game use and television (TV)/video watching), and BMI on a nationally representative sample of Canadian children. Context: A representative sample of Canadian children aged 7-11 (N=7216) from the 1994 National Longitudinal Survey of Children and Youth was used in the analysis. Context: Physical activity and sport participation, sedentary behaviour (video game use and TV/video watching), and BMI measured by parental report. Context: Both organized and unorganized sport and physical activity are negatively associated with being overweight (10-24% reduced risk) or obese (23-43% reduced risk), while TV watching and video game use are risk factors for being overweight (17-44% increased risk) or obese (10-61% increased risk). Physical activity and sedentary behaviour partially account for the association of high socioeconomic status and two-parent family structure with the likelihood of being overweight or obese. Think step by step to answer my question. [/INST] This study provides evidence supporting the link between physical inactivity and obesity of Canadian children.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does the wide application of endovascular AAA repair affect the results of open surgery? Answer the question given the following information: Context: to examine the effect of the adoption of endovascular aneurysm repair (EVAR) on the outcome of open repair (OR). Context: between May 1998 and December 2001, EVAR (Zenith) was performed in 117 patients, and OR was performed because of anatomic restrictions in 40 (group A), and because of young age in 11 patients (group B). Context: EVAR patients had higher ASA classifications (p<0.0001). EVAR was associated with a 98.3% (115 patients) technical success rate, one conversion to OR and one fatal cardiac arrest. Thirty-day mortality was 2.6% (3 patients) in EVAR, 15% (6 patients) in group A and none in group B. There was no difference in late survival between the three groups. Late reinterventions, mainly endovascular, were more frequent in EVAR. At a median follow-up of 17 months one stent-graft had migrated 5 mm distally and five stents had fractured, but without clinical consequence. Think step by step to answer my question. [/INST] EVAR provides good results even with inclusion of high-risk patients. The adoption of EVAR may adversely affect the results of OR offered to patients because of anatomic considerations. However, OR continues to be the first option for low-risk young patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Enucleation: is wrapping the implant necessary for optimal motility? Answer the question given the following information: Context: To compare the mobility of wrapped and unwrapped hydroxyapatite orbital implants after enucleation. Context: Fifteen consecutive adult patients underwent enucleation with hydroxyapatite implant placement. These patients randomly received either a wrapped or unwrapped implant. A masked observer measured the motility of implants at 6 weeks after implantation. The conjunctiva was marked and measured with a ruler. These measurements were used to compare the motility of the wrapped versus unwrapped implant. Context: The mean elevation for the wrapped group (n = 7) was 4 mm and for the unwrapped group (n = 8) was 3.9 mm. Depression was 4.1 mm for the wrapped group and 3.6 mm for the unwrapped group. Medial excursions were 5.3 for the wrapped group and 5.0 mm for the unwrapped group. Lateral excursions were 3.7 mm for the wrapped group and 3.5 mm for the unwrapped group. A repeated-measures analysis of variance was performed, and no statistically significant difference was found between the two groups. Think step by step to answer my question. [/INST] We conclude that placement of unwrapped hydroxyapatite implants after enucleation provides essentially the same motility as wrapped implants. This technique also saves time and money and eliminates the possibility of infectious disease transmission from donor wrapping materials.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Tryptase levels in patients after acute coronary syndromes: the potential new marker of an unstable plaque? Answer the question given the following information: Context: Mast cells (MCs) are multifunctional immune cells that produce a number of vasoactive or thromboactive mediators. Elevated numbers of human heart MCs are observed in the shoulder regions of coronary atherosclerotic plaques, suggesting that they play a role in plaque rupture. Cardiac MC degranulation after myocardial ischemia has been documented in animal models. Cardiac MCs are highly profibrinolytic cells and release tryptase, their specific protease, after ischemic events. Context: Mast cell activation and release of tryptase may differentiate among patients with acute coronary syndromes (ACS), potentially determining the clinical course of ACS. Tryptase levels may indirectly reflect the fibrinolytic status of patients. Context: Mast cell activation after ACS was estimated in 10 controls and 52 patients by measuring the serum levels of tryptase in the acute phase, at 2 weeks, and at 3 months after the ACS episode. Total tryptase levels were determined by using the UniCAP system and analyzed with respect to the patients' clinical types of ACS on admission (ACS with persistent ST-segment elevation on electrocardiogram or with ST-segment depression). Context: Significant differences in serum tryptase levels between the groups were found, with higher serum tryptase concentrations in the ST-segment depression group in the acute phase, and at follow-up. Think step by step to answer my question. [/INST] Serum tryptase concentration differences among patients with distinct types of ACS may indicate a more important role of human heart MCs in ACS with ST-segment depression pathogenesis. To our knowledge, this is the first report indicating that serum tryptase levels may differentiate patients with distinct types of ACS.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Depressive symptoms in intellectual disability: does gender play a role? Answer the question given the following information: Context: Gender issues remain largely unaddressed in the dual diagnosis arena, even in the area of depression where there is a 2:1 female to male ratio in the general population. This paper argues that women with intellectual disability (ID) report higher levels of depressive symptoms than men with ID and that risk factors for depression identified for women in the general population are relevant to this group. Context: Findings are based on structured interviews with 99 men and women with ID, with corroborative information provided from caregivers and casebook reviews. Context: Overall, women reported higher levels of depression than men. Individuals with higher depression scores were more lonely and had higher stress levels than individuals with lower scores. Women with higher depression scores were more likely to report coming from abusive situations, to have poor social support from family and to be unemployed when compared to women with lower scores, but similar differences were not found when comparing men with higher and lower depression scores. Think step by step to answer my question. [/INST] Men and women who report experiencing these psychosocial correlates of depression should be a target group for future prevention efforts, taking gender specific concerns into consideration.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: The minimum data set pressure ulcer indicator: does it reflect differences in care processes related to pressure ulcer prevention and treatment in nursing homes? Answer the question given the following information: Context: To determine whether nursing homes (NHs) that score in the extreme quartiles of pressure ulcer (PU) prevalence as reported on the Minimum Data Set (MDS) PU quality indicator provide different PU care. Context: Descriptive, cohort. Context: Sixteen NHs. Context: Three hundred twenty-nine NH residents at risk for PU development as determined by the PU Resident Assessment Protocol of the MDS. Context: : Sixteen care process quality indicators (10 specific to PU care processes, five related to nutrition, and one related to incontinence management) were scored using medical record data, direct human observation, interviews, and data from wireless thigh movement monitors. Context: There were no differences between homes with low- and high-PU prevalence rates reported on the MDS PU quality indicator on most care processes. NHs with high PU prevalence rates used pressure-reduction surfaces more frequently and were better at documentation of four wound characteristics when PUs were present. No measure of PU care processes was better in low-PU NHs. Neither low- nor high-PU prevalence NHs routinely repositioned residents every 2 hours, even though 2-hour repositioning was documented in the medical record for nearly all residents. Think step by step to answer my question. [/INST] The assumption that homes with fewer PUs and thus low PU prevalence according to the MDS PU quality indicator are providing better PU care was not supported in this sample. NHs that scored low on the MDS PU quality indicator did not provide significantly better care than NHs that scored high. All NHs could improve PU prevention, as evidenced by the poor performance on prevention care processes by low- and high-PU NHs. The MDS PU quality indicator is not a useful measure of the quality of PU care in NHs and can be misleading if not presented with an explanation of the meaning of the indicator.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does the inhalation device affect the bronchodilatory dose response curve of salbutamol in asthma and chronic obstructive pulmonary disease patients? Answer the question given the following information: Context: This open randomized study examined differences between the effects of an equal dose of salbutamol administered via the Diskus, Turbuhaler, and pMDI plus Volumatic. Measurements included dose response curves, dynamic and static lung volumes, respiratory muscle strength, and systemic effects. Context: The cumulative dose-response study compared the biological effects (pulmonary function, respiratory muscle function, systemic effects) of an equal dose of salbutamol delivered via four different devices in 23 patients with asthma and 21 patients with moderate or severe chronic obstructive pulmonary disease (COPD). Context: Salbutamol via Volumatic showed significantly better bronchodilation than via pMDI or Turbuhaler in both patient groups. No significant difference was found between salbutamol via Volumatic and Diskus. However, the advantage of Volumatic is of marginal clinical relevance since the additional bronchodilation was a maximum of 140 ml FEV(1) and did not exceed the minimal patient-perceivable improvement. In the asthma group a more evident plasma K(+) decrease was found after salbutamol delivered via pMDI and pMDI plus Volumatic. Furthermore, especially in the COPD patients a significant decrease was observed in hyperinflation and consequently an improvement in maximal inspiratory pressure as a result of salbutamol via all devices. Think step by step to answer my question. [/INST] Bronchodilation by salbutamol was slightly more effective via Volumatic than via pMDI or Turbuhaler. No significant difference in bronchodilation was found between salbutamol via Volumatic and Diskus. The advantage of Volumatic is not of clinical relevance.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does heavy drinking affect academic performance in college? Answer the question given the following information: Context: This study examined the effects of heavy drinking, alcohol-related problems and drinking opportunities on academic performance (grade point average [GPA]) in a prospective cohort of college students attending the University of California at Berkeley. Context: Several waves of survey data were collected from 465 students beginning in the summer prior to their freshman year. Cross-sectional and regression analyses were conducted to determine whether heavy alcohol use, alcohol-related problems and drinking opportunities were associated with college GPA before and after controlling for demographics and high school GPA. Context: Cross-sectional analyses generally revealed modest and nonsignificant associations between college GPA and measures of heavy alcohol use, alcohol-related problems and drinking opportunities in the first year of college. High school GPA was modestly associated with both heavy alcohol use and college GPA. Only a summative measure of alcohol-related academic problems was significantly associated with college GPA, but this relationship did not persist in a regression model that included high school GPA and student demographic characteristics as control variables. Think step by step to answer my question. [/INST] Heavy alcohol use, alcohol-related problems and drinking opportunities do not appear to have an important effect on students' academic performance, but additional research with longitudinal data from representative student samples is needed to confirm these findings.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Relationship between Helicobacter pylori negative chronic superficial gastritis and functional dyspepsia: are they the same disease? Answer the question given the following information: Context: To discriminate between Helicobacter pylori (Hp) negative chronic superficial gastritis and functional dyspepsia (FD) from therapeutic point of view. Context: 214 patients with Hp negative chronic superficial gastritis were randomly assigned into two groups. One group was case control trial group, another was cross-treated self-control group. Ordinary treatment of chronic gastritis (plan A) and FD plan (plan B) were given. Symptoms and pathologic changes were analysed and compared. Context: In the case control group, the total effective rate of plan A and plan B was 89.2% and 88.5% respectively; in the cross-treated self-control group, the total effective rate of plan A and plan B was 81.8% and 89.8% respectively; There was no significant difference in the effective rate of the two different plans (P>0.05). Think step by step to answer my question. [/INST] Hp negative chronic superficial gastritis is similar to FD from therapeutic point of view. The method of treatment of the two diseases may be same, though they are named differently.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Human leukocyte antigen class II genes and Helicobacter pylori infection: does genotype overwhelm environmental exposure? Answer the question given the following information: Context: We investigated associations between human leukocyte antigen class II genes, environmental exposures, and Helicobacter pylori infection. Context: Sixty-eight subjects with histologically confirmed H. pylori and intestinal metaplasia (cases) and 70 healthy subjects without H. pylori (controls) matched for age, sex, and year of birth were included in this study. All patients answered a detailed questionnaire designed to collect sociodemographic characteristics, smoking, alcohol drinking, and dietary habits. Human leukocyte antigen class II genes were typed with genomic DNA. The cytotoxins CagA and VacA were investigated with serology. Odds ratios and corresponding 95% confidence intervals were estimated from multivariate conditional logistic regression. Multiple correspondence analysis was used to represent the interrelationships of a multiple contingency table. Context: Human leukocyte antigen DRB1, DQA1, and DQB1 genotypes were not significantly associated with H. pylori infection and intestinal metaplasia. No significant association with blood group or Lewis antigen system was found. However, multiple correspondence analysis clearly associated H. pylori with environmental exposure: the control group largely consumed olive oil, fresh fruits, and vegetables and histories of never or formerly smoking and the case group (those positive for H. pylori and metaplasia) largely consumed eggs, meat and butter and had histories of smoking cigarettes. Think step by step to answer my question. [/INST] These findings suggested that H. pylori infection is not influenced by a genetic compound and confirmed the relevance of environmental exposure.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is olestra consumption associated with changes in dietary intake, serum lipids, and body weight? Answer the question given the following information: Context: There is considerable controversy regarding the effects of fat substitutes (such as the non-caloric fat substitute, olestra) on Americans' diet and health. This report gives associations of olestra consumption (in savory snacks) with changes in nutrient intake, serum lipid concentrations, and body weight 1 y after these snacks became available nationally in the United States. Context: Participants were 1178 adults recruited from three large U.S. cities. At baseline (before the availability of olestra), participants attended a clinic visit and completed questionnaires (including a food-frequency questionnaire), provided fasting blood samples, and had height and weight measured. The clinic visit was repeated about 1 y later, after the introduction of olestra-containing snacks in the marketplace. Olestra consumption was categorized as "none," "very low" (>0 to<0.4 g/d), "low" (>/=0.4 to<2.0 g/d), and "moderate/high" (>/=2.0 g/d). Context: Twenty-five percent of participants reported consuming olestra-containing savory snacks in the preceding month, but only 2% were categorized as moderate/high consumers. Men reported nearly twice as much olestra consumption as women (1.22 versus 0.68 g/d, P = 0.01). Among moderate/high olestra consumers, total energy and carbohydrate intakes increased by 209 kcal/d and 37 g/d, compared with decreases of 87 kcal/d and 14 g/d, respectively, among non-consumers (both Ps for trend = 0.01), corresponding to non-significant changes in percentages of energy from carbohydrate and total fat. Olestra consumption was not associated with statistically significant changes in serum lipids or body weight. Think step by step to answer my question. [/INST] This study found very modest changes in total diet, but no changes in serum lipids or body weight, associated with consumption of olestra-containing savory snacks. However, the low use of olestra by the study sample limited the ability of this study to detect significant effects.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Systematic safety follow up in a cohort of 107 patients with spondyloarthropathy treated with infliximab: a new perspective on the role of host defence in the pathogenesis of the disease? Answer the question given the following information: Context: Recent studies with infliximab indicate the therapeutic potential of tumour necrosis factor alpha blockade in spondyloarthropathy (SpA). Because defective host defence is implicated in the pathogenesis of SpA, the potential side effects of this treatment due to impact on the antimicrobial defence are a major concern. Context: To report systematically the adverse events seen in a large cohort of patients with SpA treated with infliximab, with special attention to bacterial infections. Context: 107 patients with SpA were treated with infliximab for a total of 191.5 patient years. All serious and/or treatment related adverse events were reported. Context: Eight severe infections occurred, including two reactivations of tuberculosis and three retropharyngeal abscesses, and six minor infections with clear bacterial focus. One patient developed a spinocellular carcinoma of the skin. No cases of demyelinating disease or lupus-like syndrome were seen. Two patients had an infusion reaction, which, however, did not relapse during the next infusion. Finally, three patients with ankylosing spondylitis developed palmoplantar pustulosis. All patients recovered completely with adequate treatment, and infliximab treatment had to be stopped in only five patients with severe infections. Think step by step to answer my question. [/INST] Although the global safety of infliximab in SpA is good compared with previous reports in rheumatoid arthritis and Crohn's disease, the occurrence of infections such as tuberculosis and retropharyngeal abscesses highlights the importance of careful screening and follow up. Focal nasopharyngeal infections and infection related symptoms, possibly induced by streptococci, occurred frequently, suggesting an impairment of specific host defence mechanisms in SpA.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: CD44v6: a potential marker of malignant transformation in intestinal metaplasia of the stomach? Answer the question given the following information: Context: Intestinal metaplasia is a well-established risk factor in the development of stomach cancer. However, since the specificity is low it would be of great practical value to find a marker to separate cases of intestinal metaplasia into low and high risk for progression to dysplasia/carcinoma. So far this has not been achieved. CD44 is a cell surface molecule involved in cell-cell and cell-matrix interactions, and the spliced variant 6 has been shown to play a role in the progression of gastric carcinoma. The aim of this study was therefore to evaluate CD44v6 as a marker of increased cancer risk in intestinal metaplasia. Context: The current study investigated immunohistochemical CD44v6 expression in biopsies of normal gastric mucosa (n = 154) and gastric mucosa with intestinal metaplasia (n = 127). A third group consisted of cancer gastrectomies (n = 117) in which both tumour and uninvolved mucosa was studied. Proximal (cardia) and distal (corpus/antrum) locations were noted in all cases. Context: There was a significant sequential increase in CD44v6 expression from normal mucosa and mucosa showing intestinal metaplasia to uninvolved mucosa adjacent to cancers without and with intestinal metaplasia to tumour. The most striking increase was from 'normal' to intestinal metaplastic mucosa adjacent to cancers. There were no differences between proximal and distal cases in any group. Think step by step to answer my question. [/INST] These findings strongly suggest that CD44v6 expression is a late phenomenon in the transformation of intestinal metaplasia to dysplasia/cancer. It may therefore be a useful marker of cancer risk in patients with intestinal metaplasia.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Gastric juice nitrite and vitamin C in patients with gastric cancer and atrophic gastritis: is low acidity solely responsible for cancer risk? Answer the question given the following information: Context: N-nitroso compounds are carcinogens formed from nitrite, a process that is inhibited by vitamin C in gastric juice. Helicobacter pylori infection has been reported to increase nitrite and decrease vitamin C in gastric juice. Therefore, susceptibility to gastric cancer in H. pylori-infected patients may be derived from increased N-nitroso compounds in gastric juice. However, most H. pylori-infected patients do not develop gastric cancer. Context: To investigate additional factors that may affect susceptibility to gastric cancer, we compared nitrite and vitamin C levels in gastric juice from H. pylori-infected patients with and without gastric cancer. Context: Serum and gastric juice were obtained from 95 patients undergoing diagnostic endoscopy, including those with normal findings, duodenal ulcer, gastric ulcer, atrophic gastritis and gastric cancer. Serum was analysed for H. pylori antibody, nitrate and nitrite, gastrin and pepsinogens; gastric juice was analysed for pH, nitrite and vitamin C. Context: pH and nitrite levels were increased and vitamin C levels decreased in the gastric juice of patients with atrophic gastritis and gastric cancer compared with other patients. However, in patients with a similar gastric acidity (pH 5-8), nitrite concentrations in the gastric juice were significantly higher and vitamin C levels significantly lower in patients with gastric cancer than in those with atrophic gastritis. Think step by step to answer my question. [/INST] Although hypochlorhydria increases intraluminal nitrite and decreases intraluminal vitamin C, which increases the intraluminal formation of N-nitroso compounds, our results indicate that patients with gastric cancer may have additional factors that emphasize these changes.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the risk of adult coeliac disease causally related to cigarette exposure? Answer the question given the following information: Context: Previous studies have shown an association between cigarette smoking and coeliac disease, but it has yet to be established whether this relationship is causal. The aim of this study was to assess causality using the Bradford Hill criteria. Context: A matched case-control study using a questionnaire to establish a detailed smoking history for 138 incident cases of adult coeliac disease and 276 age-matched and sex-matched controls. Subjects were categorized according to their active cigarette exposure prior to diagnosis of the matched case, and odds ratios and tests for linear trends were calculated. Context: At the time of diagnosis, 10% of cases and 30% of controls were current smokers (odds ratio, 0.21 and 95% confidence interval, 0.11-0.40 for coeliac disease in current smokers versus never smokers). A biological gradient was demonstrated for total, recent and current cigarette exposure. The greatest risk reduction related to current exposure (odds ratio, 0.15, and 95% confidence interval, 0.06-0.37 for coeliac disease in current heavy smokers versus never smokers). Think step by step to answer my question. [/INST] This study strengthens the case for a causal relationship between smoking and coeliac disease by demonstrating a strong, temporally appropriate and dose-dependent effect, thus meeting the Bradford Hill criteria. This suggests that cigarette smoking truly protects against the development of adult coeliac disease.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the current treatment of primary and secondary amyloidosis effective? Answer the question given the following information: Context: Retrospective study about results of treatment of patients (pts) with primary (AL) and secondary (AA) amyloidosis is given. 31 pts with systemic forms of amyloidosis have been treated and followed-up in our department since 1993. Context: 6 men and 11 women were in the AL group with the mean age of 59 years. Multiple myeloma was diagnosed in 9 pts, monoclonal gammapathy of undetermined significance (MGUS) was found in 8 pts. The kidneys were affected in all pts, heart in 59% of pts, liver, joints and skin in 26% of pts and polyneuropathy was detected only in 1 pt. Progression of renal insufficiency with decrease of glomerular filtration rate (GFR) was detected in the AL group at the end of follow-up period compared with the initial level (p<0.05) despite the intensive treatment. The difference did not reach statistical significance in other investigated parameters. Median of survival was 13 months from the assessment of diagnosis. Partial remission of amyloidosis was achieved in 9 pts, stable disease was in 5 pts and in 3 pts the disease progressed. 4 men and 10 women were in the AA group with mean age of 58 years. Underlying disease was rheumatoid arthritis in 7 pts, ankylosing spondylitis in 2 pts, juvenile chronic arthritis in 1 pt, Crohn's disease in 2 pts, eosinophilic fasciitis in 1 pt and chronic abscesses in NK cell deficiency in 1 pt. The kidneys were affected in all pts, bowels and heart in 36% of pts. GFR (p<0.05) and plasma creatinine (p<0.01) significantly decreased at the end of follow-up period compared with initial levels. Median of survival was 30 months. Partial remission was achieved in 2 pts, stable disease was in 3 pts and progression was detected in 9 pts despite the use of various treatment regimens. Think step by step to answer my question. [/INST] Both forms of systemic amyloidosis represent severe disease with limited response to treatment. The use of new drugs is promising and could lead to better response to treatment.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are elevated homocysteine plasma levels related to peripheral arterial disease? Answer the question given the following information: Context: It is still unclear whether the strength of the association between elevated plasma homocysteine (HC) levels and peripheral arterial disease (PAD), coronary artery disease (CAD) and cerebrovascular disease (CVD) is similar. Context: Fasting homocysteine plasma levels were measured in 6880 unselected primary care patients aged 65 years or older. Presence of PAD was determined with the ankle brachial index, and both CAD and CVD were recorded according to patient history. Context: Median homocysteine levels in the total sample (58.0% females, mean age 72.5 years, mean body mass index 27.3 kg m-2) differed between patients with and without PAD: 15.2 micro mol L-1 (95% confidence interval [CI] 14.8; 15.7, vs. 13.9 micro mol L-1 (CI: 13.8; 14.1; P<0.001). Peripheral arterial disease prevalence moderately increased from 13.0% in the lowest HC quintile to 24.3% in the highest quintile (crude odds ratio [OR], 2.1 [CI: 1.7; 2.6]). The frequency of atherothrombotic manifestations in the patients' history increased nearly linearly across the homocysteine quintiles in the univariate analysis. However, the association diminished substantially after adjusting for known interfering variables: the ORs between the HC highest fifth vs. lowest fifth (adjusted for age, gender, smoking status, diabetes, hypertension lipid disorders, and estimated glomerular filtration rate levels) for PAD decreased to 1.4, for CAD to 1.0 (NS), and for CVD to 1.1. (NS). Think step by step to answer my question. [/INST] Elevated HC is only slightly more related to PAD than to CAD and CVD. After adjustment for known risk factors, the effect size is small, and an association can no longer be observed between homocysteine and CAD and CVD.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is digital image compression acceptable within diabetic retinopathy screening? Answer the question given the following information: Context: The National Screening Committee (NSC), whilst recommending the use of digital mydriatic retinal photography for diabetic retinopathy screening, has not yet accepted the use of digitally compressed images for grading. By greatly reducing the file size, however, compression of images is invaluable for storage and for its rapid transmission across computer networks. We undertook a study to compare the different levels of JPEG compression with the original bit-mapped image to determine whether there was any loss of clinical detail following compression. Context: Three hundred and thirty images were analysed in this study. These images had been captured from 66 eyes consecutively photographed in a diabetic retinopathy screening programme, using a Sony DXC-950 P 3CCD colour video camera mounted on a Canon CR6-45NMf fundus camera. Single 45 degrees macula-centred images were taken from each eye. The images were compressed using the JPEG algorithm within Adobe Photoshop (version 4.0) and then displayed with a Sony Trinitron colour monitor. Four different levels of compression were used, JPEG-1, JPEG-2, JPEG-3, JPEG-4, and an objective analysis was undertaken using 'lesion counts'. The compressed images were assessed separately and blindly and the results compared with their original BMP images. Context: Eight BMP images could not be evaluated (five right eye and three left eye). A total of 290 images were therefore used in the final evaluation. All the JPEG-1 images with file sizes between 16 and 24 kb were found to be 'pixelated', while the JPEG-4 images (66-107 kb) appeared similar to the original BMP (1.3 Mb) images. Both JPEG-2 and JPEG-3 images had significantly lower counted lesions than the BMP images. Think step by step to answer my question. [/INST] From our findings we can conclude that only some degree of image compression (compression ratios of 1 : 20 to 1 : 12) with file sizes of 66-107 kb is permissible using JPEG format, whereas the images obtained after higher compression ratios may not be suitable for diabetic retinopathy screening.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Rectal cancer and ulcerative colitis: does it change the therapeutic approach? Answer the question given the following information: Context: The aim of this study was to examine the incidence of coexisting colorectal cancer in ulcerative colitis in a population of patients undergoing ileal pouch anal anastomosis. The frequency of rectal cancer in this population, surgical intervention, general outcomes and cancer recurrence are described. Context: Data on 1850 patients undergoing restorative proctocolectomy from 1983 to 2001 were reviewed. Information was gathered from data in the department's pelvic pouch database, as well as pathology and surgical reports. Follow-up questionnaires routinely sent to patients as part of the database were included in the analysis to determine current functional status. Mean follow-up period was 7.5 years after surgery. Context: Seventy patients had coexisting colorectal cancer at time of IPAA. 7 (10%) of cancers were incidental. Pre-operative duration of disease was 18.6 years. Twenty-six of the cancers were rectal cancers. The most common form of anastomosis in the rectal cancers was mucosectomy, especially in pre-operatively known rectal cancer or low lying dysplasia. Preferred surgical technique for rectal cancer in mucosal ulcerative colitis (UC) included high ligation of mesenteric vessels with radical colectomy and taped occlusion of the rectum with irrigation of the rectal stump with Turnbull solution prior to mucosectomy. Patients with Stage 3 cancers received postoperative chemotherapy. Post-operative radiation therapy was not commonly recommended. Five of 70 patients were deceased from metastatic colon cancer; 55 patients were confirmed alive with good to excellent pouch function with a follow-up range of 1-17 years. Think step by step to answer my question. [/INST] Restorative proctocolectomy with ileal pouch anal anastomosis is a successful surgical approach for patients with coexisting colorectal cancer in UC. When the appropriate surgical technique is used in patients with colon or rectal cancer, along with adjuvant chemotherapy when appropriate, prognosis and function is very good.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the human papillomavirus a mutual aetiological agent in oral and cervical squamous cell carcinoma? Answer the question given the following information: Context: Oncogenic HPV-types are the most important risk factor in cervical SSC and have also been implicated in the aetiology of OSSC. This evidence of infection at different anatomical sites suggests systemic susceptibility that implies that different expressions of disease should more or less correlate over long periods of time. Context: This was undertaken to establish whether any correlation could be found between the incidence of cervical SCC and OSCC in females and OSSC in males in South Africa, over a ten-year period, 1986 to 1995. Context: Several moderate to strong correlations, which ranged from significant (p<0.05) to highly significant (p<0.01), between the incidence of cervical SSC and OSSC in the Black and Coloured populations, and OSSC in the White male population, were found. Think step by step to answer my question. [/INST] These results support the idea of systemic susceptibility, and infection through a common agent such as HPV, contributing to the cause of SSC.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do we need a chart of quality for websites related to cosmetic surgery? Answer the question given the following information: Context: Convergence of medicine and Internet may be one of the most remarkable transformations in the health care business. Following the path led by the United States, the number of French websites related to cosmetic surgery is growing rapidly. In this study, we intend to assess the quality of French websites dedicated to cosmetic surgery regarding good quality criteria currently available and recommendations suggested by the French Medical Association. Context: We browsed the main French search engines on the Web that initially answering the following question: how many webpages are available regarding cosmetic surgery and what are the best referenced websites. For each website, we surveyed the following data: author's name and qualification, date of creation and last update, sources of information, level of interactivity, and adherence to a chart of quality such as HON. Context: Eighty-five websites were surveyed and assessed. Forty-five French websites were active websites dedicated to cosmetic surgery. Websites are mainly hosted by private clinics (18 sites = 40%), with informative content. We found that no website adheres to any chart of quality, and the French Society for Plastic Surgery (SOF.C.P.R.E.) is never mentioned. Intrinsic quality criteria for websites (author's identification, last update, sources of information, confidentiality) are only partially present. Context: We recall the key statistics regarding e-health business in the world, the various charts of quality available for medical websites, and recommendations provided by the French Medical Association. We suggest that websites should be available as a service (for information to the patient, for managing the office, for setting up medical records) rather than a poor personal webpage or a showcase. Think step by step to answer my question. [/INST] The quality of websites for cosmetic surgery is poor; however, as in the USA, the number of web surfers on medical sites is growing. Online presence of our speciality should evolve. To improve medical websites, collective awareness is required. We recommend using a specific chart of quality, with recommendations rather than constraints.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Liver regeneration in a retrorsine/CCl4-induced acute liver failure model: do bone marrow-derived cells contribute? Answer the question given the following information: Context: Adult bone marrow contains progenitors capable of generating hepatocytes. Here a new liver failure model is introduced to assess whether bone marrow-derived progeny contribute to liver regeneration after acute hepatotoxic liver failure. Context: Retrorsine was used to inhibit endogenous hepatocyte proliferation, before inducing acute liver failure by carbon tetrachloride. Bone marrow chimeras were generated before inducing liver failure to trace bone marrow-derived cells. Therefore, CD45 and major histocompatibility complex (MHC) class I dimorphic rat models were applied. Context: Early after acute liver failure a multilineage inflammatory infiltrate was observed, mainly consisting of granulocytes. In long-term experiments small numbers of CD90+/CD45- cells of donor origin occurred in clusters associated with portal triads. Bone marrow cell infusion was not able to enhance liver regeneration. Cellular hypertrophy was the predominant way of liver mass regeneration in models applying retrorsine. Think step by step to answer my question. [/INST] Retrorsine pretreatment did not affect sensitivity for carbon tetrachloride. A multilineage inflammatory infiltrate was observed in rats whether pretreated with retrorsine or not. Few donor cells co-expressing CD90 (THY 1) were present in recipient livers, which may resemble donor-derived hematopoietic progenitors or oval cells. No other donor cells within liver parenchyma were detected. This is in contrast to other cell infusion models of acute cell death.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is it possible to differentiate early-onset accommodative esotropia from early-onset essential esotropia? Answer the question given the following information: Context: To determine the frequency of>or =2.50 diopter (D) hyperopia in infantile esotropia with onset up to the age of 6 months and by evaluating the treatment results of these cases retrospectively, to find the factors that may help to differentiate early-onset accommodative esotropia from early-onset essential esotropia. Context: The charts of 256 patients with infantile esotropia were reviewed. Thirtyseven cases, with hyperopia of>or =2.50 D, no other systemic and neurologic disease, and at least 1 year of follow-up, were included in this study. The age at the start of therapy, refractive error, deviation angle, type of therapy (antiaccommodative therapy, surgery) and the presence of amblyopia, latent nystagmus, inferior oblique overaction, dissociated vertical deviation and cross-fixation were recorded for each case. Context: The prevalence of high hyperopia was found to be 14.4% (37/256) in infantile esotropia. In 18 of the cases (48.6%), antiaccommodative therapy alone was found to be adequate (Group I). In the remaining 19, although antiaccommodative therapy was found to decrease the deviation angle significantly (P<0.001), surgery was also required (Group II). Groups were compared with respect to age at the initial examination, refractive error, deviation angle, presence of amblyopia, anisometropia, and inferior oblique overaction, but no factor could be determined to predict the pure refractive ones (P>0.05). Essential infantile esotropia-associated findings did not help because they are rarely evident at the time of initial diagnosis. Think step by step to answer my question. [/INST] Half of the high hyperopic infantile esotropes could be corrected fully by antiaccommodative therapy alone, while the remaining ones could also benefit significantly. It is strongly recommended to try spectacles at first in the treatment of infantile esotropia with hyperopia>or =2.5 D.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Strabismus surgery: adjustable sutures-good for all? Answer the question given the following information: Context: The role of adjustable sutures in strabismus surgery has mainly been limited to conditions like dysthyroid restrictive myopathy, blow-out fractures of orbit, aberrant regeneration of nerves, and certain other long-standing and complicated squints. In this clinical study, an attempt has been made to analyse the efficacy of adjustable sutures in squint surgery as a routine procedure. We also studied patients' acceptability and satisfaction following this procedure and analysed various factors that may influence the surgical outcome (age, sex, previous surgeries, injections of botulinum toxin, etc). Context: A total number of 443 patients, aged between 13 and 78 years, who underwent strabismus surgery in our department, from January 1996 to January 2000, were included in this study. Of these patients, 141 had surgery with adjustable sutures and 302 patients without adjustable sutures. Surgical results were followed up for a period ranging from 12 to 50 months. The main outcome measure was a need for a reoperation in the two groups. In addition, we also studied patients' satisfaction with regard to final cosmetic appearance or relief of diplopia; percentage change in angle of deviation in two groups, and influence of various factors such as age, sex, previous surgeries, and injection of botulinum toxin on the final surgical outcome. The results were statistically analysed using Levene's test for equality of variances, t-test for equality of means, and statistical significance of the results was analysed by calculating P-values. Context: In total, 8.51% of the patients in the adjustable group and 27.15% in the nonadjustable group needed a reoperation. Surgical results were found to be significantly better in patients who had adjustable sutures in comparison to those who did not have adjustable sutures (P<0.005). Patients' satisfaction and percentage change in angle of deviation was also much higher in adjustable sutures group. Age, sex, number of previous surgeries, previous injections of botulinum toxin, and type and amount of deviation had no statistically significant influence on the surgical outcome. Think step by step to answer my question. [/INST] Strabismus surgery with adjustable sutures has a statistically significant better, final result than surgery without adjustable sutures. Patients' satisfaction and percentage change in angle of deviation is also much higher in the adjustable sutures group. As age, sex, number of previous surgeries, previous injections of botulinum toxin, and type and amount of deviation do not influence the final outcome, this type of surgery can be performed in virtually all types of patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: A prospective randomized comparison of unsedated ultrathin versus standard esophagogastroduodenoscopy in routine outpatient gastroenterology practice: does it work better through the nose? Answer the question given the following information: Context: In an outpatient gastroenterological practice setting, highly effective diagnostic procedures and patient satisfaction play an important role. Ultrathin endoscopy in unsedated patients has been shown to be more cost-effective and time-efficient in comparison with standard endoscopy. A prospective randomized study was carried out in unsedated patients to compare performance, feasibility, safety, and patient tolerance between ultrathin transnasal (UT), ultrathin oral (UO), and standard (SO) esophagogastroduodenoscopy (EGD). Context: A total of 200 of 600 eligible patients consented to participate in the study, and were randomly assigned to undergo UT, UO, or SO. Patients reported their tolerance of the procedure (anxiety, pain, gagging, and overall satisfaction; Likert scale 1-10), and the endoscopists reported the effectiveness of the procedure (handling, picture quality, and overall performance; Likert scale 1-10). Statistics were calculated using the Kruskal-Wallis test. Context: After randomization, 65, 67, and 68 patients were allocated to the UT, UO, and SO groups, respectively. Failure to achieve complete EGD by the intended route occurred in 14 patients (22 %) in the UT group. Compared to the SO group, patients in the UT and UO groups rated anxiety before the procedure as being more intense - median score (10 % quantile estimate; 90 % quantile estimate): UT, 2.0 (1.0; 4.0); UO, 2.0 (1.0; 4.0); SO, 0.0 (0.0; 2.0); p<0.0001), whereas SO patients experienced a higher level of anxiety during the procedure ( P<0.0001). Pain during insertion of the endoscope was the least intense in the UO group: UT, 2.0 (1.0; 5.0); UO, 1.0 (1.0; 3.0); SO, 2.0 (1.0; 4.0); P<0.001). Gagging during insertion was more pronounced in the UO group: UT, 2.0 (1.0; 4.0); UO, 3.0 (1.0; 7.0); SO, 2.0 (1.0; 5.0); P<0.01). The patients' score for the overall assessment was better in the SO group ( P<0.0001). The endoscopists' overall assessment for ultrathin EGD was poorer than for standard EGD: UT, 3.0 (2.0; 5.0); UO, 3.0 (2.0; 5.0); SO, 2.0 (1.0; 3.0); P<0.0001). Think step by step to answer my question. [/INST] Ultrathin endoscopy through both the transnasal and oral routes has limited use in routine outpatient practice. Techniques for reducing pain and gagging may improve patient tolerance. Further technical improvements are needed to allow routine implementation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Participatory ergonomics as a return-to-work intervention: a future challenge? Answer the question given the following information: Context: Participatory ergonomics (PE) are often applied for prevention of low back pain (LBP). In this pilot-study, a PE-program is applied to the disability management of workers sick listed due to LBP. Context: The process, implementation, satisfaction, and barriers for implementation concerning the PE-program were analyzed quantitatively and qualitatively for 35 workers sick listed 2-6 weeks due to LBP and their ergonomists. Context: Two-hundred-and-seventy ergonomic solutions were proposed to the employer. They were targeted more at work design and organization of work (58.9%) than at workplace and equipment design (38.9%). They were planned mostly on a short-term basis (74.8%). Almost half (48.9%) of the solutions for work adjustment were completely or partially implemented within 3 months after the first day of absenteeism. Most workers were satisfied about the PE-program (median score 7.8 on a 10-point scale) and reported a stimulating effect on return-to-work (66.7%). Main obstacles to implementation were technical or organizational difficulties (50.0%) and physical disabilities of the worker (44.8%). Think step by step to answer my question. [/INST] This study suggests that compliance, acceptance, and satisfaction related to the PE-program were good for all participants. Almost half of the proposed solutions were implemented.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do parents understand emergency department discharge instructions? Answer the question given the following information: Context: Understanding discharge instructions is crucial to optimal healing but may be compromised in the hectic environment of the emergency department. Context: To determine parents' understanding of ED discharge instructions and factors that may affect it. Context: A convenience sample of parents of children discharged home from the ED of an urban tertiary care pediatric facility (n = 287) and a suburban level II general hospital (n = 195) completed a 13 item questionnaire covering demographics, level of anxiety, and quality of physician's explanation. Parents also described their child's diagnosis and treatment instructions and indicated preferred auxiliary methods of delivery of information. Data were analyzed using the BMPD statistical package. Context: Full understanding was found in 72% and 78% of the parents at the respective centers for the diagnosis, and in 82% and 87% for the treatment instructions (P = NS between centers). There was no statistical correlation between level of understanding and parental age, gender, education, level of anxiety before or after the ED visit, or time of day. The most contributory factor to lack of understanding was staff use of medical terminology. Parents suggested further explanations by a special discharge nurse and written information as auxiliary methods. Think step by step to answer my question. [/INST] Overall, parental understanding of ED discharge instructions is good. However, there remains a considerable number (about 20%) who fail to fully comprehend the diagnosis or treatment directives. This subset might benefit from the use of lay terminology by the staff, institution of a special discharge nurse, or use of diagnosis-specific information sheets.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Erysipelothrix rhusiopathiae endocarditis: a preventable zoonosis? Answer the question given the following information: Context: Erysipelothrix rhusiopathiae is a bacterium ubiquitous in the environment. It can cause a variety of diseases and the risk of infection is closely related to the level of occupational exposure to infected or colonised animals. Context: To discuss the clinical features and treatment of this zoonosis, to increase awareness of this pathogen and to emphasise the need for meticulous attention to hygienic work practices in reducing the risk of infection. Context: A case report of a farmer with E. rhusiopathiae endocarditis and the management of the infection. Context: The patient was successfully treated with valve replacement surgery and antimicrobial therapy. Think step by step to answer my question. [/INST] Early identification of this microorganism is essential for appropriate treatment of endocarditis. Greater awareness and safe work practices can help reduce the risk of human infection by this microorganism.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does repair of mitral regurgitation eliminate the need for left ventricular volume reduction? Answer the question given the following information: Context: Effects of partial left ventriculectomy (PLV) remain ill-defined because mitral regurgitation (MR) repair by isolated annuloplasty alone has been reported to improve patients with dilated left ventricle and severe MR. Context: Among patients undergoing PLV, 120 had paired pre- and postoperative (<1 week) Doppler echocardiograms. Effects of preoperative MR were studied by comparing 45 patients with no preoperative MR (MR-) and 75 patients with significant MR (MR+; MR = 1.51 when MR is enumerated as none = 0, mild = 1, moderate = 2). Context: MR- patients as compared with the MR+ group were older (53.8 vs. 49.2 years, P = 0.047), had less frequent dilated cardiomyopathy (33.3% vs 49.3%,P<0.01), similar ventricular dimension (72.3 mm vs 73.0 mm), septal thickness (9.5 mm vs 9.6 mm), posterior wall, fractional shortening (15.9% vs 16.8%) and ventricular mass (330 g vs 345 g), resulting in comparably reduced functional capacity (NYHA 3.40 vs 3.67). Although the MR- group required significantly less frequent mitral procedure (64.4% vs 84.0%, P<0.01) and shorter cardiac arrest time, they had similar postoperative MR (0.22 vs 0.39), highly significant parallel reduction in ventricular dimension (P<0.001 in either group), and improved %FS (P<0.001 in either group), resulting in similar hospital survival (87.1% vs 86.4%) and 90-day survival (71.1% vs 78.7%) with significantly comparable improvement in functional class (P = 0.011 in both groups). Histological severity of interstitial fibrosis (P = 0.80), weight (P = 0.93), and thickness (P = 0.76) of excised myocardium was comparable between the two groups. Think step by step to answer my question. [/INST] Patients with no preoperative MR were found to benefit from PLV as did patients with significant MR. Beneficial effects of PLV appeared to derive mainly from volume reduction rather than abolished MR in this study.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Triple incision to treat phimosis in children: an alternative to circumcision? Answer the question given the following information: Context: To evaluate the functional and cosmetic results and patient satisfaction after triple incision plasty for phimosis in children. Context: The study included 197 boys who had a triple incision for phimosis (mean age 5.8 years, range 0.25-18). The indications for preputial surgery were recurrent balanoposthitis, ballooning during micturition and severe phimotic stenosis. The results after surgery were assessed using a questionnaire about the child's/parent's satisfaction, and an outpatient follow-up examination for functional and cosmetic preputial appearance. Context: Of 128 parents/children responding, 108 (84%) were satisfied with the function and 102 (80%) reported a good cosmetic outcome. Triple incision as preputioplasty would be recommended to other parents by 119 (93%) respondents. Ninety-one (71%) of the parents feared disadvantages in their son's later life if the child had been circumcised. The outpatient examination showed an excellent functional and cosmetic outcome in 71 (77%) of the children. Think step by step to answer my question. [/INST] Triple incision is a simple, fast and safe technique for preputial relief, with good functional and cosmetic results, and was well accepted by the patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do changes in pulse oximeter oxygen saturation predict equivalent changes in arterial oxygen saturation? Answer the question given the following information: Context: This study investigates the relation between changes in pulse oximeter oxygen saturation (SpO2) and changes in arterial oxygen saturation (SaO2) in the critically ill, and the effects of acidosis and anaemia on precision of using pulse oximetry to predict SaO2. Context: Forty-one consecutive patients were recruited from a nine-bed general intensive care unit into a 2-month study. Patients with significant jaundice (bilirubin>40 micromol/l) or inadequate pulse oximetry tracing were excluded. Context: A total of 1085 paired readings demonstrated only moderate correlation (r= 0.606; P<0.01) between changes in SpO2 and those in SaO2, and the pulse oximeter tended to overestimate actual changes in SaO2. Anaemia increased the degree of positive bias whereas acidosis reduced it. However, the magnitude of these changes was small. Think step by step to answer my question. [/INST] Changes in SpO2 do not reliably predict equivalent changes in SaO2 in the critically ill. Neither anaemia nor acidosis alters the relation between SpO2 and SaO2 to any clinically important extent.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: "Cold calling" in psychiatric follow up studies: is it justified? Answer the question given the following information: Context: The ethics of cold calling-visiting subjects at home without prior appointment agreed-in follow up research studies has received little attention although it is perceived to be quite common. We examined the ethical implications of cold calling in a study of subjects with defined neurotic disorders followed up 12 years after initial assessment carried out to determine outcome in terms of symptoms, social functioning, and contact with health services. The patients concerned were asked at original assessment if they would agree to be followed up subsequently and although they agreed no time limit was put on this. Context: To decide if cold calling was ethically justifiable and, if so, to set guidelines for researchers. Context: The study was a cohort study of patients with neurotic disorder treated initially for 10 weeks in a randomised controlled trial. Context: At follow up by a research medical practitioner 18 of the 210 patients had died and of the remaining 192 patients 186 (97%) were seen or had a telephone interview. Four patients refused and two others did not have interviews but agreed to some data being obtained. However, only 104 patients (54%) responded to letters inviting them to make an appointment or to refuse contact and the remainder were followed up by cold calling, with most patients agreeing readily to the research interview. The findings illustrate the dilemma of the need to get the maximum possible data from such studies to achieve scientific validity (and thereby justify the ethics of the study) and the protection of subjects' privacy and autonomy. Think step by step to answer my question. [/INST] More attention needs to be paid to consent procedures if cold calling is to be defended on ethical grounds but it is unreasonable to expect this to be obtained at the beginning of a research study in a way that satisfies the requirements for informed consent. A suggested way forward is to obtain written consent for the research at the time that cold calling takes place before beginning the research.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does endograft support alter the rate of aneurysm sac shrinkage after endovascular repair? Answer the question given the following information: Context: To test the hypothesis that stent-graft support influences sac shrinkage independent of endoleak rates after endovascular repair of abdominal aortic aneurysms (AAA). Context: Ninety AAA patients underwent treatment with bifurcated endoluminal devices at our institution between October 1996 and February 1999. Fifty-two patients were treated using a nonsupported (NS) Ancure endograft and 38 using a fully supported (FS) Excluder endograft. Computed tomographic (CT) scans were obtained during the first postoperative month and at 6, 12, and 24-month intervals. Aneurysm diameter was measured as the minor axis of the largest AAA axial slice on the CT scan. Six, 12, and 24-month sac sizes were compared to the first postoperative evaluation. Context: Successful endoluminal graft placement was accomplished in all patients. The two groups were matched for age, anatomical criteria, and comorbidities except for baseline AAA size: the mean diameter was 5.4 cm in the NS group and 5.0 cm for the FS group (p<0.01). Endoleak rates were 25% (13/52) in the NS group and 18% (7/38) in the FS group (p<0.05) at 1 month. All endoleaks that did not resolve spontaneously at 6 months were treated. Initial endoleak status did not affect the sac shrinkage rates at the 12 and 24-month evaluations. At 2 years, the NS group had greater shrinkage of the sac (1.2 cm) versus the FS cohort (0.3 cm, p<0.05). In addition, more patients in the NS group had sac shrinkage>or =5 mm (83% versus 18%, p<0.05). Think step by step to answer my question. [/INST] Despite a higher endoleak rate, the nonsupported Dacron Ancure endografts were associated with greater sac shrinkage at up to 24 months following implantation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does the type of endograft affect AAA volume change after endovascular aneurysm repair? Answer the question given the following information: Context: To compare thrombus volume changes in a longitudinal study over 2 years after endovascular aneurysm repair using the Ancure and Excluder endografts. Context: In 2 institutions, all consecutive patients treated with a bifurcated Ancure or Excluder endograft were included in this retrospective comparison of computed tomographic angiography (CTA) data recorded and stored to disk postoperatively and at the 12 (12M) and 24-month (24M) follow-up examinations. In one institution, among 45 Ancure endograft patients, 35 (group A) had the 3 requisite scans available. In the second institution, 23 (group B) of 36 patients with the Excluder endograft were eligible for analysis. The proportional volume change was calculated at 12M and 24M and compared to the postoperative CT data. More than 10% shrinkage was considered significant. Context: In both groups, the median absolute volume changed significantly. In group A, significant shrinkage was found in 66% (23/35) at 12M and 74% (26/35) at 24M; in group B, 46% (10/23) had significant shrinkage at 12M as well as at 24M (p=0.027 for the difference between groups A and B at 24M). Statistical analysis of the proportional volume change showed a significant difference between the Ancure and the Excluder devices at 12M (p=0.009) and 24M (p=0.001). Multivariate analysis found aneurysm size (p<0.012) and endograft type (p=0.026) to be independently predictive of the absolute volume change. Think step by step to answer my question. [/INST] Sac volume shrinkage after endovascular aneurysm repair is less pronounced and less frequent with the Excluder endoprosthesis than with the Ancure endograft.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can intrasac pressure monitoring reliably predict failure of endovascular aneurysm repair? Answer the question given the following information: Context: To determine if pressure measured at a single location within aneurysm sac thrombus accurately reflects the force applied to the aneurysm wall and the risk of rupture by examining (1) if pressure is distributed uniformly within aneurysm thrombus, (2) the pressure transmission through aneurysm thrombus, and (3) the microstructural basis for pressure transmission. Context: Pressure within aneurysm thrombus was measured by direct puncture through the aneurysm wall at 121 sites in 26 patients during open abdominal aortic aneurysm repair. Measurements were taken prior to cross clamping and compared with intrasac pressure measured at 30 sites in 6 patients without aneurysm thrombus (controls). Transmission of pressure through aneurysm thrombus was further examined ex vivo by subjecting fresh thrombus to a pressure gradient in a custom-made pressure cell. Pressure transmission was correlated with matrix density as determined by light microscopy and image analysis. Context: Mean pressure within aneurysm thrombus was higher than mean systemic pressure in 11 patients, lower in 1, and identical in 9. In 5 patients, the pressure was greater than systemic in some areas of the thrombus but less in others. Sac pressure was identical to systemic pressure at all sites in the controls. In 12 thrombus specimens (6 patients) examined in the pressure cell, pressure transmission varied significantly between specimens, correlating directly with matrix density (R(2)=0.747, p=0.001). Think step by step to answer my question. [/INST] Pressure transmission through aneurysm thrombus is variable and depends upon the microstructure of the thrombus. Pressure measured at a single location may not, therefore, accurately reflect the pressure acting on the aneurysm wall.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Lung disease and internalizing disorders. Is childhood abuse a shared etiologic factor? Answer the question given the following information: Context: To investigate the role of childhood abuse in the relationship between panic attack, depression and lung disease among adults in the population. Context: Data were drawn from the National Comorbidity Survey (n=5877), a representative sample of adults age 15-54 in the United States. Multiple logistic regression analyses were used to determine the association between childhood abuse and lung disease, and to determine whether childhood abuse is an independent predictor of the co-occurrence of lung disease, panic attack and depression. Context: Childhood abuse was associated with significantly increased odds of panic attacks (OR=2.2 (1.5, 3.1)) and depression (OR=1.6 (1.1, 2.3)). Childhood abuse increased likelihood of lung disease (OR=1.5 (1.1, 2.2)). Childhood abuse independently predicted the co-occurrence of lung disease, panic attack and depression (OR=10.7 (2.2, 51.5)). Think step by step to answer my question. [/INST] These data are preliminary, but if replicated, suggest that childhood abuse may be associated with increased risk of lung disease during adulthood, and further may reflect a shared vulnerability for the co-occurrence of lung disease, panic attack and depression in the community. Future studies are needed to further explore the mechanism of this association.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Diagnostic hysteroscopy: a valuable diagnostic tool in the diagnosis of structural intra-cavital pathology and endometrial hyperplasia or carcinoma? Answer the question given the following information: Context: 1045 diagnostic hysteroscopic procedures performed throughout six consecutive years were evaluated, focussing on its value in diagnosing endometrial hyperplasia and carcinoma. Context: Retrospective study performed in the gynaecological endoscopy clinic of a training hospital. Subjects were 1045 pre- and post-menopausal patients. Context: A normal cavity was found in 54.2%. Most common abnormal findings were fibroids (21.0%) and endometrial polyps (14.4%). Hysteroscopically diagnosed hyperplasia of the endometrium was confirmed histologically in only less than half the cases. Endometrial carcinoma was suspected on hysteroscopic view in two cases of a total of seven proven cases. In three cases initially an endometrial polyp and in two cases a fibroid was diagnosed. Once the diagnosis was missed even after biopsy taking. Think step by step to answer my question. [/INST] Diagnostic hysteroscopy is a valuable diagnostic tool in diagnosing structural intra-cavital pathology, very suitable for the outpatient clinic. The value in diagnosing hyperplasia or endometrial carcinoma is limited and even after guided biopsy a malignancy cannot be ruled out.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Bicycle helmet campaigns and head injuries among children. Does poverty matter? Answer the question given the following information: Context: To assess the impact of a community based bicycle helmet programme aimed at children aged 5-12 years (about 140,000) from poor and well off municipalities. Context: A quasi-experimental design, including a control group, was used. Changes in the risk of bicycle related head injuries leading to hospitalisation were measured, using rates ratios. Context: Reductions in bicycle related head injuries were registered in both categories of municipalities. Compared with the pre-programme period, the protective effect of the programme during the post-programme period was as significant among children from poor municipalities (RR= 0.45 95%CI 0.26 to 0.78) as among those from richer municipalities (RR=0.55 95%CI 0.41 to 0.75). Think step by step to answer my question. [/INST] Population based educational programmes may have a favourable impact on injury risks in poor areas despite lower adoption of protective behaviours.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are we sectioning the cochlear efferent system during vestibular neurotomy? Answer the question given the following information: Context: In addition to sensory neurons which transmit information from the inner ear to the brain, there is a system of efferent feedback fibers, called the olivocochlear system, carrying signals from the brain to the ear. Over the past half-century, the efferent system has been extensively studied in animals and results provided theories as to the functional significance of these efferents: to improve signal-to-noise ratio in the auditory periphery, to mediate selective attention, and to protect the inner ear from acoustic overexposure. The results of several studies conducted in man rely on the study of patients who have undergone a vestibular neurectomy. Indeed, anatomical data show that olivocochlear efferents could travel along or inside the vestibular part of the auditory nerve before reaching the organ of Corti. Therefore, these patients may be considered as an experimental model of unilaterally de-efferented subjects. However, to date, none has reported the existence of olivocohlear efferents in the vestibular section following neurectomy. Context: In this study, we present the histological results from 18 vestibular sections and show the absence of olivocochlear efferents. Think step by step to answer my question. [/INST] These results provide a reason to reconsider the results of previous experiments conducted in similar patients and ask for further studies on the olivocochlear efferents pathways.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can we predict the premature labor in patients with placenta previa? Answer the question given the following information: Context: This study aimed to predict the gestational weeks by characterizing maternal genital bleeding and uterine contraction during pregnancy in patients with placenta previa. Context: Included in this study were 87 patients with placenta previa, diagnosed at the time of delivery at our institution. Genital bleeding and uterine contraction characteristics and clinical data from mothers who delivered at<37 weeks were compared to that of mothers who delivered at>or = 37 weeks. Context: There were 37 deliveries (42.5%) at<37 gestational weeks and 50 deliveries (57.4%) at>or = 37 gestational weeks. In 69 of 87 cases (79.3%), genital bleeding was recognized during pregnancy, and in 63 cases (72.4%) genital bleeding was the first symptom to occur during pregnancy. Uterine contraction during pregnancy was recognized in 48 cases (55.2%), including 36 (41.4%) that occurred as the first symptom of pregnancy. Logistic regression analysis revealed that when genital bleeding occurred at<29 and<31 weeks, patients were at high risk for delivery at<34 and<37 weeks, respectively, and when first uterine contraction occurred at<29 weeks, they were at high risk for delivery at<34 weeks. Think step by step to answer my question. [/INST] In patients with placenta previa, the number of gestational weeks to the occurrence of the first genital bleeding can be used as a predictor of the number of weeks to term.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do antidepressants induce rapid cycling? Answer the question given the following information: Context: To investigate the influence of antidepressant use and gender in the genesis of rapid-cycling bipolar illness. Context: The charts of bipolar patients treated at the Massachusetts General Hospital Bipolar Clinic (Boston, Mass.) were reviewed for gender, presence or absence of rapid cycling, and antidepressant use prior to first mania. Context: Data were obtained for 129 bipolar patients (55% women), 45% of whom had experienced a rapid-cycling course. Overall, there was no significant difference in the rates of rapid cycling between the subjects who were exposed to antidepressants prior to their first manic/ hypomanic episode and those who were not. Additional analysis carried out separately by gender found a significant association between rapid cycling and antidepressant use prior to first mania/hypomania for women but not for men. A logistic regression analysis with rapid cycling as dependent variable revealed a significant interaction between antidepressant use prior to first mania/hypomania and gender. Think step by step to answer my question. [/INST] We found a gender-specific relationship between antidepressant use prior to first manic/hypomanic episode and rapid-cycling bipolar illness. When antidepressants are prescribed to depressed women who have a risk of bipolar disorder, the risk of inducing rapid cycling should be considered. Differing proportions of women and men in previous studies may account for conflicting results reported in the literature for the relationship of antidepressants and rapid cycling. However, this naturalistic trial was uncontrolled, and controlled research is required to confirm our findings.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can salivary lead be used for biological monitoring of lead exposed individuals? Answer the question given the following information: Context: Measurement of blood lead (BPb) is the usual method for biomonitoring of persons exposed to inorganic lead.AIM: To explore the use of salivary lead (SPb) as an alternative. Context: BPb and SPb levels were measured in a group of 82 lead exposed adults. Context: The mean BPb of the workers was 26.6 microg/dl (SD 8.6, range 10-48) and the mean SPb level 0.77 microg/dl, or 3% of the BPb level. As the SPb distribution was skewed, logarithmic transformation was performed to normalise the distribution. A bivariate scattergram of BPb and logSPb (r = 0.41, p = 0.00) had a line of best fit expressed as BPb = 29.7 + 8.95logSPb. The relation of logSPb and BPb was stronger among non-smokers (r = 0.42) compared to smokers (r = 0.3); and among those without a medical condition (r = 0.44). Multiple linear regression analysis (fitting smoking and medical condition into the model) yielded an R of 0.54, and an adjusted R(2) of 0.26. Think step by step to answer my question. [/INST] The study findings do not support the use of SPb for biomonitoring at BPb levels ranging from 10 to 50 microg/dl.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Nasal bone hypoplasia: is it a common finding amongst chromosomally normal fetuses of southern Chinese women? Answer the question given the following information: Context: To assess the incidence of nasal hypoplasia among fetuses of southern Chinese women. Context: This prospective observational study was conducted at Princess Margaret Hospital, Hong Kong. All pregnant women referred for chromosomal studies before 14 weeks were assessed. The crown-rump length, nuchal translucency thickness, and nasal bone were assessed between 11 and 14 weeks. Context: A total of 143 women were recruited. In 119 fetuses, facial profiles were successfully obtained and the presence or absence of nasal bones was assessed. One hundred and fourteen fetuses had normal karyotypes. The rate of absence nasal bone when assessed between 11-14 weeks was 0.88% in the fetuses with a normal karyotype. During the same period, 2 out of 3 fetuses with Down syndrome had absence of nasal bones. A nasal bone was visualized in one fetus with Edward syndrome and the other with Turner syndrome (45 X). Think step by step to answer my question. [/INST] The incidence of nasal hypoplasia is not increased among fetuses of southern Chinese women. Assessment of ossification of the nasal bone can be used to supplement first-trimester screening in Chinese women.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Malignant melanoma and (18)F-FDG-PET: Should the whole body scan include the legs? Answer the question given the following information: Context: In this retrospective analyse 213 consecutive PET studies of 153 patients with suspected or recent malignant melanoma were re-evaluated for metastatic spread by a blinded investigator. Histopathological follow-up was assessed for confirmation. Context: Suspicious findings at the legs were depicted in 53 patients on 76 occasions. 38/53 showed pathologic uptake in the torso as well. In 15/53 patients it was restricted to the legs. One of them had a hitherto unknown, clinically relevant finding that was not apparent in palpation and inspection. In 6 other patients with primary location at the legs a validation of the positive PET findings was not possible up to now. Think step by step to answer my question. [/INST] Metastases and local recurrence of malignant melanoma at the legs were found in 41% of women and 27% of men. However, a long scan does not yield relevant additional data. We found isolated new manifestations at the legs in only 1/153 patients. We recommend performing a long scan only in patients with previous melanoma manifestations restricted to the legs. In all other cases a short scan of the torso and proximal thighs is sufficient. This allows a higher number of PET-scans without loss of diagnostic power and a shorter examination time.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do the incontinent patients improve their equality of life using a humidity detector device? Answer the question given the following information: Context: To evaluate the effect of a humidity detector device on the quality of life of patients with urinary incontinence IU. Context: Quasi-experimental study: a series of ten cases followed for a month. The devices were placed and the questionnaires filled in before and after using it for at least ten hours a day during a month. Health related quality of life was assessed through the questionnaires for IU convalidated and adapted to our specific environment: Urogenital Inventory Distress (UDI) and Incontinence Impact Questionary (IIQ). An improvement of 58 points by a four option Likert scale was considered a positive impact in the quality of life (IIQ). The scores obtained in UDI and IIQ are described before and after use the device and paried T test and Wilcoxon sign test were carried out to compare the scores obtained in each instance. The capacity to detect a difference of 58 points on the UDI scale was calculated (minimum relevant difference). A binomial test was undertaken to ascertain a probability of achieving an increase in the above mentioned index which would exceed the clinical relevance threshold. Context: Average increase in IIQ improvement: x = 5.48 (Std Error = 20.43) 95% CI = -34.56 to 45.56. Average increase in UDI improvement: x = -11.87 (Std Error = 20.70) 95% IC = -52.45 to 28.70. The power of the analysis to detect as relevant a difference of a 588 point increase in IIQ 71.1% and probability of obtaining a relevant improvement in the questionnaire IIQ 10% (IC 95%) 0% to 39.4%. Think step by step to answer my question. [/INST] A negative impact in the Quality of Life due to frequent changes of incontinence pads.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does regular garlic intake affect the prevalence of Helicobacter pylori in asymptomatic subjects? Answer the question given the following information: Context: The in vitro antibacterial activity of garlic against Helicobacter pylori (H.pylori) is well documented and the potential for its use in vivo was suggested. Garlic intake, a traditional habit by the Taskopru population in Turkey for decades, was examined for its effect on the prevalence of H. pylori and compared with the non garlic consuming group. Context: Eighty-one garlic consuming asymptomatic subjects in Kastamonu province in Turkey (68 males, 13 females) of 23-82 years of age (average 46) were selected on a very restricted bases in regards to the garlic intake (raw or cooked, or both), amount, duration and other criteria. Control group (non-garlic consuming) of 81 asymptomatic subjects (66 males, 15 females) of 23-90 years of age (average 43) were enrolled for comparison with the garlic consuming group. Serum samples were collected from both groups during the period from September 2001 through to April 2002 and examined by the enzyme linked immunoassay test for anti H.pylori antibodies. Context: An overall H.pylori prevalence of 79% and 81% was detected in the garlic and non garlic consuming groups. A significantly lower average antibody titer was detected in the garlic consuming group than that of the control group and similarly in those who consumed mixture of raw plus cooked garlic as compared to those who consumed raw or cooked garlic alone. Think step by step to answer my question. [/INST] Garlic intake for long durations (years) did not appear to have an effect on the prevalence of H.pylori infection. Garlic consuming subjects had a significantly lower average antibody titer than non garlic consuming groups, which might suggest an indirect inhibitory effect on the reproduction of H.pylori and possibly progression to more serious peptic ulcer diseases.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does the episode of cardiopulmonary resuscitation in cardiac donors increase the risk of heart transplantation? Answer the question given the following information: Context: The aim of this study is to evaluate the risk of accepting cardiac donors after an episode of cardiopulmonary resuscitation. Context: Since 1997, 13 resuscitated donor hearts (10 M, 3 F, age 15-54 years) after sudden cardiac arrest have been transplanted. The retrospective analysis was used. Context: Allografts after resuscitation episode were implanted in 13 patients (6 M, 7 F, age 31-65 years). 11 patients were on the urgency list and two of them required periodically intravenous inotropic therapy. Two patients (P.A, B.J) died in the first 24 hours after procedure (cause of death: pulmonary embolism, extensive cardiac ischemia). During follow up (6-48 months, avg. 25.1 +/- 15.9 months) none of the 11 patients died. All patients are NYHA functional class I or I/II. Total time of cardiopulmonary resuscitation did not influence the time of reperfusion (p>0.05). Analysis of cardiac index Cl (l/min/m2) at 2, 4, 6, 8, 12, 24, 72 hours after heart transplantation showed correct values during following days. Echocardiographic and invasive examinations (8 patients) do not show any abnormalities. Think step by step to answer my question. [/INST] These results suggest that acceptance of cardiac donors after cardiopulmonary resuscitation may not increase the risk of heart transplantation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does methadone maintenance treatment based on the new national guidelines work in a primary care setting? Answer the question given the following information: Context: General practitioners (GPs) are being encouraged to treat more drug users but there are few studies to demonstrate the effectiveness of primary care treatment.AIM: To determine whether patients retained on methadone maintenance treatment for one year in a modern British primary care setting, with prescribing protocols based on the new national guidelines, can achieve similar harm reduction outcomes to those demonstrated in other settings, using objective outcome measures where available. Context: Longitudinal cohort study. Context: The Primary Care Clinic for Drug Dependence, Sheffield. Context: The intervention consisted of a methadone maintenance treatment provided by GPs with prescribing protocols based on the 1999 national guidelines. The first 96 eligible consenting patients entering treatment were recruited; 65 completed the study. Outcome measures were current drug use, HIV risk-taking behaviour, social functioning, criminal activity, and mental and physical health, supplemented by urinalysis and criminal record data. Context: Frequency of heroin use was reduced from a mean of 3.02 episodes per day (standard deviation [SD] = 1.73) to a mean of 0.22 episodes per day (SD = 0.54), (chi 2 = 79.48, degrees of freedom [df]= 2, P<0.001), confirmed by urinalysis. Mean numbers of convictions and cautions were reduced by 62% (z = 3.378, P<0.001) for all crime. HIV risk-taking behaviour, social functioning, and physical and psychological wellbeing all showed significant improvements. Think step by step to answer my question. [/INST] Patients retained on methadone maintenance treatment for one year in a primary care setting can achieve improvements on a range of harm reduction outcomes similar to those shown by studies in other, often more highly structured programmes.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does orthostatic hypotension predict the occurrence of nocturnal arterial hypertension in the elderly patient? Answer the question given the following information: Context: To determine whether the presence of orthostatic hypotension--which, in this age-group, could be due to varying degrees of autonomic dysfunction--is an indicator of nocturnal arterial hypertension. Context: Between 1999 and 2001 we prospectively and consecutively studied 93 elderly patients with untreated (office) arterial hypertension, 65 (70%) of whom were true hypertensives according to 24 h ambulatory blood pressure monitoring (ABPM). Context: The patients were studied by clinical examination including blood pressure (BP) measurement in dorsal decubitus and orthostatic position, 24 h ABPM, evaluation of vascular distensibility by carotid-femoral pulse wave velocity (PWV) and Doppler echocardiography. For this study we analyzed especially the ambulatory behavior of BP, so we could relate the variation of systolic blood pressure (SBP) during orthostatism with non-dipper status for SBP and absolute nocturnal values of SBP. Context: The results indicated that a greater decrease of blood pressure with orthostatism corresponded to a greater probability of nocturnal hypertension (p = 0.005) and of non-dipper status (p = 0.02). These results are in agreement with those subsequently found by other authors (Kario et al., 2002). Think step by step to answer my question. [/INST] In this way, by means of a simple clinical maneuver that should always be performed in an elderly hypertensive patient, we can suspect the presence of nocturnal hypertension--which is a high-risk cardiovascular situation--and use this information to help select patients to undergo 24 hour-ABPM.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Should scrotal ultrasound be discouraged in cases of suspected spermatic cord torsion? Answer the question given the following information: Context: To assess the value of scrotal ultrasound to guide the diagnosis of torsion of the spermatic cord. Context: Retrospective study from January 1995 to June 2001. One hundred and sixty eight patients were admitted to the emergency department with an empirical diagnosis of torsion of the spermatic cord. Scrotal ultrasound was performed when there was a doubt about the diagnosis or in the presence of atypical clinical features. All patients underwent surgical exploration of the scrotum. Two groups were distinguished: torsion and no torsion. We evaluated the contribution of ultrasound signs. Context: Scrotal ultrasound was performed in 66 cases (39%) and suggested the diagnosis of torsion in 30 cases and showed no signs of torsion in 36 cases. Seven of these 36 cases actually presented torsions confirmed by surgical exploration (false-negative), corresponding to a sensitivity of 79% and a specificity of 88%. The interval between arrival of the patient in the emergency department and scrotal exploration was 2.6-fold longer when scrotal ultrasound was performed (p<0.001). Surgical exploration identified 99 torsions (59%). Orchidectomy had to be performed in 15 cases (15% of torsions). However, the need for orchidectomy was not significantly different according to whether or not scrotal ultrasound was performed (p = 0.08). Think step by step to answer my question. [/INST] As scrotal ultrasound gave false-negative results in 10% of cases and delayed surgery, we do not recommend this examination as an emergency investigation. Systematic surgical exploration of the scrotum in all cases of painful testis must be performed urgently without preoperative morphological assessment.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Myxoglobulosis in oral extravasation mucocele: an entity? Answer the question given the following information: Context: Myxoglobulosis is a recognized variant of mucocele of the vermiform appendix. Myxoglobulosis has recently been reported in extravasation mucocele of the oral cavity. This morphological study was carried out to identify the prevalence and possible pathogenesis of this unusual feature. Context: A retrospective review of archival material diagnosed as oral cavity mucocele was undertaken. This covered a period of 32 months and consisted of 76 cases. In accordance with the proposed traumatic origin of extravasation mucocele, histological changes were classified on the basis of mucin extravasation and cyst formation. Globular structures, as described in the reports of myxoglobulosis, were looked for, as were changes that could be ascribed to their formation. Think step by step to answer my question. [/INST] Globular structures were noted in 22 (31%) of 71 cases of extravasation mucocele. They were present within cysts (11 samples) and in extraluminal connective tissue in the rest. They appeared to originate from alterations in connective tissue collagen following mucin extravasation. Their structure is different from that described in appendicial mucocele. When observed, they are best regarded as part of the normal sequence in the formation of oral cavity extravasation mucocele, without attaching special importance to them.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Pseudomigraine with lymphocytic pleocytosis: a calcium channelopathy? Answer the question given the following information: Context: To report the clinical findings of 10 patients diagnosed with pseudomigraine with lymphocytic pleocytosis and the results of mutational analysis of the CACNA1A gene in 8 of these patients. Context: Pseudomigraine with lymphocytic pleocytosis, also referred to as headache with neurologic deficits and cerebrospinal fluid lymphocytosis (HaNDL), is characterized by episodic transient neurologic dysfunction associated with moderate to severe headache and cerebrospinal fluid lymphocytic pleocytosis. Episodes are recurrent and the condition is self-limiting. The etiology of this sporadic condition remains unknown, but the episodic nature and its ability to be triggered by angiography is somewhat reminiscent of the phenotypic features of familial hemiplegic migraine, a condition caused by mutations in the CACNA1A gene.DESIGN/ Context: Utilizing retrospective chart review, we describe the clinical features of pseudomigraine with lymphocytic pleocytosis in 10 patients. Whole blood was taken from 8 patients (2 were lost to follow-up) and used for DNA testing. The CACNA1A gene was screened for mutations using heteroduplex analysis and direct DNA sequencing. Context: Clinical features of pseudomigraine with lymphocytic pleocytosis included transient episodes of weakness, sensory and visual symptoms, aphasia, and confusion lasting minutes up to 4 hours. Sensory symptoms, typically affecting the face and arm, were the most common presentation. Localization of symptoms did not conform to vascular territories. Headache was typically throbbing and most often bilateral. Genetic analysis did not identify any mutations in the CACNA1A gene. Think step by step to answer my question. [/INST] Similarities between familial hemiplegic migraine and pseudomigraine with lymphocytic pleocytosis include recurrent headache with reversible neurologic deficit, cerebrospinal fluid lymphocytic pleocytosis, and triggers such as angiography. Even so, heteroduplex analysis and DNA sequencing failed to identify any sporadic mutations or shared polymorphisms in the exons or the intron/exon boundaries of the CACNA1A gene. These results do not support a role of the CACNA1A gene in the etiology of pseudomigraine with lymphocytic pleocytosis.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are there HLA combinations typical supporting for or making resistant against aggressive and/or chronic periodontitis? Answer the question given the following information: Context: Human leukocyte antigens (HLA)/alleles have been considered as risk factors for periodontal disease. However, data from HLA associations is not consistent. Diversity of HLA antigen combinations and en bloc inherited HLA alleles (haplotypes), as known in systemic diseases, can be variable factors in disease association. Therefore, the aim of this study was to investigate the incidence of HLA homozygosities, heterozygosities and estimated haplotypes in German Caucasian groups with generalized aggressive (N = 50) and chronic (N = 102) periodontitis in comparison to control probands without periodontitis (N = 102). Context: HLA-A, -B, -Cw, -DRB1, -DRB3/4/5, -DQB1 typing was carried out using both serologic (microlymphocytotoxicity test) and genomic (PCR-SSP: PCR with sequence specific primers) techniques. Frequencies of all homozygosities, heterozygosities and haplotypes were determined in all patients and controls. Context: In both patient groups, associations to HLA homozygosities and heterozygosities were found. Most striking was the significantly lower frequency of HLA-DRBblank* homozygosity (non-DRB3*/DRB4*/DRB5*) in chronic periodontitis (p<0.05), whereas HLA-DRB1*15 : DRB5*(DR51) : DQB1*06 showed a slightly higher homozygosity rate in all patients. As the combination HLA-A*02,A*03 was significantly decreased in aggressive periodontitis (p<0.05), HLA-A*01,A*03 heterozygosity was significantly lowered in chronic periodontitis (p<0.05). Among others, the known positive associations for HLA-A*68/69 (A28) and HLA-DRB1*04 were confirmed by the haplotypes HLA-A*68/69 : Cw*07 : B*18 in aggressive periodontitis (p<0.05) and HLA-Cw*08 : B*14 : DRB1*04 in chronic periodontitis (p<0.05). Think step by step to answer my question. [/INST] The present study elucidates the variety of HLA associations and therefore the difficulty to assign single HLA markers to periodontal disease. Susceptibility/resistance of both aggressive and chronic periodontitis may rather be influenced by particular HLA marker combinations. Associated HLA haplotypes may be of further importance for unknown gene loci representing a part of the genetic background for periodontitis. The different associations in aggressive and chronic periodontitis indicate different susceptibility/resistance factors for both diseases.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do measures of body fat distribution provide information on the risk of type 2 diabetes in addition to measures of general obesity? Answer the question given the following information: Context: To investigate which anthropometric measurements of obesity best predict type 2 diabetes in a population of Pima Indians and whether additional information on diabetes risk could be obtained by combining measures of general obesity with measures of body fat distribution. Context: We conducted a prospective study of 624 men and 990 nonpregnant women>18 years of age without diabetes. Subjects were followed a mean of 5.25 years for the development of type 2 diabetes (using 1997 American Diabetes Association criteria). Context: A total of 322 new cases of type 2 diabetes (107 men and 215 women) were diagnosed during follow-up. Baseline obesity measurements were highly correlated and predicted diabetes in proportional hazards models adjusted for age. BMI had the highest hazard ratio in men and women, with age-adjusted hazard ratios per SD of 1.73 (95% CI 1.44-2.07) and 1.67 (1.45-1.91), respectively. According to receiver-operating characteristic analysis, BMI and waist-to-height ratio were the best predictors of diabetes in men, while in women BMI, waist-to-height ratio, waist circumference, and waist-to-thigh ratio were the best predictors. The predictive abilities of models containing BMI were not significantly improved by including other measures of general obesity or measures of the body fat distribution. Think step by step to answer my question. [/INST] Throughout its range, BMI was an excellent predictor of type 2 diabetes risk in Pima Indians and was not significantly improved by combining it with other measures of general adiposity or body fat distribution.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Could the [14C]urea breath test be proposed as a 'gold standard' for detection of Helicobacter pylori infection ? Answer the question given the following information: Context: The urea breath test (UBT) with a microdose of [14C] is a non-invasive and simple method for the assessment of gastric infection by Helicobacter pylori. The aim of this study was to compare the [14C]UBT with invasive methods widely used for assessment of H. pylori gastric infection, including histology with hematoxylin-eosin staining, the gastric smear technique using Giemsa staining, and the biopsy urease test.MATERIAL/ Context: We evaluated patients referred to our clinic for elective upper gastrointestinal endoscopy excluding those on antibiotics and/or bismuth during the previous 4 weeks, patients on H+ blockers or H2 antihistamines during the previous 7 days, pregnant women, and patients who had undergone gastric surgery or had bleeding disorders. Eighty-nine patients ranging in age from 18-75 years were included in the final study population, 61 women and 28 men (mean age: 43(15 years). Context: When histology alone was considered as the reference standard, sensitivity for the [14 C]UBT was 94%, with a specificity of 37%; when the Giemsa technique, sensitivity was 95%, and specificity 35%; and when the biopsy urease test, sensitivity was 94% and specificity 45%. With two or more invasive techniques together considered as the reference standard, the [14C]UBT had a sensitivity of 95%, with a specificity of 44%. Think step by step to answer my question. [/INST] [14C]UBT is an objective and reproducible technique, capable of sampling the whole gastric mucosa. It shows high sensitivity, but low specificity, which could be explained by limited gastric sampling plus subjective interpretation in the invasive techniques that are currently used as gold standard.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does plasma leptin concentration predict the nutritional status of hemodialyzed patients with chronic renal failure? Answer the question given the following information: Context: Patients with chronic renal failure are characterized by hyperleptinemia, and leptin is presumed to be an anorectogenic hormone. The aim of this prospective study was to analyze changes in body composition and parameters of nutritional status in relation to changes in plasma leptin concentration in uremic patients during the first year of hemodialysis therapy.MATERIAL/ Context: 21 patients (10 F, 11 M, mean age 51+/- 3 years, BMI 24.3+/-1.1 kg/m2) were enrolled in this study. Nutritional status was evaluated by anthropometric parameters, estimation of body composition (DEXA method), and biochemical markers (plasma concentrations of albumin, cholesterol, triglycerides, transferrin) and plasma leptin concentration. Tests were performed twice: immediately after initiation of hemodialysis therapy and again 12 months later. Context: After 12 months of hemodialysis therapy, the changes in body mass (-2.6+/-0.8 kg; p=0.23), total fat mass (TFM) (-0.3+/-0.8 kg; p=0.68) and total lean mass (TLM) (+0.5+/-0.8 kg; p=0.26) were insignificant. Plasma leptin concentration and estimated biochemical nutritional parameters did not change markedly. A significant positive correlation was noticed between TFM and plasma leptin concentration (R=0.521; p=0.02) at the beginning of hemodialysis therapy and between changes in TFM and plasma leptin concentration (R=0.466; p=0.04) after one year. Think step by step to answer my question. [/INST] Plasma leptin concentration does not predict forthcoming changes in body composition and changes of nutritional status in uremic patients after the first year of hemodialysis.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Determination of peroxidase positive cells in semen: is it a secure parameter for the diagnosis of silent genital infections? Answer the question given the following information: Context: The presence of leukocytes, detected by peroxidase test in semen, can be a good indicator of infections in the male genital tract. Peroxidase positive cells have been positively correlated with elevated values of elastase, one of the major proteases liberated by granulocytes at the inflammation place. However, seminal granulocytes may not be adequately detected by the peroxidase test in comparison with immunological methods.AIM: To correlate the determination of peroxidase positive cells with the elastase level in the seminal plasma. Context: Seminal plasma from 64 patients with a high number of round cells (>106/ml) in semen, was studied. Correlation analysis was done using the Pearson correlation coefficient. Context: No correlation between the level of granulocyte elastase and the number of peroxidase positive cells (r = 0.2237, p>0.05), or even the number of round cells (r = 0.03934, p>0.05) was observed. Think step by step to answer my question. [/INST] Our results suggest that the determination of peroxidase positive cells is not a reliable indicator of leukocytes in the seminal plasma and their absence do not discard a silent genital tract infection.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: The 'two-week' target for the diagnosis of pancreatic carcinoma: an achievable aim? Answer the question given the following information: Context: The notes of all patients with pancreatic cancer from June 1998 to June 2000 were reviewed to determine the time to diagnosis, investigations and procedures performed, number of admissions, length of hospital stay and survival Context: There were 146 patients in total with a median (range) age of 71 (38-92) years. 18 (12%) had resectable lesions, while the remaining 128 patients had 134 palliative interventions (33 surgical; 101 radiological or endoscopic). The median number of hospital admissions for each patient was 2 (range 1-6) with a median length of hospital stay of 9 days (range 1-35 days). The median (IQR) time to diagnosis was significantly less in the jaundiced patients [7 (6-10) days vs. 32 (18-46) days, P<0.0001]. There was no significant correlation between age and time to diagnosis (r=0.08, P=0.36). There were 105 (72%) deaths in the study population, 82 in the jaundiced group and 23 in the non-jaundiced group. There was no significant difference in median (IQR) duration from referral to death in the jaundiced and non-jaundiced groups [59.5 (18-175) days vs. 35 (16-137) days, P=0.45]. Think step by step to answer my question. [/INST] A diagnosis within 14 days was achieved in 77% of patients. Patients with jaundice were more likely to have an earlier diagnosis than those without jaundice but this had no impact on survival.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does reporting of plain chest radiographs affect the immediate management of patients admitted to a medical assessment unit? Answer the question given the following information: Context: During a 3 month period we prospectively evaluated 200 patients who had a plain chest radiograph on admission. After the post on-call ward round, an independent medical specialist registrar reviewed the notes, retrieving relevant clinical details. The plain chest films were reported independently by a trainee radiologist and consultant, reaching a consensus report. Context: There was 93% agreement between trainee and consultant radiologists (95% CI=89-96%). Seventy percent had documented reports by the on-call medical team. There was disagreement between radiology and medical reports in 49% of reported films (95% CI=40-57%). The radiologist's report led to a direct change in the immediate management of 22 patients (11%). Think step by step to answer my question. [/INST] Only 70% of films had documented reports in the clinical notes despite this being a legal requirement. Radiology reporting does cause a direct change in patient management. Chest radiographs of patients admitted to a medical admissions unit should be reported by a radiologist with the minimum of delay.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Using volume criteria: do California hospitals measure up? Answer the question given the following information: Context: Many studies have demonstrated a significant relationship between high procedural volume and better outcomes. As the public becomes increasingly aware of this medical literature, consumer groups have collaborated with medical researchers to operationalize this body of evidence. One such organization, the Leapfrog Group, has proposed annual volume criteria for four operations: coronary bypass grafting (CABG), abdominal aortic aneurysm (AAA), carotid endarterectomy (CEA), and esophageal cancer resection (ECR). This study analyzes California hospitals within the context of these volume criteria. Context: Using the California inpatient database from 2000, we identified all CABG, AAA, CEA, and ECR operations performed at metropolitan hospitals. The volume of each of the four operations was tabulated by hospital and evaluated. Comparisons were made between academic and nonacademic hospitals. Context: Most hospitals in California did not meet Leapfrog's volume criteria. Only 2 hospitals of 287 (0.7%) met the volume criteria for the operations that it performed. Of the 71 (25%) hospitals that performed all four procedures, none met the volume criteria of all four procedures. In fact, only 10% of California hospitals performing these operations were high-volume hospitals based on Leapfrog's volume criteria. When comparing academic to nonacademic hospitals, academic hospitals performed more AAA operations than nonacademic hospitals (36 vs 12, P = 0.02). Although academic hospitals tended to have higher caseloads for CABG, CEA, and ECR, these did not reach statistical significance. Also, academic hospitals were more likely to be high volume for AAA (43.8% vs 7.0%, P<0.01) and for ECR (23.1% vs 4.0%, P<0.01). Think step by step to answer my question. [/INST] California's hospital system is far from being regionalized. Although academic hospitals appear better positioned than nonacademic hospitals, the vast majority of all hospitals do not meet Leapfrog's volume criteria. As efforts to use volume as a proxy measure of quality gain momentum, hospitals and physicians will be forced to measure and report quality. As such, surgeons need to decide between accepting volume as an adequate measure of quality and developing other possibly more direct and reliable methods.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do young breast cancer patients have worse outcomes? Answer the question given the following information: Context: Previous studies have suggested that young breast cancer patients have poorer survival as compared with their older counterparts. Most of this research reflects single institution experiences that may not be representative of the population. This study was designed to determine whether young breast cancer patients have poorer survival as compared with an older cohort using a national population-based cancer registry and, more specifically, to determine whether differences in survival are caused by more advanced tumor stage, more aggressive disease, or patient-specific characteristics. Context: Using the Surveillance, Epidemiology, and End Results cancer database (1992-1998), data for all patients with a diagnosis of invasive breast cancer were extracted. Two age categories were analyzed: young group (<or=35 years old, n = 4616) and older group (50-55 years old, n = 20319). Patient demographics, 5-year survival rates, tumor characteristics (stage, grade, and receptor status), surgical treatment, and use of radiation were compared between the groups. Context: Overall, young patients had worse 5-year survival when compared with the older group (74.3% vs. 85.1%). Stage for stage, the young patients also had poorer survival (except for stage IV). They present with more advanced stage disease and have more aggressive tumor characteristics, that is, higher grade tumors and more estrogen- and progesterone receptor-negative tumors. Even after controlling for patient characteristics, tumor factors, and receipt of treatment, a multivariate regression showed that young age was an independent risk factor for death (HR = 1.095). Think step by step to answer my question. [/INST] Young breast cancer patients have poorer outcomes, which are in part attributed to later stage disease, more aggressive tumors, and less favorable receptor status. There still appears to be other important factors, not included in our study, that are contributing to the worse outcomes for these young patients, such as socioeconomic status. Physicians need to have heightened awareness when evaluating this population, and increasingly efficacious adjuvant therapies need to be developed.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is telephone assessment a valid tool in rehabilitation research and practice? Answer the question given the following information: Context: To determine if face-to-face and telephone administration of questionnaires produce comparable results in rehabilitation research studies. METHOD A total of 80 participants who used eyeglasses as their primary visual assistive device agreed to participate. All completed the Life Orientation Test and the Psychosocial Impact of Assistive Devices Scale. Approximately half of the participants completed the forms after being approached by an interviewer and then were contacted by telephone 2 weeks later to complete the forms a second time. The other half of the participants initially completed the forms over the telephone and then met with an interviewer 2 weeks later and completed the forms face-to-face. Context: For the forms used no statistically significant differences were found between groups or over time. Think step by step to answer my question. [/INST] For some questionnaires telephone administration may provide a convenient and cost-effective method of data collection. However, it should not be automatically assumed that all questionnaires will yield the same results regardless of the mode of administration used.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Are gender differences important for the clinical effects of antidepressants? Answer the question given the following information: Context: Gender differences in antidepressant treatment response, side effects, dropout rates, and plasma concentrations were examined in patients with major and predominantly melancholic depression. Context: The study included a subgroup of 292 inpatients (96 men, 196 women) from three Danish double-blind, randomized, controlled trials. All patients completed a 5-week treatment period and fulfilled the DSM-III or DSM-III-R criteria for major depression. Clomipramine (150 mg/day) was the reference treatment, and comparable treatments were citalopram (40 mg/day), paroxetine (30 mg/day), and moclobemide (400 mg/day). Assessments were performed by using the 17-item Hamilton Depression Rating Scale and the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale. In a subgroup of 110 patients, weekly measurements of clomipramine plasma concentrations were obtained. Nonparametric statistical tests and multiple linear and logistic regression models were used for statistical evaluations. Context: Both genders had similar remission rates (Hamilton depression scale score<8) when treated with clomipramine and had significantly higher remission rates with clomipramine than with the comparable treatments. The plasma concentrations of clomipramine were significantly higher for female than for male patients. No gender differences were found in posttreatment Hamilton depression scale scores, nor did the therapeutic effects of treatment depend on gender. Rates of dropout and side effects were similar for men and women. No relationship between plasma concentrations, gender, and therapeutic outcome was found. Think step by step to answer my question. [/INST] In a group of patients with major and predominantly melancholic depression, differentiation according to gender was not important in treatment with common antidepressants. Women appeared to have higher plasma concentrations of tricyclic antidepressants than men. The consequences of this difference for clinical effects are unclear. Gender-specific recommendations for dosing of tricyclic antidepressants may be considered.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Ki-67 immunocytochemistry in liquid based cervical cytology: useful as an adjunctive tool? Answer the question given the following information: Context: To test the ability of Ki-67 to detect cytological lesions in a screening setting and its use as a surrogate marker of human papillomavirus (HPV) infection. Context: A study of liquid based cytology, HPV DNA testing by MY09/MY11 consensus polymerase chain reaction (PCR), type specific PCRs, and Ki-67 immunocytochemistry on a randomly selected series of 147 patients. Context: Comparison of the number of Ki-67 immunoreactive cells/1000 cells in the different cytological groups showed that the HSIL group yielded a significantly higher mean count than did the other groups. The number of Ki-67 immunoreactive cells/1000 cells was significantly higher in HPV-16 positive samples than in samples containing infections with other high risk types. Receiver operating characteristic curves indicated a test accuracy (area under curve) of 0.68, 0.72, and 0.86 for atypical squamous cells of undetermined significance (ASCUS), low grade squamous intraepithelial lesions (LSIL), and high grade squamous intraepithelial lesions (HSIL), respectively. Thresholds for 95% sensitivity were 0.07, 0.08, and 0.15 Ki-67 immunopositive cells/1000 cells for ASCUS, LSIL and HSIL, respectively. The threshold for 95% specificity was 1.9 Ki-67 immunopositive cells/1000 cells. Think step by step to answer my question. [/INST] Ki-67 immunocytochemistry can be applied to liquid based cytology. The accuracy and diagnostic indices of the test are good when compared with those of other techniques. As part of a panel of screening procedures, it could be used as an adjunct to liquid based cytology to identify HSIL, and as a surrogate marker of HPV-16 infection.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Courses of substance use and schizophrenia in the dual-diagnosis patients: is there a relationship? Answer the question given the following information: Context: Interrelationship of schizophrenia and substance use is complex and multifactorial. Examining the influence of various psychoactive substances on course of patients with pure dual-diagnosis schizophrenia may help to solve this riddle.AIM: To examine the relationship of the courses of substance use and schizophrenic symptomatology in substance abusing "dual-diagnosis" patients with schizophrenia. Context: Outpatient Deaddiction and Treatment Center of a tertiary care hospital with a retrospective design. Context: Twenty-two substance abusing dual-diagnosis patients with schizophrenia were investigated regarding the course of substance use (abuse/dependence, use, non-use) and that of schizophrenia (psychotic, non-psychotic, in remission). A graphical representation of course of schizophrenia and substance abuse was made and their relationship studied by superimposition of respective graphs. Context: The Friedman two-way analysis of variance of ranks was applied to see the relationship between time spent by patients while on and off various substances. Context: In five cases, the onset of schizophrenia preceded the onset of substance use. In seven out of 22 subjects, the schizophrenic exacerbation was clearly preceded by increase in substance abuse in the preceding two-twelve months. In none of the subjects decrease in substance use led to a decrease or increase in schizophrenic symptoms. Think step by step to answer my question. [/INST] Although substance use disorder preceded the onset of schizophrenic illness in the majority, and increase in substance abuse preceded schizophrenic exacerbation in one-third of dual-diagnosis patients, overall there was no evidence that the course of substance use was associated with that of schizophrenia after both disorders were diagnosed.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does monitoring of pre-/post-dialyzer pressure difference improve efficiency in intermittent hemodialysis? Answer the question given the following information: Context: Continuous monitoring of pre-/post-dialyzer pressure difference (DeltaP) is widely used in continuous renal replacement therapies to monitor extracorporeal circuit function. The aim of this study was to verify whether DeltaP may help to identify chronic subclinical worsening of dialysis quality due to incomplete dialyzer clotting in intermittent hemodialysis. Context: Nine chronic hemodialysis patients were enrolled in the study and dialyzed twice (high-flux polysulfone dialyzer) with DeltaP and urea-clearance monitoring: the first session with a standard anticoagulation and the second without. To verify whether a visible clotting of the dialyzer precedes or follows a significant DeltaP increase, we checked the dialyzers for the presence of red clots after a saline flush performed when a 50% increase in DeltaP was registered. Context: In the second dialysis session after a 50% increase in DeltaP (documented in 7/9 patients), all dialyzers, after saline flush, showed a visible fiber clotting but not a significant reduction (>15%) in urea clearance. In the majority of the patients (6/7), until a few minutes before complete occlusion of the extracorporeal circuit, the urea clearance did not change significantly (-8.9 +/- 12.7%). Think step by step to answer my question. [/INST] The usual check of the presence or absence of red clots in the dialyzer at the end of the dialysis session is enough, in the absence of red clots, to ensure that dialyzer efficiency is maintained during the whole treatment. Contrary to what is applied in CRRT, a continuous monitoring of DeltaP during intermittent hemodialysis would not significantly help to unmask unnoticed inefficient hemodialysis sessions.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is assessment of kidney involvement in patients with essential hypertension satisfactory? Answer the question given the following information: Context: According to ANAES guidelines (2000) adapted from the international guidelines, kidney function should be regularly monitored in hypertensive patients in order to detect vascular nephropathy at an early stage and prevent kidney failure which is a major cardiovascular factor. The PHENOMEN survey was conducted between January and July 2001 on a representative sample of 16,358 patients suffering from hypertension being followed by a General Practitioner (GP). The population included patients from all 22 administrative regions in France. Context: To determine the prevalence of renal involvement in patients with hypertension (both treated and untreated); to compare the GP's subjective evaluation of the extent of renal involvement with a more objective assessment made according to ANAES guidelines. Context: Kidney function was evaluated by measuring plasma creatinine levels to derive a value for the creatinine clearance rate (CCR) using the Cockeroft-Gault formula. Context: Out of the 16,358 patients included, plasma creatinine levels could be measured in 11,586 (76%) [53% men; 47% women, mean age = 63 +/- 12 years]: mean plasma creatinine = 90 +/- 49 mumol/l, i.e. a mean CCR of 83 +/- 32 ml/min. For 8,650 of the patients (75%), kidney function had been monitored in the preceding twelve months. The physicians defined their patient's kidney function as normal in 10,080 (87%) of cases whereas in reality, 4,411 of 8,650 (51%) were suffering from some degree of renal insufficiency (RI): in 2,422 (28%), RI was mild (>or = 60 CCR<80 ml/min): in 1,903 (22%) RI was moderate (>or = 30 CCR<60 ml/min). A minority of patients (44 i.e. 1%) showed severe RI (CCR<30 ml/min). Think step by step to answer my question. [/INST] Most GPs apply ANAES guidelines and order plasma creatinine assays. However, there is a discrepancy between how the physician "perceives" the seriousness of the renal insufficiency and a more objective measure based on the CCR figure. It would seem that the CCR derivative is insufficiently exploited despite the widespread availability of converters. Thus, the PHENOMEN survey has revealed that the extent of renal involvement in patients with hypertension still tends to be underestimated by GPs despite the major implications of this complication in terms of therapeutic strategy and global cardiovascular risk.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is the prevalence of specific IgE to classical inhalant aeroallergens among patients with respiratory allergy changing? Answer the question given the following information: Context: The aim of this study was to evaluate the relative frequencies of sensitisation to four common inhalant allergens in two atopic populations suffering from asthma and/or rhinitis. One had been studied in the period of 1975 till 1979, and a second population was evaluated between 1992 and 1995. Context: At both time periods patients with inhalant allergy and visiting our outpatient clinic were included. Quantification of IgE to Dermatophagoides pteronyssinus, birch, timothy grass, and mugwort was performed via the Phadebas RAST technique (Pharmacia, Brussels, Belgium). Context: In patients suffering from respiratory allergy the frequency of birch pollen sensitisation significantly increased from 13% in the period 1975-1979 to 34% in the period 1992-1995. In contrast, the frequency of house dust mite, timothy grass pollen, and mugwort pollen sensitisation remained almost unchanged. The increase was not associated with an increase in the birch pollen count. Think step by step to answer my question. [/INST] Birch pollen hypersensitivity has almost tripled among atopic subjects during the last 2 decades. The exact mechanisms for this increase remain to be evaluated.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do patients with a higher body mass index have a greater risk of advanced-stage renal cell carcinoma? Answer the question given the following information: Context: To evaluate whether patients with a higher body mass index (BMI) are at elevated risk of an advanced tumor stage for renal cell carcinoma at diagnosis. A high BMI has recently been proved to be associated with advanced tumor stages for some malignant diseases. Context: From January 1994 to December 2000, 693 operations for renal cell carcinoma were performed in 683 patients at our institution. Ten patients underwent surgery twice for bilateral tumors. Of the 683 patients, 417 were men and 266 women. The mean age at surgery was 62.2 years, and the mean tumor diameter was 5.2 cm. Seventy-eight percent of the patients were asymptomatic at tumor diagnosis. The following parameters were evaluated with regard to a possible correlation to tumor stage and/or tumor diameter: BMI, presence of symptoms, age, sex, hemoglobin, lactate dehydrogenase, erythrocyte sedimentation rate, serum cholesterol, and triglycerides. For statistical analysis, the Spearman rank correlation test was used. Context: The mean BMI was 26.8 +/- 4.4 (range 16.9 to 44.3). Statistical analysis showed a significant positive correlation between advanced T stage and the presence of symptoms (P<0.0001), erythrocyte sedimentation rate (P<0.0001), lactate dehydrogenase (P = 0.0015), and age (P = 0.046), and an inverse correlation with hemoglobin (P<0.0001) and serum cholesterol (P<0.0001). For all other investigated parameters, including BMI, no significant correlation could be proved. Think step by step to answer my question. [/INST] Our data indicate that obese patients are not at greater risk of advanced tumor stages of renal cell carcinoma at the time of diagnosis compared with a population of normal weight.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Collateral formation in patients after percutaneous myocardial revascularization: a mechanism for improvement? Answer the question given the following information: Context: Percutaneous myocardial revascularization (PMR) has emerged as a novel therapeutic strategy for patients with ischemic heart disease not amendable to traditional revascularization approaches. Despite the symptomatic improvement documented in clinical trials, underlying mechanism remains unknown. Context: We assessed the coronary angiograms of 25 patients before and 6 months after the PMR procedures for collateral vessel formation. The Rentrop scoring system was used to score the extent of collateral vessel formation. The angiograms were analyzed by 2 independent reviewers. The change in Rentrop score and improvement in angina status was correlated. Context: During follow-up period of 6 months, no patient died or suffered from myocardial infarction. Overall the mean Canadian Classification Society (CCS) class among the study patients was significantly improved from 3.5 to 2.4; mean difference = 1.08 (p<0.0001). Among these, 8 (32%) had improvement of>2 CCS classes (p = 0.003) (improvement group). The rest of the patients had either no change (n = 8; 32%) or improvement of 1 CCS class (n = 9; 36%) (no improvement group). The Rentrop score improved in 3 (12%), remained unchanged in 22 (88%) and deteriorated in 0 patient. Overall, there was no significant change in Rentrop score at 6-month follow-up; mean difference 0.13 (p = 0.08). There was also no correlation between the change in extent of collateral vessel formation and the improvement in angina status (correlation coefficient r = 0.09) at 6 months after PMR. Think step by step to answer my question. [/INST] Improvement in collateral vessel formation is unlikely to be a mechanism responsible for symptomatic improvement in patients after PMR.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Metabolically controlled reperfusion in acute myocardial infarction: should the polarizing solution be given subselectively? Answer the question given the following information: Context: In working rat hearts, metabolic support of injured tissue enhances recovery after acute myocardial infarction. Clinical experience with a systemic "polarizing solution" supports this claim. Context: In a dog model of ischemia/reperfusion, we tested the feasibility of subselectively supplying adapted metabolic substrates before instituting blood reperfusion. Context: Thirty-five dogs underwent ligation of the proximal left anterior descending artery and collaterals for 90 minutes. The animals were randomly assigned to receive direct blood reperfusion (Group I), intracoronary glucose, insulin, and potassium (Group II), or intracoronary glucose, insulin, and potassium plus propionyl-L-carnitine (PLC) (Group III). After 30 minutes of artificial reperfusion, prograde blood flow was resumed in groups II and III. A routine necropsy was performed 3 to 5 days later. Primary endpoints were severe arrhythmias, death, markers of infarct size, and specific histologic features. Context: We excluded 4 dogs for technical reasons and 2 others for preexisting cardiomyopathy. In the remaining 29 animals, large apical infarctions were documented ventriculographically during arterial ligation. One dog died of irreversible ventricular fibrillation during the initial ischemic period, and 9/28 dogs (32.1%) died during early reperfusion. Ventricular fibrillation was more common with 10% (versus 5%) dextrose concentrations and was eliminated by PLC. Irreversibly injured (versus jeopardized) areas of myocardium were more common in Group III (85.9 19.3%) than in Groups I and II (16.9 10.8%). Think step by step to answer my question. [/INST] Subselective infusion of metabolically supportive solutions during acute myocardial infarction is technically feasible. To prevent osmotic endothelial damage, the perfusate must have a low (<5%) dextrose content.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Comparison of abdominal aortic aneurysm diameter measurements obtained with ultrasound and computed tomography: Is there a difference? Answer the question given the following information: Context: Accurate diameter measurements of abdominal aortic aneurysm (AAA) with both computed tomography (CT) and ultrasound (US) are essential for screening, planning surgical intervention, and follow-up after endovascular repair. Often there is a discrepancy between measurements obtained with CT and US, and neither limit of agreement (LOA) nor correlation between the two imaging methods has been clearly established. The purpose of this study was to assess the paired differences in AAA diameter measurements obtained with CT and US in a large national endograft trial. Context: CT and US measurements were obtained from an independent core laboratory established to assess imaging data in a national endograft trial (Ancure; Guidant, Menlo Park, Calif). The study included only baseline examinations in which both CT and US measurements were available. Axial CT images and transverse US images were assessed for maximal AAA diameter and recorded as CT(max) and US(max), respectively. Correlations and LOA were performed between all image diameters, and differences in their means were assessed with paired t test. Context: A total of 334 concurrent measurements were available at baseline after endovascular repair. CT(max) was greater than US(max) in 95% (n = 312), and mean CT(max) (5.69 +/- 0.89 cm) was significantly larger (P<.001) than mean US(max) (4.74 +/- 0.91 cm). The correlation coefficient between CT(max) and US(max) was 0.705, but the difference between the two was less than 1.0 cm in only 51%. There was less discrepancy between CT(max) and US(max) for small AAA (0.7 cm, 15.3%) compared with medium (0.9 cm, 17.9%) and large (1.46 cm, 20.3%) AAA; however, the difference was not statistically significant. LOA between CT(max) and US(max) (-0.45-2.36 cm) exceeded the limits of clinical acceptability (-0.5-0.5 cm). Poor LOA was also found in each subgroup based on AAA size. Think step by step to answer my question. [/INST] Maximal AAA diameter measured with CT is significantly and consistently larger than maximal AAA diameter measured with US. The clinical significance of this difference and its cause remains a subject for further investigation.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does a general surgery clerkship influence student perceptions of surgeons and surgical careers? Answer the question given the following information: Context: Student perceptions of surgeons and surgical careers may influence their decision to pursue a surgical career. We evaluated the impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers and of the clerkship on student interest in surgical careers. Context: We conducted voluntary pre- and postclerkship surveys of third-year medical students who were enrolled in their required general surgery clerkship and used 5-point Likert scale rankings to capture agreement with declarative statements (1 = strongly agree; 5 = strongly disagree). T-tests were used to evaluate both paired and individual items. Context: Students indicated that their surgical clerkship improved their opinion of surgeons (2.47; P<.001). Several perceptions changed after the clerkship. First, students agreed more strongly that surgeons were compassionate physicians (ranking, 2.87 vs 2.53; P =.003) and that patients respected surgeons (ranking, 1.84 vs 1.62; P =.026). Acknowledgment of career satisfaction by students increased (ranking, 2.57 vs 2.22; P =.008). Students more strongly disagreed that "surgeons [were] respectful of other physicians" (ranking, 3.29 vs 3.62; P =.009). Interest in surgical careers did not change significantly during the clerkship (ranking, 2.83 vs 2.68; P =.218). Think step by step to answer my question. [/INST] Medical student perceptions of surgeons and surgical careers generally improve during the surgical clerkship. However, student impressions of surgeons' collegial behavior and commitment to teaching deteriorate significantly during the surgical clerkship.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Contact isolation in surgical patients: a barrier to care? Answer the question given the following information: Context: Contact isolation is commonly used to prevent transmission of resistant organisms. We hypothesized that contact isolation negatively impacts the amount of direct patient care. Context: For 2 hours per day over a 5-week period, a single observer recorded provider/patient contact in adjacent isolated and nonisolated patient rooms on both the surgical intensive care unit (ICU) and surgical wards of a university hospital. Number of visits, contact time, and compliance with isolation were recorded, as was illness severity as assessed by APACHE II score. Context: Isolated patients were visited fewer times than nonisolated patients (5.3 vs 10.9 visits/h, P<.0001) and had less contact time overall (29 +/- 5 vs 37 +/- 3 min/h, P =.008), in the ICU (41 +/- 10 vs 47 +/- 5 min/h, P =.03), and on the floor (17 +/- 3 vs 28 +/- 4 min/h, P =.039), in spite of higher mean APACHE II scores in the isolated (10.1 +/- 1.0 vs 7.6 +/- 0.8, P =.05). Among floor patients with APACHE II scores greater than 10, patients in the isolated group had nearly 40% less contact time per hour than patients in the nonisolated group (19 +/- 4 vs 34 +/- 7 min/h, P =.05). Think step by step to answer my question. [/INST] Because of the significantly lower contact time observed, particularly among the most severely ill of floor patients, we propose a reexamination of the risk-benefit ratio of this infection control method.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Sample size calculations in surgery: are they done correctly? Answer the question given the following information: Context: Randomized controlled trials (RCTs) are considered the gold standard for evidence-based clinical research, but prior work has suggested that there may be poor reporting of sample sizes in the surgical literature. Sample size calculations are essential for planning a study to minimize both type I and type II errors. We hypothesized that sample size calculations may not be performed consistently in surgery studies and, therefore, many studies may be "underpowered." To address this issue, we reviewed RCTs published in the surgical literature to determine how often sample size calculations were reported and to analyze each study's ability to detect varying degrees of differences in outcomes. Context: A comprehensive MEDLINE search identified RCTs published in Annals of Surgery, Archives of Surgery, and Surgery between 1999 and 2002. Each study was evaluated by two independent reviewers. Sample size calculations were performed to determine whether they had 80% power to detect differences between treatment groups of 50% (large) and 20% (small), with one-sided test, alpha = 0.05. For the underpowered studies, the degree to which sample size would need to be increased was determined. Context: One hundred twenty-seven RCT articles were identified; of these, 48 (38%) reported sample size calculations. Eighty-six (68%) studies reported positive treatment effect, whereas 41 (32%) found negative results. Sixty-three (50%) of the studies were appropriately powered to detect a 50% effect change, whereas 24 (19%) had the power to detect a 20% difference. Of the studies that were underpowered, more than half needed to increase sample size by more than 10-fold. Think step by step to answer my question. [/INST] The reporting of sample size calculations was not provided in more than 60% of recently published surgical RCTs. Moreover, only half of studies had sample sizes appropriate to detect large differences between treatment groups.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Is obesity an inflammatory disease? Answer the question given the following information: Context: Most obese individuals have elevated concentrations of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), markers of inflammation closely associated with diabetes, hypertension, and stroke. Context: Obesity is a low-grade inflammatory disease, and Roux-en-Y gastric bypass (RYGB) reduces biochemical markers of inflammation and modifies gene expression in hypothalamic food intake/energy-related nuclei and subcutaneous abdominal fat (SAF). Context: Obesity was induced in 24 3-week-old Sprague Dawley pups fed a high-energy diet (HED). Three groups (n = 8/group) were studied: RYGB, sham-operated pair-fed, and sham-operated ad libitum HED. Controls were nonobese rats fed chow (n = 6). Rats were killed 10 days after operation, and blood was collected to measure corticosterone and SAF and mesenteric fat to measure IL-6, TNF-alpha, and corticosterone. Total mRNA from arcuate nucleus and SAF purified for gene expression profiling. Data were analyzed with analysis of variance, Mann-Whitney test, and t test. Context: Before operation, the body weight of the obese groups was 493 +/- 7 g and control = 394 +/- 12g. The 10-day postoperative weight was RYGB = 417 +/- 21 g, pair-fed = 436 +/- 14 g, and ad libitum HED = 484 +/- 15 g. Mesenteric and SAF weight decreased in RYGB. Mesenteric/SAF ratio of IL-6, TNF-alpha, corticosterone, and gene profiling showed decrease of inflammation after RYGB. Think step by step to answer my question. [/INST] Gastric bypass reduces biochemical markers of inflammation, suggesting that obesity is an inflammatory condition.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Do required preclinical courses with family physicians encourage interest in family medicine? Answer the question given the following information: Context: Many medical schools, including the University of California, San Francisco (UCSF), added required preclinical course work with family physicians in the 1990s. We examined whether current UCSF students interested in family medicine noted more contact with family physicians and more faculty support of their interest than current Stanford students and 1993 UCSF students, neither of whom had required preclinical course work with family physicians. Context: A questionnaire was administered to students interested in family medicine at UCSF and Stanford in February 2001, with response rates of 84% and 90%, respectively. Previously published 1993 data from UCSF were also used for comparison. Data were analyzed using chi-square and t statistics as appropriate. Context: UCSF students in 2001, despite exposure to required preclinical course work with family physicians, did not perceive greater contact with family physicians than Stanford students. Stanford students perceived greater encouragement from their family medicine faculty but less from faculty overall, compared with 2001 UCSF students. UCSF students in 2001 perceived no more overall faculty encouragement than did UCSF students in 1993. Think step by step to answer my question. [/INST] Required preclinical course work with family physicians was not consistently associated with greater student perception of faculty support for students' interest in family medicine, nor was it demonstrated to increase the amount or quality of interested students' interaction with family medicine faculty.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Can serum lipid and CRP levels predict the "severity" of aortic valve stenosis? Answer the question given the following information: Context: Results of the studies performed have suggested that hypercholesterolaemia and inflammation are important aetiologic factors in aortic valve stenosis (AVS). However up to now no such data has been obtained to evaluate whether these predictors may still serve as valuable tools to estimate the progression and severity of AVS. If factors contributing to the "progression" of degenerative process can be understood and preventive measures can be taken, both clinical and economical beneficial effects can be achieved. The objective of this study is to investigate the correlation of serum cholesterol, triglyceride and CRP levels with the severity of aortic stenosis echocardiographically evaluated in patients with aortic valve stenosis. Context: Aortic valvular areas of 60 patients (pts) hospitalized in our clinic with suspected AVS were calculated with Doppler echocardiography. Patients were grouped into mild, moderate and advanced AVS, each category containing 20 pts, and then were subclassified regarding those with and without coronary artery disease (CAD). Context: Total cholesterol and CRP levels were found to be 215+/-42 mg/dl and 2.0+/-1.4 mg/dl; 224+/-43 mg/dl and 2.4+/-2.1 mg/dl; 225+/-55 mg/dl and 2.7+/-2.1 mg/dl in pts with mild, moderate and advanced AVS, respectively. A statistically significant difference was not detected among the three groups (p>0.05). When subclasses were classified the levels were found to be much more increased in those patients having additional CAD. Think step by step to answer my question. [/INST] We have demonstrated that severity of AVS does not correlate significantly with hypercholesterolaemia and CRP and their levels do not rise in accordance with increasing severity of AVS. Elevations of lipid levels in AVS were found to correlate with the presence of CAD rather than the severity of AVS. So, not in patients with simply AVS but in patients under higher cardiovascular risks, investigation of CRP plus lipid levels might provide benefit with respect to preventive treatment and benefit from cholesterol-lowering drugs can be expected in such kind of patients.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Morbidity in children born to women infected with human immunodeficiency virus in South Africa: does mode of feeding matter? Answer the question given the following information: Context: The population consisted of infants born to HIV-infected women in South Africa who were participating in a vitamin A intervention trial to prevent MTCT of HIV. Women chose to breastfeed or formula feed their infants according to UNAIDS guidelines. Actual feeding practices and morbidity were recorded at clinic follow-up visits at I wk, 6 wk, 3 mo and every 3 mo thereafter until 15 mo of age or cessation of breastfeeding. The infant's HIV status was assessed according to a predetermined algorithm. Context: HIV-infected infants who were never breastfed had a poorer outcome than those who were breastfed; 9 (60%) of those who were never breastfed had 3 or more morbidity episodes compared with 15 (32%) of breastfed children [odds ratio (OR) 4.05, 95% confidence interval (95% CI) 0.91-20.63, p = 0.05]. During the first 2 mo of life, never-breastfed infants (regardless of HIV status) were nearly twice as likely to have had an illness episode than breastfed infants (OR 1.91, 95% CI 1. 17-3.13, p = 0.006). Think step by step to answer my question. [/INST] The significant extra morbidity experienced in the first few months by all never-breastfed infants and at all times by HIV-infected infants who are not breastfed needs to be considered in all decisions by mothers, health workers and policy makers so as not to offset any gains achieved by decreasing HIV transmission through avoiding breastfeeding.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does Helicobacter pylori infection relate to iron deficiency anaemia in prepubescent children under 12 years of age? Answer the question given the following information: Context: Haemoglobin levels, iron parameters and serum IgG antibodies to H. pylori were measured in 693 children aged 9 to 12 y. Context: No significant differences in the seroprevalence of H. pylori infection and antibody titres to H. pylori were found between the IDA group and the non-anaemic controls. Think step by step to answer my question. [/INST] H. pylori infection does not seem to contribute to iron deficiency in prepubescent children.</s>

<s>[INST] <<SYS>> You are an expert in medicine, genetics, and human biology. <</SYS>> Here is my question: Does access to screening through health maintenance organization membership translate into improved breast cancer outcomes for African American patients? Answer the question given the following information: Context: To investigate breast cancer outcomes in a group of African American and white patients offered the same access to mammography screening in a health maintenance organization located in suburban Philadelphia, Pennsylvania. Context: We used medical chart reviews and retrospective tumor tissue studies to investigate disparities in the mode of diagnosis and breast cancer outcomes among African American and white patients in a health maintenance organization. Context: African American women were more likely to have detected their breast cancers accidentally and to have breast tumors larger than 2 cm than were whites. Invasive breast cancers with both lymph node involvement and systemic metastases were more prevalent in African American than in white women. Think step by step to answer my question. [/INST] These results suggest that even in health care settings that provide access to routine screening, African American women are more likely to have their breast cancers diagnosed accidentally and at more advanced stages than their white counterparts.</s>